Not really news if you pay even casual attention to health policy or any of the debate surround the Affordable Care Act. However, the numbers in stories like this are always staggering:
For a 200 mg gemcitabine injection, Hopkins collected $143. UPMC got $1,051.
That's over 7 times as much.
We must stop insisting on calling expert opinions guidelines. We should only call something a guideline when the data are very clear and we really have consensus on those data.
Guidelines fail when there is little or poor evidence; guidelines themselves are not inherently bad. Where we lack good evidence, we should invest in conducting sound research to fill-in our gaps in knowledge.
Perhaps when professional societies and government institutions develop guidelines they should include within them a roadmap for future research to answer looming questions...
Better information systems will revolutionize the practice of infectious diseases. The pieces [1] are already in place, we just need to stitch them together into a smarter digital tool. Penn Medicine seems to be working on such a solution.
The pieces include antibiograms detailing local resistance patterns, national data tracking the spread of infectious pathogens, patient-level microbiologic data from diagnostic tests like cultures and PCR analysis, and antimicrobial pharmacokinetic data. ↩
Admitting diagnoses can put blinders on to other possible diagnoses. This is a real problem and I think two possible solutions exist: (1) change the term 'admitting diagnosis' to 'preliminary diagnosis' or (2) change the admitting diagnosis to a list of the differential diagnoses based on the patient's presenting symptoms. I prefer the second solution, but also think many will do a poor job of developing a rationale differential.
A truly chilling article drawing corollaries between the contribution of performance metrics to the legal field's demise and the growing demand for similar performance metrics in medicine.
With each passing year, Big Med is following Big Law. Physicians, medical schools, and hospitals all proudly trumpet their standing in national rankings. Efforts to preserve and augment revenue streams produce a less patient-centered and more business-oriented approach to organizing the practice of medicine. Physicians are more and more commonly referred to as healthcare providers.
This is why the doctor-patient relationship—and using those specific identifiers—is crucial to the field of medicine. Doctors are more than care providers and patients are more than customers.
[Apple] wants to develop software and sensors that can predict heart attacks by identifying the sound blood makes as it tries to move through an artery clogged with plaque, the source said.
I find it highly improbable that Apple is trying to enter the medical device market. It just seems like an awkward move for them. Apple is secretive and prefers to control as much of the customer experience as possible. As 23andMe found out, the FDA likes to exercise their control over medical products. Why would Apple move into such a highly regulated market?
Regardless, I’m excited to see what they have up their sleeve, medically-focused or not.
Tim Lahey writing about a recent essay in Health Affairs discussing medical education’s ‘hidden curriculum’:
There is no doubt we need a better culture of safety in medical education. In a survey of Iowa medical students, 32 percent reported inadequate communication to families, 19 percent saw patient confidentiality breached, and 14 percent witnessed deliberate deception in the context of medical care. A New York state study called out another likely universal problem: medical students fear reprisal if they report errors to protect patient safety.
[…]
Amid such efforts, we must be mindful that there is more to culture change than talking about it, or even speaking up about medical error. Culture is constructed of words, undoubtedly, but the context in which those words occur is at least as important as the words themselves. We must remember, as McLuhan reminded us, the medium is the message. And the medium in medical education—from morning report to ward rounds and every committee meeting in between—is teamwork.
Great insights throughout this article. In current medical culture, physicians (specifically attending physicians) still function as leaders of care teams. A culture of patient safety begins with their leadership and their sense of inclusivity in terms of discussing patient care with the entire team.
A Canadian perspective on the role of social media in medicine.
Dr. Kendall Ho told the Straight that physicians need to inject their expertise into the health conversations that patients are having on social media or others will fill the void.
Exactly.
Multiple-choice board exams may not be the best assessment modality for doctors in training:
Educators may not actually teach to the test, but students think to the test, in linear multiple choice.
We spend the first few years of medical training imbuing our bright medical students with test-taking expertise focused on obscure and rare but well-characterized diseases. We then expend the remaining years breaking them of these habits to get them thinking of horses instead of zebras.
[See this related post about what med students use to study.]
Great podcast about the wonderful world of med school. Check out this episode for a great discussion of using technology on your med school journey. Subscribe to their feed in iTunes for automatic downloads of their episodes when they're released.
This movie should be required viewing for medical students, residents, pretty much any health care professional. Though there are several themes, I think it does an excellent job portraying the gulf that exists all too often between patients and doctors. Physicians tend to take a broader, more complex view while patients just want to do whatever it takes to get better. Both perspectives are valid and necessary, but are incompatible with one another without empathy. This is why I believe we need to be more inclusive of patients in all aspects of health care and do more things like patient-centered outcomes research.
