My Au Pair is on vacation this week. Miami. Lucky girl. After a week of unremitting motherhood I have found myself saying to my children things I swore I would never say. Like “Because I said so!” and “Enough is enough!”. My kids are six years old and under, so perhaps such non-logic works. Unfortunately, I sometimes find myself wanting to say the same things about to fully grown adults.
A few days ago WBUR.org (Oh, my beloved NPR, how could you!) published a piece about the so-called “Home birth Caesarean Section”, otherwise known as “Holy %$^&# there a big problem, call a doctor!”. (http://commonhealth.wbur.org/2015/03/what-to-expect-when-youre-birthing-at-home-a-c-section-possibly#more-49283) It seems that women, wanting an “ideal” home birth and finding themselves or their babies in dire straights, need years of therapy to assuage the guilt, shame and terror that accompanies transfer to an hospital and the subsequent medical interventions that save the lives of themselves and their offspring.
People, women used to die in droves while undergoing “ideal”, “natural” childbirth. The reason they don’t anymore is not because midwives and doulas have perfected breathing techniques and patented birthing benches. It is because of science and medicine. The anti-vaccine movement is a parallel example. Children don’t die in droves anymore from measles; why? Medicine and science.
Enough is enough! Science is not the enemy. Doctors are not out to ruin your beautiful, natural, organic lives. Use the advances that scientists and doctors have worked so hard to discover and develop. All our lives are immeasurably easier because of what these men and women have done. Do what we say, because we say so, just every once in awhile. Please.
When I was a young violin student I had to change violin sizes at various times as I grew. Each time felt funny, and each time my teacher would say “You’ll get used to it”. The Affordable Care Act, i.e ACA, i.e Obamacare, is now hated by fewer people. Only 43% of Americans oppose it, down from 53%. Pundits are saying this is because the recent open enrollment period went smoothly. That may be true, but if we take a lesson from history we can see that slow acceptance of the ACA is to be expected. We’ve gotten used to it.
Take, for example, the New Deal. The New Deal was a set of laws enacted in the wake of the Great Depression. These laws resulted in policies and institutions such as the FDIC, the criminalization of child labor, the Fair Labor Standards Act that established the 40 hour work week, and Social Security. Most people today would consider much of the New Deal to have been a pretty good idea. But that was not the case in the 1930s when these laws were passed. Rich people didn’t like it. Republicans didn’t like it (they thought the Social Security Act smacked of socialism. Funny, huh?). Conservatives thought there was too much infringement on individual rights. A third of the public didn’t like it, as judged from the 1936 election. Doomsday predictions claimed that the legislation would take away human rights, create too much big government, and ruin the constitution. Some would still argue that these predictions came true to some extent, but no one wants a repeal of child labor laws, and Social Security is now a political third rail.
In the case of the ACA, the opposition has been remarkably similar. Infringement on individual rights, states rights, big government, socialism, unconstitutionality, all these accusations have been thrown at the ACA. Additionally we have been told that the ACA would bankrupt the government, limit physician choice, and establish death panels. Some of these claims are still under review. But health care spending has gone down, more people have access to health care, and no death panels have materialized.
Parts of both the New Deal and the ACA either didn’t work or were deemed unconstitutional. But some parts stayed, and eventually became part of life in America. People got used to it. Just as people are getting used to the ACA.
As Congressional Republicans are acutely aware, it is much easier to prevent something from happening than it is to take it away once it has happened. This fact is based in the human tendency to give much more weight to loss than gain. We see this in end-of-life discussions, where doctors find it is more painful for families to decide to remove life support than to decide not to institute it. Such tendencies can be positive or negative. At work it is well known that once a new rule gets instituted we’re stuck with it; a rule, once made, is virtually impossible to get rid of, even if it doesn’t have the desired effect. Standardized testing in public schools is here to stay too, even though such testing has been shown to be a poor measure of real learning. On the other hand, a rule that works and makes sense, like a seat belt law, will also never go away, and eventually people get used to it and lives are saved. Once people got used to Social Security it became impossible to take it away. Once people get used to having insurance it will eventually become impossible to take it away.
