*A Pacemaker Wrecks a Family’s Life* Can faith in medicine be restored? #hcsm #hcr

When the surgeon asked us why we were there, my mother said, “To ask questions.” She was no longer a trusting and deferential patient. Like me, she no longer saw doctors — perhaps with the exception of Fales — as healers or her fiduciaries. They were now skilled technicians with their own agendas. But I couldn’t help feeling that something precious — our old faith in a doctor’s calling, perhaps, or in a healing that is more than a financial transaction or a reflexive fixing of broken parts — had been lost.


It saddens me to read articles like this…

  • How many other patients feel this way? 
  • The majority?  
  • Why do they feel like this?  

I see many many patients each and every day that still have *faith* that their physicians are acting on their behalf with the best of intentions. However,  I also meet a handful of patients each week who are very skeptical and cynical about the motivation that may lie beneath my recommendations.   

I fully understand (and agree with) this woman’s position. A number of pertinent issues are brought to the surface by this article, the largest of which, in my opinion, is the issue of end of life care...  I do not want to go there… today.   This is a tremendous problem and represents an enormous cost burden to society, and it can become an enormous painful, emotional and *costly* burden to both the patient and their family.   

But I digress…. 

I found this article very intriguing… and very enlightening.  I have long felt that the trust patients once had in their physicians is eroding.  Many will blame the likes of Obama who states we would prefer to amputate a leg for $50,000 then to treat the underlying cause—diabetes.  

Many will blame the physicians themselves… After all, they are trying to care for patients and run a business. In today’s environment that can be a very tough juggling act for many of my non-procedural colleagues. They need to remain in the black, and in many instances are trying to avoid being sued.  This leads to the ordering of poorly indicated testing or procedures, or it leads to the provision of unneeded DME services such as braces, and perhaps even poorly indicated surgery.  

This article (potentially) also brings up the failings of the current fee for service (FFS) model.

  • Did the cardiologist in this case put a pacemaker in because he needed the money? 
  • Did he put it in because the patient would have died without it and was afraid of being sued? 
  • Or did he honestly think it was in the patient’s best interest? 
 I hope it was the later.  In this particular case I doubt we will know the answer to that.  But look at the enormous *cost* and *burden* that was set upon this family because of this one decision.  It’s the sad reality of the dramatic effects (some of which we can not possibly fathom) that a relatively *straight forward* decision making process can have.  

We need to:

  • focus on modifying the fee for service model…
  • embrace (reimburse physicians to adopt) a patient (family)-centric model that engages the values the patient and family bring to the table—
  • deal with end of life care.  
  • deal with the fear of frivolous lawsuits that motivate some of these decisions. 

If you think that simply cutting fees to providers is going to solve the cost burden of our health system you are sadly mistaken.  The exact opposite will occur— as the *system* seeks to maintain the status quo the simple truth is that  cases like this will become ever more prevalent and the *cost* burden to the system, the patients and the families will simply increase along with it.  



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Breaking Down the Barriers… How Should Physicians and Pharma Collaborate— it’s in everyone’s best interest.

For decades the relationship between Pharma and physicians was a distant one. There was no collaboration, nor collective thinking. Physicians wanted to use the most appropriate medication for their patient.  I doubt that many physicians’ prescribing habits were driven by more than that.   Pharma wanted access to the physician to peddle their formulations— the physicians by and large were receptive to the wonderful lunch (and pens) they received.   Occasionally a golf game or dinner was organized, and most physicians felt this was a nice opportunity to mix it up with their colleagues in a stress-less environment.  I’m sure Pharma has very detailed analytics on this but I’m don’t believe the ROI of these mid-day or after hours endeavors were particularly high.  

Enter the government, and the perception that docs who received something from Pharma were in their pocket and the relationship was changed…. dramatically, literally overnight.   Pharma has gone back to the drawing board and tried to re-work the relationship they have with physicians while maintaining the distance stipulated by the government.   Who does this benefit?  How should Pharma engage the physician? Does the physician want to be engaged?  Is there a way for Pharma and physicians to work together in a mutually beneficial manner?
How should the Pharma-Physician interaction change to foster a workflow environment that improves the physicians ability to treat their patients efficiently, effectively, safely and in a non-disruptive or non-intrusive manner?


    Most physicians are smart phone users…. and many people far smarter than me have pointed out that the smart phone will be the device that eventually facilitates useful communication, collaboration,  content sharing and information gathering for those of us who function within the health care system.   

    It stands to reason that the smartphone will become the device utilized to access timely, useful information… the users of Epocrates will testify to that.  But is Epocrates enough?  

    First and foremost, in order to meet the criteria I mentioned physicians need a slick, simple (html5) platform that provides us with the ability to rapidly obtain reliable information on the Pharma product we wish to inquire about.  What the current applications or platforms do not offer is a means to crowd-source the information or content and allow the physician to share thoughts, evidence or content on a particular subject or patient.  I do not look to Pharma to provide the platform… however, Pharma does need to reach out to the developer community and the start-ups out there (iMedExchange) who are developing mobile apps so that the physician has access to representatives of the company to query them about their product.   

    In the end… rich, simple, meaningful content— delivered on a mobile platform that enables access to colleagues and Pharma— will effectively and efficiently empower the busy physician to improve the care he/she delivers while avoiding disruptions to their workflow.   Everyone wins…after all, We are all patients! 


