Saturday, June 13, 2009

Medicine in the Age of Twitter -

I blog, I tweet and I use Facebook. And as I recently told a medical colleague, social media has been an enormously useful tool in my work.

“I can barely keep up with e-mail,” he snorted back. “I’m not about to open up that black box.”

About 15 years ago, during my residency and just as the first blogs were starting up, I took care of a patient in his mid-40s whom I’ll call Eddie. In a waiting room filled with elderly patients crippled by vascular disease, Eddie looked out of place. Until you looked closer at his fingers and toes. Parts of them had been amputated.

Eddie suffered from Buerger’s disease, or thromboangiitis obliterans, an illness that causes clotting and inflammation of the blood vessels of the hands and feet. Considered an “orphan” disease because of its relative rarity, Buerger’s disease compromises the blood supply to a patient’s fingers and toes. Eventually these patients, who are usually men in their 20s to 40s who smoke, develop excruciating pain, severe ulcerations and gangrene. And more often than not, they must undergo progressively higher amputations.

There is no cure for Buerger’s disease; the only way to slow the process is to quit smoking. Therein lies the tragedy. For unknown reasons, patients who suffer from Buerger’s disease are profoundly addicted to tobacco, far more so than most smokers. It is nearly impossible for them to quit.

Eddie wanted desperately to quit. Over the two years that I cared for him, he tried at least a dozen times. But his already challenging task was made even more difficult by his isolation. Eddie lived alone, estranged from his family, with friends and co-workers who grew increasingly unsympathetic to his plight. “They don’t understand why I keep smoking if I keep losing fingers,” he said to me one afternoon. “They just don’t understand how hard it is for me.” Moreover, because his disease was so rare, he had no community of fellow patients to turn to in his town or at our hospital.

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Steven Pearlstein - Fixing Health Care Starts With the Doctors- Washington Post

It's the doctors, stupid.

If we really want to fix America's overpriced and under-performing health-care system, what really matters is changing the ways doctors practice medicine, individually and collectively. Everything else -- mandate or no mandate, the tax treatment of health benefits, whether there's a "public plan" to compete against private health insurers -- is just tinkering at the margin.

I was reminded of this reality by a recent article in the New Yorker by Atul Gawande, a surgeon at Brigham and Women's Hospital and the Dana Farber Cancer Institute who somehow manages to find time to turn out deeply reported and elegantly written essays on health care. Like many health reformers, Gawande says the essential problem with the American health-care system is that so much of what we spend -- as much as a third of the $2.3 trillion spent in 2007 -- goes toward care that is either unnecessary or inappropriate. Fixing that is the first step to fixing everything else.

It is tempting to lay the blame for this enormous waste of resources on greedy drug companies or incompetent insurers or misguided government policies -- and surely all of these contribute to the system's high cost and disappointing results. We consumers also share some of the blame when we demand to have all the latest treatments, whether we need them or not, or when we fail to shop around for the best value, knowing that our health insurance plan will pick up most of the tab.

At the end of the day, however, it is physicians who have the greatest impact on the cost and quality of health care we get. It is the docs who drive the decisions on what tests are ordered up, what surgeries performed and what drugs prescribed. And it is around the doctors and their practices that the medical system is organized.

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Better Health - health blog network

Better Health is a network of popular health bloggers, brought together by Dr. Val Jones, founder and CEO. Participating bloggers maintain their own individual blog sites, but offer a portion of their content to Better Health for syndication purposes. Better Health maintains a blog feed that is featured on participating blogger, partner, and supporter websites. Our network reaches approximately 10 million unique users per month and is growing.

Better Health's mission is to support and promote healthcare professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on healthcare reform, science, research, and patient care.

The Health Care Blog

The Health Care Blog (THCB) has acquired a reputation as one of the most respected independent voices in the healthcare industry. The Wall Street Journal calls us "among the most widely read insider publications in the field. Web MD calls us "a free-wheeling discussion of the latest healthcare developments."

The Cost Conundrum: What a Texas town can teach us about health care. by Atul Gawande: The New Yorker

It is spring in McAllen, Texas. The morning sun is warm. The streets are lined with palm trees and pickup trucks. McAllen is in Hidalgo County, which has the lowest household income in the country, but it’s a border town, and a thriving foreign-trade zone has kept the unemployment rate below ten per cent. McAllen calls itself the Square Dance Capital of the World. “Lonesome Dove” was set around here.

