Saturday, September 12, 2009

Patient Advocates Help Find Health Care Answers -

When Kathleen Henry's uncle was told he had bladder cancer in May, she knew she needed help. Even though Ms. Henry has a nursing degree, she worried about deciphering treatment options and picking the best hospital for her uncle's care.

So Ms. Henry hired Betty Long, a registered nurse, patient advocate and founder of Guardian Nurses in suburban Philadelphia, to help her and her uncle make crucial decisions.

Ms. Long accompanied her uncle, Thomas Murray, who is 69 and has no children, on office visits and explained the various treatments his doctors recommended.

"I would have been stumped without her," Mr. Murray said. "They ought to call her a guardian angel."

These days, even a person well versed in medical lingo can become overwhelmed by the complexity of the health care system. That is why many patients and their families who can afford it are turning to patient advocates for help. These professionals, who often have nursing or health care experience, can help a patient research treatment plans, sort out insurance claims and even accompany a patient on doctor's visits. They can frequently open doors to specialists that a patient may not have access to.

Patient advocates have been around for decades, but in the last few years the profession has gained more momentum and acceptance, said Laura Weil, director of the 30-year-old Health Advocacy Program at Sarah Lawrence College in Bronxville, N.Y. "Now everyone seems to agree that you need help navigating a fragmented and technical health care system that is not always friendly," Ms. Weil said.

Indeed, some lawmakers working on health care legislation in Washington have argued that improving the coordination of care would be a way to improve medical care and reduce unnecessary, costly treatments and procedures.

Although there are no firm statistics on the number of patient advocates in this country, or the number of people who are using their services, U.S. News & World Report and recently put patient advocates on their list of hot growth careers.

Many employers, large and small, are also adding patient advocacy to their benefit offerings.

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Thursday, September 10, 2009

Smartphone Training Apps Help You Sweat the Details -

To prepare for his first marathon last year, Michael Nolan trained for six months with the New York Road Runners Club, running up to 20 miles a day five days a week.

Nevertheless, he finished with an average speed of about 11 minutes a mile, a full 60 seconds a mile off his target pace. This year, he vowed to be faster. "I didn't want to take that long again," he said.

So he got a personal trainer. Now as Mr. Nolan prepares for this year's New York marathon, he is leaner, stronger and "easily" averages eight-and-a-half-minute miles on training runs, he said.

Mr. Nolan's new workouts are not coached by a running guru, but by iPhone applications that show video workout instructions and tabulate every set of burpees, a full-body exercise for strength training, and step-ups.

The sports and health industries are just beginning to tap the computing power of smartphones. Applications range from simple calorie counters to heart-rate monitors that use complex metabolic calculations.

These apps can help an athlete achieve a personal best, but some doctors say that more important is their ability to produce no-fail routines for the sedentary and obese, which could improve health and drive down medical costs. Here are some of the popular fitness apps out there.

Big Food vs. Big Insurance (Michael Pollan) -

We're spending $147 billion to treat obesity, $116 billion to treat diabetes, and hundreds of billions more to treat cardiovascular disease and the many types of cancer that have been linked to the so-called Western diet. One recent study estimated that 30 percent of the increase in health care spending over the past 20 years could be attributed to the soaring rate of obesity, a condition that now accounts for nearly a tenth of all spending on health care.

The American way of eating has become the elephant in the room in the debate over health care. The president has made a few notable allusions to it, and, by planting her vegetable garden on the South Lawn, Michelle Obama has tried to focus our attention on it. Just last month, Mr. Obama talked about putting a farmers' market in front of the White House, and building new distribution networks to connect local farmers to public schools so that student lunches might offer more fresh produce and fewer Tater Tots. He's even floated the idea of taxing soda.

But so far, food system reform has not figured in the national conversation about health care reform. And so the government is poised to go on encouraging America's fast-food diet with its farm policies even as it takes on added responsibilities for covering the medical costs of that diet. To put it more bluntly, the government is putting itself in the uncomfortable position of subsidizing both the costs of treating Type 2 diabetes and the consumption of high-fructose corn syrup.

Why the disconnect? Probably because reforming the food system is politically even more difficult than reforming the health care system. At least in the health care battle, the administration can count some powerful corporate interests on its side — like the large segment of the Fortune 500 that has concluded the current system is unsustainable.

That is hardly the case when it comes to challenging agribusiness. Cheap food is going to be popular as long as the social and environmental costs of that food are charged to the future. There's lots of money to be made selling fast food and then treating the diseases that fast food causes. One of the leading products of the American food industry has become patients for the American health care industry.

The market for prescription drugs and medical devices to manage Type 2 diabetes, which the Centers for Disease Control estimates will afflict one in three Americans born after 2000, is one of the brighter spots in the American economy. As things stand, the health care industry finds it more profitable to treat chronic diseases than to prevent them. There's more money in amputating the limbs of diabetics than in counseling them on diet and exercise.

