Friday, November 13, 2009

Primary Care’s Image Problem -

In my medical school class of 140, Kerry was one of the best and the brightest. Gregarious, unassuming and a dedicated fitness buff with a weakness for ice cream, she managed to sail through the weekly exams that most of us struggled with during the first two years. Later on, in the third year on the hospital wards, she quickly became what every one of us so wanted to be: the indispensable medical student.

When it came time to choose specialties in our last year of medical school, most of us thought Kerry would do what every high achiever and even the not-so-high achievers were already doing: line herself up for a coveted spot in one of the prestigious subspecialties, a field like dermatology, orthopedics, plastic surgery or radiology.

But Kerry wanted to become a primary care physician.

Some of my classmates were incredulous. In their minds, primary care was a backup, something to do if one failed to get into subspecialty training. "Kerry is too smart for primary care," a friend said to me one evening. "She'll spend her days seeing the same boring chronic problems, doing all that boring paperwork and just coordinating care with other doctors when she could be out there herself actually doing something."

Unfortunately those comments would not be the last ones I would hear disparaging primary care. Even today, similar beliefs persist among medical students and trainees, though they have long since been condensed, reduced to an oft repeated acronym among those choosing specialties: I'm heading for the ROAD (radiology, ophthalmology, anesthesia and dermatology).

That ROAD has had devastating effects on the physician work force in the United States. While 50 years ago half of all physicians were in primary care, almost three-quarters are now specialists. The future implications are even more dismal. According to one study published last year in The Journal of the American Medical Association, as few as 2 percent of medical students are choosing to step away from the ROAD or from other similar "high prestige" and competitive specialties in order to pursue general internal medicine. The statistic has the power to bring even the best efforts at reform and universal coverage to a grinding halt. Even with other health care practitioners like nurses and physician assistants helping to care for as many patients as they can, universal health care will be doomed if there are not enough primary care doctors.

Experts in medical education have pointed to three reasons for this lack of enthusiasm: debt, income and lifestyle. The vast majority of medical students finish their schooling saddled with enormous educational debt — the average amount is in excess of $140,000 — and primary care remains one of the lowest-paid specialties.

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Medicines to Deter Some Cancers Are Not Taken - Series -

Many Americans do not think twice about taking medicines to prevent heart disease and stroke. But cancer is different. Much of what Americans do in the name of warding off cancer has not been shown to matter, and some things are actually harmful. Yet the few medicines proved to deter cancer are widely ignored.

Take prostate cancer, the second-most commonly diagnosed cancer in the United States, surpassed only by easily treated skin cancers. More than 192,000 cases of it will be diagnosed this year, and more than 27,000 men will die from it.

And, it turns out, there is a way to prevent many cases of prostate cancer. A large and rigorous study found that a generic drug, finasteride, costing about $2 a day, could prevent as many as 50,000 cases each year. Another study found that finasteride's close cousin, dutasteride, about $3.50 a day, has the same effect.

Nevertheless, researchers say, the drugs that work are largely ignored. And supplements that have been shown to be not just ineffective but possibly harmful are taken by men hoping to protect themselves from prostate cancer.

As the nation's war on cancer continues, with little change in the overall cancer mortality rate, many experts on cancer and public health say more attention should be paid to prevention.

But prevention has proved more difficult than many imagined. It has been devilishly difficult to show conclusively that something simple like eating more fruits and vegetables or exercising regularly helps. And, as the response to the prostate drugs shows, people are not enthusiastic about taking anticancer pills, or are worried about side effects or not really convinced the drugs work. Others are just unaware of them.

And prostate cancer is not unique. Scientists have what they consider definitive evidence that two drugs can cut the risk of breast cancer in half. Women and doctors have pretty much ignored the findings.

Companies have taken note, saying that it makes little economic sense to spend decades developing drugs to prevent cancer. The better business plan seems to be looking for drugs to treat cancer. That is a sobering lesson, said Dr. Ian M. Thompson Jr., chairman of the urology department at the University of Texas Health Science Center in San Antonio.

"A scientific discovery that is very clear cut and that is not implemented by the public is a tragedy," he said.

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Tuesday, November 10, 2009

Googling can mislead people seeking health information

It always starts out innocently enough -- for example, with an eye twitch. It's just a little tic, but it keeps coming and going over the course of a few weeks, and so I decide to do a little medical investigation online. I plug "recurrent eye twitch" into my friendly search engine and, after several hours poring over a range of health-related Web sites -- skimming over likely explanations such as fatigue, stress and too much caffeine in favor of dozens of worst-case scenarios, and growing increasingly panicky all the while -- I am utterly convinced that I have multiple sclerosis, at the very least, and quite possibly Lou Gehrig's disease.

