Posts Tagged ‘New England Journal’

Zen and the art of pediatric practice

July 27, 2012  |  General  |  No Comments

The picture shows Robert Pirsig and his son on the motorcycle trip that figured in his classic meditation about quality, Zen and the Art of Motorcycle Maintenance (1974). A wonderful recent editorial by Perri Klass in the New England Journal of Medicine, has the referential title “Zen and the art of pediatric health maintenance.” (The full editorial may be behind a paywall — if anybody wants a copy let me know.) Her essay is a riff on Pirsig’s pursuit of Quality.

The point is that it is a very, very difficult thing for a doctor to be completely centered in the moment when talking to a family about their child’s medical problem. It is similarly difficult when another person, say a medical student or a resident is describing the patient to you. It’s easy to skip ahead in your mind when you hear things, for example, jumping ahead to what tests the child might need or what to do next. I’ve certainly found myself listening somewhat distantly to a story, only to be yanked back to the moment by some trigger statement, as in: “Pardon me, Mrs. Jones, but he did what?” The hurried and harried aspects of today’s practice environment makes this especially hard: it’s difficult not to be thinking of the next task.

Taking a medical history is a conversation, and all of us have this sort of thing happen to us in usual conversations, especially if we are talking to someone who tends to ramble and circle around the point. We tune them out. So among many of the challenges of practicing medicine, really putting all else out of your mind and listening is something doctors struggle with every day. The good ones learn how to do it well.

That great sage of medicine, William Osler, is well known for his aphorisms. One of them is: “Listen to the patient — he is telling you the diagnosis.” Or, as Dr. Klass puts it:

So zen and the art of health care maintenance: it’s being there in the exam room, in the moment — clearing away the noise of yourself so you can look with eyes that aren’t looking beyond the person in front of you, listen with ears that are truly hearing what is said and what is not said. And I guess I invoked those religious overtones because, done right, there is something sacred about this encounter: the air is somehow hushed and stilled, and an elusive but everyday virtue hovers near to light the way — but only if you truly and absolutely pay attention.

Do ads for drugs affect physician prescribing behavior?

January 22, 2012  |  General  |  No Comments

Open most any medical journal, including the most prestigious of them, such as the New England Journal of Medicine, and you will see page upon page of glossy advertisements from drug companies for their products. This has been going on for many decades. Do these ads affect physician behavior? Are we more likely to prescribe ones we read about in ads rather than in scientific reports?

There has always been a concern that advertising, not science, can affect doctors’ prescribing practices. Surely the drug companies think so, or they wouldn’t spend all the money on the ads. They’re not stupid. Now one medical journal, Emergency Medicine Australasia, has taken a stand against the practice; they’ve banned drug company advertising from their pages. In an editorial, they explained why.

This followed extensive debate on the growing evidence about the detrimental effects of the drug industry in medicine. Among the issues discussed were that the industry, one of the most profitable in the world, distorts research findings, such that drug company sponsored research is approximately four times as likely to be favourable to its product than independently funded research; authors of company-sponsored research are far more likely to recommend a company’s drug than independent researchers, and researchers with industry connections are more likely to publish data favourable to a company’s product than those without; selective reporting of results by industry is likely to inflate our views of the efficacy of company products; the drug industry has been shown to engage in dubious and unethical publishing practices, including guest and ghost authorship, and to apply pressure to academics to withhold negative findings; and the industry spends enormous amounts of money on advertising, which has been shown to change the prescribing practices of doctors, increasing sales in a dose-related manner to the volume of advertising.

Doctors, for their part, generally claim that such advertising has no effect at all on their prescribing practices. I know I would deny it. But really, how would I know? Advertisers put enormous effort into sending subliminal messages that work beneath the surface of our conscious radar. I could be manipulated as much as the next physician.

Drug companies value drug advertising in medical journals because it works. It is regarded as highly effective by pharmaceutical marketers, generating at least US $2-5 in revenue per dollar spent, with returns growing in the long term.

Not taking drug company ads has large financial consequences for journals, especially the second and third-rank ones; they more or less run on advertising revenue. The top ranking journals can depend upon high subscription fees; the lesser ones can’t. There are also many journals sent out to doctors that are actually free. We call them “throw-aways.” Trash cans next to the mailboxes in doctors’ lounges are stuffed with them. These can have a useful bit of information in them here and there, but mostly they are massive advertisements for the pharmaceutical industry. Doctors recognize this. But I think we’re less aware of the huge number of ads that appear in highly-ranked journals.

