Friday, June 26, 2009

When the Heart Pays the Price of Anger - Robert Allan -

Not long ago, a cardiac patient in a cardiac support group I was leading told of his response to a recent incident: He and a female friend were on the plaza at Lincoln Center after seeing a performance of Verdi's opera "Il Trovatore" when a car nearly hit the woman. She ran after the vehicle, which was slowly moving away, and slammed the trunk with her rolled up program. The driver emerged from the car hurling expletives in her direction. The patient then hit the driver with his cane. The driver shoved the patient into a fender, at which point, the patient insisted, he had no choice … It was no ordinary cane he was carrying, but a beautiful 19th-century model with a sleek, sharp sword concealed within. He then insisted that the driver "apologize at swordpoint" in front of a small crowd that had gathered. The characters in "Il Trovatore," he added, proudly brandished swords.

The patient shared this story at his first — and only — session of the support group. (He terminated treatment, insisting that the others needed my help with their anger far more than he did.) Even after deliberating for several weeks, the patient felt justified and vindicated, totally satisfied by his actions.

Many of us harbor the "make my day" fantasy, emblazoned into the American psyche by Clint Eastwood's Dirty Harry. Americans get mad — and get even. However, whenever one pursues such satisfaction they run the risk of triggering someone else's thirst for revenge, and so begins a recurring, sometimes escalating cycle. Soon, one always has to look behind his or her back in fear that a former adversary will find an opportunity for the proverbial knifing.

Not many people on earth can claim regular, deep, long-lasting satisfaction. Satisfaction is fleeting, and often whittled away by recorded telephone menus, rude waiters and any number of other indignities of contemporary society. And of course, this has particular currency today. Many of us are justifiably angry at our former employers for loss of jobs or at the financial service industry's inability to protect our life savings.

Challenging times certainly increase the tendency for negative moods and aggressive behavior (this dynamic was described in the "frustration-aggression hypothesis" first put forth in the 1940s.[1] However, giving way to an angry impulse makes nearly any situation worse.

The aforementioned patient's life, in spite of considerable intelligence, advanced degrees, and a personable demeanor, was one of mere survival in a cramped studio apartment. When we met, he was selling some of his few remaining valuables to make the next month's rent. This patient's career was marked with disappointments – in others who disappointed him. Moreover, he was a cardiac patient with a bad family history and suffered a heart attack at a young age. The swordsman was keenly aware of the link between chronic anger and heart disease. Indeed, a recent meta-analysis of 44 prospective studies in the Journal of the American College of Cardiology[2] confirms a strong relationship between anger and both the onset and outcome from coronary heart disease; moreover, approximately 1.5 percent of heart attacks are "triggered" by intense anger.

While it is not possible to make a definitive causal connection between the swordsman's actions and unfortunate life circumstances, the experience of a 35-year practice as a clinical psychologist and abundant literature on the subject all inform me that the sort of satisfaction of which he was so fond ultimately did him in, both in health and life. Expressing his anger didn't benefit him at all.

People often challenge this view with the idea that unexpressed anger "builds up," leading to resentment, high blood pressure, a heart attack or stroke. Many of us conceive of anger just as we fill a balloon with (hot) air. We get angry, the balloon expands. An injustice befalls us, we get angrier — the balloon gets larger. Something else "bad" happens and the balloon gets so big that it … bursts! The comedian Jonathan Katz described a moment like this in a joke about having dinner with his father: "I meant to say, 'Can you pass me the salt, please?' But it comes out, You creep, you ruined my childhood!"

Jokes aside, anger is not a measurable substance. There is no organ, gland, or other repository in our bodies for anger. Yet, we have myriad terms that make reference to anger as an accumulating substance. Anger "builds up," "leaks out," and is sometimes transformed into "explosive rage." The idea that anger accumulates is a myth that can sometimes lead to the sort of "satisfaction" achieved by my patient. His didn't "bottle-up" his anger; he "released" it ("it," in his thinking, transformed into a substance). My patient obtained "real satisfaction" by drawing his sword — but ultimately slashed his existence to a sliver of what he might have become.

When faced with frustrating disappointments, we may all secretly wish to advise our money managers, as well those with whom we are close, about their expanding waistline, receding hairline, or the pimple that has suddenly sprung up in the middle of their forehead. But such "satisfaction" inevitably comes back to haunt us as others are even more likely to remember our insult than we are to relish getting the best of them. To quote another patient, "life is very lonely when you are always right."

Thursday, June 25, 2009

Can Health Care Come With a Warranty?

From the time I was in grade school until just a few years ago, my parents owned a series of small neighborhood businesses. The first was a corner convenience store in an Italian neighborhood; eventually they traded up to three small clothing shops situated in neighborhood malls. Whether posted above the register or acknowledged during conversations, the message behind each transaction in every one of these stores was this: you were getting the best service and quality my parents could muster or you would get your money back.

