In order to lessen the chance of misdiagnosis you need to treat your next doctor’s appointment like a job interview
In the June 30, 2014
Denver Post, Claire Martin’s article asked the
question “Is your doctor listening to you?” and she went straight to the source for answers, interviewing
Leana Wen, MD – a doctor who is truly a #patientsafety champion.
Wen’s research suggests that we don’t get our ’15 minutes’ when it comes to our docs’ attention at
appointments. It’s more in the range of ten (10) seconds! Read the full article in
the Post
here to learn how to be prepared!
Simple steps make a big difference: list your meds, provide context and detail over simple yes/no
answers, and write it down! For more low-tech healthcare solutions, I highly recommend watching Leana’s
TED Talks, starting with
this one. She’s one of my #patientsafety heroes!
A disgraced
Virginia OB/GYN who for years performed unnecessary surgeries on women -- including
hysterectomies -- in an insurance fraud scheme was found guilty on 52 counts for his
crimes.
The former doctor, Javaid Perwaiz, faces more than 400 years in prison when he is sentenced
by a federal judge next spring,
the Washington Post reported .
Perwaiz, who practiced in Hampton Roads, forced women into surgeries by telling them they
had cancer and used broken equipment to perform procedures, according to the report.
At his three-week trial in federal court, victims of the doctor testified how he performed
hysterectomies and other permanent, life-altering surgeries on them.
Perwaiz profited from the scheme by pocketing millions of dollars from Medicaid and private
insurers that paid for the unnecessary medical procedures he performed on the women.
"Doctors are in positions of authority and trust and take an oath to do no harm to their
patients," Karl Schumann, an FBI agent in the Norfolk field office, told the Washington Post in
a statement.
"With unnecessary, invasive medical procedures, Dr. Perwaiz not only caused enduring
complications, pain and anxiety to his patients, but he assaulted the most personal part of
their lives and even robbed some of their future," he added.
At trial, Perwaiz defended himself, arguing he performed the surgeries to help his patients,
not siphon money from their insurers.
I
n the early 2000s
Terry Mitchell's dentist retired. For a while,
Mitchell, an electrician in his 50s, stopped seeking dental care altogether. But when one of his wisdom teeth began to
ache, he started looking for someone new. An acquaintance recommended John Roger Lund, whose practice was a convenient
10-minute walk from Mitchell's home, in San Jose, California. Lund's practice was situated in a one-story building with
clay roof tiles that housed several dental offices. The interior was a little dated, but not dingy. The waiting room was
small and the decor minimal: some plants and photos, no fish. Lund was a good-looking middle-aged guy with arched eyebrows,
round glasses, and graying hair that framed a youthful face. He was charming, chatty, and upbeat. At the time, Mitchell and
Lund both owned Chevrolet Chevelles, and they bonded over their mutual love of classic cars.
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Lund extracted the wisdom tooth with no complications, and Mitchell began seeing him regularly. He never had any pain or
new complaints, but Lund encouraged many additional treatments nonetheless. A typical person might get one or two root
canals in a lifetime. In the space of seven years, Lund gave Mitchell nine root canals and just as many crowns. Mitchell's
insurance covered only a small portion of each procedure, so he paid a total of about $50,000 out of pocket. The number and
cost of the treatments did not trouble him. He had no idea that it was
unusual to undergo so many root canals
-- he thought they were just as common as fillings. The payments were spread out
over a relatively long period of time. And he trusted Lund completely. He figured that if he needed the treatments, then he
might as well get them before things grew worse.
Meanwhile, another of Lund's patients was going through a similar experience. Joyce Cordi, a businesswoman in her 50s,
had learned of Lund through 1-800-DENTIST. She remembers the service giving him an excellent rating. When she visited Lund
for the first time, in 1999, she had never had so much as a cavity. To the best of her knowledge her teeth were perfectly
healthy, although she'd had a small dental bridge installed to fix a rare congenital anomaly (she was born with one tooth
trapped inside another and had had them extracted). Within a year, Lund was questioning the resilience of her bridge and
telling her she needed root canals and crowns.
Cordi was somewhat perplexed. Why the sudden need for so many procedures after decades of good dental health? When she
expressed uncertainty, she says, Lund always had an answer ready. The cavity on this tooth was in the wrong position to
treat with a typical filling, he told her on one occasion. Her gums were receding, which had resulted in tooth decay, he
explained during another visit. Clearly she had been grinding her teeth. And, after all, she was getting older. As a
doctor's daughter, Cordi had been raised with an especially respectful view of medical professionals. Lund was insistent,
so she agreed to the procedures. Over the course of a decade, Lund gave Cordi 10 root canals and 10 crowns. He also
chiseled out her bridge, replacing it with two new ones that left a conspicuous gap in her front teeth. Altogether, the
work cost her about $70,000.
In early 2012, Lund retired. Brendon Zeidler, a
young dentist looking to expand his business, bought Lund's practice and assumed responsibility for his patients. Within a
few months, Zeidler began to suspect that something was amiss. Financial records indicated that Lund had been spectacularly
successful, but Zeidler was making only 10 to 25 percent of Lund's reported earnings each month. As Zeidler met more of
Lund's former patients, he noticed a disquieting trend: Many of them had undergone extensive dental work -- a much larger
proportion than he would have expected. When Zeidler told them, after routine exams or cleanings, that they didn't need any
additional procedures at that time, they tended to react with surprise and concern: Was he sure? Nothing at all? Had he
checked thoroughly?
In the summer, Zeidler decided to take a closer look at Lund's career. He gathered years' worth of dental records and
bills for Lund's patients and began to scrutinize them, one by one. The process took him months to complete. What he
uncovered was appalling.
W
e have a fraught relationship
with dentists as
authority figures. In casual conversation we often dismiss them as "not real doctors," regarding them more as mechanics for
the mouth. But that disdain is tempered by fear. For more than a century, dentistry has been half-jokingly compared to
torture. Surveys suggest that up to 61 percent of people are apprehensive about seeing the dentist, perhaps 15 percent are
so anxious that they avoid the dentist almost entirely, and a smaller percentage have
a genuine phobia
requiring psychiatric intervention.
When you're in the dentist's chair, the power imbalance between practitioner and patient becomes palpable. A masked
figure looms over your recumbent body, wielding power tools and sharp metal instruments, doing things to your mouth you
cannot see, asking you questions you cannot properly answer, and judging you all the while. The experience simultaneously
invokes physical danger, emotional vulnerability, and mental limpness. A cavity or receding gum line can suddenly feel like
a personal failure. When a dentist declares that there is a problem, that something must be done before it's too late, who
has the courage or expertise to disagree? When he points at spectral smudges on an X-ray, how are we to know what's true?
In other medical contexts, such as a visit to a general practitioner or a cardiologist, we are fairly accustomed to seeking
a second opinion before agreeing to surgery or an expensive regimen of pills with harsh side effects. But in the dentist's
office -- perhaps because we both dread dental procedures and belittle their medical significance -- the impulse is to comply
without much consideration, to get the whole thing over with as quickly as possible.
The uneasy relationship between dentist and patient is further complicated by an unfortunate reality: Common dental
procedures are not always as safe, effective, or durable as we are meant to believe. As a profession, dentistry has not yet
applied the same level of self-scrutiny as medicine, or embraced as sweeping an emphasis on scientific evidence. "We are
isolated from the larger health-care system. So when evidence-based policies are being made, dentistry is often left out of
the equation," says Jane Gillette, a dentist in Bozeman, Montana, who works closely with the
American Dental Association's Center for Evidence-Based Dentistry
, which was established in 2007. "We're kind of behind
the times, but increasingly we are trying to move the needle forward."
Consider the maxim that everyone should visit the dentist twice a year for cleanings. We hear it so often, and from such
a young age, that we've internalized it as truth. But this supposed commandment of oral health has no scientific grounding.
Scholars have traced its origins to a few potential sources, including a toothpaste advertisement from the 1930s and an
illustrated pamphlet from 1849 that follows the travails of a man with a severe toothache. Today, an increasing number of
dentists acknowledge that adults with good oral hygiene need to see a dentist only once every 12 to 16 months.
Many standard dental treatments -- to say nothing of all the recent innovations and cosmetic extravagances -- are likewise not
well substantiated by research. Many have never been tested in meticulous clinical trials. And the data that are available
are not always reassuring.
The Cochrane organization
, a highly respected arbiter of evidence-based medicine, has conducted systematic reviews of
oral-health studies since 1999. In these reviews, researchers analyze the scientific literature on a particular dental
intervention, focusing on the most rigorous and well-designed studies. In some cases, the findings clearly justify a given
procedure. For example, dental sealants -- liquid plastics painted onto the pits and grooves of teeth like nail polish -- reduce
tooth decay in children and have no known risks. (Despite this, they are not widely used, possibly because they are too
simple and inexpensive to earn dentists much money.) But most of the Cochrane reviews reach one of two disheartening
conclusions: Either the available evidence fails to confirm the purported benefits of a given dental intervention, or there
is simply not enough research to say anything substantive one way or another.
Fluoridation of drinking water seems to help reduce tooth decay in children, but there is insufficient evidence that it
does the same for adults. Some data suggest that regular flossing, in addition to brushing, mitigates gum disease, but
there is only "weak, very unreliable" evidence that it combats plaque. As for common but invasive dental procedures, an
increasing number of dentists question the tradition of prophylactic wisdom-teeth removal; often, the safer choice is to
monitor unproblematic teeth for any worrying developments. Little medical evidence justifies the substitution of
tooth-colored resins for typical metal amalgams to fill cavities. And what limited data we have don't clearly indicate
whether it's better to repair a root-canaled tooth with a crown or a filling. When Cochrane researchers tried to determine
whether faulty metal fillings should be repaired or replaced, they could not find a single study that met their standards.
"The body of evidence for dentistry is disappointing," says
Derek Richards
, the director of the Centre for Evidence-Based Dentistry at the University of Dundee, in Scotland.
"Dentists tend to want to treat or intervene. They are more akin to surgeons than they are to physicians. We suffer a
little from that. Everybody keeps fiddling with stuff, trying out the newest thing, but they don't test them properly in a
good-quality trial."
The general dearth of rigorous research on dental interventions gives dentists even more leverage over their patients.
Should a patient somehow muster the gumption to question an initial diagnosis and consult the scientific literature, she
would probably not find much to help her. When we submit to a dentist's examination, we are putting a great deal of trust
in that dentist's experience and intuition -- and, of course, integrity.
When Zeidler purchased Lund's
practice,
in February 2012, he inherited a massive collection of patients' dental histories and bills, a
mix of electronic documents, handwritten charts, and X‑rays. By August, Zeidler had decided that if anything could explain
the alarmingly abundant dental work in the mouths of Lund's patients, he would find it in those records. He spent every
weekend for the next nine months examining the charts of hundreds of patients treated in the preceding five years. In a
giant Excel spreadsheet, he logged every single procedure Lund had performed, so he could carry out some basic statistical
analyses.
The numbers spoke for themselves. Year after year, Lund had performed certain procedures at extraordinarily high rates.
Whereas a typical dentist might perform root canals on previously crowned teeth in only 3 to 7 percent of cases, Lund was
performing them in 90 percent of cases. As Zeidler later alleged in court documents, Lund had performed invasive, costly,
and seemingly unnecessary procedures on dozens and dozens of patients, some of whom he had been seeing for decades. Terry
Mitchell and Joyce Cordi were far from alone. In fact, they had not even endured the worst of it.
Dental crowns were one of Lund's most frequent treatments.
A crown is a metal or ceramic cap that completely encases an injured or decayed tooth, which is first shaved to a peg so
its new shell will fit.
Crowns
typically last 10 to 15 years. Lund not only gave his patients superfluous crowns; he also tended to replace
them every five years -- the minimum interval of time before insurance companies will cover the procedure again.
More than 50 of Lund's patients also had ludicrously high numbers of root canals: 15, 20, 24. (A typical adult mouth has
32 teeth.) According to one lawsuit that has since been settled, a woman in her late 50s came to Lund with only 10 natural
teeth; from 2003 to 2010, he gave her nine root canals and 12 crowns. The American Association of Endodontists claims that
a root canal is a "quick, comfortable procedure" that is "very similar to a routine filling." In truth, a root canal is a
much more radical operation than a filling. It takes longer, can cause significant discomfort, and may require multiple
trips to a dentist or specialist. It's also much more costly.
Root canals are typically used to treat infections of the pulp -- the soft living core of a tooth. A dentist drills a hole
through a tooth in order to access the root canals: long, narrow channels containing nerves, blood vessels, and connective
tissue. The dentist then repeatedly twists skinny metal files in and out of the canals to scrape away all the living
tissue, irrigates the canals with disinfectant, and packs them with a rubberlike material. The whole process usually takes
one to two hours. Afterward, sometimes at a second visit, the dentist will strengthen the tooth with a filling or crown. In
the rare case that infection returns, the patient must go through the whole ordeal again or consider more advanced surgery.
Zeidler noticed that nearly every time Lund gave someone a root canal, he also charged for an incision and drainage,
known as an I&D. During an I&D, a dentist lances an abscess in the mouth and drains the exudate, all while the patient is
awake. In some cases the dentist slips a small rubber tube into the wound, which continues to drain fluids and remains in
place for a few days. I&Ds are not routine adjuncts to root canals. They should be used only to treat severe infections,
which occur in a minority of cases. Yet they were extremely common in Lund's practice. In 2009, for example, Lund billed
his patients for 109 I&Ds. Zeidler asked many of those patients about the treatments, but none of them recalled what would
almost certainly have been a memorable experience.
In addition to performing scores of seemingly unnecessary procedures that could result in chronic pain, medical
complications, and further operations, Lund had apparently billed patients for treatments he had never administered.
Zeidler was alarmed and distressed. "We go into this profession to care for patients," he told me. "That is why we become
doctors. To find, I felt, someone was doing the exact opposite of that -- it was very hard, very hard to accept that someone
was willing to do that."
Zeidler knew what he had to do next. As a dental professional, he had certain ethical obligations. He needed to confront
Lund directly and give him the chance to account for all the anomalies. Even more daunting, in the absence of a credible
explanation, he would have to divulge his discoveries to the patients Lund had bequeathed to him. He would have to tell
them that the man to whom they had entrusted their care -- some of them for two decades -- had apparently deceived them for his
own profit.
