Real Men Wear Gowns

But must they be so ridiculous – no one has ever explained to me why the gowns in hospitals are made the way they are.

Why, why why!

I can see that removing them when you are bed might be easier but there has to be a better solution…..
That aside – this is a serious point – The Agency for Healthcare Research and Quality (AHRQ) has set up a site directed at men to encourage them to be healthier and specifically to seek  medical advice and get regular checks ups

As noted in the recent article in the Washington Post Men Die Younger.

“It isn’t really that women are living longer, but men are dying sooner,” I persisted. “Among the top 10 causes of death, men have a higher mortality rate than women. Men are four times more likely than women to suffer from cirrhosis of the liver and alcoholism.” My voice rose a bit dramatically. “Men are dying, and no one is paying attention.

In the review in this posting the journey of discovery went through the self destructive habits of men (more men are drug addicts, drunk drivers and for every one woman dieing as a result of homicide. suicide and accidental death three men die). In fact it turns out that women visit their doctor and receive preventive care nearly twice as often as men! In addition genetics plays a role

males are built for competition and females for longevity

So AHRQ is trying to address some of these issues and behavior

The single most important way you can take care of yourself and those you love is to actively take part in your health care. Educate yourself on health care and participate in decisions with your doctor—even if it means wearing an examination gown. This site will help you get started.

So take the step, start getting as educated as you are on what Flat Screen to buy, what Derek Jeter’s RBI average is (OK if that doesn’t make sense – analyzing the terrible offside call and the Yellow card issued to Gates in the box!) – you get the picture.

Online Symptom Checkers

A long review of online symptom checkers (a Google system of searching medical texts) appeared on this Dutch web site WebWereld that made for interesting reading

The downside to these tools is the problem medical students, doctors, nurses and most other healthcare professionals suffer from – the recurrent fear they are suffering from <insert latest disease you read/studied here> (as a balancing side bar to this I went to medical school with someone who suffered a ruptured brain aneurysm and recognized his symptoms and walked himself to the ED/Casualty)

As the writer points out in many cases getting an appointment is tough proposition in the best of circumstances no matter what country you are in and when you do it requires getting there, waiting in a room full of lots of other people who are sick (increased risk of contracting additional infection!) and unless you are really lucky waiting interminably to be seen. Add to that the distinct probability that you receive treatment that may not be warranted (antibiotics for a viral infection for instance) simply because the expectation has been set that you took the day off, made the trip the least you should receive is a prescription for your trouble.

The sites reviewed

WebMD – which interesting did not produce different results even if you answered the questions it asked differently
Revolution Health – basic mapping to the body and symptoms and really more about educating the user than diagnosing (to include the usual disclaimer of calling your healthcare professional no matter what)
Mayo Clinic – still very broad with little to narrow searches to anything useful
About.com – yikes a general site for clinical diagnosis seems like a bad idea and sure enough no ability to get to useful information quickly enough
WrongDiagnosis.com – now you would expect this given the name to be a better performer but with 10,000 medical conditions and enormous lists of symptoms to choose form unwieldy

Their summary (not all scientific but worth listing)

• WebMD: 12 clicks to get a list of 15 possible causes
• Revolution Health: 2 clicks to get a list of 13 possible causes
• MayoClinic.com: 5 clicks to get a list of 7 possible causes
• About.com: 9 clicks to get a list of 3 possible causes
• WrongDiagnosis.com: 1 click to get a list of 6 possible causes

The New York times feature today covered the struggles of young adults balancing limited income with large insurance premiums and high cost of living. As one participant put it

There was no way that I could pay my rent, buy insurance and eat

So despite the limits of these systems they are being used and for many probably with reasonable success but this is tempered with the negative effect that include antibiotic misuse and resistance or masking of problems with pain medication:

We see people with urinary tract infections taking meds better suited for ear infections or pneumonia — the problem is, they haven’t really treated their illness, and they’re breeding resistance….Or they take pain medicine that masks the symptoms. And this allows the underlying problem to get worse and worse

