Archives For Doctors

Our insurance mess

November 19, 2015 — 1 Comment

FailA few months ago, I read the horrifying story in the New York Times written by a physician, Aaron Carroll entitled “Trapped in the System: A Sick Doctor’s Story”, about how difficult it was for him to get his prescription filled. At the time I joked with my husband that the story didn’t sound that bad to me.  My daughter has been taking “specialty drugs” (expensive drugs that are used to treat complicated medical problems like cancer, rheumatoid arthritis and multiple sclerosis) for several years and we have had many frustrating experiences, especially trying to figure out the medical bills. Her recent switch to a new specialty drug has caused the biggest problems yet.

Most insurance plans use other companies, called pharmacy benefit managers or PBMs, to manage prescription drugs. And PBMs use companies called “specialty pharmacies” (often owned by them) to manage specialty drugs, which are a key factor in driving up healthcare costs.

Continue Reading…

PeopleMy 85-year-old mother was recently hospitalized and the experience was a great example of how far our healthcare system has come and how far it still needs to go.

The good news is that she only required 2 days in the hospital, had no complications, felt dramatically better at discharge and felt “cared for” during her hospitalization.

Here are a few things that were great: everyone we encountered was very nice, she received a printed record of her hospitalization when she was discharged (it didn’t contain much useful information but that’s a separate issue) and she was helped to sign up for access to the hospital portal so she could review her records online.

In short, the customer service was excellent. However, there were 2 important failures to see things through her eyes – one on admission and one on discharge.

Continue Reading…

PillRandomized controlled trials (RCTs) may have lots of problems, but they remain the “gold standard” to determine whether a drug or treatment works. A recent study published in the BMJ, again raises concerns about trusting clinical trial results. The situation is outlined in an article in the New York Times about the antidepressant drug Paxil (paroxetine) and its safety in teens. The original study was published in 2001 in the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP) and the authors concluded that Paxil is “generally well tolerated and effective” for adolescents with major depression. However, since that time, experts have questioned whether the data really supports this conclusion and whether Paxil is really safe in young adults with depression.

In the recent BMJ analysis, the authors looked at the data from the original 2001 study and also some additional data they were able to get from the drug company that makes Paxil, GlaxoSmithKline. They concluded that Paxil is neither safe nor effective in adolescents with depression.

Continue Reading…

Scalpel combinedSeveral years ago a close friend asked me to recommend a surgeon for an elective procedure. I told her I had a colleague with a great bedside manner who also had great technical skills. He was absolutely the person I would go to if I needed general surgery. My friend went to see him but ended up using a different surgeon. When I asked her what she liked about the other guy, she said that he told her that he was “the best” surgeon to perform the procedure. She didn’t like his personality but he instilled her with confidence.

The truth is that there is no single “best” surgeon for everyone. And there are many factors that go into picking a surgeon: insurance issues, convenience, etc. And there are advantages to going to a surgeon who works well with our primary care physician (communication) and in having surgery in a place that has an electronic medical record that our primary care physician can access (coordination of care). But the most important thing is how skilled the surgeon is at performing the surgery we need. How do we figure that out? The short answer is that we don’t.

Continue Reading…

Using art to heal

June 30, 2015 — Leave a comment

Health factors2Because Health is Life, our lifestyles are just as important to our health as going to the doctor or taking our medicines. In a paper published June 30, 2015 in the Annals of Internal Medicine, a study looking at survey data found that half the heart disease deaths in the US from 2009-2010 were caused by 5 factors all of which can be modified through healthy behavior: smoking, obesity, high cholesterol, diabetes and high blood pressure. But many of these behaviors are difficult to change and are influenced by our families, our culture and our community.

This picture shows that clinical care by doctors and hospitals accounts for only about 20% of health outcomes. The picture comes from a project called County Health Rankings developed by the University of Wisconsin Population Health Institute (and supported by the Robert Wood Johnson Foundation) that looks at health by county in the US. Addressing factors like cigarette smoking, income, education, employment, housing and clear air can help make communities healthier places to live.