Arsh
Raziuddin
The idea of the dentist as potential
charlatan
has a long and rich history. In medieval Europe, barbers didn't just trim hair and
shave beards; they were also surgeons, performing a range of minor operations including bloodletting, the administration of
enemas, and tooth extraction.
Barber surgeons
, and the more specialized "tooth drawers," would wrench, smash, and knock teeth out of people's mouths
with an intimidating metal instrument called a
dental key
: Imagine a chimera of a hook, a hammer, and forceps. Sometimes the results were disastrous. In the 1700s,
Thomas Berdmore, King George III's "Operator for the Teeth,"
described one woman
who lost "a piece of jawbone as big as a walnut and three neighbouring molars" at the hands of a
local barber.
Barber surgeons came to America as early as 1636. By the 18th century, dentistry was firmly established in the colonies
as a trade akin to blacksmithing (
Paul
Revere
was an early American craftsman of artisanal dentures). Itinerant dentists moved from town to town by carriage
with carts of dreaded tools in tow, temporarily setting up shop in a tavern or town square. They yanked teeth or bored into
them with hand drills, filling cavities with mercury, tin, gold, or molten lead. For anesthetic, they used arsenic,
nutgalls, mustard seed, leeches. Mixed in with the honest tradesmen -- who genuinely believed in the therapeutic power of
bloodsucking worms -- were swindlers who urged their customers to have numerous teeth removed in a single sitting or charged
them extra to stuff their pitted molars with homemade gunk of dubious benefit.
In the mid-19th century, a pair of American dentists began to elevate their trade to the level of a profession. From
1839 to 1840,
Horace Hayden and Chapin Harris
established dentistry's first college, scientific journal, and national association.
Some historical accounts claim that Hayden and Harris approached the University of Maryland's School of Medicine about
adding dental instruction to the curriculum, only to be rebuffed by the resident physicians, who declared that dentistry
was of little consequence. But no definitive proof of this encounter has ever surfaced.
Whatever happened, from that point on, "the professions of dentistry and medicine would develop along separate paths,"
writes Mary Otto, a health journalist, in her recent book,
Teeth
. Becoming a practicing physician requires four
years of medical school followed by a three-to-seven-year residency program, depending on the specialty. Dentists earn a
degree in four years and, in most states, can immediately take the national board exams, get a license, and begin treating
patients. (Some choose to continue training in a specialty, such as orthodontics or oral and maxillofacial surgery.) When
physicians complete their residency, they typically work for a hospital, university, or large health-care organization with
substantial oversight, strict ethical codes, and standardized treatment regimens. By contrast, about 80 percent of the
nation's 200,000 active dentists have individual practices, and although they are bound by a code of ethics, they typically
don't have the same level of oversight.
Throughout history, many physicians have lamented the segregation of dentistry and medicine. Acting as though oral
health is somehow divorced from one's overall well-being is absurd; the two are inextricably linked. Oral bacteria and the
toxins they produce can migrate through the bloodstream and airways, potentially damaging the heart and lungs. Poor oral
health is associated with narrowing arteries, cardiovascular disease, stroke, and respiratory disease, possibly due to a
complex interplay of oral microbes and the immune system. And some research suggests that gum disease can be an early sign
of diabetes, indicating a relationship between sugar, oral bacteria, and chronic inflammation.
Dentistry's academic and professional isolation has been especially detrimental to its own scientific inquiry. Most
major medical associations around the world have long endorsed evidence-based medicine. The idea is to shift focus away
from intuition, anecdote, and received wisdom, and toward the conclusions of rigorous clinical research. Although the
phrase
evidence-based medicine
was coined in 1991, the concept began taking shape in the 1960s, if not earlier (some
scholars trace its origins all the way back to the 17th century). In contrast, the dental community did not begin having
similar conversations until the mid-1990s. There are dozens of journals and organizations devoted to evidence-based
medicine, but only a handful devoted to evidence-based dentistry.
In the past decade, a small cohort of dentists has worked diligently to promote evidence-based dentistry, hosting
workshops, publishing clinical-practice guidelines based on systematic reviews of research, and creating websites that
curate useful resources. But its adoption "has been a relatively slow process," as a
2016 commentary
in the
Contemporary Clinical Dentistry
journal put it. Part of the problem is funding: Because
dentistry is often sidelined from medicine at large, it simply does not receive as much money from the government and
industry to tackle these issues. "At a recent conference, very few practitioners were even aware of the existence of
evidence-based clinical guidelines," says Elliot Abt, a professor of oral medicine at the University of Illinois. "You can
publish a guideline in a journal, but passive dissemination of information is clearly not adequate for real change."
Among other problems, dentistry's struggle to embrace scientific inquiry has left dentists with considerable latitude to
advise unnecessary procedures -- whether intentionally or not. The standard euphemism for this proclivity is
overtreatment
.
Favored procedures, many of which are elaborate and steeply priced, include root canals, the application of crowns and
veneers, teeth whitening and filing, deep cleaning, gum grafts, fillings for "microcavities" -- incipient lesions that do not
require immediate treatment -- and superfluous restorations and replacements, such as swapping old metal fillings for modern
resin ones. Whereas medicine has made progress in reckoning with at least some of its own tendencies toward excessive and
misguided treatment, dentistry is lagging behind. It remains "largely focused upon surgical procedures to treat the
symptoms of disease," Mary Otto writes. "America's dental care system continues to reward those surgical procedures far
more than it does prevention."
"Excessive diagnosis and treatment are endemic," says Jeffrey H. Camm, a dentist of more than 35 years who wryly
described his peers' penchant for "
creative
diagnosis
" in a 2013 commentary published by the American Dental Association. "I don't want to be damning. I think the
majority of dentists are pretty good." But many have "this attitude of 'Oh, here's a spot, I've got to do something.' I've
been contacted by all kinds of practitioners who are upset because patients come in and they already have three crowns, or
12 fillings, or another dentist told them that their 2-year-old child has several cavities and needs to be sedated for the
procedure."
Trish Walraven, who worked as a dental hygienist for 25 years and now manages a dental-software company with her husband
in Texas, recalls many troubling cases: "We would see patients seeking a second opinion, and they had treatment plans
telling them they need eight fillings in virgin teeth. We would look at X-rays and say, 'You've got to be kidding me.' It
was blatantly overtreatment -- drilling into teeth that did not need it whatsoever."
Studies that explicitly focus on overtreatment in dentistry
are rare, but a recent field experiment provides some clues about its pervasiveness. A team of researchers at ETH Zurich, a
Swiss university, asked a volunteer patient with three tiny, shallow cavities to visit 180 randomly selected dentists in
Zurich. The Swiss Dental Guidelines state that such minor cavities do not require fillings; rather, the dentist should
monitor the decay and encourage the patient to brush regularly, which can reverse the damage. Despite this, 50 of the 180
dentists suggested unnecessary treatment. Their recommendations were incongruous: Collectively, the overzealous dentists
singled out 13 different teeth for drilling; each advised one to six fillings. Similarly,
in
an investigation for
Reader's Digest
, the writer William Ecenbarger visited 50 dentists in 28 states in the U.S.
and received prescriptions ranging from a single crown to a full-mouth reconstruction, with the price tag starting at about
$500 and going up to nearly $30,000.
A multitude of factors has conspired to create both the opportunity and the motive for widespread overtreatment in
dentistry. In addition to dentistry's seclusion from the greater medical community, its traditional emphasis on procedure
rather than prevention, and its lack of rigorous self-evaluation, there are economic explanations. The financial burden of
entering the profession is high and rising. In the U.S., the average debt of a dental-school graduate is more than
$200,000. And then there's the expense of finding an office, buying new equipment, and hiring staff to set up a private
practice. A dentist's income is entirely dependent on the number and type of procedures he or she performs; a routine
cleaning and examination earns only a baseline fee of about $200.
In parallel with the rising cost of dental school, the amount of tooth decay in many countries' populations has declined
dramatically over the past four decades, mostly thanks to the introduction of mass-produced fluoridated toothpaste in the
1950s and '60s. In the 1980s, with fewer genuine problems to treat, some practitioners turned to the newly flourishing
industry of cosmetic dentistry, promoting elective procedures such as bleaching, teeth filing and straightening, gum lifts,
and veneers. It's easy to see how dentists, hoping to buoy their income, would be tempted to recommend frequent exams and
proactive treatments -- a small filling here, a new crown there -- even when waiting and watching would be better. It's equally
easy to imagine how that behavior might escalate.
"If I were to sum it up, I really think the majority of dentists are great. But for some reason we seem to drift toward
this attitude of 'I've got tools so I've got to fix something' much too often," says Jeffrey Camm. "Maybe it's greed, or
paying off debt, or maybe it's someone's training. It's easy to lose sight of the fact that even something that seems
minor, like a filling, involves removal of a human body part. It just adds to the whole idea that you go to a physician
feeling bad and you walk out feeling better, but you go to a dentist feeling good and you walk out feeling bad."
Arsh
Raziuddin
In the summer of 2013,
Zeidler
asked several other
dentists to review Lund's records. They all agreed with his conclusions. The likelihood that Lund's patients genuinely
needed that many treatments was extremely low. And there was no medical evidence to justify many of Lund's decisions or to
explain the phantom procedures. Zeidler confronted Lund about his discoveries in several face-to-face meetings. When I
asked Zeidler how those meetings went, he offered a single sentence -- "I decided shortly thereafter to take legal action" -- and
declined to comment further. (Repeated attempts were made to contact Lund and his lawyer for this story, but neither
responded.)
One by one, Zeidler began to write, call, or sit down with patients who had previously been in Lund's care, explaining
what he had uncovered. They were shocked and angry. Lund had been charismatic and professional. They had assumed that his
diagnoses and treatments were meant to keep them healthy. Isn't that what doctors do? "It makes you feel like you have been
violated," Terry Mitchell says -- "somebody performing stuff on your body that doesn't need to be done." Joyce Cordi recalls a
"moment of absolute fury" when she first learned of Lund's deceit. On top of all the needless operations, "there were all
kinds of drains and things that I paid for and the insurance company paid for that never happened," she says. "But you
can't read the dentalese."
"A lot of them felt,
How can I be so stupid?
Or
Why didn't I go elsewhere?
" Zeidler says. "But this is not
about intellect. It's about betrayal of trust."
In October 2013, Zeidler sued Lund for misrepresenting his practice and breaching their contract. In the lawsuit,
Zeidler and his lawyers argued that Lund's reported practice income of $729,000 to $988,000 a year was "a result of
fraudulent billing activity, billing for treatment that was unnecessary and billing for treatment which was never
performed." The suit was settled for a confidential amount. From 2014 to 2017, 10 of Lund's former patients, including
Mitchell and Cordi, sued him for a mix of fraud, deceit, battery, financial elder abuse, and dental malpractice. They
collectively reached a nearly $3 million settlement, paid out by Lund's insurance company. (Lund did not admit to any
wrongdoing.)
Lund was arrested in May 2016 and released on $250,000 bail. The Santa Clara County district attorney's office is
prosecuting a criminal case against him
based on 26 counts of insurance fraud. At the time of his arraignment, he said
he was innocent of all charges. The Dental Board of California is seeking to revoke or suspend Lund's license, which is
currently inactive.
Many of Lund's former patients worry about their future health. A root canal is not a permanent fix. It requires
maintenance and, in the long run, may need to be replaced with a dental implant. One of Mitchell's root canals has already
failed: The tooth fractured, and an infection developed. He said that in order to treat the infection, the tooth was
extracted and he underwent a multistage procedure involving a bone graft and months of healing before an implant and a
crown were fixed in place. "I don't know how much these root canals are going to cost me down the line," Mitchell says.
"Six thousand dollars a pop for an implant -- it adds up pretty quick."
Joyce Cordi's new dentist says her X‑rays resemble those of someone who had reconstructive facial surgery following a
car crash. Because Lund installed her new dental bridges improperly, one of her teeth is continually damaged by everyday
chewing. "It hurts like hell," she says. She has to wear a mouth guard every night.
What some of Lund's former patients regret most are the psychological repercussions of his alleged duplicity: the
erosion of the covenant between practitioner and patient, the germ of doubt that infects the mind. "You lose your trust,"
Mitchell says. "You become cynical. I have become more that way, and I don't like it."
"He damaged the trust I need to have in the people who take care of me," Cordi says. "He damaged my trust in mankind.
That's an unforgivable crime."
"... One thing this article doesn't distinguish between are hospital doctors and solo practitioners (i.e. family doctors, or occasionally doctors in small hospitals). There is a huge issue with doctors simply not keeping up with current research if they don't have the peer pressure and oversight that you would expect in a well run hospital. I was a victim of this as for years as a child I was repeatedly given antibiotics by my family doctor for 'chest infections'. In fact, I had asthma triggered by a cold air sensitivity, and was only diagnosed in my late teens (after I'd been carted to hospital after a school outdoors sport session). ..."
"... I've also heard numerous stories about terrible practices by specialists in small hospitals, who can become mini-emperors with nobody to contradict their professional opinions. This is one reason why all doctors will generally advise that the best place when you are ill is a large teaching hospital (definitely not a small private hospital). Bad diagnostic practice is much more likely to be stamped out in the biggest hospitals where there is greater peer oversight. ..."
"... Physicians aren't bots. There are different reasons people go into medicine, not all of them about "patient care" and altruism -- "unselfish regard for or devotion to the welfare of others behavior by not beneficial to or may be harmful to itself but that benefits others of its species." Sometimes quite the opposite, thanks to greed and pleasure-seeking and the burdens of "debt" assumed by so many "providers," or even rare psych phenomena like von Muchausen's by proxy ..."
"... Always, the smart kids in the room want to systematize and organize every kind of function, and in the neoliberal universe, reduce complexity to profit-generating, "management"-centric forms. Sometimes that application of rationalization is a good thing, it can help focus attention wisely and lead to those often undefined "good outcomes." ..."
"... Constant mechanization of medicine results in stuff like the ICD-10 classification thing, which is mostly about Big Data and payments. "Billable" medicine has been "reduced" to about 70,000 "diagnosis codes" and a whole lot of treatment and procedure codes, up from about 13,000 diagnosis codes in ICD-9. ..."