Something I didn't expect when I started medical school—the importance of negotiation and 'selling'. Doctors are constantly negotiating with patients, which includes 'selling' them on a particular diagnostic or treatment plan. Those who do this best meet that patient halfway. They empathize with the patient's situation while estimating their health literacy (which requires knowing your patient) and think creatively how to present options in a logical, understandable way. And that simple sentence encompasses what 7 years of training is largely about.
Great post on the bureaucratic nightmare that is the 'compassionate use' process for using unapproved drugs.
I recently had the misfortune of experiencing the compassionate use process...I did a quick Google search to see how I could obtain IV zanamivir and learned that I needed to contact the drug manufacturer, the FDA and my IRB. I soon learned there were numerous forms to complete, almost all of which required me to record the same information over and over. From start to finish it took approximately 4 hours and the best word to describe the situation was kafkaesque...Maybe I'm just a simpleton, but couldn't there be a website where information is entered once and then routed to the appropriate agencies?...All of this makes me wonder how many patients don't receive treatment with potentially lifesaving drugs because the process is so painful, duplicative, time intensive and byzantine.
Similar byzantine processes exist for things like reporting adverse drug events...you know, not important stuff we don't want to have good data about.
Nice summary of the potential pitfalls for medical apps intended for use by medical professionals. Their last major area of concern:
Finally, the researchers cite concerns about medical app developers. Developers may lack an understanding of healthcare contexts and standards. They may be using data mining tools as mentioned above. They may also have included very little (if any) end user input during the design of their apps, which could lead to safety risks and inaccurate information or algorithms.
We need to generate a robust developer community that includes physicians in order to create a generation of great digital tools specifically designed for doctors.
Excellent primer on what exactly an antibiogram is and how it can help you. Required reading for all med students and residents. The antibiogram is your friend!
A few days ago, rumors surfaced about Apple’s upcoming release of their next iPhone operating system (iOS 8) and the much-rumored ‘iWatch’ device. The rumors include details of a new health and fitness app with the code name ‘Healthbook’. Here are a few links:
I highly recommend each of these articles to get a broad picture; for those who are time limited, the first post from 9to5Mac gives great overall context while the analyses from Fred Wilson and MG Siegler (two tech VCs) discuss important questions.
To Fred Wilson’s point about hooking collected data into existing health infrastructure via APIs, not only does there need to be data exchange but there also has to be demonstrated value. We always think more data is better. More data is only better when it is actionable. The big elephant in the mHealth/quantified self room is that no one has quite figured out what to do with all the data. Some highly motivated quantified selfers are using it to change their habits, but what impact will it have on the rest of the world?
[The following is an annotated Twitter chat between myself, Karan Chhabra, and Allan Joseph about the medical student debt problem. The quoted sections are our actual tweets and clicking the 
at the end of each will take you to the original tweet. I want to thank Karan and Allan for having the foresight to put this together. You can read more of their excellent writing at Project Millennial. Enjoy!]
America might never agree on how much doctors deserve to earn. But there ought to be much less debate on the immense debt today’s medical students incur on the way to becoming doctors. Few people are more aware of the stress of medical student debt than med students themselves and there is evidence that it affects our specialty and practice decisions later on down the line.
The costs of American medical care are obnoxiously high. On this, few disagree. Part of these costs stem from the high salaries of our physicians. But their salaries might (or might not) be justified by their astronomical debt levels upon graduation. Few people are more aware of the stress of medical student debt than med students themselves, and there’s evidence that it affects our specialty and practice decisions later on down the line.
Enter this tweetchat. What began as a typical med student complaint about their debt load evolved into a provocative discussion about the underlying factors and potential solutions to the debt problem. We’ve incorporated some notes explaining perhaps unfamiliar concepts, but otherwise this is the unvarnished product of a few med students procrastinating on a Sunday night.
@JoshHerigon: Median med school debt today = $170k vs in 1978 = $48K (adjusted for inflation). http://goo.gl/iTtMH9 #meded
@krchhabra: ARGH RT @JoshHerigon: Median med school debt today = $170k vs in 1978 = $48K (adjusted for inflation). http://goo.gl/iTtMH9 #meded
@allanmjoseph: @krchhabra @JoshHerigon Yes, but…more demand than ever for spots, & vastly higher teaching/resources since then. Complex issue.
AJ: The easiest way to tell if med-student debt is becoming an acute problem is if the demand for medical-school spots (easily measured by the number of applicants) is declining relative to the supply. That’s just not happening. In fact, the opposite is.
@krchhabra: @allanmjoseph @JoshHerigon I’m skeptical that teaching is any more resource-intensive than it once was (except perhaps for standardized pts)
KC: Standardized patients are actors paid by medical schools to act out clinical scenarios as we pretend to be doctors. They’ve been a useful component of clinical skills instruction for several decades—but their help isn’t free.
