Thursday, March 29, 2012

ACA debate in the Supreme Court - Join Me as I talk with Sam Bierstock at 2:30pmET #voiceofthedoctor

Cited as the "most important debate of our time" and the hottest ticket in Washignton DC this week the healthcare debate kicked off a record setting 6 hours of arguments over a period of three days. You can listen to proceedings here. You can download Monday (pdf transcript), Tuesday (pdf transcript) and Wednesday Part 1 (pdf) and Part 2 (pdf).

Tomorrow I will have the pleasure of talking with Dr Sam Bierstock, MD BSEE on Healthcare RadioNow in what will be my regular radio podcast spot for Voice of the Doctor 2:30pm ET. We will be discussing our initial thoughts on the proceedings and the potential impact this will have on healthcare and in particular clinicians. It should prove to be a lively debate as Sam and I have opposing views. We will be discussing the Affordable Care Act (ACA) (full text in pdf form) and in particular the Supreme court debate that centered on four questions

1) Threshold Question (Monday)
The justices must decide whether an 1867 law called the Tax Anti-Injunction Act prevents the court from even considering this bill right now. (A provision dating back to 1867 to prevent every man and his dog from challenging and holding up any taxation by challenging it as unconstitutional, refusing to pay it till the courts make a hearing and tying up the government in court rulings and bankrupting them in the process.

Under the regulation there are no penalties until 2015 so the argument is that there is no case because nobody has paid the penalty or suffered any financial injury yet.

The debate was lively and provided much fodder for various interpretations and views of possible outcomes. It seems unwise to attempt to divine the tea leaves - what does seem to be generally agreed is that healthcare has to change. On its current trajectory with the aging "baby boomers" who will get sicker and require more care and a current cost per head of population far higher than any other developed country, healthcare is on life support and not doing well.

2) Individual Mandate
The regulation requires everyone to have health insurance. Challengers assert that this is the first time the federal government 

Central to this requirement is the need to spread risk to allow for the other provisions in the regulations that mandate affordable coverage for everyone with no discrimination based on previous medical conditions, and a requirement to charge people in the same age groups the same rates.

The government counters that everyone consumes health care and that the only question is when. without the requirement to have health insurance the people who get healthcare without insurance are forcing everyone else to pay for it predominantly in the form of cross subsidization in the pricing

No matter who pays for healthcare there is an increasing focus  on value based purchasing. In fact e-patient Dave blogged on his most recent attempts to be a responsible engaged patient and his frustrations at the lack of transparency in fees, bills and the ultimate cost of the care and tests we receive. 

3) Striking down all other provisions
Is the mandate is truck down should this apply to all components and if not do some remain while others are struck down. Much of this is tied up with the concept fo shared risk. If there is no requirement for everyone to have health insurance then only those that are sick will buy healthcare coverage making the health insurance unaffordable and uneconomic

In this point there is mostly agreement - the government agreeing that the insurance companies could not sustain a business model with out the shared risk and the opponents arguing that all components are so inextricably intertwined that everything would have to be invalidated.

It does seem that without putting *everyone* in the pool the other principles of extended coverage are unfunded and likely non-starters. The underlying question seemed to be could the Supreme court carve this bill up or was this really a job for congress. Given the 2700 pages and the push back from the justices of going through this item by item if the individual mandate falls so goes the rest of the elements.

4) Is the Expansion of Medicaid Unconstitutional
Is coercing the states into participating in the program where the states share 50% of the costs for the poor and disabled. States have the option of opting out (none have done so to date). As set out in the regulations the costs of the big expansion of coverage are covered by the federal government for 3 years but this shifts to the states over the following years rising to 10% by 2020. The opt out is an all or nothing proposition - they can't opt out of just the expansion, and must either opt out of the whole program or take it plus the expansion and increased costs

My simple take on this - the states are happy to take the hand outs and have become increasingly dependent on federal funds but balk at the idea they might be required to extend the coverage.... or as one justice put it

"It’s just a boatload of federal money for you to take and spend on poor people’s health care"

There are three ways to tune in:

• Stream the show live – click the Listen Live Now to launch our Internet radio player.
• You can also call in. A few minutes before our show starts, call in the following number:  Call: 1-559-546-1880; Enter participant code: 840521#
• HealthcareNOWradio.com is now on iTunes Radio!  Stream the show live – you’ll find this station listed under News/Talk.

We will take questions in two ways:
• On the station website you can hit Join the Conversation on the top nav and post a question.

• Post a tweet in your Twitter account and make sure to use hashtag #voiceofthedoctor at the start or end of the tweet.