"... ICD-9 is widely considered to be based on outdated technology, with codes unable to reflect the use of new equipment. ICD-10 offers far more integration with modern technology, with an emphasis on devices that are actually being used for various procedures. The additional spaces available are partly designed to allow for new technology to be seamlessly integrated into codes, which means fewer concerns about the ability to accurately report information as time goes on. In Conclusion, ICD-10 is not a simple update to ICD-9. The structural changes throughout the entire coding system are very significant, and the increased level of complexity requires coders to be even more thoroughly trained than before. However, it is possible to prepare for the changes by remembering a few simple guidelines: ..."
"... Train early- The more familiar your staff are with ICD-10, the better. While currently scheduled to begin Oct. 1, 2014, beginning the training now is not a bad idea. ..."
"... Understand the ICD-10- The structural changes require a change in the way people think about coding, and understanding it will help to break current coding habits. Medical professionals used to reporting things a certain way so they can be coded may need to change what they say in order to work well with the new system. ..."
"... EBM is just another management buzz(kill)word, like "total quality management" and "zero defects" and "zero-based budgeting." All supported by proponents who rationalize and argue in the language of squishy "disciplines" like psychology and economics, using "specialized" lexicons that often are cloudy restatements of commonplaces in arcane terminologies, and the creation of intellectual artifacts that have tenuous or little relationship to the reality most "uneducated" observers perceive -- yes, sometimes incorrectly as more acute observations might show, but more often accurately than the modeling and force-fitting that "experts" soar off on. How many of the articles cited as authoritative on various points have anything other than presence in peer-reviewed land as proof of the claimed "findings" both of the original researchers and authors, or acuteness and accuracy of the proposition for which they are offered subsequently? And how much fraud and selectiveness (like medication trials that exclude likely non-responders to the therapies) and purblindness fills the vast swath of "published studies" ..."
"... I've personally experienced and seen lots of misdiagnoses and clinician blindness and tunnel vision, starting as a child ..."
"... And our favored subsequent family doctor, who mis-diagnosed my mother's fatal ovarian cancer (a common failing given vagueness of symptoms) for a year or more after her original office visit, as a gall bladder problem needing bile salts. (Said doctor, seeking alpha, had moved largely into "industrial medicine," doing workers comp and employment physicals -- a wonderfully nice guy, but clinical skills atrophy or lose focus or get too sharpened into narrow channels– totally understandable, given human nature -- channels that get reinforced by "economic" forces, stuff like HMOs and corporate bottom lines, and stuff like the vast and geometrically growing pile of "medical knowledge" of more or less validity, on and on. ..."
"... And "we" can hope that AI and EBM and the horrors wrought by the other false gods of "modern medical practice" like "Electronic Medical Records" don't intermediate and leverage their way into the care we mopes need and hope for. EBM from what I have seen can be a useful approach in some ways, but then Smith's Law of Crapification is as universal as Murphy's ..."
"... I think, what this article alludes to is that medicine is complex and not easily algorithmic ..."
"... The problem with the art of medicine, is that it takes time as it comes with experience. Much more experience that one can learn in medical school or residency. ..."
"... My suspicion is that those early in their careers would benefit from practicing a high level of guideline based medicine until they gain experience. ..."
"... Above, I speak of how to practice medicine without consideration of how to pay for it. Now when you start adding payments, reimbursements, and insurance claims, you add another level of complexity, bias, and incentive. It appears the free market insurance model is not working, as well as the fee for service model. Here the trick is to change the way medicine is reimbursed and incentivized. ..."
"... My point is that there are mandates and financial incentive for hospitals to pressure physicians into adhering to guidelines which are not universally good for patients or for cost of care ..."
Interesting article and a couple of clarifications:
Psychologists have studied the accuracy of risk assessments made by statistical
predictors and by clinicians, but they have not done similar studies of the accuracy of
evaluations of patient preferences over health outcomes.
True but health economists have
done so . And they got so scared by the results that some (Dolan) left the field to do
something else. This particular example is that whilst the general population reckons
"extreme pain" to be worse than "extreme depression/anxiety", those members of the population
who'd experienced them both put them the other way round. Which has profound implications for
the UK values assigned to health outcomes. Of course other countries might do things in
different ways and this is NOT some veiled attack on what the US might do if single payer
gets onto the playing field. It's merely adding to the warning in the paper about how to do
it. Which leads to a second warning I'd make – averages. They conceal a lot.
Mental health is the archetypal example and, again, maybe the paper is right that
something like maximin is warranted, given that "living by averages" means some groups
automatically lose out. Just some thoughts, which hopefully are constructive this time round
and expand on points made.
One thing this article doesn't distinguish between are hospital doctors and solo
practitioners (i.e. family doctors, or occasionally doctors in small hospitals). There is a
huge issue with doctors simply not keeping up with current research if they don't have the
peer pressure and oversight that you would expect in a well run hospital. I was a victim of
this as for years as a child I was repeatedly given antibiotics by my family doctor for
'chest infections'. In fact, I had asthma triggered by a cold air sensitivity, and was only
diagnosed in my late teens (after I'd been carted to hospital after a school outdoors sport
session).
I talked much later to a family member who is a specialist in prescribing practice who
said that this was by far the most common misdiagnosis/treatment and as late as the 1990's in
the UK (where he did research on the subject), he found that 25% of GP's (family doctors)
were not identifying asthma correctly. Very often, pharmacists are the only gatekeepers to
identify bad prescribing practices.
I've also heard numerous stories about terrible practices by specialists in small
hospitals, who can become mini-emperors with nobody to contradict their professional
opinions. This is one reason why all doctors will generally advise that the best place when
you are ill is a large teaching hospital (definitely not a small private hospital). Bad
diagnostic practice is much more likely to be stamped out in the biggest hospitals where
there is greater peer oversight.
I'd ask what the author assumes is the best model for doctor-patient interaction, what
"patient care" means. To me it should be two or maybe more (including nurses and family
members and other caregivers) people, ones with more knowledge of physiology and systems,
others with more knowledge and experience of whatever the "presenting condition" happens to
be, interacting to increase longevity, reduce pain, repair damaged structures, correct
physiological malfunctions and problems with homeostatic functions and so forth, to maximize
function, independence and comfort -- an incomplete definition of a very complex notion.
Physicians aren't bots. There are different reasons people go into medicine, not all
of them about "patient care" and altruism -- "unselfish regard for or devotion to the welfare
of others behavior by not beneficial to or may be harmful to itself but that benefits others
of its species." Sometimes quite the opposite, thanks to greed and pleasure-seeking and the
burdens of "debt" assumed by so many "providers," or even rare psych phenomena like von
Muchausen's by proxy
Always, the smart kids in the room want to systematize and organize every kind of
function, and in the neoliberal universe, reduce complexity to profit-generating,
"management"-centric forms. Sometimes that application of rationalization is a good thing, it
can help focus attention wisely and lead to those often undefined "good outcomes."
But there's almost an infinite number of ways humans can get injured, sickened and die.
Human physiology is vastly complex. The interaction pathways are likewise near infinite.
Medicine is an art of observation compounded over time, and a lot of the knowledge base (I
personally hate that term) is just wrong, from a wide variety of causes including bias,
sample size, things like referred pain, atypical "presentations," "normal variation" and so
forth. When what to me is a semi-mystical interaction between practitioner and person works
well, it is a thing of beauty and kindness. As with anything human-created and -mediated, too
often the result is far worse -- most of us can insert one or more anecdotes here, on either
extreme.
Constant mechanization of medicine results in stuff like the ICD-10 classification thing,
which is mostly about Big Data and payments. "Billable" medicine has been "reduced" to about
70,000 "diagnosis codes" and a whole lot of treatment and procedure codes, up from about
13,000 diagnosis codes in ICD-9. It's a "whole new way of doing business:"
ICD-9 is widely considered to be based on outdated technology, with codes unable to
reflect the use of new equipment. ICD-10 offers far more integration with modern technology,
with an emphasis on devices that are actually being used for various procedures. The
additional spaces available are partly designed to allow for new technology to be seamlessly
integrated into codes, which means fewer concerns about the ability to accurately report
information as time goes on. In Conclusion, ICD-10 is not a simple update to ICD-9. The
structural changes throughout the entire coding system are very significant, and the
increased level of complexity requires coders to be even more thoroughly trained than before.
However, it is possible to prepare for the changes by remembering a few simple
guidelines:
Train early- The more familiar your staff are with ICD-10, the better. While currently
scheduled to begin Oct. 1, 2014, beginning the training now is not a bad idea.
Understand the ICD-10- The structural changes require a change in the way people think about
coding, and understanding it will help to break current coding habits. Medical professionals
used to reporting things a certain way so they can be coded may need to change what they say
in order to work well with the new system.
EBM is just another management buzz(kill)word, like "total quality management" and
"zero defects" and "zero-based budgeting." All supported by proponents who rationalize and
argue in the language of squishy "disciplines" like psychology and economics, using
"specialized" lexicons that often are cloudy restatements of commonplaces in arcane
terminologies, and the creation of intellectual artifacts that have tenuous or little
relationship to the reality most "uneducated" observers perceive -- yes, sometimes
incorrectly as more acute observations might show, but more often accurately than the
modeling and force-fitting that "experts" soar off on. How many of the articles cited as
authoritative on various points have anything other than presence in peer-reviewed land as
proof of the claimed "findings" both of the original researchers and authors, or acuteness
and accuracy of the proposition for which they are offered subsequently? And how much fraud
and selectiveness (like medication trials that exclude likely non-responders to the
therapies) and purblindness fills the vast swath of "published studies"
I've personally experienced and seen lots of misdiagnoses and clinician blindness and
tunnel vision, starting as a child when the family doctor, a partisan of allergies as the
most common source of disease, and who patch-tested me and my sisters unmercifully,
supposedly told my mom that my broken right forearm was the result of an allergy. And our
favored subsequent family doctor, who mis-diagnosed my mother's fatal ovarian cancer (a
common failing given vagueness of symptoms) for a year or more after her original office
visit, as a gall bladder problem needing bile salts. (Said doctor, seeking alpha, had moved
largely into "industrial medicine," doing workers comp and employment physicals -- a
wonderfully nice guy, but clinical skills atrophy or lose focus or get too sharpened into
narrow channels– totally understandable, given human nature -- channels that get
reinforced by "economic" forces, stuff like HMOs and corporate bottom lines, and stuff like
the vast and geometrically growing pile of "medical knowledge" of more or less validity, on
and on.
These observations only touch on an enormously complex and painfully meaningful subject.
Seems to me that the best "we" patients and patients-to-be can expect is that we connect with
clinicians that still start from "Do no harm" and aspire to better the lives of we who seek
and depend on their expertise -- a notably, and inevitably, ever smaller fraction of the
available "knowledge base." And "we" can hope that AI and EBM and the horrors wrought by the
other false gods of "modern medical practice" like "Electronic Medical Records" don't
intermediate and leverage their way into the care we mopes need and hope for. EBM from what I
have seen can be a useful approach in some ways, but then Smith's Law of Crapification is as
universal as Murphy's
Yeah I agree entirely . But more holistic approaches (judging medicine by overall quality
of life) get into areas that have got a little Shall we say Controversial So I'm keeping my
comments focused to stay within site guidelines.
There are two reasons why patient care adhering to guidelines may differ from the care
that clinicians provide:
Guideline developers may differ from clinicians in their ability to predict how decisions
affect patient outcomes; or
Guideline developers and clinicians may differ in how they evaluate patient outcomes.
I think, what this article alludes to is that medicine is complex and not easily
algorithmic. The concerns in medical decision making as noted by Yves and others is that if
your data/knowledge you base your treatment choices on is outdated, or flat out wrong, you
will be doing your patient's a disservice at best and harm at worse. In these situations
evidence based medicine should be used as a guide. Where evidence based medicine runs into
trouble, is two fold. One, when the guidelines are based on flawed evidence/data, and two,
when they are no longer used as a guide, but as the law.
So in that case you may
statistically help the population at large, based on the data at hand, but at the cost of
doing preventable harm to a large cohort that could have been picked up by rational
clinical decision making. This is where the "Art of Medicine" should theoretically be
superior. The problem with the art of medicine, is that it takes time as it comes with
experience. Much more experience that one can learn in medical school or residency.
My suspicion is that those early in their careers would benefit from practicing a high
level of guideline based medicine until they gain experience.
With experience, the guidelines should still be understood but there is more flexibility
to stray from the guidelines for individual patients based on patient preference and
physician experience.
For those in the late stages of their careers, it is again important to understand and
try to follow the guidelines so as to not become outdated in your practice knowledge.
At all three stages, one must understand the rational and methodology of the guidelines
figure out which guidelines are to be used for most cases and which guidelines are just
that, a guide.
Above, I speak of how to practice medicine without consideration of how to pay for it.
Now when you start adding payments, reimbursements, and insurance claims, you add another
level of complexity, bias, and incentive. It appears the free market insurance model is not
working, as well as the fee for service model. Here the trick is to change the way medicine
is reimbursed and incentivized.
I am a practicing internal medicine hospitalist in a major US city. While in the past,
there were large delays in physicians taking evidence-based practice and turning it into new
habit and too much unwanted variation in clinical practice -- I feel like in the US, the
pendulum is swinging too far the other way -- and in unintelligent ways, forcing clinicians
into care protocols without regard for individual circumstance. Now there are clinical care
guidelines from Medicare, the American Heart Association, the CDC, and others around major
disease states (like stroke, heart failure, sepsis) that hospitals must follow for
reimbursement -- yet the guidelines do not keep pace with current peer-reviewed evidence.
My point is that there are mandates and financial incentive for hospitals to pressure
physicians into adhering to guidelines which are not universally good for patients or for
cost of care (sepsis guidelines now are a good example of this). Often these expectations are
negotiated by bureaucrats, not clinicians. The healthcare industry needs a better way of
giving physicians real-time feedback about their clinical practice habits in relation to
their peers -- - and having some common-sense expectations around unwanted variations in
practice.
Hopefully you can get yourself on some committees dealing with these issues. Very
important to have physician input.