Wednesday, September 9, 2009

Obama’s Audience Speaks First -

Over the last few years, in preparation for a new play, I interviewed doctors, patients and healers about the human body, its resilience and its vulnerability. Although our conversations were not primarily about the health care debate, they do reveal many of the feelings and thoughts of the people in the audience President Obama will address tonight.

The unruliness that now animates the conversation stems from our passions, hopes and discomforts — about life, death, who should (or should not) take care of us and whom we should take care of. The president's audience has a million and one perspectives, some of them clumping together like blood platelets under one political roof or another. The following excerpts (not all of which are in my play) reflect the range of views.

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Summer of Work Exposes Medical Students to System’s Ills -

This summer, medical students from the University of Washington took a long look under the hood of the health care system they are about to inherit, and many returned to campus last week with their eyes wide open and their idealism tempered.

Jacob R. Opfer shadowed a pediatrician in Gillette, Wyo., who sometimes saw 45 patients a day, allowing little more than five minutes a visit. Amanda I. Messinger worked with a family practitioner in Kodiak, Alaska, who eschewed electronic medical records, leaving staff members to decipher histories from illegible script. Jens N. Olsgaard manned a community health center in Butte, Mont., where four of five patients had no insurance, and treatment was often structured around ability to pay.

The students learned not only to deliver babies and suture wounds, but also to order unnecessary tests as protection against lawsuits, to hector specialists into seeing Medicaid patients, to match patients with prescriptions on Wal-Mart's $4 list. And they saw firsthand what Mr. Olsgaard called "a tidal wave of chronic disease" — diabetes, hypertension, obesity, depression — that left many questioning how much any one physician could really accomplish.

"I often wondered what we were actually doing to help people," Mr. Olsgaard said. 

Not surprisingly, many concluded that it was critical to reorient a reimbursement system that had profoundly devalued primary care and prevention.

"You have to reimburse for primary care," said Ms. Messinger, 24, who grew up in Snohomish, Wash. "You have to reimburse doctors for spending the time to catch things early, to manage chronic things, to be able to offer people treatments they can afford early instead of waiting until there's a catastrophic surgery. It's pretty simple."

For 21 years, the University of Washington School of Medicine has dispatched its rising second-year students across the Northwest to provide primary care in rural or underserved areas. The monthlong program is elective, but a record number of students took part this year — 117 from a class of 216.

The school has a cooperative agreement to train medical students from Alaska, Idaho, Montana and Wyoming, none of which has a medical college of its own. The summer program is one of several vehicles, along with loan forgiveness enticements, designed to lure students back to their home states to practice in areas with a shortage of primary care givers.

This year, the students set out as negotiations were intensifying in Washington over wholesale changes to the health care system they will soon be joining. Whether there will be improvements to the system remains to be seen, but few students returned thinking there was little to fix.

Payment policies that leave primary care providers struggling to cover their costs have pushed family practitioners and internists into early retirement, and discouraged newly minted doctors from replacing them. To make a living, and chip away at immense educational debt, general practitioners often find they must churn patients and work long, unsatisfying hours.

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Monday, September 7, 2009

Coming to Know the Limits of Healing -

As I pondered postgraduate choices in medical school, I divided the medical specialties into joyful ones like obstetrics (congratulations, it's a healthy baby girl), grim ones like oncology (better get your affairs in order) and faceless ones like pathology (in which the good or bad news is delivered via an impersonal report).

I recognized I didn't have what it took to be grim. And because I love dealing with people, faceless was out. I landed in pain medicine by chance, and surprisingly, I've found that it fits in the joyful category: there are few better feelings than easing a patient's suffering.

Still, after a demoralizing recent constellation of patients, I was left wondering which is worse: informing people that they are going to die, or that they are likely to spend the rest of their lives in pain.

I've followed one older patient for five years now. He is a lovable gentleman in his 80s with chronic back and leg pain. Over the years, we've been through successive trials of different medications and treatments — some of them quite unconventional. Despite our best efforts, he continues to suffer moderately severe chronic pain.

My patient and his family are habitually early for clinic appointments, always exquisitely polite, forever compliant with my treatment recommendations. That he is never demanding, only grateful, makes it all the harder when my efforts fail.

Then there are the young veterans, frequently in their 20s, freshly back from combat. Chronic pain is often complicated by traumatic brain injury, untreated post-traumatic stress disorder, and sleep and mood disorders.

The challenge here is to find a balance between pain relief and side effects; to ensure that opioid painkillers like Percocet and Vicodin are being used to treat pain, not mood or sleep. I find myself in the unenviable position of limiting access to pain medications if their use will lead to functional decline.

The American Pain Society and the American Academy of Pain Medicine recently published their joint Opioid Treatment Guidelines. They include some sobering facts — for example, that nearly all the highest-quality trials evaluating the value of opioids for chronic noncancer pain were short-term efficacy studies, just 16 weeks or less. In clinical practice, patients are often maintained on opioids for years or decades.