Once something becomes status quo people tend to forget what they were so worried about.
As an anesthesiologist, and a recently retired one at that, I have looked upon the battle between the American Board of Internal Medicine (ABIM) and internal medicine doctors about Maintenance of Certification (MOC) with a sort of interested detachment. I’m interested because the corresponding anesthesia society is having the same arguments, and detachment because I’m not an internal medicine doctor. In case you haven’t heard, credentialing societies within medicine are having a bit of an argument with the doctors who are credentialed over re-certification exams and other MOC requirements. The societies say they are necessary to maintain standards, the doctors say they are pointless and expensive. I have talked about MOC on this site before and readers have generally either sided with the doctors or decided that all doctors are whiners who just don’t want to be held accountable.
Believe what you want about the actual educational value of MOC requirements. A new report out in Newsweek suggests that there is no question as to the monetary value of MOC requirements. (http://www.newsweek.com/ugly-civil-war-american-medicine-312662) And you don’t have to believe me, or Newsweek author Kurt Eichenwald. Wes Fisher, a fellow MD blogger and a leader on the social media front of the ABIM battle, has a very in-depth piece about it on his own site (http://drwes.blogspot.com/2014/12/the-abim-foundation-choosing-wisely-and.html).
In 2001 (just before the new exam requirements) the ABIM had revenue of around $16 million, and the boss got about $230,000. In 2013 ABIM raked in $55 million, and paid the boss $645,000. But that’s not all. The ABIM Foundation, a somewhat murky organization founded in 1999 dedicated to “professionalism”, has $74 million in assets and brought in $20 million on those assets. Both the ABIM and the ABIM Foundation are non-profits.
OK, you say, but the ABIM needs the money to help it’s physicians with educational programs, continuing education, and so forth. And the foundation does good work with it’s Choosing Wisely campaign (a program designed to encourage appropriate use of diagnostic testing and other interventions). Well, OK, but there is that $645,000 salary for Christine Cassel (the boss). And the fact that 97% of ABIM money comes from physicians paying fees while only 14% of the money goes to physician education programs. And of course there’s the condo. Oh, you didn’t know about the condo on a posh street in Philadelphia? Yeah, it’s super nice. $2.3 million bucks. It comes with a chauffeur.
What has happened to medicine? How have we come to this place where doctors don’t trust patients, patients don’t trust doctors, and doctors can’t even trust other doctors?
Medicine is obsessed with numbers. Or rather, journalists and medical administrators are. Here are two related examples of how large a grain of salt one must put on numbers.
Cardiac surgical procedures, like everything else in medicine, have quality indicators. One of these is what we doctors call “30-day mortality”. What this term means is that surgeons are evaluated in part on how many of the patients they operated on died within a month of having surgery. Presumably a surgeon whose patients rarely die within 30 days is a better surgeon than one whose patients die all the time. The American Academy of Hospice and Palliative Medicine, whose members deal frequently with the elderly, thinks this number, 30, harms old people. http://nyti.ms/1AR3OqB. The problem, according to Paula Span of the New York Times, is that surgeons refuse to operate on people who are more likely to die within 30 days, and that they keep patients alive in ICUs until day 31 to keep their numbers up. Bad doctors!
The problem with the number 30 is not that it’s to short or too long, it is that it is a terrible metric for quality. Patients die despite everyone’s best efforts, especially patients who are at higher risk for dying to begin with. We need to find a metric that actually reflects quality of care. Of course doctors are going to be leery of operating on really sick people, if their jobs are at stake! I know people would like for doctors to be saints who take care of everyone all the time with nary a pecuniary thought, but I’m sorry, doctors are not saints. Neither are patients.
