Sunday, April 25, 2010

Comparative Effectiveness Research: Follow the Herd or Lead It?

I never took a psychology course in my life. Perhaps, I should have. How was I to know, or even suspect, that years beyond college, I would be the father of 5 kids? In retrospect, I should have been a psych major, so that I could have developed essential parenting skills in negotiating techniques, behavior modification, unflappable self control, brinkmanship, verbal dueling and mind reading. Without a solid psychological foundation, I have been fenced in and cornered by teenagers who know very well that I am shooting blanks. This has not been a fair fight.

Two weeks ago, my daughter and I traveled to the east coast to visit 3 institutions of higher learning. This is the 3rd child that I have done college visits with. By now, I could give these ‘info sessions’ myself. They are verbal versions of Mad Libs, where the speaker simply plugs in terms specific to his institution. For example:

“What really makes __________ University so unique, is our (insert superlative adjective) professors. In our institution, (select a number between 96-99) % of all courses are taught by full professors. They (insert gushing verb with exaggerating potential) undergraduates! Ou professors would much rather hang out in office hours teaching you Physics 101, then pursuing their (insert adjective that is synomym of boring) research with grad students who worship them. For our profs, teaching trumps tenure. An advantage to having a campus in the middle of nowhere, is that our students can (insert activity that sounds amazingly fun even if it doesn’t exist on campus) every weekend.

The sessions often with remarks suggesting that the college can be anything the applicant desires.

"Our institution combines the advantages of a large research university with a small liberal arts intitutions.  It is both urban and rural.  It strives for collaboration and cooperation, but encourages independent inquiry.  It is both vegan and carnivorous..."
You get the idea.

Like most parents, I want our kids to be exposed to a spectrum of ideology. Even without a psych background, I coyly influenced my daughter’s choices so that we would be visiting 3 colleges that were philosophically distinct.

      College                                Campus Philosophy

Standard Ivy League                           Liberal

Urban Liberal Arts University         Really liberal

Small Liberal Arts Institution           Socialist

After the ‘info session’, the high schoolers and their parents tour the grounds. This is when various campus features are pointed out that will surely determine if that particular college is the right choice. Here are some sample comments that demonstrate the value of the campus tour.

“Here is the chemistry building. This is where we study chemistry.”
“This is a dorm room. Can everyone see the sink?”
“Our library has 14 gazillion volumes. Most colleges of this size only have 11.”
“This is our main cafeteria. I just started giving tours, so I don’t remember what happens here.”
At the beginning of one of these tours, I witnessed a real live psychology experiment in progress. The courteous admissions staff had provided us with umbrellas as rain was likely. Minutes later on the tour, it started to drizzle. It wasn’t real rain yet, but was steady enough to be annoying. Although we were getting wet, no one opened their umbrella. My daughter whispered to me, “Can I open it?” I needed to think quickly as the wrong advice could jeopardize her chances of admission. “Go ahead,” I replied. She complied. Within 30 seconds, every other umbrella popped open. All this crowd needed was for one person to act, so they could all follow. Why didn’t they act at the proper time? Even my daughter wanted my approval before taking bold action.

Folks are comfortable when they are following the herd. I wondered about this observation with regard to the medical profession. How many of our medical actions and decisions are done in imitation of others? How many of our practices are examples of group think and playing follow the leader? Why does medical dogma and practice take so long to modify?

Physicians, including me, perpetuate practices that may be more based on custom and tradition than on sound or changing medical evidence. Here are some examples, most from my own specialty.

  • Physicians continue to support Prostate-Specific Antigen (PSA) testing despite mountains of evidence against this practice.
  • Gastroenterologists perform colonoscopies reflexively to evaluate fecal occult blood, even though this exercise only rarely yields a significant lesion.
  • Cardiologists stent narrowed coronary arteries that should never have been discovered and aren’t responsible for clinical symtoms.
  • Gastroenterologists have been obtaining biopsies from patients with Barrett’s esophagus on a regular basis for decades, even though there is no persuasive evidence supporting this practice.
  • Hepatitis C is treated with toxic medications that don’t work well. They are widely prescribed.
  • Remicade and its cousins have become mainstream treatment in inflammatory bowel disease. My review of the data, even with publication bias, shows rather modest long term benefits, despite risks of opportunistic infections and cancer. The medicine cost a fortune and are often given lifelong.
  • Acute pancreatitis had been treated with bowel rest for decades, until recently.
  • Helicobacter pylori is an enemy of mankind and must be eradicated in our lifetime.
  • Sequential rounds of chemotherapy for incurable diseases are often prescribed because this is a mainstream oncological practice.