Posted via email from drnic's posterous

Monday, March 26, 2012

Facebook May Not Be So Friendly For Those With Low Self-Esteem : Shots - Health Blog : NPR

<blockquote class='posterous_short_quote'>Facebook May not be so Friendly</blockquote>

Facebook connects us but for those who struggle with social interactions the connections can amplify disconnects with main stream society. In an interesting piece on NPR featuring research from Ontario in Canada researchers found that:


People with low self-esteem posted far more negative updates than those with high self-esteem. Forest says they described a host of unhappy sentiments, from seemingly minor things like having a terrible day or being frustrated with class schedules to more extreme feelings of rage and sorrow

The effect was compounded by the perception of others on Facebook who disliked the type of negative comments, worsening the isolation. What does not appear in the piece but is in the actual broadcast with an interview with one student who had deleted his post he made a telling point, especially relative to middle school and high school age students. As he put it, at a time when children are moving away from the family, friends are more important and Facebook amplified isolation. It was not just about being "friended". The simple action of being tagged in a picture highlighted to you (and your peers) that you were "there". And for those that were not that they had not been invited. It used to be occasional discovery of exclusion from events - now your appearance, or more importantly lack of appearance, highlighted to the world your exclusion further disconnecting you from your peers.

So that makes me wonder how great an idea is for younger children in their formative years - is the age limit (ignored and certainly not policed) of 12 high enough?

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Cholesterol Drugs May Slow MS

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In an interesting development the Statin cholesterol lowering group of drugs is showing some effect at reducing the progression of MS suggesting that MS may be linked to lipid metabolism?


It included 81 patients with early-stage MS randomly selected to take either 80 milligrams a day of Lipitor (atorvastatin) or a placebo. After 12 months of treatment, 55.3 percent of patients taking the drug had developed no new brain lesions, compared with 27.6 percent of those who took the placebo.

While early results needing more study it does offer some promise of a treatment

Posted via email from drnic's posterous

Cholesterol Drugs May Slow MS

Media_httpdsservingsy_ihgfx

In an interesting development the Statin cholesterol lowering group of drugs is showing some effect at reducing the progression of MS suggesting that MS may be linked to lipid metabolism?


It included 81 patients with early-stage MS randomly selected to take either 80 milligrams a day of Lipitor (atorvastatin) or a placebo. After 12 months of treatment, 55.3 percent of patients taking the drug had developed no new brain lesions, compared with 27.6 percent of those who took the placebo.

While early results needing more study it does offer some promise of a treatment

Posted via email from drnic's posterous

Wednesday, March 21, 2012

Neglecting the patient in the era of health IT and EMR

Neglecting the patient in the Era of Health IT
Not to see what lies dimly in the distance but to do what clearly lies at hand

Dr Verghese from Stanford who has authored several books make the point that the doctor patient interaction is the most important aspect of healthcare


Here he talks about the importance of being present during the exam, in an era with so many distractions threatening to erode the vital relationship between doctor and patient. This interview was introduced by CEO Jonathan Bush and then appeared in two parts on the

And I commented on this back in 2008 in this piece
Doctor Please look at me not Your EMR that featured my own family experiences at the doctors office that I personally as excited about but my then 10 year old pointed out to me that all the attention was not eh technology not the patient

BUt it would seem that some clinicians are able to manage th challenges of time


One of my heroes is a physician who trained at Harvard and came from a small community in Laredo, Texas. He trained at Harvard and went back to Laredo and practices now, even in his 80s. And he has this ability to walk into a room and sit on the patient’s bed and create the illusion that he has all kinds of time and nowhere else he needs to be. And paradoxically by being so completely in the moment he manages to spend less time with patients than many of us who are hurrying to get on to the next thing.

So if there was some advice for busy clinicians today from the famous Scottish historian and critic Thomas Carlyle:


Not to see what lies dimly in the distance but to do what clearly lies at hand

Seems that this is good advice not just for healthcare but life in general given all the distraction we face

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Wednesday, March 14, 2012

Brain imaging, behavior research reveals physicians learn more by paying attention to failure

ScienceDaily (Nov. 24, 2011) — Research on physicians' decision-making processes has revealed that those who pay attention to failures as well as successes become more adept at selecting the correct treatment. The researchers also found that all the physicians in the study included irrelevant criteria in their decisions about treatment.

When seeking a physician, you should look for one with experience. Right? Maybe not. Research on physicians' decision-making processes has revealed that those who pay attention to failures as well as successes become more adept at selecting the correct treatment.

"We found that all the physicians in the study included irrelevant criteria in their decisions," said Read Montague, Ph.D., director of the Human Neuroimaging Laboratory at the Virginia Tech Carilion Research Institute, who led the study. "Notably, however, the most experienced doctors were the poorest learners."

The research is published in the Nov. 23 issue of PLoS One, the Public Library of Science open-access journal, in the article, "Neural correlates of effective learning in experienced medical decision-makers," by Jonathan Downar, M.D., Ph.D., assistant professor of psychiatry at the University of Toronto and Toronto Western Hospital; Meghana Bhatt, Ph.D., assistant research professor at Beckman Research Institute, the City of Hope Hospital, Duarte, Calif.; and Montague, who is also a professor of physics in the College of Science at Virginia Tech.