McAllen has another distinction, too: it is one of the most expensive health-care markets in the country. Only Miami—which has much higher labor and living costs—spends more per person on health care. In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns.

The explosive trend in American medical costs seems to have occurred here in an especially intense form. Our country’s health care is by far the most expensive in the world. In Washington, the aim of health-care reform is not just to extend medical coverage to everybody but also to bring costs under control. Spending on doctors, hospitals, drugs, and the like now consumes more than one of every six dollars we earn. The financial burden has damaged the global competitiveness of American businesses and bankrupted millions of families, even those with insurance. It’s also devouring our government. “The greatest threat to America’s fiscal health is not Social Security,” President Barack Obama said in a March speech at the White House. “It’s not the investments that we’ve made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nation’s balance sheet is the skyrocketing cost of health care. It’s not even close.”

The question we’re now frantically grappling with is how this came to be, and what can be done about it. McAllen, Texas, the most expensive town in the most expensive country for health care in the world, seemed a good place to look for some answers.

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Thursday, June 11, 2009

Overseas, Under the Knife -

One consequence of the high cost of medical care in the United States has been the rise of medical tourism. Every year, thousands of Americans undergo surgery in other countries because the allure of good care at half the price is too good to pass up.

Average total fees at well-regarded hospitals like Apollo and Wockhardt in India are 60 percent to 90 percent lower than those of the average American hospital, according to a 2007 study by the consulting group Mercer Health and Benefits (where Dr. Milstein is affiliated). Even compared with low-cost American hospitals, the offshore fees are 20 percent to 50 percent lower.

Most medical travelers seek cosmetic procedures like facelifts and liposuction, but an increasing number have high-risk operations like heart surgery and joint replacement in places like India, Singapore and Thailand.

Is this a good idea? The only way to know is to find out how foreign hospitals and surgeons compare with their American counterparts.

Which Americans consider this option? Typically, they are people who have either no health insurance or meager coverage. Though not poor enough to qualify for Medicaid, they cannot afford a good health plan. But lately, even some people with good coverage have been encouraged to take advantage of cost savings abroad.

A few pioneering American insurers like Blue Cross Blue Shield of South Carolina and self-insured employers like the Hannaford Brothers supermarket chain sent American doctors to evaluate foreign hospitals. Favorably impressed, they now offer payment for travel expenses and cash incentives as high as $10,000 for choosing offshore hospitals.

For very costly operations like open heart surgery or hip joint replacement, savings far exceed these payments. That is not to say that offshore surgery could substantially lower health care costs. Less than 2 percent of spending by American health insurers goes to the kind of non-urgent procedures that Americans seek overseas.

Other negatives are obvious: people having surgery done halfway around the world are far from their regular doctors as well as friends and family. Consider, also, what happens if an American abroad falls victim to negligent care. Arranging transfer to another hospital may be difficult — and malpractice suits typically face longer odds and smaller payments than in the United Sates. To mitigate these problems, some insurers and free-standing medical travel services offer coordination with American doctors, local concierge services and supplementary medical malpractice insurance.

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A.M.A. Opposes Government-Sponsored Health Plan -

As the health care debate heats up, the American Medical Association is letting Congress know that it will oppose creation of a government-sponsored insurance plan, which President Obama and many other Democrats see as an essential element of legislation to remake the health care system.

The opposition, which comes as Mr. Obama prepares to address the powerful doctors' group on Monday in Chicago, could be a major hurdle for advocates of a public insurance plan. The A.M.A., with about 250,000 members, is America's largest physician organization.

While committed to the goal of affordable health insurance for all, the association had said in a general statement of principles that health services should be "provided through private markets, as they are currently." It is now reacting, for the first time, to specific legislative proposals being drafted by Congress.

In the presidential campaign last year and in a letter to Congress last week, Mr. Obama called for a new "public health insurance option," which he said would compete with private insurers and keep them honest.

Speaker Nancy Pelosi of California said Wednesday that she supported that goal. "A bill will not come out of the House without a public option," she said Wednesday on MSNBC.

But in comments submitted to the Senate Finance Committee, the American Medical Association said: "The A.M.A. does not believe that creating a public health insurance option for non-disabled individuals under age 65 is the best way to expand health insurance coverage and lower costs. The introduction of a new public plan threatens to restrict patient choice by driving out private insurers, which currently provide coverage for nearly 70 percent of Americans."

If private insurers are pushed out of the market, the group said, "the corresponding surge in public plan participation would likely lead to an explosion of costs that would need to be absorbed by taxpayers."