Medicine is a great profession, and it can be better. We physicians need to be more skeptical and creative. We should challenge our own clinical practices periodically to verify that they are truly best practices for patients. It is not be enough for us to ‘do what we were trained to do’. For a long time, gallbladders and uteruses were yanked out for reasons that would not survive strict scrutiny. I enthusiastically endorse comparative effectiveness research, although I expect it will be provoke fierce battles from those whose economic survival depend upon the results

It’s easy and comfortable to keep on the same path without deviation. We need folks, however, who will shake it up and make us think, explain and justify what we do. I know that my own practice could stand to be shaken up. Patients can be part of the process by asking us pointed questions, such as, “Doctor, explain exactly why I need this test or medication now?”

There is an undertow that pulls all of us to follow the herd. This is perfectly fine, depending upon the herd’s destination. If it’s headed the wrong way, however, it’s not easy to change a herd’s direction, but it can be done. One person has to stand up when it’s raining and lead the rest of us to drier ground.

Sunday, April 18, 2010

Does Board Certification Really Matter?

My patients have the confidence of knowing that I am a board certified gastroenterologist (GI). I haven’t disclosed this to them personally, but somehow resourceful and curious patients can now find out facts about me that heretofore would have required a government warrant. (In fact, for my entire medical career, I have never displayed a diploma or any professional certificate in my office, which annoys my mom.) Now, with a few keystrokes, patients can read about my suspension from the fifth grade after making an unwelcome comment about another student. Being from the northeast, my initial reaction to this transgression was, “Will this be on my college record?” Assuming that I successfully recertify in gastroenterology in the coming year, I will enjoy this prestigious designation for another decade. I hope I that I am still practicing then, since the health care reformists have promised us a medical nirvana in in the coming years. It would be a shame if I retired just before the nirvana tsunami struck our shores.

What does a board certified label mean for patients? Patients seem to be reassured when their physicians have received the American Board of Internal Medicine’s ‘Good Housekeeping Seal of Approval’, but do they really know what it means?

Here’s a short quiz for patients to gauge their knowledge of this issue. While each answer may seem reasonable, you are charged to choose the best answer. Don’t agonize over this. After all, this is not the SAT or the ACT, where a single incorrect response can determine one’s ultimate success in life. Indeed, we have taught our 5 kids since kindergarten that failure on important standardized tests is tantamount to failure in life. For this reason, since our kids were small, I placed a different ‘flash card’ under the toilet seat each morning, so that their gastrointestinal function could be combined with educational enhancement. Our kids wondered if this activity needed to be continued during their high school years, but I emphasized that knowledge acquisition is ongoing, and should not be prematurely flushed aside.

Here’s the quiz question.

Board certified gastroenterologists, in comparision to 'board eligible' GI wannabees are able to :

(1) Perform rectal exams with all 10 digits

(2) Complete a colonoscopy speedily before the sedation has taken effect

(3) Impress patients with fancy jargon like dyspepsia, instead of using common verbiage, such as stomach ache

(4) Profess ignorance of the cost of procedures since health has no price

(5) Order enemas routinely assuming that patients will enjoy the experience

(6) Make an involuntary donation every 10 years to the American Board of Internal Medicine (ABIM) so that hospitals and insurance companies won’t kick us off their rosters.

I am now deep in the recertification experience, which is known by the ABIM as MOC, or Maintenance of Certification. I have completed most of the required modules, which are home study sessions that can be retaken, if they are not successfully passed. Afterwards, I can proceed to the culminating experience of the entire recertification process – the all day test. Here's where I will likely have an opportunity to guess at answers that I could look up in a book or computer in real life. Physicians in private practice like me are always delighted to sacrifice a day’s income to serve the greater good. In this digital era (who knows more about digital than gastroenterologists?), would it not be possible to take this exam from my own computer on my own time? However, it is not for me, a simple blogger, to question the infinite wisdom of the ABIM who has commanded from a Philadelphia mountaintop:

 Thou shalt set aside a day of wages on the Altar of Knowledge after the check has cleared.