@allanmjoseph: @krchhabra @JoshHerigon At least here, our student:instructor ratio is insanely good, and so are our useful support structures.
@allanmjoseph: @krchhabra @JoshHerigon Not saying it’s all reflected, but I also don’t think it’s an apples-to-apples comparison.
@JoshHerigon: @allanmjoseph @krchhabra Our campus is probably nicer…
JH: Even more than a decade ago when I was an undergraduate, the arms race between universities to build bigger and better facilities was well underway. Examples are not hard to find. Medical schools and academic medical centers are active participants in this trend. In 2007, my own institution announced a 10 year, $800 million expansion. It’s not clear how capital improvement projects impact student tuition—administrators argue such projects are paid by dedicated capital funds, supported by the state, private donations, and/or bond initiatives. But, new facilities increase annual maintenance budgets and in the face of shrinking annual operating budgets, where do administrators make up the difference? Again, the impact of capital projects is not obvious; what is obvious is that tuition rates have not decreased with these projects.
@krchhabra: @JoshHerigon @allanmjoseph But we’re talking about secular time trends. Is your student/teacher ratio better than it was 20 years ago?
@krchhabra: @JoshHerigon @allanmjoseph of course there’s more small group learning than there used to be. But that doesn’t justify 3x price increase
@krchhabra: @JoshHerigon @allanmjoseph I use “price” intentionally - schools can charge whatever they want; the govt and students will always oblige.
KC: Once an English major, always an English major. I’m trying to highlight the difference between prices and costs here–costs the amount of resources expended in providing a service (a pretty objective quantity), whereas prices are chosen by the seller (often based on the highest amount the market will tolerate). What I’m trying to say is, the rapidly rising price of medical education doesn’t necessarily reflect increases in its underlying costs.
JH: Federal support of education through student loan programs has increased access to higher education, but at what cost? Students are now insulated from the true price of their education. Their tuition payments are abstract numbers on a page they see once a semester. Financial aid counselors (in my limited experience) fail to explain the true financial impact of student loan payments. Students are sold on the various deferrment options, repayment plans, and forgiveness programs (most of which students won’t qualify for or will increase the overall cost through deferred interest payment). Even with sufficient explanation, it’s hard to fully conceptualize until you make that first payment.
@allanmjoseph: @krchhabra @JoshHerigon Fair enough. Aside: I also think med students whining about debt can come off as tone-deaf, even if justified.
AJ: Quite frankly, when physician unemployment is nonexistent and even the lowest-paid specialties average six-figure salaries, we don’t have a lot to whine about. The reasons to care about this, from a policy perspective, are the positive externalities (that don’t accrue to doctors) from having the best and brightest students enter medicine.
@krchhabra: @allanmjoseph @JoshHerigon in light of future incomes? Perhaps. Though I think the average doc’s income will drop vs those trained in 78.
@allanmjoseph: @krchhabra @JoshHerigon From a systemic standpoint, they probably should, at least in many specialties. (Shh, don’t let the AMA hear!)
@krchhabra: @allanmjoseph @JoshHerigon it’s okay. There will always be surgicenter facility fees for when we need a quick buck (right?)
KC: Historically, doctors and hospitals have been paid separately for work that happens within a hospital’s walls. Doctors get a “professional fee” for their time and expertise, and hospitals get a “facility fee” for nursing care, materials, and all the other costs they incur in providing care. But in physician-owned surgical centers, doctors get both the professional fee and the facility fee. It’s as lucrative as it sounds, though Obamacare plans to curb these arrangements.
@JoshHerigon: @krchhabra @allanmjoseph Ha! Or you can always moonlight during residency…
JH: Moonlighting is when a doctor works outside their regularly scheduled hours (typically overnight, hence the name). Residents have historically done this during their training to supplement their paltry salaries. However, resident work hour restrictions are now decreasing this (moonlighting hours count against the total hours worked).
@JoshHerigon: @krchhabra @allanmjoseph Not saying med school should be free or even debt-free, but we need lower prices and better loan terms.
JH: I believe loan terms are the core issue and have been for a long time.
@krchhabra: @JoshHerigon @allanmjoseph You nailed it with loan terms. Super generic, don’t account for reliable, delayed income doctors get
AJ: Most medical students borrow for medical school through the federal government’s Stafford loan program, as well as the Graduate PLUS program if needed. It looks like there’s a lot of repayment options, but when you dig into it…they’re all variations on very few themes.