Speaking of risk, here’s number two reason numbers are evil. A recent article in the Journal of the American Medical Association reviewed the current literature on how accurate patients assessments of risks and benefits are. The authors found that 65% of the time patients overestimate the benefits and 67% of the time they underestimate the risks. The problem, according to Austin Frakt and Aaron Carroll of the New York Times, is that doctors don’t give patients adequate information about risks and benefits. http://nyti.ms/1wJ8LwC. Bad Doctors!
The problem is not that doctors don’t give people the numbers. The problem is that the numbers don’t influence patient’s decisions. Reams of research as well as best-selling books by people like Nobel prize winner Daniel Kahneman tell us that risk assessment has little to do with statistics. Humans estimate risk based on things like what is most prominent in the news, how they feel about the risk in question, and how closely they compare to others who have undergone the event in question. For example, women who have had bilateral mastectomies after a breast cancer diagnosis were asked how much the surgery had decreased their risk of recurrence. The average response was women felt their risk had gone from 76% to 11%. The actual risk before surgery is actually only 17%, so the surgery reduces the risk of recurrent breast cancer six percentage points. (This is for women who don’t have the BRCA gene). I’m sure women are told what the risk of recurrence is and how much the surgery decreases the risk. I’m sure they are. But the numbers are being told to women who are scared out of their minds about breast cancer and just want it to go away. They don’t hear nor care what the statistics are. That’s called being human. Pick a subject. Vaccinations – gross overestimation of risk because the guy down the street has an autistic kid. Dying in a plane crash – driving in your car is way more dangerous but the newspaper just had a big story about a horrific plane crash. Ebola – one case in the US but everyone is afraid they will get infected because it’s a really bad disease.
Please. No more numbers.
The New York Times is driving me batty today. No fewer than three articles on over-medicating, and all of them confusing.
Article number 1: Psychiatric drug overuse. http://nyti.ms/1wHaQJn.
Federal investigators say they have found evidence of widespread overuse of psychiatric drugs by older Americans with Alzheimer’s disease, and are recommending that Medicare officials take immediate action to reduce unnecessary prescriptions. Toby S. Edelman, who represents patients as a lawyer at the Center for Medicare Advocacy, said, “We could save money and provide better care if nursing homes reduced the inappropriate use of antipsychotic drugs.”
This one is the least confusing, actually. Nursing homes, and sometimes caregivers in the home, use antipsychotics to control patients with dementia. The reason they do this is that staffing at a lot of these places is abysmal. The ratio of staff to patient that would be needed to adequately keep these patients safe would likely cause Mr. Edelman to protest that we are spending too much money on nurses’ aides.
Article number 2: SSRIs. http://nyti.ms/189klLa.
At least one in four women in America now takes a psychiatric medication, compared with one in seven men. Women are nearly twice as likely to receive a diagnosis of depression or anxiety disorder than men are. For many women, these drugs greatly improve their lives. But for others they aren’t necessary. The increase in prescriptions for psychiatric medications, often by doctors in other specialties, is creating a new normal, encouraging more women to seek chemical assistance. Whether a woman needs these drugs should be a medical decision, not a response to peer pressure and consumerism. Obviously, there are situations where psychiatric medications are called for. The problem is too many genuinely ill people remain untreated, mostly because of socioeconomic factors.
Julie Holland, who has been getting a lot of journalistic mileage from her assertion that women are over-medicated, has me wondering what the problem really is? Over-treatment or the “problem that too many genuinely ill people remain untreated”? Which is it?
Article number 3: Painkillers. http://nyti.ms/18fEsr2.
Using a strong painkiller is appropriate if clearly needed but a review of the relevant scientific data, published on Feb. 17 in Annals of Internal Medicine, casts doubt on how much opioid treatment is really necessary. The review was conducted by recognized experts in evaluating medical evidence and treating chronic pain at the Oregon Health and Science University, in Portland, Ore., and the University of Washington, in Seattle, Wash. The researchers found little or no evidence that long-term opioid therapy (therapy lasting more than three months) relieves chronic pain, in part because almost all the studies are of short duration. It is extremely reckless to allow opioid usage and deaths to soar in the absence of proof that the treatment is effective. By contrast, there is considerable evidence of opioid therapy’s dangers, including overdoses, opioid abuse, fractures, heart attacks and sexual dysfunction. Doctors and patients must approach long-term opioid therapy with great care. Many patients with chronic pain do not get enough painkillers at high enough doses, meaning that their pain is undertreated. Many others are overtreated and harmed by doses they probably don’t need.