Economics is definitely important, not only for improving the hospitals bottom line but
for making medicine economically responsible generally.
Single payer, I think would be great but we still need to watch what we are paying for. No
need for pharmaceutical companies to make outrageous profits.
One interesting area now is that many very expensive tests are becoming available for
cancer testing. These need to be ordered responsibly and that takes physician, social and
admin input. And at a deeper level needs to examine why the tests, drugs etc are so
expensive.
Tranylcypromine – first generation antidepressant and still the gold standard for
effectiveness (the "cheese effect" side effect has been overblown as numerous studies have
more recently shown – I'm on it and can confirm this) costs the NHS over £1000
per month for me. It's been off patent for 50 years. However there is a monopoly supplier
(price gouger). Why don't generic suppliers move in? Because the market is too small. Two
generations of doctors have been taught that this class (MAOIs) are akin to leech therapy.
Thus the assumption is that most people on them will be old and will die off. Scandalous, as
any psychiatrist worth their salt will tell you (never mind the health economist like
me).
Prime case of cr*pification in medicine if you ask me. Doctors bowled over by the drug
companies selling SSRIs/SNRIs which let's not forget don't even work as the pharmacology says
they should – they should show benefits at day 4/5 like MAOIs if their original
pharmacological justification is paid attention to. Now does that mean they don't work? No
I'm not saying that. But their method of action is clearly odd and not in line with the
original pharmacological data and models.
Health economics 102 is derived demand – patients rely on doctors to enunciate their
demand function. But when doctors have effectively undergone the medical equivalent of
regulatory capture then Houston we have a problem.
Thanks for the reply. The problem here is that patient advocacy requires systemic change:
change in the medical curriculum along with a concerted effort to tell GPs about the new data
on "old" drugs And they are already overburdened with stuff "coming at them from on
high".
Plus even if (say) they learn the real data concerning MAOIs they still can't prescribe
them straight off A psychiatrist must initiate it (then GP can carry on) And mental health
services are close to breaking point. My local service is at critical levels. Austerity yet
again .
I was going to a physical therapist practice for spasticity and weakness and pain related
to a pretty radical cervical laminectomy and progressive spine problems. I was a Medicare
patient and they insisted on using the guidelines for rehabilitation after operation, even
though my operation took place 12 years earlier. This consisted of exercises which only made
my spasticity worse and aggravated my arthritis. What I needed was to have my chest and arms
worked on to counteract the contraction of muscles caused by spasticity, which the therapist
knew how to do. But she refused and told me that If I did not do the exercises, she would no
longer treat me as I was violating the "guidelines", which did not apply to my circumstance.
There was apparently nothing to allow treatment for chronic problems (except opiods, which I
refused).
Sorry to hear that. I had reason to look at the UK guidelines on a range of conditions
(from NICE). I was actually pleasantly surprised: although they do in many cases follow
"stepped care" functions from medicine, there were a surprising number of "get outs"
regarding if the patient cannot tolerate /has good reason to reject the official guidance.
Patient preferences have begun to get recognised in the UK.
Of course whether austerity allows the doctors to *afford* differences is another sad
story .
I guess that what I need now is what amounts to palliative care (non-pharmaceutical). I
find now that I have discovered high-CBD hemp (Otto II strain) which I can grow myself, I can
actually slow down the progressive effects of my condition. Ironically, though I qualify for
the medical marijuana card, I can't afford to buy from the dispensaries, and they mainly
offer high THC strains anyway. I am lucky to have found a way to treat myself!
American Family Physicians defines
overtreatment as follows: "Treatment initiated when there is little or no reliable evidence of
a clinically meaningful net benefit, where net benefit equals benefit minus harm. "
Over-treatment involves actual procedures performed on a patient, often surgically.
Unnecessary cardiac stents is one example and is a real epidemic due to excessive green and
pervert incentives.
Notable quotes:
"... By Lambert Strether of Corrente. ..."
"... Over the weekend, the New York Times published a head-turning tale about Dr. Mark Midei, a star cardiologist at St. Joseph Medical Center in Townson, Maryland. According to federal investigators, Dr. Midei implanted potentially dangerous cardiac stents in the arteries of as many as 585 patients who didn't need them. A hard worker, he managed to knock off those 585 procedures in just two years, from 2007 to 2009. Medicare paid $3.8 million of the $6.6 million charged for the treatments. ..."
"... The report reveals that Midei was a favorite son of Abbott Laboratories, the company that manufactured the stents. Indeed, in August of 2008, Abbott celebrated the fact that the handy doctor had inserted 30 of the company's cardiac stents into trusting patients in a single day: "Two days later, an Abbott sales representative spent $2,159 to buy a whole, slow-smoked pig, peach cobbler and other fixings for a barbecue dinner at Dr. Midei's home." Employees from St. Joseph's attended the feast. ..."
Over the past, oh, decade or so I've been so consumed with the battle to get everybody into
the heatlh care system -- "Everybody in, nobody out," as Quentin Young puts it
-- that I haven't put much energy into thinking about the heatlh care itself. After all, just
because a house is energy inefficient doesn't mean that it's OK to leave people out in the
cold. Now that single payer is no longer
"never, ever," but a program that could actually be achieved with (an enormous) level of
effort, KHN's new series, "Treatment Overkill," which starts with Liz Szabo's
"So Much Care It Hurts: Unneeded Scans, Therapy, Surgery Only Add To Patients' Ills,"
provides me with a change to broaden my scope a bit, with a survey post like this one.
So I'm going to look at two issues: (1) Is overtreatment a real problem? and (2) What are
the causes of overtreatment? Spoilers: Yes, and it's complicated.
Confession time: I'm the sort of person who doesn't get the idea of deductibles at all; I
can't understand why anyone would seek out medical treatment unless they were
absolutely sure they needed it. And the reason I fear the health care system is, in fact, the
prospect (painful) overtreatment; the dental clinic that was going to give me full anesthesia
to remove a wisdom tooth; or my nightmare of "end of life care" hooked up to a machine in a
nursing home in a room with a television I can't turn off.
Overtreatment Is Real Problem
Evidence for overtreatment[1] falls into two categories: Anecdotes, and studies and surveys.
I'll look at anecdotes first.
"Anecdotes" isn't really a fair word, though; most of the stories are more about entire
vertical markets (for example, stents, as we shall see). Szabo starts out with this
example:
When Annie Dennison was diagnosed with breast cancer last year, she readily followed
advice from her medical team, agreeing to harsh treatments in the hope of curing her
disease.
"In addition to lumpectomy surgery, chemotherapy and other medications, Dennison underwent
six weeks of daily radiation treatments. She agreed to the lengthy radiation regimen, she
said, because she had no idea there was another option.
Medical research published in The New England Journal of Medicine
in 2010 -- six years before her diagnosis -- showed that a condensed, three-week radiation
course works just as well as the longer regimen. A year later, the American Society for Radiation
Oncology , which writes medical guidelines, endorsed the shorter course.
In
2013 , the society went further and specifically told doctors not to begin radiation on
women like Dennison -- who was over 50, with a small cancer that hadn't spread -- without
considering the shorter therapy.
"It's disturbing to think that I might have been overtreated," Dennison said. "I would
like to make sure that other women and men know this is an option."
(Note, sadly, that Dennison immediately puts the onus on the consumer patient to
be informed; an obvious tax on time, to be paid with the patient has the least time or energy
to spare, instead of looking for the systemic solution she vaguely hints at with "would like to
make sure." This impulse is a topic for another post.)
Nobel Prize Winner Bernard Lowns gives a second example
in this interview (after demolishing "bed rest" for heart attack patients as "a form of
medieval torture" as well):
[DR. LOWN]: At the Peter Bent Brigham Hospital [now Brigham and Women's Hospital in
Boston] in 1960, I was asked to see a patient who was in her late 70s, demented, and had
burns over 60 percent of her body. She had been smoking in bed. They asked me to consult
about putting in a pacemaker, which she did not need. Furthermore, she was clearly dying, and
implanting a pacemaker would only have increased her suffering without prolonging her life. I
was mortified. I wrote a note urging against a pacemaker. It created quite a rumpus. If that
were an isolated episode, it would be tragic. But that kind of thing happened daily.
Here is a third, and egregious example, from Health
Beat :
Over the weekend, the New York Times published a
head-turning tale about Dr. Mark Midei, a star cardiologist at St. Joseph Medical Center in
Townson, Maryland. According to federal investigators, Dr. Midei implanted potentially
dangerous cardiac stents in the arteries of as many as 585 patients who didn't need them. A
hard worker, he managed to knock off those 585 procedures in just two years, from 2007 to
2009. Medicare paid $3.8 million of the $6.6 million charged for the treatments.
The Baltimore Sun broke Dr. Midei's story in January. In February the U.S. Senate
Committee on Finance, which oversees Medicare and Medicaid, began investigating. Monday, the
Finance Committee released a 1200-page report..
The report reveals that Midei was a favorite son of Abbott Laboratories, the company that
manufactured the stents. Indeed, in August of 2008, Abbott celebrated the fact that the handy
doctor had inserted 30 of the company's cardiac stents into trusting patients in a single
day: "Two days later, an Abbott sales representative spent $2,159 to buy a whole, slow-smoked
pig, peach cobbler and other fixings for a barbecue dinner at Dr. Midei's home." Employees
from St. Joseph's attended the feast.
(It may seem that I'm stacking the deck on causality here, but I'm really not, although it
would be foolish to deny that such cases exist.)
Note again that these examples all involve treatment : Radiation treatment, a
pacemaker, and stents. We're not talking about ordering a few two many tests. ( The American Family Physican
supplies numerous classes of overtreatment, not just anecdotes. See Table I.) Now to
the studies and surveys.
"Overtreatment in the United
States," by Heather Lyu, et al (from the Public Library of Science, and thus peer-reviewed)
has induced a good deal of discusson since its publication in September 2017. From the
Findings:
The response rate was 70.1%. Physicians reported that an interpolated median of 20.6% of
overall medical care was unnecessary, including 22.0% of prescription medications, 24.9% of
tests, and 11.1% of procedures.
Dear me. If one-fifth of all medical care is unnecessary, that does seem like rather a lot
of stress and fear induced for no reason. And if one out of every ten treatments is unncessary,
that's rather a lot of people going to Pain City because their number came up, and not for any
medical reason. Those odds aren't quite as bad as Russian roulette, but they'e in the ballpark!
I haven't (yet) been able to find figures on the costs of overtreatment, but there have been
studies done on the costs of unnecessay care. Health
Affairs :
Current estimates for unnecessary expenditures on overuse range from 10 to 30 percent of
total health care spending. Even the lower estimate,
from the Institute of Medicine , amounts to nearly $300 billion a year. No specialty is
immune from practices that lead to overuse, as a recent spate of papers in medical journals
can attest. In cardiology, even using criteria that are relatively permissive, an estimated
11 percent of stents are delivered to " inappropriate patients ." At some hospitals,
that rate is closer to 20 percent.
(Note that the figure of 11% unnecessary stents jibes well with Lyu's figure of 11.1% of all
procedures being unnecessary.)
I'm sure none of this is new to any medical professionals in the NC readership, but it was
new to me, and may well be new to NC readers -- especially those who received treatments that
they retrospectively, or just now, understood to be unnecessary.
The Causes of Overtreatment
It's clear that one cause for overtreatment is the profit motive. (I would
speculate that individuals like Midei, the stent dude, are edge cases, and that the real causes
are more subtle and systemic.) Quoting again from Lyu, et al. :
The top three cited reasons for overtreatment were "fear of malpractice" (84.7%), "patient
pressure/request" (59.0%), and "difficulty accessing prior medical records" (38.2%)
Seventy-one percent of respondents believed that physicians are more likely to perform
unnecessary procedures when they profit from them. The interpolated median response for the
percentage of physicians who perform unnecessary procedures with a profit motive was 16.7%;
28.1% of respondents believed that at least 30–45% of physicians do so (Fig 2).
Respondents who were attending physicians with at least 10 years of experience (OR 1.89
(1.43–2.50) vs trainees) and specialists (OR 1.29 (1.06–1.57)) were more likely
to believe that physicians perform unnecessary procedures when they profit from them
Respondents' compensation method and hospital characteristics were not associated with
differences in perceptions on the profit motive associated with unnecessary care.
So, the more experienced the doctor is, the more likely the doctor is to believe that profit
drives unnecessary procedures. However, the profit motive imputed to individuals cannot be the
sole driver (see "DICE: Nonclinical
Causes of Overtreatment" for a model that includes "Economics" without being reductive) as
this letter in the
British Medical Journal shows :
As a person who follows the evolution of health care policy from the vantage point of the
United States, I found BMJ's May 12 article on "Choosing Wisely in the UK" [see here ; CW is an "informed consumer" model]
very interesting. The authors ascribe the phenomenon of medical overtreatment in the UK to a
culture of "more is better" fostered by such factors as "defensive medicine," "patient
pressures," "commercial conflicts of interest," "payment by activity," and the demands of
"pay for performance."
Many critics of the American health care scene ascribe the problem of irrational
overtreatment unsupported by available evidence in the U.S. to precisely the same causes, and
argue that the key to rationalizing American medical practice lies in adoption of the UK's
single payer, universal coverage health care system and the UK's system of civil justice. The
fact that a Choosing Wisely program is necessary in the UK, and for most of the same
underlying reasons as apply in the U.S., proves that the UK has not found the panacea to
achieving rational medical practice and that emulation of the UK methods of health insurance,
physician payment, and civil justice will not work as a panacea in the U.S. either.
So, sadly, single payer as such is unlikely to solve overtreatment (although I
can't think of an advocate who ever said it would).
Conclusion
If there were one kind of doctor-patient relationship that I would like to see incentivized
when single payer comes to pass, it's this one.
Again Dr. Lown :
U.S. News: Problems with America's health care system are economic, but they are also
human. What's been lost in modern medicine?
[DR. LOWN: In my view the lost art of listening is a quintessential failure of our health
care system. I think that you cannot heal the health care system without restoring the art of
listening and of compassion. You cannot ignore the patient as a human being. A doctor must be
a good listener. A doctor must be cultured in order to understand where the patient lives,
why he lives like that, and also realize that the leading cause of disease in the world is
poverty.