We need to find ways to build healthier communities and the arts may be one way to accomplish this.

Continue Reading…

N-of-1During my medical training, we were taught that if a patient responds to a treatment, it doesn’t necessarily mean that every patient will respond in the same way. The results in a single patient might be due to chance so it was important to look at the results of well-designed research studies before we could conclude that the treatment really worked.  In statistics, “N” refers to the sample size in an experiment so we referred to these individual observations as “N-of-1” experiments (and we did not look at them very favorably).

Unfortunately, there are lots of problems with research studies – they take a long time to complete, the patients in the studies are very carefully selected and may be very different from you, there is often bias in the way the results are interpreted, etc.

What if doctors and patients had tools that allowed them to design high-quality experiments specifically for the individual patient?

Continue Reading…

Vaccines and trust

February 27, 2015 — Leave a comment

VaccinesMany years ago I worked in a travel clinic advising people about the immunizations they needed before visiting other countries. Sometimes shots were required for entry into a country, such as the yellow fever vaccine. But we also made sure that MMR (measles-mumps-rubella) and other vaccines were up-to-date. The reason was that while immunizations have been very successful in getting rid of measles (and other childhood illnesses) in the US, many countries still have outbreaks. The booster shots were not necessary in the US because we no longer had cases of measles. Until now.

We are seeing cases of measles (and other childhood illnesses) again because parents are increasingly refusing to get their kids vaccinated. The current outbreak of measles in California is causing a lot of public debate about how to force people to get their kids vaccinated. While we may need to find new ways to enforce vaccination, we also need to restore trust – people increasingly don’t trust doctors, pharmaceutical companies, government agencies or payers.

Continue Reading…

The gut and the brain

December 19, 2014 — Leave a comment

Gut BrainWe don’t normally think about the gut and the brain being connected. And yet many of us have gotten a stomach ache, nausea or diarrhea from stress or a feeling of “butterflies” from excitement. Or we may experience pleasure from certain foods or feel a need to eat when under stress.

The vagus nerve travels between the brain and other organs in the body and can transmit messages in both directions. The brain can send messages to the gut through chemicals (called neurotransmitters). The gut has its own nervous system (called the enteric nervous system or ENS) that controls digestion. But scientists now think that the ENS can also produce neurotransmitters to send to the brain.

The big question is whether the gut can actually cause symptoms and diseases of the nervous system.

Continue Reading…

The power of placebos

November 19, 2014 — Leave a comment

placeboLots of people talk about the placebo effect but what exactly is it?

The most reliable clinical studies compare a treatment that is being tested with a fake treatment (called a placebo). Generally, half the people in the study get the treatment and half get the placebo and the then the two groups are compared. In the case of pills the placebo is often a sugar pill. Researchers can even test the effectiveness of a surgical procedure by comparing it with a sham or fake procedure. In these studies (called randomized controlled trials or RCTs), patients (and their healthcare teams) don’t know who is getting the pill or procedure being studied and who is getting the placebo. The reason for this is that patients sometimes get better when they are given a placebo because they believe they will get better (called the “placebo effect”) or because their disease got better on its own.

So can patients get better just by believing they will get better? And can doctors actually prescribe placebos to help people get better?

Continue Reading…

Research in real time

October 15, 2014 — Leave a comment

Big Data2This past week, I was reminded of the problem of fraud in medical research when the British courts ruled that the mother of a child with autism had lied about her child’s symptoms. The woman was a supporter of Dr. Andrew Wakefield, the British doctor who published studies connecting the Measles Mumps and Rubella – MMR – vaccine to autism based on “data” he made up.

Published medical studies, especially randomized controlled trials, remain the most reliable way for doctors to make treatment decisions. But, in addition to fraud, there are many other problems with medical research studies including the fact that they cost a lot of money to perform and take a long time to complete. An even bigger problem is that research studies have not been done for most of the questions that doctors and patients want answered. And even if there is a relevant published study, the people in the study may be very different from you.

Continue Reading…