Wait. I thought the authors (the editorial board of the New York Times) said that research has shown that long-term opioid therapy doesn’t help. Then they say that “many patients with chronic pain do not get enough painkillers at high enough doses”. I’m not sure what the medical expertise is of this editorial board, but I have to ask: Which is it?
I agree that there’s a lot of overprescribing going on. While demographic trends are all well and good, at the end of the day health care is personal. A woman on an SSRI performs much better at work, where crying is frowned upon. A nurse’s aide with 15 patients can’t watch them all adequately. Treating chronic pain is a very complex process involving narcotics, nerve blocks and stimulators, and psychological support, among other things, and no treatment plan is a smooth ride. These articles, which constitute blanket statements about what doctors should and shouldn’t be doing, are not helpful in the exam room. There it’s just two people trying to figure out what to do.
I was talking to a colleague of mine yesterday. (At least I flatter myself that I am a colleague. He has a writing job at a prestigious magazine while I, well, don’t.) We were talking about the doctor-patient relationship, as is our wont, and he said something that stood out to me as the quintessential statement of patients’ expectations about doctors. It goes something like this:
I expect that when I am sick the doctor, who makes a thousand times more than I ever will, will make me well.
There are two wildly different ideas in this sentence, which as we will see have become conflated in a way that was never intended. First of all, patients seem to be extremely sticky about money, specifically, how much a doctor earns. They seem sticky about it to an extent that they aren’t about sports figures and movie stars. While it seems to bother no one that a player in the NFL makes $20 million a year and that tickets to the home games cost $500, it irks the heck out of people to pay a $15 copay to a doctor who earns 100 times less. It might be that the NFL player’s purpose is to entertain us, while the doctor’s job is to “serve” us. Medicine is, after all, considered a service industry. Maybe making money off other people’s suffering bothers people, although lawyers and bankers are much better at that than doctors. Historically, doctors expected to get paid very little. One hundred years ago the doctor who saw you in the emergency room wouldn’t get paid anything at all, unless you were a private patient, in which case you would never go to an ER in the first place. The doctors who attended in the hospital, rounded, and taught medical students were unpaid. The money thing is fairly recent, and reflects the amount of money and time invested in education and training. Our society has chosen to make us pay a lot and then pay us a lot in return. In countries in which medical education is free or practically so, doctors get paid much less. And in areas of this country where most people have no insurance or only Medicaid, doctors don’t get paid much here either.
So that’s the first part. The second part of the sentence is the one that says when I am sick I will go to a doctor who will make me well. This is also a recent development. People used to call doctors when they were sick, if they could afford one, but they didn’t have any great expectations that the doctor would heal them. It was enough that he attended upon them and did the best he could with the limited means he had. As our ability to treat things has gotten better, expectations have risen, as they should. At this point, though, the expectation has become that somehow doctors can treat death itself. Doctors do the best they can with the means they have. That is all anyone can expect.
The biggest problem with my colleague’s sentence really is that the two ideas in the sentence, doctors get paid a lot and doctors make me well, have melded into a new sentence: When I am sick a doctor gets paid a lot of money so he better make me well. This is not a statement that leads to healthy doctor-patient relationships.
By the way, my colleague is an award-winning journalist, so when he writes his best-seller he’ll find out just how much more money he can make than his doctor!