Call me Polyanna, but I think if the health care system started treating patients like human
beings, that a good deal of overtreatment would be avoided.
NOTES
[1] Overtreatment is not the same as overtesting, or overdiagnosis. Over-treatment involves
actual procedures performed on a patient, often surgically. In other words, lots of pain and
suffering imposed to no good purpose. (Szabo's article considers all three, but I am focusing
only on overtreatment.) American Family Physicians defines
overtreatment as follows: "Treatment initiated when there is little or no reliable evidence of
a clinically meaningful net benefit, where net benefit equals benefit minus harm. "
I worked as a disability advocate for years, which is a high volume practice. I read
literally tens of thousands of medical records during that time. I can say, unequivocally,
overtreatment is an issue.
Causes are far more difficult to deal with. The high cost of medical care is a reflection
of the low quality of life many USAians are living. Listening is a good start, but far from
the answer. Getting everyone in the system, so that more preventative medicine can work,
avoiding patient demanded surgeries with low-probabilities of success would help as well. But
even these two are just the tip of the iceberg.
In disability, chronic physical ailments mix with unemployment to form a deep pool of
depressed individuals. Even with access to great healthcare (which few have), the advice to
exercise, stretch, and eat healthy that would improve many conditions (spinal stenosis, other
arthritis and orthopedic issues, obesity, heart disease) is worth very little. In a depressed
state, changing long term habits into healthy ones is very difficult, and the prevalence of
patients seeing a professional to make behavioral adjustments in concert with their disease
treatment is few, not counting those that show up to the psychiatrist for medication
regularly.
This is why single payer, jobs guarantee, and redistribution tax policy are necessary
together.
After a car wreck, both of my parents were hospitalized for a week. During that time, I
got a lot of phone calls from the hospital, and many of them related to getting my permission
for this, that, and the other test on my mother. Dad had Alzheimers, and, lucky for him, he
evaded the endless tests. I guess the doctors figured that he wasn't going to live much
longer, so what was the point? (He died nine months later.)
One of the phone calls really stood out. Mom was anemic, and the doctors wanted to do a
colonoscopy to find out why. "Malnutrition!" I said. Loudly.
This had been a problem for years. Mom and Dad simply weren't eating enough. I'll get back
to that point in a minute. But let me say that I refused the colonoscopy for my mother. In
addition to being very invasive, I thought it was unnecessary.
Anyway, Mom got sent home and Dad was discharged to a nursing home. Once he was separated
from my mother, he started eating like a horse. Gained 15 pounds in less than three months.
Then he started losing weight and the nursing home sent him to hospice. In his case, that was
the correct call.
Let's just say that my mother still has issues with food. Not a new problem. I remember it
from my childhood. But she does have caregivers who insist on proper nutrition. And she
complies.
Last time I spoke with Mom's doctor, he didn't say anything about anemia. Sounds like
that's no longer a problem.
General Practice doctors are hugely important in the healthcare system. They are the
traffic cops that direct patients to the appropriate specialist. They do most of the
listening.
I think specialists are more likely to zero in on the "problem"
Call me skeptic after being a practioner of Medicine over 40 years! I was a GP before got
trained as Diagnostic Radiologist after nearly 5 years of residency. I also worked as ER
Physician in early years. I am also licensed to practice in Ontario(Canada) but practiced
only in USA after the residency training!
A Diagnostic Radiologist is called ' a doctor's doctor" since the myriad of imaging exists to
help the clinical diagnosis. I came across virtually all kind of specialists, medical and
surgical kind! Ifound out to whom I wouldn't even send my 'dog' for treatment!
There are ethical and morally conscious docs, but they are in the minority!VERY FEW!
A specialist is like a HAMMER, s/he sees everything as if it is just problem of NAIL!
Surgeon thinks through SCALPEL. Go to Pulmonologist, more likely you get bronchoscoped
(needed or not), Gastroenterologist – gastro or colonoscopy, so on!
Imagine going to a restaurant where the waiter got to order for you.
"You want the steak? OK better start off with these two appetizers I think you'll
like.
You'll need some wine too. There's a 1994 Cabernet that will pair great with this. I'll
mark
that down. The cost? Oh don't worry about that, your dining insurance will cover it.
Now for dessert. They're all so good, I have picked out three for you. You don't need
to finish them. Now I'll just add in my customary 25% tip (I am highly trained) and we'll
call it a meal."
As a regular lurker here, it's great to see you on this beat Lambert. We've been on this
for awhile now at the Lown Institute. I refer you and the rest of the commentariat to a
series we did in the Lancet which is here:
The Drivers paper is pertinent as a description of the ecosystem of bad care.
If the patient is the one who controls the payment, things may improve. Right now with
insurance, there is no one to one relationship between the patient and the health provider.
Insurance companies stand between the patient and payment. Even in the case of single payer,
if the patient is given incentives to get second opinions and refuse unnecessary treatment,
things may work better.
Single payer is likley to require second and if need be third opinions for non emergency
surgery. Most insurance pays for a second opinion if you want one (and would be a fool not to
get) and if need be a third opinion if the first and second don't agree.
Kip Sullivan unequivocally disputes the "overtreatment" meme To the contrary, we are under
treated in the US ..
Please read:
"The Health Care Mess: How we got into it and how we'll get out of it" by Kip Sullivan ..
Over treatment: My mom's story. From several years ago.
So I was the guardian for my very (VERY) demented mom whom we kept at home, at great cost
but also great benefit to her. She had a basal cell tumor on her forehead. About the size of
a nickel. She was 90 at the time. I live in one state, she the next state over about 2 hours
away. She had full time help at home.
So one of my innumerable trips to help out and oversee, involved taking her to her md
appointment at Brigham and Women's. She had a wonderful gerontologist, who referred me to a
dermatologist affiliated with B &W. Her care giver took her a few weeks later and I got a
call from the dermatologist, a young woman. Now I'm an old woman but a trained m.d. in
Internal Medicine. I also knew (by then ) a great deal about dementia. And especially
dementia in my particular mother.
So when the dermatologist called me she said "your mom needs a MOHS procedure". Well, a
Mohs procedure is an 8 hour stop and go procedure. They keep cutting until the margins are
clean. They cut, send the specimen to the lab, wait for the result and cut again. Patient is
awake the whole time so there's no anesthesia risk, but 8 hours on a table for a woman with
advanced Alzheimer's was not going to work. I told the dermatologist that there's no way my
mom could tolerate that. The dermatologist got irate. Tried to scare me by saying, "the tumor
could grow into her brain!". I said, "mom's 90, she'll be dead b/f the tumor goes
anywhere!"
They were so intent on this procedure and challenged my right to speak on mom's behalf. so
.. I had to fax PROOF of my guardianship for them to let me have the last say. I was pretty
discharged. And complained bitterly to the referring doc when we saw him next . and he
mentioned that my complaint wasn't the first.
Then I found out that the MOHS surgeons get a ton of money at the places they work, like
$700,000.00 / year.
Thank you for sharing. It helps to know I am not alone in such experiences.
I often wonder how epidemic stories like yours are. I feel like I could write a whole book
based on personal experiences along with those of family and friends. A person really has to
educate oneself just to avoid being robbed blind or worse yet harmed, and you at least have
the fortune of a medical education. To have to education oneself (trying to filter all the
misleading 'marketing' information and quacks out there) on complex medical procedures on top
of everything else is exasperating beyond words.
How long do we, and those we care about, have to continue suffering the indignities and
malfeasance of a broken and corrupt (not worth using euphemisms to debate the issues at this
point anymore) healthcare system?
The underlying premise of "modern medicine" is flawed. It dumber than Medieval
bloodletting.
Allopathic medicine is brilliant for catastrophic events. In the case of paraplegic
injuries, over the last 50 years, their survival rate, in the first two years after the
injury, has increased dramatically. However their long term life expectancy is about the same
as it was 50 years ago.
Trends in Life Expectancy After Spinal Cord Injury
"Results
Other factors being equal, over the last 3 decades there has been a 40% decline in mortality
during the critical first 2 years after injury. However, the decline in mortality over time
in the post–2-year period is small and not statistically significant ."
We are bamboozled by the "complexity" of the modern medicine model, BUT, "it" is stupidly
simple. They define a "normal" range of numbers. This range is arbitrary and always changing.
What is normal cholesterol? PSA? Blood sugar? ferritin? vitamin D?
Then they subject the patient to an array of blood tests, x rays, scans, urine tests
Then, the allopatic doctors use drugs or surgery in order to get your test numbers in the
normal range.
Before you know it, the patient is on 15 drugs. They cannot sleep so they are prescribed
sleeping pills. Then they are depressed, so anti-psychotics- Finally Oxycontin for the
constant unbearable pain.
Allopathic care in NZ is cheap, readily available, but a death trap for the trusting
(except for catastrophic events). USAians pays hundreds of thousands of dollars for misery
and drug induced ill-health.
If cat poop (feces) were cheap and available in one place (NZ), but outrageously expensive
and rationed in another (USA), it is still, basically, just cat shite.
The problem is for profit healthcare. The more tests and treatments, the higher the
managers bonuses. There is no regulation except for the insurance companies who are only
interested in their own bottom line. The patient is not in a position to rationally oversee
their care by themselves. All that matters today is profits; no matter how they are achieved.
That is why American life expectancy is decreasing. Besides giving everyone healthcare; a
system of primary physicians, government oversight of hospitals and care facilities plus jail
time for criminals are also needed.
I have relatives by marriage who live in southern Indiana near the Kentucky border. They
are "respectable working class," and I guess they must have good health insurance. I have
never known anyone to have so many surgeries. It is astounding. Cardiac surgeries and
orthopedic surgeries, for the most part. The ones I have in mind are 58 and 62 years old;
they have never smoked; they go to Mass every Sunday, they have been happily married since
they were young and while they don't eat health food they don't eat every meal at McDonald's.
But it is surgery after surgery after surgery. They never question the doctors; they never
hesitate. And now, unfortunately, some consequences of the surgeries are coming due; the guy
is in the hospital with infections both in his pacemaker and in his heart valve (they just
replaced both; he'll probably be okay). No-one else I know has surgeries like this. I think
it is a regional scam. It's true that my dad in CT has had a number of vascular surgeries,
but he smoked for decades and the dire need for them has been very apparent.
Here in northern CA, I have a friend whose girlfriend's son went to the emergency room a
number of years ago for a bad finger cut. He was told he needed amputation. Then they found
out he had no insurance. He was told to use a salve, and in fact it worked fine. I also have
a friend here in Silicon Valley who recently had digestive problems. The MRIs, CAT scans, lab
tests and probings under sedation were endless. Finally she was told to stop eating acidic
food.
Reducing the profit motive as much as possible is why I would prefer a National Health
Service (call it VA for all). Insurance, even if it's single payer, is still open to fraud
and overtreatment. Let's try to think of medical practitioners as professionals rather than
entrepreneurs, and get them to think of themselves that way. I also see it as a possible way
to reduce the very high premium given to specialists, so that more would go into primary
care.
In modern Medical practice, PROCEDURALISTS ( Surgeons of all kind, Cardiologists,
orthopods, Pulmonologists, gastro enterologists anfd of course, invasive and diagnostic
Radiologists etc ) always get compensated more than the primary care providers!
There are more CPT codes to charge for specialists than the GPs or FPs
Medicine is business run by 3rd parties! Vested interests won't allow any challenges to
status quo, just the banking system and the FIRE Economy!
With all due respect, if the UK system has embraced, "commercial conflicts of interest,"
"payment by activity," and the demands of "pay for performance" then that means they have a
substantial set of profit incentives already in place, rendering their medical system *more*,
not *less*, similar to America's. They may have single payer but that just captures the
monopoly rents by regulating the cartel/monopoly/utility or whatever you want to call the
medical establisment (it's per se difficult to even talk about market competition when
there's only one drug or treatment that will save a patient).
The unregulated private provision of public goods like medical care always leads to
extortion for profit. If you privatize fire-fighting, entire cities will burn to the ground.
If you privatize schools, you get ignorance. If you privatize prisons, you get
kidnapping-for-profit and the highest incarceration rate in the civilized world.
If you privatize the military, you get endless war. Why would a for-profit business ever
win a war? For that matter, why would they ever lose? The war's over and they'd be out of
money. You think it's just a coincidence that in the age of corporate personhood (Citizens
United) and unlimited bribery of public officials, you've had two of the longest, most
expensive and least determinative conflicts in our history in Iraq and Afghanistan?
You think it's a coincidence that the more unregulated "markets" we through at medicine,
the more expensive our medical care becomes and the sicker we all get?
Cures don't make money. Repeat customers do.
Show me a for-profit business that's in business to go out of business and I'll show you
the perfect company for insuring against social hazards.
It's simple middle-manager fraud. Politicians love privatizing government because they get
to pocket the public budget. When the marines or public school principals hand tax dollars
back to politicians and their cronies, everybody goes to prison. Privatize it and then you
can have the contractor or charter school give you "campaign donations" – no doubt
celebrating your economic genius in the process. They can hire your spouse and cousins. The
contractor can even bid up the real estate and then rent it back to themselves at exorbitant
prices. There are a million ways to launder the money.
Why do you think there is no transparent public accounting on most of this stuff? The
budget disappears into a black hole – which, incidentally, you'll discover the minute
you're in a hospital, dealing with a pharmacy benefit manager (PBM) or health insurer. That
was the true purpose of MERS – to make good mortgage information disappear so CDO
purchasers would never know what was in the mystery meat.
This is the great unraveling of Progressive Era controls on public corruption.
If you pay a dotor for every surgical screw he installs, is it any surprise then that a
diabetic winds up getting several in his spine he never needed?
This is also how we have set up the aluminum and copper markets, letting speculators buy
and horde commodities to drive up the price. It's also how we run drug distribution under the
PBMs. PBMs provide a kickback in the form of a "stocking fee" to pharmacies which would get
people sent to prison in other industries. When derivatives traders are not end consumers or
producers of a commodity, they bid up prices the same way. We actually give pharmacies a
profit incentive to drive cheap, effective, public domain chemicals off the market in favor
of expensive, privately patented medicines. Because they are expensive, they pay a greater
kickback so the pharmacy has greater incentives to stock and push it.