Emergency Medicine Australasia is a foreign journal, based in Australia, and has small impact on American physicians. But the principle they are arguing may well become a trend. I think the internet will help this, since the high costs of printing and mailing medical journals could be dramatically reduced by having the journals online only. Only a small paid editorial staff would be required, since the folks who review and decide on publication are nearly all unpaid as it is. (I used to do that a lot; you get an annual thank-you note — and maybe a calendar —  for your efforts.)

I think it’s something to watch closely.

Still another reason your insurance premiums go up: cost-shifting from public to private payers is getting worse and worse

October 24, 2011  |  General  |  No Comments

A recent editorial in the New England Journal of Medicine makes an interesting contrast between the approaches public and private health plans have taken in controlling costs. It points out how governmental health programs — Medicare and Medicaid — have long focused on controlling costs by focusing on the unit cost of things. So they have paid less attention to how many of something, say a surgical procedure, gets done and more attention to the cost of each one. What can happen in this approach is that doctors do more and more of whatever it is in order to make up the lost revenue. This can be quite bad for patients. Overutilization of health services is already a huge problem; some estimates are that a quarter to a third of medical care provided in America is unnecessary. More care is not better care, although that notion in some way seems to go against our national ethic.

Private insurers have generally tended to take another approach: instead of largely focusing on the unit cost of providing a service, they have tried to control the number of times the service is provided, using such things as preauthorization requirements. The result has been predictable — the gap between the unit cost paid by private insurers, always more than public programs paid, has been getting steadily larger. In 2000, providers on average billed private payers about 15% more than public ones for the same procedure; by 2009, the difference was 30-40% more for the private ones. In the same period, public payers on average cut by 10-15% what they would pay for the procedure. So if you add up the math, you can see what has happened: in order to maintain revenues, providers are shifting the costs to the private payers. This cost shifting has been known in the healthcare world for years, but it is getting worse and worse. It represents a sort of hidden tax on all of us, and it is one of the things driving healthcare costs even higher.

I recommend the editorial. It’s short and easy to understand. It’s also eye-opening as to the magnitude of the cost-shifting phenomenon.

Quantity and quality in children’s healthcare

October 21, 2007  |  General  |  2 Comments

It is unclear what will happen after the president’s veto of the bill reauthorizing the State Children’s Health Insurance Program (SCHIP) and the inability of Congress to override his veto. John Iglehart, the highly-respected national correspondent for the New England Journal of Medicine, reviews the episode here. It is brief, understandable, and to the point. Whatever you think of the issue, it is clear opponents of the program misrepresented what it was.

But there is a deeper issue — quality, as well as quantity, matters. In a way, the SCHIP debate is about quantityof healthcare because it concerns access to care; children and adolescents are disproportionately more likely than adults to be poor, something SCHIP was designed to address. Another recent New England Journal article shows how qualityof healthcare for children is also a major problem.

This observation goes against the common wisdom, which has been that problems in quality of healthcare are not such a problem for children as they are for adults. The unspoken assumption has been that children’s conditions are somehow easier to diagnose and less complicated to treat than those adults get. So if the child could get to the doctor, then we presumed the child usually got the correct care. This is not true; deficiency rates in the quality of care for children were similar to those noted in adults.

What is the solution? We need to assume children are just as complicated as adults in their healthcare needs.

Quantity and quality in children's healthcare

October 21, 2007  |  General  |  2 Comments

It is unclear what will happen after the president’s veto of the bill reauthorizing the State Children’s Health Insurance Program (SCHIP) and the inability of Congress to override his veto. John Iglehart, the highly-respected national correspondent for the New England Journal of Medicine, reviews the episode here. It is brief, understandable, and to the point. Whatever you think of the issue, it is clear opponents of the program misrepresented what it was.

But there is a deeper issue — quality, as well as quantity, matters. In a way, the SCHIP debate is about quantityof healthcare because it concerns access to care; children and adolescents are disproportionately more likely than adults to be poor, something SCHIP was designed to address. Another recent New England Journal article shows how qualityof healthcare for children is also a major problem.

This observation goes against the common wisdom, which has been that problems in quality of healthcare are not such a problem for children as they are for adults. The unspoken assumption has been that children’s conditions are somehow easier to diagnose and less complicated to treat than those adults get. So if the child could get to the doctor, then we presumed the child usually got the correct care. This is not true; deficiency rates in the quality of care for children were similar to those noted in adults.