KC: And the problem with that is, the incomes of med school grads have little in common with those of other grad schools. Most grads (law, business, PhD, etc.) see a healthy income soon after graduation, increasing steadily thereafter. Medical school grads look forward to 3–10 years of paltry income while they’re training, followed by a huge jump once they’re board-certified. Loan payments can be suspended while in training, but the debt still accrues interest at a rate equal to other graduate loans. This makes little actuarial sense when you consider how low physicians’ default rate ought to be, compared with graduates of other programs. (Physicians’ unemployment rate is 0.8%, versus 2–3% for graduates of any graduate/professional school.) A tailor-made loan for medical students would adjust for physicians’ comparatively low incomes at graduation as well as their substantial, reliable incomes after residency. Though I’m not an actuary, I think loans on this terms would be much more fair and affordable.
@allanmjoseph: @krchhabra @JoshHerigon Absolutely. 100 percent agree with you there.
@JoshHerigon: @allanmjoseph @krchhabra One of you guys should create a start-up that buys up med school debt at better terms. ;)
@krchhabra: @JoshHerigon @allanmjoseph I’ve actually given this some thought. Just need a few wads of money I don’t currently have ;-)
@JoshHerigon: @krchhabra @allanmjoseph Me too.
@allanmjoseph: @JoshHerigon @krchhabra And now I’m giving it thought instead of reading about NK cells. Let’s find an angel investor.
@allanmjoseph: Hey, followers, @krchhabra, @JoshHerigon and I have a killer business idea. Who wants to give us a few million to make it happen?
AJ: We joke about this, but it’s moderately surprising some enterprising financial firm hasn’t found a way to make this happen. (There’s probably a regulation about federal student debt that hampers it, but still.) More obviously, though, there’s room for policy changes to improve this system.
Wearable strategies may be getting out of hand...
Mihir Gupta:
The two most popular resources [for med students on their internal med rotation] were both banks of practice questions, while the next two included a review book and a pocket handbook. (The top four resources: MKSAP question book, USMLE World question bank, Step Up To Medicine review book, and Pocket Medicine.)
This is in no way surprising. Look at almost any med school grading rubric and you will see that for clinical rotations, the Shelf Exam (a multiple-choice test) accounts for the majority of the grade. Medical schools do a poor job of evaluating how well students care for patients and develop clinical reasoning.
…As one surgery faculty put it, “Would you really want your life in the hands of a doctor who aced his multiple-choice boards questions but hasn’t read a textbook?”
I don’t want my life in the hands of a doctor who only aced his multiple-choice boards questions nor one who just read textbooks [1]. I want a doctor that did both of those things, but also completed intensive clinical training under the guidance of expert clinicians. We can easily measure performance on multiple-choice exams and even textbook content; it’s very difficult to objectively measure clinical expertise.
Until medical schools and the National Board of Medical Examiners develop methods other than multiple-choice exams for evaluating students [2], students will continue to use the most expedient resources to learn material for such exams (e.g.—question banks).
I wonder how much this surgical faculty member has relied on Step scores and class rank for choosing residency candidates for his program. The high stakes of Step scores for residency selection drives students to study in terms of exams instead of clinical knowledge. ↩
Let’s be clear—multiple-choice exams are problematic for evaluating students. It’s not because our heavy reliance on them incentivizes students to use question banks instead of in-depth studying with textbooks. Multiple-choice exams are problematic because they limit the scope of topics to well-characterized diseases and treatments. For example, chloramphenicol is an antibiotic developed 1949 and one student’s studying for Step 1 typically memorize as it may appear on the test. Why? Because it has a well-characterized and unique side-effect—gray baby syndrome—that lends itself to biochemistry questions. Unfortunately, chloramphenicol is rarely used in clinical practice. The only people who may use are infectious diseases doctors and only as a last resort. So, students spend time learning about this drug they may never encounter in practice instead of dedicating time to more commonly used antibiotics. ↩
This hassle is exacerbated by the fact that healthcare is one of the few consumer-focused industries where being a few minutes late is a sin so grave that it’s punished with a total cancellation of the appointment, and sometimes even the forfeiture of the fee.
I was ten minutes late to an appointment the other day, and the doctor poked his head out the door to let me know I’d have to reschedule.
“Can I come tomorrow?” I said.
“Give me a call.”
This article is full of such great quotes it’s hard to choose a single one to highlight its awesomeness.
One problem with American healthcare is that it attempts to staple a simple documentation system favored by doctors, who prefer to focus on patient care, onto an increasingly convoluted payment system favored by insurers. Nothing compares with the agony of losing the paper itemized receipt from an out-of-network doctor that you were planning to file for reimbursement using your insurance website. (Also, be sure you have a scanner at hand! Remember scanners? You bought yours in 1998.)
I pulled out this paragraph because I see this as a major problem. Medical records, which have traditionally functioned as a physician-to-physician communication tool, are now driven by billing considerations. Since payment by insurers is dictated by what is contained in the medical record, doctors are bastardizing their records to conform with what the insurers want. No longer are they about the patient; they’re about insurers.