When railroads charged both farmers and consumers shipping and receiving food, it
bankrupted both sides of the transaction by creating incentives to reduce supply in the
monopoly transportation network. Reducing rail capacity bid up transportation prices and
saved the company on investment. That's how you raise profits: raise prices, lower expenses.
They had no rival to compete. That's why these kickbacks were outlawed. Imagine if the post
office made you buy a stamp for every letter you receive. Oh, wait. We have that with the end
of net neutrality. The ISPs get paid both by the service supplier (e.g., Netflix) and by
their "customer" (you and I).
You this same "rationing" take place now with drugs. Since legalizing PBM kickbacks, drug
prices have soared and we've lived through some of the greatest drug shortages since the
Soviet Union went bankrupt. Hundreds of chemotherapy patients per year have died because
cartels control supply and they don't like patients getting cheap, efective, public domain
treatments. Go look at the availability of methotrexate over the last ten years or your
platinum-based compounds. No one tells you this. It's a blip on the back page of a newspaper
(and pretty soon we won't even have those). Do you think TV "news" – making its profits
off drug ads – will ever talk about this?
It's a new war of enclosure – and it's far more extensive than simply drug markets.
The privatizers are confiscating clean air, potable water, healthy food, public education,
public policing and a host of other "general welfare" functions of the government promised us
in the preamble. It all traces back to the ideology of for-profit government – which,
in technical political science terms, is called fascism – when businesses own and
operate the government for private gain.
By the way, we don't need less testing in medicine. We need more. I don't know a single
idiot in Silicon Valley who ever said we need less data collection. The simple fact is we
need to test everything in a patient and compare everything we collect across thousands of
diseases. The cost of sensors and DNA sequencing, imaging and protein detection – not
to mention data processing – has been falling dramatically and yet "reformers" always
stress "rationing" as the cure for health care prices. It's partly because we ration
preventative medicine and diagnostics that we're in this situation.
Another great place to start would be separating diagnostics (evaluation) and treatment.
Would you let the bank's chief loan officer also serve as the chief auditor? Yet we let the
same doctor diagnose, treat and evaluate his own work.
As someone with serious chronic illness from these frauds, listen to me when I tell you we
should be practicing medicine thousands of patients at a time with transparent public
auditing and big data model building. Building my own private model of genetics from public
research saved my life. Nobody does that for you in medicine. Nobody is paid anywhere in the
system based on whether you get the cheapest, most effective and safest treatment; in fact,
I've heard of people getting fired for exactly that.
You've answered your own question. No single measurement, in isolation, is 100% accurate.
That's why we need thousands.
We need a cheap gene array chip that measures 10,000 markers in the blood and we need a
big data project to match those measurements against a baseline. We need cheap, safe whole
body scans. We need measurements of what every cell is up to and how they deviate from the
norm.
Nobody's very angry that cell phone cameras keep getting better, yet somehow we're always
upset that doctors want plenty of tests. That camera is a sensor that measures our
environment and the chip gets better and cheaper each year. We need the same attitude in
medicine. But then cardiologists might get upset that an immuno-assay shows you're at risk
for atherosclerosis. These guys still don't want to accept that clogged arteries are an
immune system problem and the immune specialists don't want to accept that it mostly gets
started in the gut. And the gut guys don't want to have anything to do with immunology or
cardiology.
I'll have to read the post this evening, but I have something to add to the theme:
I was in a meeting where a prominent local single-payer advocate, an emergency room
doctor, told us, passionately, that administrative costs were only half the problem,. or
less. Overtreatment and overtesting were the bigger part. He blamed the doctors, but of
course their billing practices are a big factor.
A big advantage of single-payer is that it creates an institution with the power and
motive to change medical practice. Iatrogenic illness is a big factor; overtreatment can
kill.
My wife has some chronic health issues and is a regular visitor at–and occasional
guest of– the Mayo Clinic, traditionally seen as the home of "integrated medicine"
(i.e. the various specialties speak with each other). We count ourselves ridiculously,
ridiculously fortunate to be able to so often and easily rely on the oft-named best hospital
system in the world. That said, it's amazing to both of us, even there, how silo-ed medicine
has become. This silo-ing HAS to create an inordinate amount of overtreatment. The
generalists, however, are left far behind in the community practices, often not able to do
much beyond prescribing antibiotics and making referrals. There is a LOT of need for more
holistic thinking about the patient that modern western medicine has lost, likely
inadvertently, as greater knowledge leads to the need for greater specialization. The gap of
some type of "master generalist" (which would of course be another layer of expense in the
healthcare system) is filled either by the patient (of patient's family) or left void. As a
result, there's either a huge tax of time, stress, frustration spent searching internet chat
boards and medical reference sites to understand topics because it seems like no single
doctor "gets it", or a hugely inefficient and potentially quite harmful medical treatment
experience as each specialty chips away at their corner of the patient. I'm not sure what the
answer is, but if this is the experience of a frequent Mayo Clinic patient, I'd wager that
the question posed is a pretty fundamental one to the entire practice of modern medicine.
I would add an extra 'over' to your list – overdiagnosis.
One of the the few bright spots in published stats for the US compared to other countries
is an apparent higher survival rate from cancers. I mentioned this to a relative who is a
medical specialist and he just laughed. 'its not surprising' he said 'since an amazing number
of those treated in the US for cancer don't actually have cancer'. Quite simply, overuse of
dubious 'tests' results in a huge number of false positives for cancer. This leads to
'successful' treatments. There are many tests in the US which are simply not permitted in
countries with public systems because they produce far too many false positives to justify
their use, either because the cancer doesn't exist, or it is not sufficiently malignant to
justify treatment (apparently there are cancers that lie dormant without ever threatening
life). I'm not aware, however, if this has ever been quantified, but its certainly true that
there are many testing protocols commonly used in the US which are actively recommended
against in most European health systems as they are considered not just a waste of money, but
actively harmful.
A relative of mine who is a very highly regarded specialist in drug prescribing practice
in Europe is currently doing a one year study on practice in the US (focusing on opiates, as
it happens). He said that one of the initial findings is that there is a different culture
around prescribing in the US to what he is familiar with. Quite simply, US doctors are not
taught how to say 'no' to patients in a way which doesn't upset them or feeling they've been
given a brush off.
Someone mentioned overuse of heart operations above. In Ireland, they developed what are
called ' Sli
na Slainte ' walks, which have spread worldwide. These were developed by the Irish Heart
Association following complains that patients were asking for too many drugs and treatments,
and not doing the simple thing which was shown to help in the aftermath of heart attacks
– exercise. They are way marked walks of set distance – doctors simply prescribe
the walk instead of drugs. They are hugely successful. But there is no money in it, so guess
where they haven't been adopted?
*disclaimer* I should say I'm not a medical professional, but I do have an interest in the
topic.
Thank you, PK. Very interesting, and follows from a thoughtful and insightful post from
Lambert, but I guess it makes common sense to strengthen heart muscle and accelerate the
body's natural ability to heal itself through exercise. Pity about the commonness of common
sense though, but I digress.
We all know we can live longer and avoid or postpone chronic ailments by maintaining a
healthy weight and doing some exercise, particularly cardio. And our arms and legs may look
the same over our declining years, but if you don't use them, you will lose them, those
muscles that is.
I post. that such an ideal is too far when you are time and money poor, constantly worried
and depressed
Poverty and sickness and lower mortality – they're all linked to one another.
Designed and baked into the dying system
None or too little, or too much, and very occasionally just the right amount of medical
care for the lucky few. What a mess.
I'll add that the elderly, and the poor's, opinions seem to be discounted by caretakers as
if you are lucky enough to be old or unlucky enough to be destitute means you're soft in the
head. So if a patient can understand and communicate what they want and realistically need
they have to fight to be listened too.
Four years ago my father who was 78 at the time began having difficulty eating. He had
been diagnosed with parkinson's a couple years earlier but the meds he was on were acceptable
and effective for him. He was a brilliant physicist. Well they did a colonoscopy and found
tiny tumors. One couldn't be taken care of at the time and the process to his death began. No
one knew how long the tumor had been there or at what speed it would grow but chemo and
radiation were prescribed to make it easier to remove. This became a very long sad story
which I will not go into detail on right now. The chemo made my Dad horribly sick. The
radiation to pin point a tiny area less than the size of a quarter ended damaging all his
organs. He died in pain on Thanksgiving morning 2 years ago. The radiation had done too much
damage. When he asked questions about treatment he was shuffled to diffident doctors or just
not answered. These were very high end NE Medical facilities. The reason he went in for
digestive problems never were fixed. Had the tumors never been addressed he could very well
be alive today. To date I have over 5 friends who have had a parent die not from the
condition they sought help for but the radiation treatment.
For me the problems start with the routine physicals which are "free" courtesy of
Obamacare. The doctors run tests and find problems with this and that, and after ultrasounds
and CT scans and little surgeries to get rid of benign little thingies, before you know it
you've spent thousands of dollars (courtesy of high deductibles ) for basically nothing. This
last time around my GP didn't like a few things in my lab results and I ended up with a
specialist. He started off with "why are you here to see me today?" After questioning me for
a little while about my (lack of) symptoms, I finally told him, "I never would have come here
on my own if my doctor hadn't have sent me here."
[DR. LOWN: In my view the lost art of listening is a quintessential failure of our
health care system. I think that you cannot heal the health care system without restoring
the art of listening and of compassion. You cannot ignore the patient as a human being. A
doctor must be a good listener. A doctor must be cultured in order to understand where the
patient lives, why he lives like that, and also realize that the leading cause of disease
in the world is poverty.
Medicine is becoming more dehumanizing. This is not only structural due to shorter patient
visits, less face to face interaction, fewer family physicians treating the whole family,
visiting the patient at their home, to see what their environment/neighborhood is like. It is
also the way physicians practice medicine, treating patient's as mere data sets. I'm not
trying to minimize data in medical decision making, but taken out of context from the human
element, treating data may be misleading and may not be treating the patient's ills.
In my experience, when I see a patient coming in over and over for the same complaints, it
is likley due to one of three main reasons. One, they are either being misdiagnosed and
mistreated, two, they are seeking a special test or drug, or three, their symptoms are not
due to an organic medical cause, but due to some sort of somatization secondary to life
stressors. Trying to figure out which it is requires the clinician to listen to the patient
and understand where they are coming from. Unfortunately, when a primary care physician only
has 10 minutes per visit, it is much easier to order a battery of tests to not miss any
important diagnoses, or to just capitulate to patient demands than to listen, and in many
cases take the time to give the patient some much needed reassurance.
That being said, the patient is not always an innocent bystander in this. There are also
many times that the clinician will pick up on the dynamics mentioned above, but reassurance
will not satisfy the patient. The patient will demand more be done for a number of reasons.
These are mostly anecdotal, such as I read an article and think I need such and such a test,
or my friend/family member had this procedure done and I need it two. It sometimes takes me
twice as long to explain to a patient why they don't need something done as it does as to why
they do. This is a societal thing and this is linked to the problem of defensive medicine. I
like to joke, that physicians always get sued for not ordering a test that may have been
indicated, but rarely if ever get sued for over treating someone and then causing harm.
Perhaps it has something to do with the ethos that it's better to do something and look like
you're trying that to do nothing, even though that may be the best course for the
patient.
In the end, I think physicians need to be better trained to listen, remember the mantra of
"first do no harm", and treat each patient as if they were their close family member. The
incentive structure in medicine has to also change, including the way physicians are
reimbursed, as well as the way information and clinical data is sourced and distributed to
avoid excess industry bias. And finally, patient's have to understand that more is not
necessarily better, they or their relative do not have a god given right to every
experimental, and outrageously expensive treatment available if it does not apply to them
clinically and if the chances of it prolonging life are minimal.
Overtreatment can't possibly be as big a problem as undertreatment, at least certainly not
in the world of crappy insurance or subsidized care our experience was definitely a solid
reluctance to order expensive tests or to consider that the problem might be complicated and
costly. Which it turned out to be, and the eventual surgery was scheduled as late as
possible, as a last resort, and we had to insist on more thorough testing to get a proper
diagnosis. They just wanted to save money. The tumor grew all the while this organization was
hoping it was something minor. I don't want to hear about overtreatment, thanks -- it seems
to always get distorted into blaming the patients for greedily consuming too much
healthcare!
The National Institute of Aging recommends scheduling interviews with prospective doctors.
The office might charge you for this one-on-one, but it could help you decide if the two of
you click. Once you get there, they suggest asking questions to help you figure out if the doctor
is a good fit for your concerns. For example: "Can I call or email you or your staff when I have
questions?" "Do you charge for telephone or email time?" and "What are you thoughts about complementary
or alternative treatments?" Open up a dialogue about the things that are important to you, and take
into consideration how receptive the doctor was to them. Think, "Did the doctor give me a chance
to ask questions?" and "Was the doctor really paying attention to me?"
Don't overlook the office dynamic
Just because you and a potential doctor get along great doesn't mean your relationship will be
completely stress free. A practice's nurses and office staff play a huge role in creating a comforting
and trustful environment. If anything seems off about your interactions with other staff members,
bring it up to your doctor.
Go with your gut
In the end, choosing a doctor is a personal decision. Because they're a person you'll be sharing
a lot with, do a gut check. If you don't feel like you'll be able to tell them intimate details,
continue searching.
"... The study, conducted using records of patients referred to the Mayo Clinic's General Internal Medicine Division over a two-year period, ultimately found that when consulting a second opinion, the physician only confirmed the original diagnosis 12 percent of the time. ..."
"... Among those with updated diagnoses, 66% received a refined or redefined diagnosis, while 21% were diagnosed with something completely different than what their first physician concluded. ..."
"... The researchers acknowledged that receiving a completely different diagnosis could result in a patient facing otherwise unexpected expenditures, "but the alternative could be deadly." ..."
"Second Opinion From Doctor Nets Different Diagnosis 88% Of Time, Study Finds"
by Daniel Steingold...4.8.2017
"ROCHESTER, Minn. - When it comes to treating a serious illness, two brains are better than
one. A new study finds that nearly 9 in 10 people who go for a second opinion after seeing a doctor
are likely to leave with a refined or new diagnosis from what they were first told.