There is no easy answer to this but as discussed in the NY times article coverage is cost prohibitive for many and the bills out of line with people’s financial circumstances.As with all caveats – Your Mileage May Vary (YMMV). It is hard to assess the usefulness of these sites as a fully trained physician. Years in medical   and clinical practice mean that you intuitively apply filters to this information and can navigate these sites as aide memoir’s to help as Zebra Hunters. So for those of you not clinically trained I’d be interested in your thoughts on any of the above sites – how did you find them

For the purposes of complete information these sites are long step away from real diagnostic support tools which base their clinical decision support on a more detailed history that is detailed enough and with specifics to help narrow the choices for causes for specific symptoms based on knowledge of disease symptoms and signs. The rule of thumb is that 80% of the diagnosis comes from the history, 15% from the physical examination and the remaining 5% from additional investigation. That mix has changed with the array of diagnostic tests and imaging choices but this is not necessarily a better more cost effective service. Case in point some years back when a relative of mine injured themselves skiing and was transported to the first aid station. They waited for their spouse to show up before allowing any kind of investigations to be carried out (in this case X-rays of the foot). Their spouse happened to be a clinicians who examined and diagnosed the specific fracture much to the amazement of the local clinicians who said that was impossible to tell without an X-ray….end result correct diagnosis and the treatment remained the same despite the X-ray. Sure it could have been more complicated but did it require an urgent (and expensive X-ray) there and then…..no way!

But there is real scope in the clinical world to use Diagnostic support tools and one I saw some years back showed tremendous promise – First Opinion. There are others Isabelle is probably the most well known and the concept is sound but the challenge is seeing the wood for the trees and getting to relevant information quickly. Integrated into an electronic medical record, driven by clinical data there is tremendous scope help support clinicians arriving at the right diagnosis quicker and more accurately and overcoming the tsunami of medical knowledge. But to get to that data requires the data to be entered somehow……forms, drop down boxes and hunt and click systems just don’t meet the need and turning clinicians into data entry clerks is not a viable or sound strategy. I made this point recently in a presentation and this was commented on in  the MTExchange forum regarding the concern over transcription jobs and the fear that this these jobs are disappearing. EMR vendors are using transcription as part of their ROI justification suggesting that the “elimination of transcription costs is as a sales selling point”. As Julie Weight said in her posting:

The fallacy in this is that highly-skilled, highly-paid professionals then perform the task of a medical transcriptionist – which makes absolutely no sense. Physicians struggle enough with the financial justification for an EMR; coupled with resistance to change, it has pretty much guaranteed slow adoption of EMRs, especially in smaller practices.

And went on to hammer this point

you wouldn’t find Jack Walsh typing his own annual reports or Warren Buffet manually entering stock values into the computer (well, maybe Warren does – but I’ll bet Jack doesn’t)

Exactly! Stop the madness, allow clinicians to capture information without creating a burden of data entry for the sake of billing and administrivia. Clinical documentation is supposed to support clinical care, so lets give clinical documentation back to the clinician, provide them with the means to capture all the fine detail necessary in a detailed narrative description that contains this detail but include the data elements that are necessary to feed the EMR’s. Allow clinicians to capture the full Healthstory that contains both these elements and satisfies the clinical need and computer’s insatiable demand for structured data.

Exercise is just Part of the Answer

There is a lot of advice in the media suggesting that with just 20 – 30 minutes of exercise per day all your troubles will be over and everyone would move into the realms of healthy  living, with no long term disease issues……this feels a lot like the old Snake Oil problems in the wild west many years ago.

One size fits all – doesn’t

The difficulty with this and the problems of selling this message are covered in this NY Times article “Does Exercise Really Keep Us Healthy?” that points out that while 20 – 30 minutes of exercise does reduce diabetic risk and improve Osteoporosis (bone loss) it will not provide sustained weight loss or blood pressure reduction on its own.