There’s a reason that so many physicians find the MOC to be an expensive hassle that doesn’t accomplish its mission to improve the quality of our care. While some argue that board certified physicians have superior clinical outcomes, this may be unrelated to the MOC process. These physicians may perform well because they are already skilled and knowledgeable practitioners. This is similar to concluding that high school students who score well on the exalted SAT examination will perform at a higher level in college. It’s the kid that determines the success, not the test score. Personally, I don’t think that the lengthy and expensive recertification process will improve my knowledge and performance. Like most physicians, I have developed my own educational strategies to remain current in my field, and I believe they are working well. It is clear, however, that the MOC delivers great benefit to the ABIM.  Not surprisingly, Christine Cassell, MD, president and CEO of the ABIM expresses on KevinMD that the current recertification process is worthwhile, although admits that reforms are needed

Would we physicians run this gauntlet if we didn’t have to? For many of us, the MOC is a Marriage of Coercion. Don’t look for my certificate on the wall.

Sunday, April 11, 2010

Cost-Effective Medicine: Cracking the Code

My friend, the Buckeye Surgeon, has resisted reforms in medical residency training programs, that have eased some of the inhumane exhaustion on young interns and residents. I have a different view on the subject. This issue generates spirited debate in the blogosphere and in teaching hospitals across the country.

Not all medical education reforms, however, provoke controversy. I learned recently from an Ohio medical student that they are now being taught about the financial costs of medical tests and treatments. This makes so much sense that I am astonished it has taken so many decades to be incorporated into medical training. Indeed, even practicing physicians like me are often clueless about the costs of the tests we recommend. Perhaps, if we saw the price tags of the prescriptions and imaging tests we ordered, we might hesitate and reflect for a few nanoseconds

A commentary in the current issue of The New England Journal of Medicine chastised medical educators and training programs for not practicing or teaching cost consciousness to physicians-in-training. 
A challenging aspect of this issue that medical pricing is fluid and incomprehensible. Churchill’s aphorism describing Russia applies perfectly to medical costs.

It is a riddle wrapped in a mystery inside an enigma.

There is no fixed price for a medical item, as we expect when we purchase a gallon of milk at the grocery store. For example, when I spend a morning performing half a dozen colonoscopies on 6 lucky individuals, the reimbursement for each procedure may be different. While I am not an economist, this seems rather odd. If 6 patrons order the same entrée at the same restaurant, their bills will be identical. Not so, in the medical world, which has a cost system so abstruse that we need CIA codebreakers and cryptographers to decipher it. As an aside, when I receive my own medical bills, I need an insurance company Rosetta Stone to decode them; and I am in the medical business. Unraveling these insurance company documents tests the wits of our most seasoned patients who must be steeled for hours of dogged inquiry to capture a windfall refund of $4.86. However, recovering even a trivial sum is a sweet victory.

A few years ago, in my own community hospital, we were provided with a running total of medical charges accrued for each patient. The financial charges were stratospheric, for even brief hospital stays. I was surprised that the administration shared this data with us, and I wondered if the disclosure was inadvertent. This speculation was supported when the data disappeared from our computer screens without warning, and has never reappeared. We lost a tool that could have helped us to practice medicine more judiciously. If we were reminded of the cost of a CAT scan, at the moment when we casually ordered it, perhaps, we would pause and consider relying on the scan from 2 months ago, which was performed for the same reason.

My hometown newspaper published an article that informed how to comparison shop by price for medical care, not an easy task. The New York Times reported on, where medical consumers can shop for medical care similar to the way many of us purchase airline and hotel tickets. There are various websites that serve this same function. When my own patients ask me for the cost of my procedures, I can’t give a straight answer to this seemingly inocuous inquiry, which they find puzzling. As stated above, each insurance carrier uses its own pricing playbook. And, if I take a biopsy, additional charges will materialize.

The medical marketplace is a unique universe. The patient receives a medical service, has no idea of its cost and likely isn’t paying for it. Any wonder why medical costs are breaking their own records?

Paradoxically, communities that spend more on health care may have inferior medical quality, as shown in the Dartmouth Atlas of Health Care. While I don’t advocate denying medical care because of cost per se, it should be a consideration when medical options are being considered. This is of critical relevance to individual and public health. For example, a flu shot may be medically indicated, but if it cost $250, and isn't covered by insurance, would we roll up our sleeves? Costs matter.

Medical pricing should be simplified, accessible and transparent. We physicians should be aware of how many health care dollars we are burning up. More importantly, patients should have this knowledge also. If they had ‘skin in the game’, and were more financially responsible for their care, this would go far to reform a health care system where mysterious and enigmatic costs, like our politicians' hot air, have nowhere to go but up.

Sunday, April 4, 2010

Obama Passes on Colonoscopy: Oh, What Might Have Been!