Researchers at the Mayo Clinic examined 286 patient records of individuals who had decided
to consult a second opinion, hoping to determine whether being referred to a second specialist
impacted one's likelihood of receiving an accurate diagnosis.
The study, conducted using records of patients referred to the Mayo Clinic's General Internal
Medicine Division over a two-year period, ultimately found that when consulting a second opinion,
the physician only confirmed the original diagnosis 12 percent of the time.
Among those with updated diagnoses, 66% received a refined or redefined diagnosis, while 21%
were diagnosed with something completely different than what their first physician concluded.
"Effective and efficient treatment depends on the right diagnosis," says lead researcher Dr.
James Naessens in a Mayo news release. "Knowing that more than 1 out of every 5 referral patients
may be completely [and] incorrectly diagnosed is troubling ─ not only because of the safety risks
for these patients prior to correct diagnosis, but also because of the patients we assume are
not being referred at all."
Considering how health insurance companies often limit the ability of patients to visit multiple
specialists, this figure could be seen as troubling.
Combine this with the fact that primary care physicians are often overly-confident in their
diagnoses, not to mention how a high number of patients feel amiss about questioning their diagnoses,
a massive issue is revealed.
"Referrals to advanced specialty care for undifferentiated problems are an essential component
of patient care," says Naessens. "Without adequate resources to handle undifferentiated diagnoses,
a potential unintended consequence is misdiagnosis, resulting in treatment delays and complications,
and leading to more costly treatments."
The researchers acknowledged that receiving a completely different diagnosis could result in
a patient facing otherwise unexpected expenditures, "but the alternative could be deadly."
According to the release, The National Academy of Medicine cites diagnostic error as an important
component in determining the quality of health care in its new publication, Improving Diagnosis
in Health Care:
....."Despite the pervasiveness of diagnostic errors and the risk for serious patient harm,
diagnostic errors have been largely unappreciated within the quality and patient safety movements
in health care. Without a dedicated focus on improving diagnosis, these errors will likely worsen
as the delivery of health care and the diagnostic process continue to increase in complexity."
* The study was published in the Journal of Evaluation in Clinical Practice.
10
Simple Steps To Naturally Lower Your Cholesterol
From: [...]
Book Review: Cholesterol Down by Dr. Janet Brill
Cholesterol Down is for the 105 million Americans who have high
cholesterol. The author, Dr. Janet Brill, a registered and
licensed dietitian/nutritionist, exercise physiologist, and
certified wellness coach has spent years counseling patients on
cardiovascular disease prevention, researching, and writing on
the subject of cholesterol. Her work has been published in the
International Journal of Obesity and the International Journal
of Sport Nutrition.
Cholesterol Down provides readers with the information they need
regarding cholesterol -- what it is and how it works both for
and against the body. It is significantly endorsed by Dr.
Jennifer H. Mieres, the National Spokesperson for the American
Heart Association. She states, "The simple, consistent, and
inexpensive lifestyle therapy outlined in her {Dr. Janet
Brill's} Cholesterol Down Plan could be the most important
investment you make in your future health." Dr. Brill explains
LDL, the bad portion of cholesterol, and offers an effective
combination therapy of foods, scientifically based, that are as
effective as statins. Besides lowering LDL, the following
ten-step program also offers further health benefits.
First, eat 1 cup of oatmeal every day. The U.S. Department of
Agriculture recommends three whole-grain servings daily. This is
linked to reduced risk of heart disease, stroke, type 2
diabetes, obesity, some cancers, lower blood pressure, and
improved bowel movement. Oatmeal lowers LDL, may raise HDL--the
good portion of cholesterol, and studies show that the more
consumed, the greater the benefit.
Second, eat a handful of almonds daily, approximately 30.
Read
more ›
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Must
Reading for Those Interested in Their Health
I have a personal interest in this
particular subject so I was pleased to be asked to read and
review "Cholesterol Down," a book which definitely should be
read by anyone with a current cholesterol problem and, for that
matter, by anyone in the younger set who wants to prevent such a
problem from occurring in his or her future. If I had had this
information many decades ago, I probably could have prevented or
at least delayed the coronary problems I am now fighting. After
my first heart attack five years ago, I had to face the fact
that some extraordinary changes were necessary and at the top of
that list was diet. I was placed on a "Mediterranean" diet which
is very similar to the diet which Dr. Brill recommends in her
book.
Dr. Brill suggests ten simple steps to lower one's cholesterol
without resorting to prescription drugs. I am all in favor of
that because nothing disturbs me more within the medical area of
my life than the taking of prescription drugs. I try to avoid
that sort of thing like the plague. I much prefer to utilize
"natural" remedies whenever and wherever possible. So far I've
been fairly successful, having to take only one prescription
medication (an anti-clotting drug) and only because I have found
no comparable natural remedy.
This book is divided into two parts plus an appendix. The first
part of the book provides the reader with information about
cholesterol and heart disease, basically the scientific
foundations upon which Dr. Brill's ten-step plan is based. This
can be read first but it is not necessary. I read the second
part first, which actually describes the ten-step cholesterol
down plan, because I was specifically interested in reviewing
what the author suggests; one can always go back to the
scientific rationale later.
Read
more ›
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5.0 out of 5 stars
/span>
By
Tom Bruce
on November 25, 2007
Format: Paperback
Verified Purchase
Good
for what ails you
The book promises "10 Simple Steps to Lower Your Cholesterol"
and it delivers. The first section of this book deals with what
cholesterol is and what it does, and as this reader-friendly
author suggests, "If science is not your cup of tea, simply cut
to Part II." Part II is the meat of the book, listing the ten
simple - and they are - steps to lowering your cholesterol. Not
only simple, but affordable, too - much more so than prescribed
medicine. With each step, the good Doctor explains how each
process helps us reach our medical goal, gives the medical proof
that exists for each, presents case histories, and lists further
options and tips on how to additionally simplify each step. Yet,
if you're not into the medical jargon, this section of the book
is formated so you can skip over much of the material presented
and get the basic information you need in a few short
paragraphs. She does make it easy. The third and final section
of the book offers charts to help you follow this course, if
you're into such regimentation. There are also a few dozen
healthful recipes, few of which appealed to me. Now here's the
bonus part: as Brill explains, each of these steps will also
help in lowering blood pressure, aiding diabetics, fighting
obesity, forestalling aging, even stopping hair loss. So, if you
suffer from any of these ills and more, you can't go wrong with
this basic recipe for good health. After five weeks on this
regimen, my cholesterol numbers were back to normal. The one
problem I found with this diet, it was almost too much to eat.
Well, not too much, but very filling. I have followed a modified
version of the plan, mainly keeping in the oatmeal and
heart-friendly orange juice, and my numbers continue to be where
they should be months later.
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Hyperlipidemia is a mouthful, but it's really just a fancy word for too many lipids – or fats
– in the blood.
That can cover many conditions, but for most people, it comes down to two well-known terms:
high cholesterol and high triglycerides . Our bodies make and use a certain amount of cholesterol
every day, but sometimes that system gets out of whack, either through genetics or diet. Higher levels
of the
"good" HDL cholesterol are associated with decreased risk of heart disease and stroke. HDL helps
by removing cholesterol from your arteries, which slows the development of plaque. The "bad" LDL
cholesterol, on the other hand, can lead to blockages if there's too much in the body.
What's the treatment?
If you are diagnosed with hyperlipidemia, your overall health status and risks will help guide
treatment . Making healthy diet choices and increasing exercise are important first steps in
lowering your high cholesterol . Depending on your overall risk, your doctor may also prescribe
medication in conjunction with healthy eating and regular exercise.
"The combination of diet and regular physical activity is important even if you're on
medication for high cholesterol ," said Dr. Vincent Bufalino, an American Heart Association volunteer.
"It's the most critical piece."
Consulting a doctor is important, since each condition has it quirks. For people with high triglycerides,
for example, alcohol can be particularly dangerous. But for those with high cholesterol, a daily
glass of wine or other alcohol, along with healthy eating and exercise, may actually help, Dr. Bufalino
said.
Once I have it, can I reverse it?
Hyperlipidemia can be improved in many cases through healthy eating and regular exercise.
Here are some tips on how to manage your risk of high cholesterol.
Read food labels and choose foods with low cholesterol and saturated trans fat. For
people who would benefit from lowering their cholesterol, the American Heart Association recommends
aiming for a dietary pattern that limits saturated fat to 5 to 6 percent of daily calories and
reduces the percent of calories from trans fat.
Limit your intake of red meat and dairy products made with whole milk to
reduce your saturated and trans fat . Choose skim milk, lowfat or fat-free dairy
products. Limit fried food, and use healthy oils in cooking, such as vegetable oil.
Check your
family history of high cholesterol . Are you more prone to high cholesterol based on genetics?
If so, take steps to minimize your risk through diet and exercise.
Lose extra weight . A weight loss of 10 percent can go a long way to lowering your risk of
or reversing hyperlipidemia.
In late 2013, after an extensive review of evidence, the
National Heart, Lung and Blood Institute
updated cholesterol guidelines. Why did they do this? These new guidelines better identify those
at risk of atherosclerotic cardiovascular disease (ASCVD), and also better diagnose people who already
have ASCVD. Patients who have ASCVD are more likely to suffer a heart attack or stroke.
To determine if someone is at risk of developing ASCVD a
risk estimator
is available through Cardio Source. Information including Systolic Blood Pressure, a patient's race,
HDL Cholesterol and more are entered.
Depending on the level of risk, patients should take different courses of action. For all patients
who are determined to be at risk for ASCVD there are behavioral modifications they should implement.
These include: eating a heart-healthy diet, regularly exercising, avoiding tobacco products and maintaining
a healthy weight.
For lower risk individuals, there are other items to take into account on whether they are likely
to develop ASCVD. These include a family history of premature ASCVD,
LDL greater than 160, high sensitivity C-reactive protein, Coronary calcium score and Ankle/brachial
index.
For those with a high likelihood of developing ASCVD and for those individuals who already have
ASCVD, statins should be taken. The guidelines have also been updated. There are non-statin medications
also available for those patients unable to take statins (due to side effects or drug interactions).
Talk with your doctor to determine which medicine is best for you.
It wasn't the mountain of debt I was sure to incur since I'd already figured out how to get Uncle
Sam to pick up the bill (a small deal that put me in a military uniform for a decade). It wasn't
the fact that medical school would delay the litter of bouncing grandbabies she wanted to fawn over.
And it certainly wasn't because she'd miss me-she'd already seen too much of me and my dirty laundry
on weekends during college.
No, my mother was legitimately disappointed in me for choosing to enter the medical profession
simply because she had a deep-seated disdain for doctors. I could almost envision her sad disgrace
as she chatted with the neighbors during my final year as a resident in brain surgery:
Mom: "What's little Festus up to these days?"
Neighbor 1: "Oh he's doin' real good. He's got hisself a carwash business up in Magna
that pulls in a couple hundred a week. Lookin' to buy a bass boat for him and the misses."
Mom: "And Cletus?"
Neighbor 2: "Almost done with his ten years up at the state pen in Bluffdale. Won
an award for license plate stampin'. Trixie and the boys are real proud of him."
Neighbor 1: "And what's Eric doing?"
Mom: "He's still not married."
My mother never told me why she disliked doctors so much. I'm left to assume that she'd had a
number of bad interactions with them over the years, but she never bothered to back up her expressions
of disapproval with any sort of details. It took several years for my mother to warm up to the idea
that I had not turned to the dark side by becoming a doctor. I think a lot of it had to do with inertia-by
the time she finally decided to express any acknowledgement of my career decision, two more of us
boys were in medical school and I supposed she realized she couldn't be disappointed in all of us.
Now that I've been in practice a number of years I've finally learned what it was that so intensely
turned my mother off about doctors: they can be arrogant, condescending and impolite. Of course,
many of my readers are at this moment wondering if I'm also going to reveal other mysteries such
as "birds fly" and "dogs bark."
I had a roommate in medical school who was a great guy. He studied hard, didn't party too much,
and always managed to put the toilet paper on the right way (rolling out from the top down, in case
you were wondering). Years after we graduated and had gone our separate ways I had a phone conversation
with a physician assistant who'd gone to work for my old roommate. "It must be great working for
Dr. X," I added. A pause on the phone. "No," he said slowly, "he's a total jerk. Everybody hates
him."
I have two theories. One is that all medical students believe they will go on to become an Albert
Schweizer in their field-kind, self-sacrificing, benevolent-but somewhere along the way a certain
fraction of them let the glory of their career go to their heads and begin to treat patients and
underlings like chewing gum on a movie theater floor. What constitutes that percentage is in the
eye of the beholder. For my mother it was some where around the 98% mark. I'm a little more generous-I'll
say 20%.
My second theory is that all doctors believe themselves to be noble, kind, and beloved by all.
Rarely do I come across an arrogant doctor who recognizes him- or herself as such. Rather, almost
all of us think we're appropriately mannered. And we are . . . most of the time.
The rubber hits the road, though, when job-related stress enters the picture. A physician who
ends up an hour behind in a busy clinic can become snappy at his nurses and receptionists. A surgeon
who is elbow-deep in a case gone awry will turn her anger toward the anesthesiologist and scrub techs.
In both cases, the doctors in question feel they were simply reacting appropriately to the situation:
"Of course I yelled at my nurse. Doesn't she realize she is making me later than I already am?" or
"Of course I hurled the Metzenbaums across the room. Am I the only one in the OR who cares what happens
to this patient?!"
As any nurse will tell you, the true measure of a doctor's demeanor is not how he or she acts
during times of ease. Instead, the nature of a physician's soul is uncovered precisely during those
times when he or she has the most right to explode in a volcano of vulgarities and instrument-throwing.
A doctor who can keep cool while juggling 3 phone calls, a clinic filled with patients, and a patient
exsanguinating on the operating table is both rare and worthy of high esteem.
In fellowship I had the misfortune to work under a cardiologist described by all other fellows
thus: "She's fun socially but awful to work with." This proved to be true: at a staff party she was
great to have around, but when faced with the challenge of rounding on 15 patients in a two-hour
period she transformed into Medusa. Yet, I'm sure, if asked, she would maintain that she is polite,
kind, and patient-as long as the situation doesn't demand otherwise. The problem is that her definition
of "situation" was pretty much every day at work.