To be clear – exercise has many benefits and changing from a sedentary lifestyle to an active one will help in *all* cases but it needs to be part of a complete program that includes weights and most importantly diet. The population in general east too much and if you have ever bothered to find out what your meals contain in the way fo calories you’d know for yourself. Calories are as a good an indicator as any and you’d be shocked at what’s in most fast foods especially when stacked up against what consumption level you should be at for your sex, age, and height. Even worse if you should be reducing this to effect some level of weight reduction.

The difficulty, Dr. Blair says, is that it’s much easier to eat 1,000 calories than to burn off 1,000 calories with exercise. As he relates, “An old football coach used to say, ‘I have all my assistants running five miles a day, but they eat 10 miles a day.

And there you have it – exercise and diet. It sounds simple but its not because if it were we would all be svelte specimens living into our 80’s with few health problems and the health bill for our nation would be a much smaller proportion than the current 16% of our GDP

Healthcare Standardization and Rationing

The knee jerk reaction’s are out – this one from Bloomberg that suggests the Stimulus package and Obama will “Ruin your Health”, and this an “alert” on a blog suggesting this is “nationalizing” healthcare. There is a mad dash to kill the stimulus bill and in particular the health care elements that could limit access to health care by developing standards, defining protocols and determining if care is cost effective.

These are all hard discussions and hard decisions and I talked about this before in my posting on “Who Should pay for healthcare” that detailed some of the challenges faced in other countries in particular the UK which has developed the National Institute for Health and Clinical Excellence (NICE) group to attempt tackle these problems in a more scientific and rigorous fashion. This kind of reaction typifies the channel that everyone is listening to WIFM (What’s in it for me). Of course no suggestion of what we can do to deal with the rising cost of healthcare – the most expensive delivered in the world but only No 23 in quality of life measures. The scaremongering on this issue is based on scant data – if you want a sobering read I suggest you look at this report from the Insure the Uninsured Project web site titled: “Health Care Systesm Around the World” (warning pdf). While they all suffer some of the same challenges they are attempting to address them and in most cases doing a better job at delivering care.

I have to ask…..Betsy McCaughey says:

Keeping doctors informed of the newest medical findings is important, but enforcing uniformity goes too far

Why exactly? Do you want each physician trying his own brand of medicine, sampling different techniques, reading about some new innovation or drug and using that. You only have to look at the lack of science behind the Alternative Medicine billion dollar industry in Trick or Treatment to get a sense of how easy it is to be deceived into believing something offers value when it does not. Then look at the low compliance with known treatment protocols to understand that the system and its care givers are creaking under the strain of overwhelming data and choices. This from the AHRQ site on quality measures:

In one study, the overall rate of prescribing beta-blockers to patients after suffering an acute myocardial infarction (AMI) was 50%, and the rates of prescribing for family physicians was lower than those of specialists.

Yet we know this saves lives. But perhaps it is Betsy’s view that we are wrong to see healthcare as a “cost problem instead of a growth industry” and suggesting Healthcare “produces almost 17% of the nations’s GDP”……this is just astounding. I am certain that our car industry does not want to see healthcare as growth industry. They cited healthcare costs as a major contributor to their difficulty in competing.

If we made every last cent of our available resources available to pay for healthcare we would still not have enough. The industry and our technology will continue to create treatments, drugs, therapies to consume those resources (and typically those treatments are of higher in cost especially when first launched).

None of this is easy – but the resources are limited and as such there must be some mechanism to share the care and get the best we can for as many that we can. We don’t currently on all the generally accepted healthcare quality metrics and we pay by far the most per head of population. The system is broken. Left to our own devices we all clutch at any possibility no matter how remote or how unlikely the improvement in outcome might be (and in some cases actually harmful).

Perhaps the alternative is to leave it to the individual – put the patients in a room and ask them to justify the treatment amongst themselves and share the limited available dollars on the care. When they agree the care can be delivered. Of course that won’t work – no one wants to face those difficult choices or decisions and overlaying the additional emotional burden on this decision is not going to help. So others will have to make some of these choices and providing sufficient data to make informed decisions is essential and trying to apply some level of analysis and data to try and make it as “fair” as possible.