Does anyone out there know why President Obama underwent a virtual  ‘colonscopy’ (VC) instead of a conventional colonoscopy earlier this year? In my gastroenterology practice, we do not offer colon cancer screening to 48-year-old individuals, unless special risk factors are present. Of course, maintaining the president’s health is in the national interest, so I understand why professional screening guidelines might not apply to him. For similar reasons, airline pilots are subjected to routine cardiac testing, not to protect the pilots' health, but to protect the passengers.  Stricter scrutiny of the president's health is proper.

So, if the national interest required that the First Colon be studied prematurely, then why didn’t the president choose the screening test that nearly every physician opts for when we turn 50?  I’m baffled.

It is inarguable that a colonoscopy is more accurate than VC and can remove polyps and obtain biopies at the time of the examination. In every instance that I recommend a colonoscopy, I present virtual colonoscopy as an alternative adventure of the lower bowel. Patients invariably reject it, despite its safety advantage, because they do not want to endure a VC laxative prep to discover afterward that they need a colonoscopy to remove a lesion.

VC also has radiation risk, which is belatedly capturing the attention of the press, physicians and the public. The FDA acknowledges that radiation exposure from VC is equivalalent to about 400 standard x-rays. We have been broiling too many patients for too long.  I am also concerned that VC, like all CAT scans, will discover incidental ‘abnormalities’ outside the colon, that will generate anxiety and a medical cascade chasing these faux lesions that are nothing more than radiographic curiosities.

Medicare has declined to cover VC for colon cancer screening, presumably as they have not been persuaded by available data.  Interestingly, ABC news reported last week that Julian Nicholas, a former FDA scientist (can I call him a ‘Whistleblower’?), stated in an interview that "there was an absence of sufficient, valid scientific evidence to conclude that the use of CT devices for colorectal cancer is both safe or effective." Nicholas alleges that after he declined to withdraw his objection to VC, he experienced a VT, a virtual termination. The FDA states that there was no retaliation against Nicholas for his dissenting view. Yeah, right. Sounds like the agency spokesman was engaging in some VS, or virtual spinning.

Perhaps, President Obama wanted to avoid the sedation that is administered before a conventional colonoscopy. Was he scared to transfer his presidential powers to the Vice-President? Did he fear that during these few hours, that Biden might go soft on Netanyahu, invite Jeremiah Wright to a White House prayer breakfast or simply start spewing ‘BFD', as he did in the president’s ear – and in ours- just prior to the signing of the health care reform bill?

What would I have done if I were the president’s gastroenterologist? I would have devised a solution that would have met two tests:

  • Provide premier presidential colonic protection
  • Permit the president to retain his powers
This is easy. I would have advised the president to undergo a traditional colonoscopy without sedation, as routinely occurs in many nations whose citizens do not have the expectation of comfort that we Americans do. In addition to receiving Cadillac colonic care, there would be a political dividend. The president, by shrugging off a few stomach cramps, would show the world his toughness. This would earn him deserved respect from his political adversaries here at home, and might induce some leaders abroad to reconsider their policies. While all of this is hypothetical, here are some headlines that might have followed a presidential colonoscopy sans sedation:

Nervous Ahmadinejad Invites U.N. Inspectors Back
Kim Jong-il Surrenders Nukes. Sends Obama Flowers
Chinese President Hu Demands Sanctions on Iran
Senator Mitch McConnell Supports Public Option
Hillary Clinton States, “Honored to Serve as Obama's #2”
Washington Monument Renamed the Obama Obelisk
Obama Promised Nobel Prize in Medicine 2011
Dick Cheney Invites President on Hunting Trip
Mr. President, your colon cancer screening choice had geopolitical ramifications. While this damage is done, there may be a way to restore some of our power and prestige. Find out when Biden is due for his next colon exam. If it's not due for a while, then declare it to be necessary now by executive order. Direct him to proceed without sedation, so the world can fear and respect the man who is a heartbeat away from the presidency. If he balks, tell him that he needs to take one for the team. Afterwards, at his bedside, let him know that his sacrifice was a 'BFD' for the nation.

Unsedated colonoscopy could become a new standard for political candidates. Their handlers would make sure that after the candidates kiss the babies, eat rubber chicken, acknowledge the local mayor and dignitaries, wear a hard hat and reject polling data; that they will jump on board the GI Colon Express with only a bullet to bite on for anesthesia.

Are you listening Mitt Romney? Here's your opportunity to vault ahead before this procedure becomes as politically required as eating at the local diner. Go for it, Mitt.  There will be light at the end of the tunnel.