While not the political behemoth it once was, the association probably has more influence than any other group in the health care industry. Lawmakers seek its opinion and support whenever possible. It has repeatedly persuaded Congress to cancel or postpone cuts in Medicare payments to doctors, though it has not secured a "permanent fix."

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Lights, Camera, Contraction! -

By her eighth month of pregnancy, Rebecca Sloan, a 35-year-old biologist living in Mountain View, Calif., had read the what-to-expect books, taken the childbirth classes, joined the mommy chat rooms and still had no idea what she was in for. So, like countless expectant mothers before her, Ms. Sloan typed "childbirth" into YouTube's search engine. Up popped thousands of videos, showing everything from women giving birth under hypnosis, to Caesarean sections, to births in bathtubs.

"I just wanted to see the whole thing," Ms. Sloan said. And see it she did, compliments of women like Sarah Griffith, a 32-year-old from the Atlanta area who, when she gave birth to her son Bastian, invited her closest friends to join her. One operated the camera, capturing Ms. Griffith's writhing contractions, the baby's crowning head and his first cries. Afterward, Ms. Griffith posted an hour of footage on YouTube in nine installments, which have since been watched more than three million times. "Childbirth is beautiful, and I'm not a private person," Ms. Griffith said.

Mom-and-pop directors like Ms. Griffith think of their home movies as a way to demystify childbirth by showing other women — and their weak-kneed husbands — candid images they might not otherwise see until their contractions begin. If YouTube can illustrate how to solve a Rubik's Cube, pick a lock and poach an egg, maybe it can also demonstrate how to give birth. Recently, a British couple became tabloid fodder after the woman gave birth, assisted only by her husband using a YouTube birthing video as tutorial.

Inevitably most childbirth videos are graphic, challenging not just YouTube's rules but also societal conventions on propriety.

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This Time, We Won’t Scare - Nicholas D. Kristof, New York Times

Perhaps you've seen those television commercials denouncing health care reform as a plot to create a Canadian-style totalitarian nightmare, and you feel a wee bit scared.

Back in the election campaign, some people spread rumors that Barack Obama might be a secret Muslim conspiring to impose Sharia law on us. That seems unlikely now, but what if he's a covert Canadian plotting to impose ... health care?

Rick Scott, a former hospital company chief executive, leads a group called Conservatives for Patients' Rights. He was forced to resign as C.E.O. after his company defrauded the government through overbilling and is now spending his time trying to block meaningful health care reform by terrifying us with commercials of "real-life stories of the victims of government-run health care."

So here's a far more representative "real-life story."

Diane Tucker, 59, is an American lawyer who moved to Vancouver, Canada, in 2006. Like everyone else there, she now pays the equivalent of just $49 a month for health care.

Then one day two years ago, Ms. Tucker was working on her office computer when she noticed that she was having trouble typing with her right hand.

"I realized my hand was numb, so I tried to stand up to shake it out," she remembered. "But I had trouble standing."

A colleague called 911, and an ambulance rushed her to the nearest hospital.

"An emergency room doctor met me at the door, and they took me straight upstairs to the CT scan," she recalled. A neurologist explained that she had suffered a stroke.

Ms. Tucker spent a week at the hospital. "The doctors were great, although there were also a couple of jerks," she said. "The nursing staff was wonderful."

Still, there were two patients to a room, and conditions weren't as opulent as at some American hospitals. "The food was horrible," she said.

Then again, the price was right. "They never spoke to me about money," she said. "Not when I checked in, and not when I left."

Scaremongers emphasize the waits for specialists in Canada, and there's some truth to the stories. After the stroke, Ms. Tucker needed to make a routine appointment with a neurologist and an ophthalmologist to see if she should drive again. Initially, those appointments would have meant a two- or three-month wait, although in the end she managed to arrange them more quickly.

Ms. Tucker underwent three months of rehabilitation, including physical therapy several times a week. Again there was no charge, no co-payment.

Then, last year, Ms. Tucker fainted while on a visit to San Francisco, and an ambulance rushed her to the nearest hospital. But this was in the United States, so the person meeting her at the emergency room door wasn't a doctor.

"The first person I saw was a lady with a computer," she said, "asking me how I intended to pay the bill." Ms. Tucker did, in fact, have insurance, but she was told she would have to pay herself and seek reimbursement.

Nothing was seriously wrong, and the hospital discharged her after five hours. The bill came to $8,789.29.