Agree…..disagree let me know. This is nto an easy issue but it does need to be addressed as satus quo is failing…rapidly.

Who Should Pay for Healthcare

A recent twitter on my part to an article by Health Imaging titled: “Americans want healthcare reform, but divided on how to pay for it” raised some comments that are worth exploring. The simplistic 4 word response I got back from one individual:

The Government should pay

Simply passes the responsibility from individuals to a group who receive power, authority and most importantly money from the same individuals . They are then charged with the responsibility of sharing out the limited resources “fairly”. As history has vividly demonstrated the challenge with fairness and charging a smaller group with equal distribution and fairness is problematic. George Orwell’s allegorical novel Animal Farm detailed some of these challenges.

Healthcare remains a central challenge to countries worldwide. Those with more resources do spend more of them on healthcare for their population. But there is no bottomless pit of money to pay for healthcare and unfortunately as the population gains increasing access to better healthcare their reaction is not satiation to the higher levels and increased life expectancy but wanting more. Countries approach this challenge in different ways – the UK healthcare system rationed healthcare with waiting lists and limited availability. In recent years they have attempted to define the rationing standards for healthcare under the banner of the “National Institute for Health and Clinical Excellence (NICE)“. A recent ruling on drug therapy

… it ruled that four drugs for advanced kidney cancer were too expensive for NHS use. The four treatments, NICE acknowledged, ‘have the potential to extend  progression-free survival by five to six months, but at a cost of £20,000 to £35,000 per patient per year’.

Their methodology assesses value against “Quality Life Adjusted Years” (QALY’s) that attempt a cost benefit analysis on treatments relative to potential outcome and quality of life. This is a difficult calculation even in the best of circumstances because the assessment of benefit changes dramatically from the perspective of the individual who in most cases assesses the value even if limited in time or effect.  In the case of the drugs for kidney cancer drugs NICE’s QALY assessment was”

Translated into QALYs—quality adjusted life years—that works out at between £71 000 and £171 000 a year; well above the rough threshold of £30 000 a year that NICE broadly applies other than in exceptional circumstances.

I commented on the NICE measure before where an individual wanted to pay for the drugs himself but in doing so fell out of the group coverage and was refused access.

There is no such thing as “free healthcare” – free at the point of service removes personal responsibility and encourages abuse. A simple case in point is the nuisance charge or co-payment. The United Kingdom has provided free home visits and free access to their General Practitioner for years.  But you only have to spend a night with an on call General Practitioner, especially round any holiday to experience the abuse. Calls at 3am for a headache. And not a new onset headache but one the patient has been suffering from in some cases days, weeks and even months. The introduction of a payment for all visits would discourage some of this and those opposed would suggest that it might discourage patients that should make the call. It might but the underlying issue of value would be solved – if the service is “free” then the value is perceived to be the same.

Providing healthcare to as many people as possible is right but in all cases a line must be drawn that is entirely dependent on the resources available. One can imagine that the availability of healthcare is much diminished in Zimbabwe. There the provision of midwifery delivery services to a preganant mother would require the patient to personally provide $20 Billion  Zimbabwean dollars (nearly US $40). But the resources available make this a bridge to far. And so to in all other countries – where we continue to consume every available healthcare resource made available. There is no instance where a country so much makes healthcare available that there is resources left unused, clinics and doctors desperate for patients because they are underutilized.

So what is the answer – personal responsibility and a full understanding of the cost and benefit of healthcare resources available. Attaching value to those resources helps comprehension. Patients can make informed choices in the same way that consumers do – why pay more for the iPod when a Micosoft Zune or SanDisk Sansa does the same job at a lower cost. Some do make the choice for iPod, others do not but they do so based on the available data and a cost benefit analysis. But if all the MP3 player’s were free or the same “cost” to us then the selection is harder and less informed. Free healthcare is a misnomer – everything has a value and attaching a value to healthcare but making it accessible to as many as possible is better strategy than just making it free.

Featured in the March issue of the British Journal of Healthcare Management – Stimulus and Effect: Rationing (full pdf subscription required)