Few people ever asked. My parents understood the power of warranties and developed a small army of loyal customers with relationships based not on money but on trust.

So I was more than intrigued last week when I read about the possibility of offering warranties to patients.

In the policy journal Health Affairs, Francois de Brantes, a nationally known advocate of health care quality, and his co-authors propose a new health care reimbursement model that comes with a warranty. Developed with the support of the Commonwealth Fund and the Robert Wood Johnson Foundation, this model, called Prometheus Payment, first offers set fees to providers. The fees cover all recommended services, treatments and procedures for specific conditions but are also "risk-adjusted" for patients who may be older or frail.

The warranty is based on the costs incurred by avoidable complications. In current fee-for-service plans, all costs from these complications are covered by the third party payer, regardless. But in the Prometheus Payment model, half of the costs from avoidable complications must be paid for by the providers themselves.

The result, Mr. de Brantes and his co-authors write, is a payment system that offers patients a health care warranty, since "providers win or lose financially based on their actual performance in reducing the incidence of avoidable complications."

I spoke recently with Mr. de Brantes and asked him about the Prometheus Plan, the feasibility of a warranty in the imperfect endeavor called "health care," and the potential impact such a plan might have on the patient-doctor relationship.

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Can You Get Fit in Six Minutes a Week?

A few years ago, researchers at the National Institute of Health and Nutrition in Japan put rats through a series of swim tests with surprising results. They had one group of rodents paddle in a small pool for six hours, this long workout broken into two sessions of three hours each. A second group of rats were made to stroke furiously through short, intense bouts of swimming, while carrying ballast to increase their workload. After 20 seconds, the weighted rats were scooped out of the water and allowed to rest for 10 seconds, before being placed back in the pool for another 20 seconds of exertion. The scientists had the rats repeat these brief, strenuous swims 14 times, for a total of about four-and-a-half minutes of swimming. Afterward, the researchers tested each rat's muscle fibers and found that, as expected, the rats that had gone for the six-hour swim showed preliminary molecular changes that would increase endurance. But the second rodent group, which exercised for less than five minutes also showed the same molecular changes.

The potency of interval training is nothing new. Many athletes have been straining through interval sessions once or twice a week along with their regular workout for years. But what researchers have been looking at recently is whether humans, like that second group of rats, can increase endurance with only a few minutes of strenuous exercise, instead of hours? Could it be that most of us are spending more time than we need to trying to get fit?

The answer, a growing number of these sports scientists believe, may be yes.

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Tuesday, June 23, 2009

Health Care Stories for America |

What Your Body Is Telling You -

The body speaks volumes about what ails it -- from obvious warnings like a fever that accompanies an infection to subtle clues like losing hair on the toes, which can be an early sign of vascular disease.

Some signs that seem alarming may actually be harmless: Bright-red stools are more likely to come from eating beets than from intestinal bleeding. But some that seem minor can warn of a serious disorder. Small yellow bumps on the eyelid, for instance, may be fatty deposits that signal high cholesterol, which in turn raises the risk of heart disease.

Other signs seem to make no logical biological sense: Eyebrows that no longer extend over the corners of the eyes can indicate an underactive thyroid, and a diagonal crease in the earlobe seems to herald a heightened risk of heart attack.

Some body signs can have a confusing range of meanings: Does that bulging tummy signify middle-aged spread or the beginning of ovarian cancer?

The problem is that many of us don't recognize the warnings, even when they're staring us in the face. Medical writer Joan Liebmann-Smith was losing weight rapidly. Her hair was falling out. Her heart was racing, and she couldn't sleep. She chalked up her symptoms to the stress of having a new baby, while a psychiatrist she consulted for insomnia told her to just "count sheep."

Over lunch one day, a relative looked at her bulging eyes and the big lump in her throat and said, "Joan -- you have a goiter!" A blood test confirmed that she had an advanced case of Grave's disease, an autoimmune disorder that causes the thyroid gland to swell and produce too much of the powerful hormone.

"I had all the classic signs, and I ignored them," says Ms. Liebmann-Smith, a medical writer, who resolved to write a guide for laymen to the warning signs of serious illnesses. "Body Signs" -- written with Jacqueline Nardi Egan, a breast-cancer survivor -- came out in 2007 and has since been published in 26 countries.

"We don't want people to panic and jump to conclusions," Ms. Liebmann-Smith says. "But it's important to pay attention to your body. Knowledge is power."

Before you race off to the doctor for every lump or discoloration, remember that anomalies you've had for years are more likely to be a harmless part of your genetic makeup. Signs and symptoms that are unusual for you, or painful or debilitating, are more likely to be significant. (Signs are external indicators that can be seen or felt; symptoms are internal sensations, such as pain, that only the patient can perceive.)