The researchers used functional magnetic resonance imaging (fMRI) to look at the brain activity of 35 experienced physicians in a range of non-surgical specialties as they made decisions.

The doctors were instructed to select between two treatments for a series of simulated patients in an emergency room setting. "First they had a chance to learn by experience which of two medications worked better in a series of 64 simulated heart-attack patients, based on a simplified history with just six factors," said Bhatt.

Unknown to the test subjects, of the six factors, only one was actually relevant to the decision: diabetes status. One medication had a 75 percent success rate in patients with diabetes, but only a 25 percent success rate in patients without diabetes. The other had the opposite profile. The physicians had 10 seconds to select a treatment. Then they were briefly presented with an outcome of "SUCCESS: (heart attack) aborted" or "FAILURE: No response."

"After the training, we tested the physicians to see how often they were able to pick the better drug in a second series of 64 simulated patients," said Bhatt. "When we looked at their performance, the doctors separated into two distinct groups. One group learned very effectively from experience, and chose the better drug more than 75 percent of the time. The other group was terrible; they chose the better drug only at coin-flipping levels of accuracy, or half the time, and they also came up with inaccurate systems for deciding how to prescribe the medications, based on factors that didn't matter at all."

In fact, all the doctors reported including at least one of the five irrelevant factors, such as age or previous heart attack, in their decision process.

"The brain imaging showed us a clear difference in the mental processes of the two groups," said Montague. "The high performers activated their frontal lobes when things didn't go as expected and the treatments failed." Such activity showed that the doctors learned from their failures, he said. These physicians gradually improved their performance.

In contrast, the low performers activated their frontal lobes when things did go as expected, said Bhatt. "In other words, they succumbed to 'confirmation bias,' ignoring failures and learning only from the successful cases. Each success confirmed what the low performers falsely thought they already knew about which treatment was better." The researchers termed this counterproductive learning pattern "success-chasing."

"The problem with remembering successes and ignoring failures is that it doesn't leave us any way to abandon our faulty ideas. Instead, the ideas gain strength from each chance success, until they evolve into something like a superstition," said Downar.

The fMRI showed that a portion of the brain called the nucleus accumbens "showed significant anticipatory activation well before the outcome of the trial was revealed, and this anticipatory activation was significantly greater prior to successful outcomes," Montague said. "Based on the outcome of the training phase, we were actually able to predict results in the testing phase for each low-performing subject's final set of spurious treatment rules."

The authors state in the article that the formation of spurious beliefs is universal, such as an athlete's belief in a lucky hat. "But the good news is that physicians can probably be trained to think more like the high performers," said Downar. "I tell my students to remember three things: First, when you're trying to work out a diagnosis, remember to also ask the questions that would prove your hunches wrong. Second, when you think you have the answer, think again and go through the possible alternatives. Third, if the treatment isn't going as expected, don't just brush it off -- ask yourself what you could have missed."

"These findings underscore the dangers of disregarding past failures when making high-stakes decisions," said Montague. "'Success-chasing' not only can lead doctors to make flawed decisions in diagnosing and treating patients, but it can also distort the thinking of other high-stakes decision-makers, such as military and political strategists, stock market investors, and venture capitalists."

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Story Source:

The above story is reprinted from materials provided by Virginia Tech, via AlphaGalileo.

Note: Materials may be edited for content and length. For further information, please contact the source cited above.

Journal Reference:

  1. Jonathan Downar, Meghana Bhatt, P. Read Montague. Neural Correlates of Effective Learning in Experienced Medical Decision-Makers. PLoS ONE, 2011; 6 (11): e27768 DOI: 10.1371/journal.pone.0027768

Note: If no author is given, the source is cited instead.

Disclaimer: This article is not intended to provide medical advice, diagnosis or treatment. Views expressed here do not necessarily reflect those of ScienceDaily or its staff.

Selecting the right treatment is a tricky business and this paper reveals some interesting results on physicians' decision-making processes
>>>Clinicians who pay attention to failures as well as successes become more adept at selecting the correct treatment.

These findings underscore the dangers of disregarding past failures when making high-stakes decisions," said Montague. "'Success-chasing' not only can lead doctors to make flawed decisions in diagnosing and treating patients, but it can also distort the thinking of other high-stakes decision-makers, such as military and political strategists, stock market investors, and venture capitalists

So when looking for a physicians maybe looking for the more experienced one if not the main characteristic to focus on.

Interesting ideas and helpful in understanding the clinical decision making process

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Monday, March 12, 2012

Doctors engaging in Social Media

Helpful piece covering the increasing number of clinicians who are jumping into the world of social media incorporating it into their practice and engaging patients in new, interesting and valuable ways.

SocialMed: Docs Worth Following


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