We doctors have chosen professions that are inherently filled with stress, deadlines, and treading
in deep emotional waters. None of that grants us a free pass to behave like spoiled toddlers. As
I see it, doctors should always follow 2 simple rules:
Rule #1: It is simply not allowable to be impolite, mean, nasty or snippy
with staff or patients even when you are in a stressful situation.
Rule #2: Whatever is stressing you is probably stressing those around you
as much or more. Under those circumstances you have to go out of your way to be kinder and more
understanding. As a doctor, you control the mood in the clinic and operating room even if you
can't control the situation.
I freely admit I am unable to always adhere to these rules but I at least recognize them and intend
to spend the rest of my career trying to do better. My mother passed away many years ago but I'm
hoping that somewhere up there she can look down and see that I didn't turn out to be so terrible
after all.
Loan Eby says:
May 15, 2012 at 4:26 pm Bedside manner
I was with my mom when her doctor told her she had Stage IV pancreatic cancer. After learning
my mom had 6-months to live, I remember walking out of Good Sam in Kearney and running into my
high school friend who was a nurse there. My friend greeted me with a smile because she had not
seen me in years. I told her the devastating news and how awful the doctor was to my mom. She
told me he was one of the best oncologists around. If he was the best round, I would have hated
to see their worst. Thank you for your post.
Nikki says:
May 15, 2012 at 4:44 pm It's refreshing to read Dr. Van De Graaff post. I have worked with
many Dr. and nurses in my time in the medical field. Sometime you get the nice fun loving Dr.
/ nurse or sometimes they are possessed, as a clinic worker it's my job ( and I take pride in
it) to not let it get so bad in the clinic and if it does everyone better start doing their best
to make the situation the best they can. I don't think that there is a day that goes by we aren't
laughing even when we are all a little crazy. It's nice to know that when you behave badly you
know you shouldn't….
Lance Taylor says:
May 15, 2012 at 10:53 pm Treat other how you would expect to be treated, and all will be well.
Sandra says:
May 18, 2012 at 8:42 am My mother also had the same attitude towards physicians. However,
my mother took everything in stride and always voiced her opinion. A few times she would bluntly
express to the physician/nurse when they were not very nice and did not answer her questions.
It was interesting to see the look on the physician/nurse's faces; it is evident that they were
not aware how they come across to their patients at any given time. Sometimes it is up to the
patient to express to their care provider how they are treating the patient. I saw first handed
how their attitudes changed each time my mother came into the clinic for the chemo/radiation treatments.
I would advise others to ask the provider/nurse how is your day going, it is amazing how their
attitude can fall into a positive manner when someone shows interest in them as a person not just
a physician/nurse. Thanks for sharing your story Dr. V.
RS says:
June 26, 2012 at 11:00 am I have to say, your mother raised you right! Its not everyone that
knows the correct way to put the toliet paper on! Your attitude is refreshing and you make your
profession proud! Your well written article should be a reminder to everyone that we should all
treat those around us with dignity and respect.
Leslie says:
August 13, 2012 at 10:22 am I am a retired respiratory therapist, my father was a pharmacist
who owned his own pharmacy and I have 3 cousins and an uncle who are physicians. I say that because
I want you to know that I have been around physicians all of my life. All that being said I would
come alot closer to your mother's 98%(probably around95%) than your generous 20%. That would include
my uncle. To find a physician who is both a good dr and a good person is rare indeed. For decades
I had to endure tamtrum throwing doctors. Now we have added millions of doctors from middle eastern
countries who have NO respect for women, zero manners and have such thick accents the poor little
old people have no clue what the physician just said, let alone who he actually was(no name, no
specialty, no time for questions, no business card).
My opinion has been for years that if you can't keep your cool under stressful conditions then
you need to be a plumber. Anyone who doesn't think that every level of healthcare is extremely
stressful-think again. Yelling at people who have done no wrong only makes them more nervous and
more likely to really make a mistake. Yep, a plumber. You can make as much money(perhaps more).
You can make your own hours. No insurance companies to deal with.
Think about it. Some people make everyone happy by entering a room…and others by leaving.
Jonathan hersch says:
August 14, 2012 at 2:05 pm I find that my patients say the same thing about other doctors
as your mother. Certainly many have let this career go to their head. I have many techniques to
control my anger and frustration when things are going bad in the operating room. It's hard but
a must.
I find myself hanging out with doctors who are like myself. Laid back and don't take life too
serious. The rest are hard to get along with. Patients feel the same.
KEITH BARKLEY says:
April 10, 2013 at 9:34 am I had the privelege of meeting DR. van de Graaf after a trip to
the hospital via rescue squad. These people really saved my life.I was near death and Dr van de
Graff helped preform a miracle for me.I haved been exposed to many medical people over the past
80+ years and I will critisize few of them – – but Dr van de Graff is truly a special person –
as well as Dr.
"Everyone will experience one meaningful diagnostic error in their lifetime," Dr. John Ball recently
told NBC News. Ball, who chairs the Committee on Diagnostic Error in Medicine, helped draft a report
on the alarming rates of late or misdiagnosis in U.S.
healthcare settings – the consequences of which are often catastrophic if not fatal
for some patients.
Prevalence of medical misdiagnoses
According to the study:
Every year, an estimated 5 percent of adults treated on an outpatient basis experience a diagnostic
error.
Diagnostic mistakes are to blame for at least 10 percent of patient deaths, according to autopsy
reports.
Incorrect or late diagnoses account for 6 to 17 percent of reported adverse events in hospitals.
In sum, the majority of American adults will suffer the effects of misdiagnosis or diagnostic
error at some point in their lives.
Doctors afraid to admit their mistakes
The report suggests that better training and guidelines can help reduce incidence of diagnostic
errors in clinical settings. However, we live in a culture where doctors and hospitals are
not always willing to speak freely about mistakes, making it that much more challenging to learn
from near misses.
"If people are afraid to speak up, then bad things can continue to happen," Ball said.
This sentiment was echoed back in 1998 by The Institute of Medicine, which found that medical
errors and surgical mistakes claimed the lives of tens of thousands of American patients each year.
The organization also called for a "culture of confession" in the hopes that healthcare
professionals wouldn't be afraid to fess up their blunders. With a more open dialogue among medical
providers regarding botched surgeries and missed
diagnoses, new approaches could be developed to help prevent the same errors from repeating themselves.
Ball also says that pathologists and radiologists should get more involved in clinical care and
patient diagnosis for more accurate testing.
Real life examples of diagnostic errors
The life-altering consequences of diagnostic mistakes are all too familiar to
Susan Sheridan of Boise, Idaho. Sheridan's husband died after his doctors
failed to diagnose an aggressive cancer in
his spine, and her child – who is now an adult – was rendered permanently disabled after physicians
failed to treat his infant jaundice.
In 1995, her newborn son Cal developed a dangerous condition known as
kernicterus which is caused by high levels of bilirubin. At just a few days old his skin
had turned a bright orange, but Sheridan's concerns were continually dismissed by pediatricians.
By the time the correct diagnosis was finally made, Cal had suffered extensive
brain damage leading to
cerebral palsy. He is both hearing and speech impaired,
uses a walker and will need medical care for the remainder of his life.
Sheridan hopes that other families will never have to endure similar heartache and loss and has
since become the director of patient engagement for the Patient-Centered Outcomes Research Institute
(PCORI). Still, Sheridan laments that there is no organization or system where medical errors
can be logged and tracked.
"The first thing I wanted to do was tell somebody, so they could make sure that will never happen
again."
Guess how much time the average physician spends listening to a patient describing her
symptoms during an outpatient office visit. Sixty seconds? Fifty?
"Studies show that doctors will interrupt you 10 seconds after you begin talking. Doctors are
under pressure to see more patients in less time. So learn how to make those 10 seconds count."
Taking her advice can be the first step into a better working relationship with your doctor or
other health-care provider. And it might avoid unnecessary (and often expensive) tests and
procedures, or even a
misdiagnosis, Wen
said.
Often, a
misdiagnosis is the result of inadequate communication between patient and physician. The
problem, says Wen: Doctors who rely on protocols and algorithms as the basis for a diagnosis,
instead of listening to the patient.
"It's not 'doctor bad, patient good,' but a system that doesn't always allow providers to get
a sense of the whole person," said Marisol Cifuentes, deputy director of
Advancing Care Together at
the University of Colorado department of family medicine.
"A patient visit isn't just about the symptoms and diagnosis, but what's really going on with
the patient, so the patient's needs can be understood, and the health-care team treats the
patient appropriately."
Some patients have a hard time asserting themselves with their doctors, Cifuentes said. That
can lead to making a problem worse instead of better.
"We had one woman who was a dance teacher, and survived a terrible car crash that left her
with major health issues, including horrible, debilitating migraines," Cifuentes said.
"When she tried to talk to her doctor about her headaches, he'd tell her, 'It's all in your
head,' following the standard algorithm, and prescribe pain meds. But her migraines got worse.
She began having panic attacks, and became severely depressed. She eventually went to another
doc, who sent her to a counselor to figure out what was causing her problems, and deal with the
issues so she could get her life back."
Many patients, especially older people raised to see physicians as authority figures, find it
hard to challenge their doctors. (The same generation, Cifuentas said, also has trouble
acknowledging the emotional and psychological issues.) Her recommendation to them: Stand up for
yourself.
"You should expect to be treated as a whole person," she said.
"The current system is built to fragment care. We need to create a different system so the
whole person is addressed and treated appropriately."
Until then, patients need to speak up for themselves. Prepare for an appointment with a
physician (or other care provider) by knowing your medical history, including the names of
prescription and over-the-counter medications, and a detailed, specific account of the problem
that led to this appointment.
"A lot of us are quick to tell a doctor that he's not listening, but maybe he is
listening, and you're not telling him what he needs to hear," said Cheryl Kruschke, a registered
nurse and associate professor at Loretto Heights School of Nursing at Regis University.
"You need to be 100 percent clear on why you're there."
Wen refers to this as
"telling your story." Few patients think through what they'll tell their health-care provider
once he or she steps into the office. That's a mistake, Wen says. Patients should think about a
doctor's visit the way they think about a job interview.
That means preparing beforehand. Write down the medications you're taking, both prescription
and otherwise. Think about the problem that prompted you to make an appointment.
When did you first notice it? What were you doing immediately before that? Have you tried to
address the problem with pain relievers, ice or heat, or rest? To what effect?
"For example, as an ER doc, if someone comes to see me and says, 'I've been coughing, and I
have trouble breathing' but doesn't mention that he also has emphysema, high blood pressure and
diabetes, then I'm going to waste his time and mine by asking questions or ordering tests to find
out what he could have told me," Wen said.
"Instead, he could say, 'I've had emphysema and high blood pressure for 10 years, but the last
two days, I can't walk from my bedroom to the bathroom without stopping to catch my breath. And I
have diabetes.' That gives me enough information to really help him."
Claire Martin: 303-954-1477, [email protected] or twitter.com/byclairemartin
Communicating effectively with your doctor
Avoid a misdiagnosis based on a cookie-cutter algorithm by preparing for your appointment,
knowing the details of your concerns along with your medical history and current medications. -
Claire Martin
1. Use a notebook to summarize your main concern, and establish a timeline for the
problem that brought you to the doctor's office. When did the problem begin? What was
happening when you noticed the problem? Has it gotten worse? Better? Include notes of the
medications you take and changes in circumstances that might affect your health.
2. When the doctor arrives, tell your story concisely. State your main
concern within 10 seconds. Start with when you first noticed the problem, and how it affects your
daily life, including the way you think, move, sleep, eat.
3. Stick to your narrative. If you're interrupted with questions that involve
a yes or no answer, answer with details. For example, if headaches brought you to the office and
you're asked when the latest headache began, instead of saying "10 a.m.," explain that you woke
up feeling fine, and then the headache struck suddenly (or built slowly) as you walked to work.
4. Ask the doctor what she thinks. Could your chest pain be related to the
way you pushed yourself in a workout earlier today?
5. Provide context in your chronology. Did the headaches begin after
significant changes at home or work? How have the symptoms changed the way you behave? If you
miss a day at work, or stay home from a family outing because of your symptoms, say so.
6. Use simple language. Don't try to imitate the language on a TV medical
show. Speak the way you'd talk to a friend. Be respectful.
7. Use the notebook to write down the doctor's suggestions.
Consumer Reports – Health:
For more than 70 years, Consumers Union has been working for a fair, just, and safe
marketplace for all consumers and empowering consumers to protect themselves. We're a leading
advocate for patient safety, health-care quality and effectiveness, and affordable health
coverage for all.
Consumers United for Evidence-based
Healthcare (CUE) is a national coalition of health and consumer advocacy organizations
committed to empowering consumers to make the best use of evidence-based healthcare (EBHC).
Health.gov: A portal to
the Web sites of a number of multi-agency health initiatives and activities of the U.S.
Department of Health and Human Services (HHS) and other Federal departments and agencies.
HealthKnowlege: We
created HealthKnowledge to give employers a tangible way to help their employees–and
themselves–get better value out of their employee benefits. If your company doesn't offer
health insurance, HealthKnowledge can be your low-cost health benefits strategy.
Informed Patient
Institute (IPI) is an independent nonprofit organization that provides credible online
information about health care quality and patient safety for consumers.
Patients Right to Know A
resource map of the United States that links consumers to a service provided by the 2007 CO
House Bill 1331, and Citizens for Patient Safety, helping consumers lookup and research
doctors by state.
PatientSafetyBlog.com : Stories
to empower patients and their families to stay safe and partner with their doctors and nurses.
Savethepatient.org sharing of
educational resources, multi-lingual tools, and links to existing health care networks, Save
the Patient's intent is to empower, inform and educate, encouraging you to take an active role
in your own health care experience.
The Mayo Clinic: More than 3,300
physicians, scientists and researchers from Mayo Clinic share their expertise to empower you
to manage your health.
United States Department of Health and Human
Services: The Department of Health and Human Services (HHS) is the United States
government's principal agency for protecting the health of all Americans and providing
essential human services, especially for those who are least able to help themselves.
The Last but not LeastTechnology is dominated by
two types of people: those who understand what they do not manage and those who manage what they do not understand ~Archibald Putt.
Ph.D
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