What is the solution? We need to assume children are just as complicated as adults in their healthcare needs.

The cost of not reauthorizing SCHIP

September 11, 2007  |  General  |  No Comments

As I write there is a looming battle between Congress and President Bush over reauthorization of the State Children’s Health Insurance Program, or SCHIP. The program ends at the end of the month unless it is reauthorized. SCHIP provides health insurance to children in families with too much income to qualify for Medicaid but too poor to afford healthcare. It is a complicated question, well reviewed in a recent New England Journal of Medicine article here. The controversy boils down to what we think the government’s role should be in providing health care to children. Most support helping the truly poor, those below the federal poverty threshold of an income of $20,650 for a family of four, but many balk at giving public money to families making as much as twice that. Another issue is that the SCHIP reauthorization bill, as with many bills, was quickly laden with extraneous add-ons.

I support SCHIP because, without it, children in families slightly above the poverty line suffer. When these children get seriously ill they will end up in PICUs like mine anyway, and if they have no insurance the government usually ends up with the bill. If these children had insurance for preventative care, they may well have not needed the expensive PICU in the first place. I would much rather see a comprehensive overhaul of our medical system, but I despair of that ever happening until the inevitable time in the future when things really do fall apart. Meanwhile SHCIP is a band-aid, but I think it is a needed band-aid.

Addendum: Here is an update–it looks as if some compromise will pass. Whether the president will sign it is another matter, of course.

Another addendum: Here is another update–a compromise passed both houses. It’s still unclear if the president will sign it.

Update: President Bush has vetoed the bill. It is unclear at this point if Congress will have sufficient votes to override the veto, but most expect that the Democrats will try to do this. They will need to attract Republicans to do so.

Sicko

August 22, 2007  |  General  |  2 Comments

No matter how you feel about Michael Moore, his new movie has highlighted an often overlooked issue in healthcare: many who think they have insurance find that, when they need it, their coverage falls short. I don’t think of his movie as a true documentary because he is, as usual, highly partisan in how he presents things. He is a polemicist, and opinionated polemicists are always loud and sometimes obnoxious. They are also wrong at times.

None of that matters here to me. What he has accomplished is to get this issue to the forefront, at least for a while. Even the New England Journal of Medicine is talking about Sicko; you can find a fairly dispassionate discussion about the movie here. It is a good review of the situation, and I recommend it.

For myself, I have encountered families who suddenly find their insurance contains key coverage gaps regarding what their critically ill child needs in the PICU, or at least in how reviewers at their insurance company interpret that coverage. It is difficult enough to have a child in the PICU; haggling with an insurance company over the telephone can add a crushing additional emotional burden to their situation. All parents want the best for their child, so a PICU admission is not the appropriate time to ask them to weigh the costs of a particular treatment and decide on that basis if they want it or not.

Medical ethics and futile care

July 8, 2007  |  General  |  2 Comments

This week’s New England Journal of Medicine carried an excellent editorial by Dr. Robert Truog, a highly-respected medical ethicist at Harvard. It is about futility of care. Most experienced pediatric intensivists, myself included, have encountered situations in which we, the doctors, believe continuing to support a child is unethical because it is not saving the life but prolonging the dying, whereas the child’s parents believe the opposite—that it is unethical to withdraw life support because all life is sacred, no matter the circumstances. Sometimes these situations arise because poor communication causes families to distrust the doctors. But sometimes both sides understand each other clearly, but still disagree profoundly about the proper thing to do. What happens then?

Doctors often make the argument that we should not prolong suffering. Establishing if a patient is actually in pain can be difficult, and anyway we virtually always have the means to relieve pain in these situations. More telling to me is the argument that families cannot compel physicians to act unethically, and most of us regard futile care as unethical. Yet even then the physician can simply withdraw from the case, although from experience I can tell you it is difficult to find another physician to take on cases like this, and abandoning our patient without finding them another physician is clearly unethical (and illegal).

What to do? I have been involved in several cases like the one Dr. Truog describes. Thankfully, in all but one the family and the doctors were ultimately able to reach an understanding both sides accepted. In the one case in which we could not agree, nature ultimately decided things for us, as she often does.

Stories like these remind me that the pediatric intensive care unit is a place where, if we pay attention, we can learn a great deal both about life and about ourselves.