Examining a patient from head to toe for such indicators is a key part of every nurse's training. "It's the foundation of patient care," says Susan Denman, a family nurse practitioner who teaches physical assessment at the Duke University School of Nursing. Knowing how to interpret all those signs and symptoms takes up much of a doctor's education and is refined over a lifetime of clinical practice.

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A Doctor's Reflections on Health-Care Reform (Mark Sklar, M.D.) -

Dear President Barack Obama and Members of Congress:

I understand that you have undertaken the Herculean task of repairing the health-care system in the United States. As a physician who has practiced medicine for the past 19 years, I think you would benefit from hearing about my experience. I am a board-certified internist with a specialty in endocrinology who currently practices in Washington, D.C. I also provide primary care to many of my patients.

There has been much concern about the rapidly rising cost of health care. I am convinced that costs have increased for a few reasons. First, there are simply more patients in the system. The baby-boom generation has gotten older and now requires care for chronic medical problems. Second, we have unparalleled levels of obesity in our country. This has led to a massive increase in diabetes, hypertension and other chronic problems.

If we could prevent even a small percentage of people from becoming obese and developing these conditions, the costs of health care could go down far enough to cover everyone's insurance. To that end, we need incentive programs to encourage healthy eating and exercise. Vending machines and fast food should be banned from our schools. Children should be provided with meals that are low in saturated fat, refined carbohydrates, and sugar.

Another major issue is reimbursement. You may find this hard to believe, but when I first started practicing medicine in 1990 I received more payment for an office visit than I am currently receiving. This has occurred despite the increasing cost of practicing medicine, which is the result of rising malpractice premiums, rents, staff salaries, professional membership fees, license fees, and costs needed to comply with various new regulations. What other profession has experienced a reduction in reimbursement over the last 20 years?

I feel strongly that if doctors are reimbursed more for office visits, they will spend more time with patients. This will lead to fewer referrals by primary-care physicians and result in lower health-care expenditures. Currently, harried primary-care physicians don't have the time to delve into medical problems with a hint of complexity. So patients who could be dealt with if more time was available are referred to specialists or expensive radiology studies.

I have heard that physicians may be mandated to participate in a government-run health plan. I sincerely hope that this is not true. First of all, it sounds unconstitutional. As free individuals and citizens of this country, physicians should not be forced to participate in any plan. We have paid for our professional training and worked hard to distinguish ourselves. We owe no debt to the government. If you want physicians to participate in your plan, give them the right incentives and they will flock toward your program.

Electronic medical records have been praised as a way to save money and avoid duplication of tests. It's true that electronic medical records will save some money, but not as much as you probably are counting on. In my practice, if a patient tells us he had a test performed, we call the physician or medical facility to retrieve the results. But a standardized electronic platform will likely be useful for physicians and should lead to better care.

Contrary to what you may have heard, my experience is that smaller practices provide better patient care than larger practices. There are no economies of scale in medicine. If you hire more physicians, you need to hire more support staff to deal with the increased work demands. Larger practices with less support per physician often end up providing worse service. They also require office managers, and sometimes even managers of managers, all of which just bloat costs.

I worked in a university multispecialty practice for seven years before establishing my own private practice. At the university practice, I found that patients' requests often went unfulfilled. Phone messages didn't get to me, and charts and laboratory tests were routinely lost. In my own practice, my fingers are continuously on the pulse of my staff and patients. Because I can overhear how staff interact with patients, I can intervene rapidly if patients are not getting good service. We routinely have patients transferring to us from larger multispecialty practices where they often wait for hours to be seen, aren't called with their test results, and their phone calls are ignored.

The idea that multispecialty practices lead to better referral patterns is erroneous. If I need to refer a patient to a physician in another specialty, I choose the best physician I know to meet that patient's needs. When making the referral, I consider the physician's clinical competence and the potential chemistry between that physician and the patient. I am not constrained by a limited choice of referral options dictated by a multispecialty group.

When I refer a patient, I fax or mail over pertinent notes, lab work and radiology results so that the specialist knows the patient's problem and doesn't need to perform additional unnecessary tests. The specialists that I refer to either call me or write comprehensive consultation letters so that I am aware of their treatment plan and can coordinate future care with them.

I have also heard that Medicare will be looking to recoup money by increasing oversight of fraud. My fear is that fraud will be poorly defined and a simple miscoding of an office visit will be misconstrued as fraud.