OK, nobody panic. Remain calm and call anesthesia. Or maybe, if you’re 2, don’t call anesthesia. The New England Journal of Medicine on Feb. 25 published an article that warns of an increasing body of evidence suggesting that anesthesia is bad for babies. Denise Grady, a New York Times reporter, said this in her piece yesterday: (http://www.nytimes.com/2015/02/26/health/researchers-call-for-more-study-of-anesthesia-risks-to-young-children.html?ref=health&_r=0)”
“… five experts described a ‘heightened level of concern’ about the potential risks, called the data from animal studies ‘compelling’ and said ‘parents and care providers should be made aware of the potential risks that anesthetics pose to the developing brain.'”
Evidence of this possible risk as been growing since the 1990’s, when the first animal studies came out. In 2009, the F.D.A. and the International Anesthesia Research Society formed Strategies for Mitigating Anesthesia-Related Neurotoxicity in Tots or SmartTots, to futher research this potential problem. In 2012, SmartTots recommended that elective surgery under general anesthesia be avoided in children younger than 3. Here is what SmartTots is saying this year (http://www.smarttots.org):
Infants and very young children who are exposed to anesthesia may experience higher rates of learning disabilities and cognitive difficulties than children who are not exposed to anesthesia, according to research and emerging data presented during the SmartTots: Pediatric Anesthesia Neurotoxicity panel at the International Anesthesia Research Society annual meeting in Vancouver, B.C. “We want to impress upon people that there is a very reliable link between the animal and human data that is rapidly emerging,” said panel moderator Dr. Vesna Jevtovic-Todorovic, M.D., Ph.D., M.B.A., Professor of Anesthesiology and Neuroscience at the University of Virginia Health System and SmartTots Scientific Advisory Board member.
SmartTots warns that “Children younger than 4 years who were exposed to anesthesia for 120 min and longer for at least two times are at high risk.”
So what is this emerging data? Well, it’s mostly primate and rat data at this point. Researchers found, for example, that a single 24-hour episode of ketamine anesthesia results in very long-lasting deficits in brain function in nonhuman primates. Another found that multiple exposures to anesthesia before a monkey is two years old are a risk factor for the development of Attention Deficit Hyperactivity Disorder. Yet a third paper has demonstrated that common anesthetics, alone and in combination, caused damage in the brain of baby rodents, with widespread death of nerve cells. These rats suffered long-lasting problems with learning and memory, which got worse as they aged.
Yikes. Now, as I said before, don’t panic. There are a few things to consider when reading about this stuff.
1. Your toddler getting her tonsils out or ear tube put in is not at risk. Those are 10 minute procedures in otherwise healthy children. Please do not let your kid suffer years of unnecessary infections and possible hearing loss because of concerns over the anesthesia. I know people are going to. Don’t.
2. Very young children exposed to surgeries lasting two or more hours on multiple occasions generally have either severe birth defects or severe injuries of some kind. I’m not sure you can isolate anesthesia as a cause of brain damage in these situations, in which cognitive development is at risk in multiple other ways.
3. I’m not sure what study Dr. Jevtovic-Todorovic is referring to when she talks about a “very reliable link” between nonhuman and human data. There is an ongoing multicenter study sponsored by Boston Children’s Hospital which is studying 650 infants getting inguinal hernia repairs, looking for neurodevelopmental outcomes in kids getting regional anesthesia (a spinal) vs. general anesthesia. Such a study will involve mostly healthy children with anesthetic exposures significantly lower than those SmartTots says are most concerning, but it might help.
4. General anesthesia is not just the drugs we use. It’s also the type of surgery being done, how much blood loss there is, how much oxygen gets to the patient, how much carbon dioxide builds up, how well blood pressure is maintained, and multiple other factors that anesthesiologists monitor very carefully. Many of these things are under our control, but all anesthesia and surgery interferes with these systems to some extent.
And since personal anecdote has been shown to be more effective than statistics, I will tell you that my second child had major thoracic surgery at age 3 days. She was under anesthesia for about 4 hours. She is now a healthy 4 1/2 year old with no signs of any mental problems except persistent four-ishness. Hope this helps.