Ms. Tucker has since lost her job in the recession, but she says she's stuck in Canada — because if she goes back to the United States, she will pay a fortune for private health insurance because of her history of a stroke. "I'm trying to find another job here," she said. "I want to stay here because of medical insurance."

Another advantage of the Canadian system, she says, is that it emphasizes preventive care. When a friend was diagnosed as being pre-diabetic, he was put in a free two-year program emphasizing an improved diet and lifestyle — and he emerged as no longer being prone to diabetes.

If Ms. Tucker's story surprises you, you should know that Mr. Scott's public relations initiative against health reform is led by the same firm that orchestrated the "Swift boat campaign" against Senator John Kerry in 2004. These commercials are just as false, for President Obama is not proposing government-run health care — just a public insurance element in the mix.

No doubt there are some genuine horror stories in Canada, as there are here in the United States.

But the bottom line is that America's health care system spends nearly twice as much per person as Canada's (building the wealth of hospital tycoons like Mr. Scott). Yet our infant mortality rate is 40 percent higher than Canada's, and American mothers are 57 percent more likely to die in childbirth than Canadian ones.

In 1993, the "Harry and Louise" commercials frightened Americans into abandoning health reform. Let's ensure those scare tactics don't work this time.

Wednesday, June 10, 2009

Medical News Today: Health News

Alexa - Top Web Sites by Category: Health/Medicine/Education

App Shopper: DocGuide (Medical)

DocGuide application for the iPhone or iPod Touch is now available on the iTunes Store.

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A special report on health care and technology - The Economist

The advances in digital medicine described in this special report have already started to move patients from the margins of the medical system to its centre. Some think there are bigger things to come. "The key is patient-driven research," explains Gregory Simon, head of Faster Cures, an advocacy group in Washington, DC. Most of the push for adopting electronic health records has come from institutions anxious to cut costs and reduce medical errors, but he thinks the biggest gains will come in the shape of better treatments for difficult diseases. He sees patients increasingly getting together online and sharing medical data and treatment histories.

On a website called PatientsLikeMe, members from around the world swap stories about their ailments and discuss subjects like adverse drug interactions, dosing strategies, new drugs and trials for more than a dozen diseases. A report by the California HealthCare Foundation, a think-tank, argues that in dealing with multiple sclerosis, a neurological disorder for which there is as yet no cure, "the collective wisdom on this website may rival the body of information that any single medical school or pharmaceutical company has assembled in the field."

Mr Brown of Ideo argues that until recently the flow of information in medicine has tended to be one way. In future, he thinks, medical knowledge will increasingly flow in many directions. Mr Brown points to a proliferation of health blogs, online groups and peer-to-peer portals as a sign that the age of social networking in medicine has arrived. Google already has a feature that allows users of its EHRs to share their health information with others.

It is easy to be sceptical about such online communities. A fatal illness will not be cured by Twittering about it. And for many people nothing will replace the personal relationship between a patient and his doctor. But it seems clear that patients are going online to get more information on their illness, to see what other consumers think of new medications and to get emotional support from fellow sufferers.

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CARP - A New Vision of Aging for Canada

The new Health Strategy Innovation Cell ("Innovation Cell") focuses on low-cost, low-tech solutions to make the user experience in healthcare perfect. There are three legs of Innovation Cell activity that draw on social media tools: 

(1) research that explores the World Wide Web to discover how patients want to experience amazing healthcare; 

(2) simple "Web 2.0" user interfaces that collect constructive low-cost and low-tech ideas from the public, and that socialize the importance of showing gratitude to people who have made a difference to the care experience; and, 

(3) engaging underrepresented groups in "unconferences" to brainstorm about low-tech, low-cost healthcare solutions. Based at Massey College at the University of Toronto, the Cell's vision and early research on the power of "health 2.0" have been cited in the Economist Magazine. Cell participants are "agile students of disruptive innovation."

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Blogs are better than newspapers for consumer health news

Consider health news: The Wall Street Journal's health blog, alone
among mainstream dailies in the world, has consistently ranked among
the top 10 most popular health blogs on the Web – as measured by page
views and global reach. Yet the vast majority of the most popular
health blogs on the Web have no relationship to mainstream media:
They are, like, "start-ups," usually targeting
readers and their families who have been affected by chronic illness.
My research, published in the current issue of Electronic Healthcare,
shows empirically that the most popular health blogs on the Web, as
compared to newspapers: provide readers with more medically relevant
news information; offer readers more confidence that any reader-
submitted content will be subject to strong privacy protections;
offer readers more objective, and less partisan, medical content; and
are more frequently monitored for accuracy by subject matter
clinician experts.