The current coding system is extremely complex and requires documentation that physicians often do not have time for. We try to code fairly but our focus is on treating patients, not mentally calculating all the elements necessary to arrive at a billing code under the current system. Even if we attempted to do everything correctly, an auditing contractor could probably find some fault with our coding, thus exposing us to unfair fines and other serious penalties. It is in the auditor's best interest to discover mistakes since it justifies his investigation, and these organizations are paid a percentage of the funds they recoup. This is a blatant conflict of interest that results in the harassment of dedicated physicians.

The government's focus should instead be limited to unscrupulous individuals and companies that are billing for services never rendered. If miscoding is a persistent problem, the algorithms for arriving at billing codes should be changed.

Finally, work needs to be done to correct the malpractice situation in our country. Physicians have been living under the threat of medical malpractice lawsuits for too long. The escalating cost of insurance premiums has driven many physicians out of practice in critical fields like obstetrics and gynecology. And the threat of malpractice litigation leads doctors to order tests that may not be critical to patients' care, resulting in billions of dollars in needless expenditures

Although I am in favor of universal access to health care, I think that we all need to be honest that universal coverage will be a very expensive program. We cannot cut reimbursement to physicians since levels are already too low. And implementing widespread use of electronic medical records and eliminating fraudulent billing will only lead to marginal savings.

I believe that in order to reduce costs, we must give the public incentives for preventing chronic disease, increase the reimbursement for office visits, and implement medical malpractice tort reform. With these changes, I am certain that we can provide more adequate insurance coverage for all.

Bad test results often don’t reach patients -

No news isn't necessarily good news for patients waiting for the results of medical tests. The first study of its kind finds doctors failed to inform patients of abnormal cancer screenings and other test results 1 out of 14 times.

The failure rate was higher at some doctors' offices, as high as 26 percent at one office. Few medical practices had explicit methods for how to tell patients, leaving each doctor to come up with a system. In some offices, patients were told if they didn't hear anything, they could assume their test results were normal.

"It really does happen all too often," said lead author Dr. Lawrence Casalino of Weill Cornell Medical College. The findings are published in Monday's Archives of Internal Medicine.

"If you've had a test, whether it be blood test or some kind of X-ray or ultrasound, don't assume because you haven't heard from your physician that the result is normal," Casalino said.

Practices with electronic medical records systems did worse or no better than those with paper systems in the study of more than 5,000 patients.

"If you have bad processes in place, electronic medical records are not going to solve your problems," said study co-author Dr. Daniel Dunham of Northwestern University's Feinberg School of Medicine.

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Sunday, June 21, 2009

At V.A. Hospital, a Rogue Cancer Unit -

For patients with prostate cancer, it is a common surgical procedure: a doctor implants dozens of radioactive seeds to attack the disease. But when Dr. Gary D. Kao treated one patient at the veterans' hospital in Philadelphia, his aim was more than a little off.

Most of the seeds, 40 in all, landed in the patient's healthy bladder, not the prostate.

It was a serious mistake, and under federal rules, regulators investigated. But Dr. Kao, with their consent, made his mistake all but disappear.

He simply rewrote his surgical plan to match the number of seeds in the prostate, investigators said.

The revision may have made Dr. Kao look better, but it did nothing for the patient, who had to undergo a second implant. It failed, too, resulting in an unintended dose to the rectum. Regulators knew nothing of this second mistake because no one reported it.

Two years later, in 2005, Dr. Kao rewrote another surgical plan after putting half the seeds in the wrong organ. Once again, regulators did not object.

Had the government responded more aggressively, it might have uncovered a rogue cancer unit at the hospital, one that operated with virtually no outside scrutiny and botched 92 of 116 cancer treatments over a span of more than six years — and then kept quiet about it, according to interviews with investigators, government officials and public records.

The team continued implants for a year even though the equipment that measured whether patients received the proper radiation dose was broken. The radiation safety committee at the Veterans Affairs hospital knew of this problem but took no action, records show.

One patient was the Rev. Ricardo Flippin, a 21-year veteran of the Air Force. "I couldn't walk and I couldn't stand," he said, citing rectal pain so severe that he had to remain in bed for six months, losing his church job and his income.

Pastor Flippin first learned of what his doctors called a radiation injury not from the V.A., but from an Ohio hospital where he underwent rectal surgery in 2006 to treat the damage. "There are times when I don't have control over my bowels," he said one recent Sunday, after excusing himself during a service at a church in West Virginia where he now preaches.

The 92 implant errors resulted from a systemwide failure in which none of the safeguards that were supposed to protect veterans from poor medical care worked, an examination by The New York Times has found.

Peer review, a staple of every good hospital, in which colleagues examine one another's work, did not exist in the unit. The V.A.'s radiation safety program; the Nuclear Regulatory Commission, which regulates the use of all nuclear materials; and the Joint Commission, a group that accredited the hospital, all failed to intervene; either their inspections had been limited or they had not acted decisively upon finding problems.

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