Moreover, the studies generally excluded patients at higher risk for substance abuse or with significant coexisting medical or psychiatric problems; that, too, is unrealistic in clinical practice.

And trials suggest that on average, patients given opioids experience an improvement of only 2 to 3 points on a pain scale of 0 to 10. Side effects and risks abound: chronic constipation, sedation and somnolence, a worsening of mood, opioid-induced hyperalgesia (a paradoxical phenomenon in which pain medications actually increase pain), hypogonadism (impaired endocrine function) and addiction. Recent studies also suggest an adverse effect on immune function.

Still another slap in the face came in an article from The Journal of the American Board of Family Medicine that a colleague helpfully placed on my desk. The title — "Overtreating Chronic Back Pain: Time to Back Off?" — and the introduction said it all: "Innovation has often outpaced clinical science, leaving uncertainty about the efficacy and safety of many common treatments. Complications and even deaths related to pain management are increasing."

The downward spiral, the authors wrote, begins with inappropriate imaging, which may reveal irrelevant and incidental findings that lead to unnecessary treatment. Echoing the new guidelines, the authors called for judicious use of opioids to treat chronic low back pain. And they advocated more careful selection of candidates for spinal injections and spine surgery, pointing out that such interventions can actually make matters worse.

"First do no harm" is the guiding principle we learned in medical school. But one skill that is not taught is an easy way to say, "There is nothing more I can offer you."

I've learned that my specialty, like every other, has its limitations. I've learned not to take those limitations personally: they are not a reflection of my inadequacies, merely the current state of the science. (Mastering this is where science becomes art.)

I've learned, too, that it is important that I come to terms with these therapeutic gaps first, so I am effectively able to convey realistic expectations, not perpetuate medical myth. At last, I've grown more comfortable with two of the hardest words in a doctor's vocabulary: "enough" and "no."

Colin Fernandes, a physician and writer, is director of a pain clinic in Northern California.

A Pharmacological Education -

Low on energy, drained of resources and out of ideas about what to do, I consulted an expert on recovery and was given my personal stimulus package. It came in a small brown bottle of 60 pills, a dose of which was to be taken twice a day (but not too late in the day, because it might cause sleeplessness, and not too closely together, because it might cause dizziness). The psychiatrist who prescribed them predicted good things — enhanced concentration, a new competitive edge — and he minimized the risks, which is what finally sold me on Adderall. The drug was a compound of amphetamines meant to combat attention deficit hyperactivity disorder, he said, that had proved safe in many trials — if used as directed. I sensed an insult. Did I look like someone who couldn't take direction? I let it pass.

That was about a decade ago, during a one-man economic downturn that is, in miniature, reflected in the current national one. What I wished for back then — a modest, short-term boost that would yield sustainable long-term gains — is what so many of us want right now, particularly, I would think, worried college students who find themselves stumbling back to school in a season of grim, uncertain prospects. "It'll help you get back on your feet," my doctor told me, using America's favorite metaphor for accepting a little help, but not too much help, when we're facing daunting circumstances that we're slightly ashamed to find daunting. The key word in this phrase, of course, is "back," because it implies that the subject stood upright previously, and all by himself.

To strivers young and old, the lure of mental accelerants like Adderall and its many molecular cousins has only grown since I swallowed my first dose and started down a pharmacological path that was more dizzying than I expected. I found out the hard way that revving up your brain in order to win the race, or just stay in it, comes at a cost that may exceed the benefits. Lately, others are learning this lesson, too, sometimes in traumatic ways. In the last eight years, it was recently reported, calls to poison-control centers concerning overdoses of legal stimulants by young people shot up 76 percent. The increase tracked a near doubling of the rates at which such medications are prescribed, from about four million prescriptions eight years ago to eight million today. Neither of these figures surprises me. In matters related to modern pep pills, everything seems to double every few years, including, sometimes, a person's appetite for them.

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Sunday, September 6, 2009

Fear of Falling -

What can you do for me that all the doctors who have already seen me
haven't?" the woman demanded. Her face was puckered with frustration,
her voice edged with irritation. Poorly fitting dentures clipped her
words. "I'm too weak to walk and almost too tired to care," she
added, her voice dropping to a whisper. Dr. Bilal Ahmed nodded
sympathetically. He had heard about the woman's mysterious debility
from the resident who admitted her to Highland Hospital in Rochester
the night before.

A couple of years earlier she started "walking like a drunk," she
told the slender, middle-aged doctor. Her legs were weak and her feet
were numb. The only feeling she had in them was a pins-and-needles
sensation, as if her feet had gone to sleep and never woke up. A few
months ago she started falling. She broke her ankle in a particularly
bad fall; the ankle got better, but she didn't. Now she was in a
Her internists referred her to a neurologist, who sent her to the
hospital for an M.R.I. After the test she was so weak that the
doctors were reluctant to send her home, and she was admitted to the
hospital. And here she was, hoping for an answer.

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