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Health in the palm of your hand

Of the telephone, Alexander Graham Bell said, "I may be given credit for having blazed the trail, but when I look at the subsequent developments I feel the credit is due to others rather than to myself."

And what subsequent developments! In just the last five years, today's telephone -- "mobile communications," in modern parlance -- has moved into a new business line: medicine.

My recent innovation challenge (Doctor in your pocket) invited Post readers to brainstorm low-cost mobile phone applications that could dramatically improve health care in this country and abroad. Entrepreneurs from around the world then wrote to me to describe their proprietary tools for "mobile health" or "mHealth".

The breadth of mobile phone applications now available for health care is inspiring. In the area of chronic disease -- notably diabetes -- mobile health is flourishing. For example, when a patient taps in her blood glucose levels by text messaging, a physician can then adjust insulin dosage with a return SMS.

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my health innovation | Share, vote, and say thanks for low-cost, low-tech ideas

What would make your experience with the health care system amazing?
Perfect? The purpose of an "Innovation Cell" − the research unit
behind Myhealthinnovation − is to collect your innovative ideas and
get hospitals, caregivers and patients to use them. We want to make
the experience of health care as close to perfect as possible. Yes,
it's ambitious. We know you've got great ideas − because you either
have, or will, encounter the health system some day. That's why we
created this Web site.

Any visitor can look at the ideas that have been posted in "Ideas in
Action" – simple, low-tech ideas to improve health care in local
communities and around the world. Anyone can also submit their own
ideas, vote and comment on ideas submitted by other people. You can
also visit the THANKbook to say thanks to others whose ideas –
posted on this site or elsewhere – have improved your life for the

mHealth Initiative

mHealth Initiative Inc. envisions the development of a wide range of healthcare applications on cell phones and other mobile devices (mDevices) and cites them as the future conduit of interoperability for essential health information.

  • Cell phone, smart phone, and other mDevice users can store their personal health information safely and securely on their phone in order to share it with authorized healthcare professionals when healthcare services are needed.
  • Specific mDevice software can provide preferred and easy communication between healthcare providers, patients, payers, pharmacists, and others, facilitating medication reminders for patients, appointment scheduling, easy emergency calling, and other functions.
  • mDevices can serve as the platform for consumer health-related software such as wellness-related programs and disease management programs. A wealth of functions related to diseases ranging from asthma to diabetes, from smoking cessation to general pediatric applications, are currently being developed and tested.
  • mDevices offer clinicians and patients quick access to health information for clinicians and patients. Patients can look up information about medication or symptoms of their health status. Imagine a patient looking up a specific medication after it has been prescribed at a clinic visit, noting it interacts with another of their medications that they failed to mention during their visit and alerting the clinic physician - also via the cell phone - before having the prescription filled. Clinicians, on the other hand, can access protocols at the point of care and/or other professional information that is available on the Internet while with a patient or away from their desk.
  • mDevices can be very efficient tools for medical research, offering the power of the Internet and enabling patient data to be transmitted easily and instantaneously to authorized, pre-programmed research centers.

Sunday, June 7, 2009

If All Doctors Had More Time to Listen -

When Dr. José Batlle met his 93-year-old patient in her small Bronx apartment, she didn't have much furniture beyond a small TV, a sofa and a wheelchair. What she did have in abundance were pills — 15 types from a variety of doctors, including a pulmonologist, a cardiologist and a gerontologist. He discovered that some medicines had expired, others were unnecessary and some were dangerous if taken together.

Sitting with his patient and her son, Dr. Batlle cut the number of her medicines to four. He also gave the family his personal cellphone number.

Before coming to see him, the woman had endured several emergency-room visits and hospital stays. With Dr. Batlle, she was able to avoid all of that.

Calling a doctor on his cell? No waiting for an appointment? It's the type of service that Dr. Batlle tries to offer to all of his 1,500 patients. "I prefer to keep them healthy than treat them when they are sick," he says.

The efforts of Dr. Batlle and other primary care physicians may get a boost at the federal level. The Obama administration is considering ways to persuade medical students to pursue careers in primary care by raising their pay, and is channeling them to work in underserved rural areas. And the White House has already set aside $2 billion for community health centers through the economic stimulus package.

But more far-reaching health care reform remains an uncertainty, and in the interim a small but growing number of doctors are trying to take matters into their own hands.

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