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Consumers Want Evidence Before Embracing Evidence-Based Medicine

My guess is that consumers believe that EBM is another phrase for rationing. After all, if EBM states you don’t need an MRI or X-ray, it is easy to see how a mis-understanding may arise. http://amplify.com/u/6u2v

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Bringing Comparison Shopping to the Doctor’s Office – NYTimes.com

This sounds great… on paper. However, until consumers are the drivers and realize that they’re not spending on someone else’s credit card this movement will go nowhere… IMHO. http://amplify.com/u/6u2s

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Despite Evidence, Patients Want More #healthcare #patient-education @myEn #In

The journal Health Affairs just surveyed more than 1,500 patients with employer-provided insurance, including dozens in focus groups and one-on-one interviews.

The “pervasive themes” from respondents, according to the authors, were “more is better, newer is better, you get what you pay for, (and) guidelines limit my doctor’s ability to provide me with the care I need and deserve.”

via npr.org


As I have stated over and over on this blog, true health care reform will encompass improving quality, increasing coverage and perhaps most important (to me) control health care costs. These issues are obviously not mutually exclusive. one can not be changed without controlling the others.   Many of the physicians I talk to feel that they have no incentive to control costs… they also feel that if they take the time, and make the effort to control costs via education,  that they will suffer financially.

As most of you know I am an orthopedist. Nearly everyone of the patients I see in the office will request or even insist upon an MRI, CT or even an X-ray. Most of these tests are simply not necessary…. and may in fact be *harmful*.   I order FAR fewer MRIs than many of my colleagues…. Does that mean the care I offer is any less advanced. Absolutely not!! The literature has proven over and over that we do not need to X-ray every ankle injury, or every low back strain— it has also shown that a quality physical examination by a well trained sports medicine doc will frequently lead to a more accurate diagnosis than an MRI will.

MRIs are useful in many circumstances. They are very useful to confirm a clinical suspicion when diagnosis isn’t clear and surgery might be necessary. They are not needed to tell someone they have an ankle sprain, a rotator cuff strain, low back strain, etc. Is there a good chance the MRI will alter your chosen clinical pathway? If the answer is yes, then an MRI is indicated. Should I MRI your knee if you injured it yesterday and the likelihood of spontaneous is high? Nope. What about someone with back pain after working in the garden all day… again, nope.  Most injuries follow easy to diagnose by a history and physical exam alone—and most injuries follow a benign course to resolution 

I need to spend quite a long time explaining to patients why an MRI isn’t necessary in their particular condition. Most will understand and go along with it. Some will not and will probably not be happy until they get their MRI (usually by another provider).

But this brings up an even more important topic. How many unnecessary MRIs are leading to unnecessary procedures?  Do you realize that a substantial number of “NORMAL”, assymptomatic individuals have meniscus (cartilage) tears in their knees, disc hernations in their neck and back, rotator cuff tears and labral tears in their shoulders? Now, suppose your mom or dad goes to the doc complaining of knee pain. Many docs will order an MRI. Based on their age they may have a high likelihood of having a tear (but most *degenerative* tears are not bothersome). So the MRI shows a tear and the patient is sent to an orthopedist who suggests surgery based on the MRI interpretation,  despite the fact that the patient has only had pain for a few days and despite the fact that they know many patients with degenerative tears will do very well without surgery. Some tears might require surgery, but that decision will based on much more than simply the MRI reading. So, many MRIs are leading to many unnecessary procedures further increasing the cost of care to the health care system. Physicians have an obligation to improve their patients understanding about a new technology and when the technology could be useful and when the technology might actually be harmful. We also have an obligation to utilize tests when clinically indicated and not simply because you do not want to have a 5 minute discussion with a patient. That time is well spent and can go a long way to diminishing the cost of health care delivery and improving a patients understanding of how the technology is useful.

Improving care, containing costs and educating patients is important to all of us… after all…

We are all patients !!!


This post is not meant as medical advice.  Whether or not imaging or other modalities are necessary to treat your condition is between you and your physician. 


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Gentle Nudges Work to Get People Exercising – WSJ.com

Great stuff… behavioral modification with simple triggers. #getupandmove and Contagion onto something! go @jensmccabe !! http://amplify.com/u/628g

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Improving the Patients Experience in Health Care…. #hcsm #PM #In

Brilliant speech by Bridget Duffy… A chief Patient Experience Officer… and a patient.

Why is our health care system so bad at addressing the needs of the patient ??? Because it is not constructed on a patient centric platform. It is constructed to provide patients with technology… it is technology centric. Hospital advertise how great their new MRI scanner is or how their robot is better than everyone else’s. Does that matter… to a point, yes— but our healthcare system fails to allay the patients’ fears about the technology and fails to address the basic human needs of the patient being exposed to that technology. The system fails to present the technology to the patient in a simple(to understand), friendly, warm and inviting environment that encourages learning, comfort and healing.

What portion of the healing process is technological ? 10%? 20%?… who knows. What I do know is that the more significant portion of the *healing encounter* is related to the entire experience the patient has with their physician, the mid-level providers, orderlies, and the *openness* of the institution. Why is our system so miserable at providing the essentials of the *healing process*? Who is going to step up and take the reins and change the system? We need to define the basics of the proper healing process and environment. We need to checklist the system so it can scale easily. We need to educate the next generation of physicians to pay attention to the entire healing process… we need physician leaders to step up, make some noise and change the process and reform the system.


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