But what really ails me? Cyberchondria, loosely defined as the baseless fueling of fears and anxiety about common health symptoms due to Internet research, or, as I like to think of it, Googling oneself into a state of absolute, clinical hysteria over every last pain, itch and strange freckle on your body.

Apparently, I'm not alone. Last year, Microsoft researchers Eric Horvitz and Ryen White documented the growing trend in "Cyberchondria: Studies of the Escalation of Medical Concerns in Web Search," which included a survey of 515 Microsoft employees and Web-search tracking of hundreds of thousands of consenting Windows Live toolbar users.

The report showed that about 2 percent of all the Windows Live searches were health-related. Of the 250,000 or so users who engaged in at least one such query during the study, roughly one-third "escalated" their subsequent Web surfing to focus on far more serious -- and much less common -- conditions. In addition, the employee survey showed that this type of escalation interrupted the everyday life of more than half the respondents at least once.

Of course, it's important to acknowledge that there is a lot of high-quality health content on the Internet that has helped a lot of people, both on respected, vetted Web sites such as WebMD and Medstory, and also within the myriad online support groups for particular illnesses, where people can seek information, encouragement or a shoulder to cry on. In addition, Horvitz and White's follow-up study found that while two in five people report that surfing the Web for health-related information has made them feel more nervous about a perceived medical condition, just over half of folks say that it reduces anxiety.

The problems arise when people turn to a broad Web search to diagnose their ills, says Horvitz, whose professional credentials include an MD degree.

"People have come to look at search engines as question-answering systems," he explains. "We now see [the Internet] as a general oracle, in our pockets and desktops, that we can just ask questions to, and people think it's going to answer all questions in a quality manner; therefore, people turn to the system and say, 'Diagnose me; here are the symptoms.' "

Horvitz notes that medical diagnostics requires taking in sets of symptoms, reflecting, having an interactive dialogue with a patient and then converging on a list of likely conditions. "It's a relatively sophisticated task that's quite different than information retrieval, which is what search engines are good at. They do not have a good sense for how to reason under uncertainty, or for probabilities. . . . The Web is really great at finding out who played the role of Gilligan on 'Gilligan's Island,' but not so good at weighing the evidence to give you good information about concerning and unconcerning health situations."

Instead, Web search rankings are often based on such things as relevance and click-through rates, which skew the results you see. For example, Horvitz and White use the example of headaches, which are just as likely to be associated with "brain tumor" as "caffeine withdrawal" in search, although the annual U.S. incidence rate of brain tumors is about 1 in 10,000, and missing your daily cup of java is one of the most likely explanations for a common headache. Yet the research also shows that the vast majority of people have interpreted the ranking of search results as a list of likely ailments, in order of probable diagnoses.

Clearly, psychology is just as much at play as technology. Stephen Josephson, a clinical associate professor of psychology at Weill Cornell Medical College in New York, says that a lot of the health concerns people have fall broadly under the category of anxiety, which can prompt compulsive behaviors such as constantly cruising the Web for information. He explains that it's well-proven that people are prone to selectively attend to negative information -- like the fact that a mole might be melanoma -- and to ignore the actual low prevalence of dire diseases,

"It's a paradox: The more you read in an attempt to reduce your fear, the more you try to figure things out, the more anxiety peaks. Very few people know how to navigate the Internet and evaluate information when they're anxious, and yet that's when they tend to go online."

Microsoft's Horvitz says the challenge for the Web is to improve health content so it more accurately reflects probability and likelihoods, and to adapt search engines to factor in many more complexities, such as family history, to be able to properly diagnose an ailment and then intervene when people are escalating inappropriately. Take, for example, someone younger than 35 with no family history of cardiac trouble who plugs "chest pain" into a search. Right now "heart attack" will pop up the most frequently, about 37 percent of the time, says Horvitz. "But if the system just knew their age and family history, it would say, 'Just take it easy; don't run to the hospital,' " because it would be extremely unusual for a young person with no history to be having a heart attack.

In the meantime, fellow cyberchondriacs, try to keep everything in perspective and seek out credible information. The Medical Library Association has some great tips for evaluating health research online.

Oh, and about that twitch? Eventually I asked my doctor about it, and he helped me figure out that I'm actually allergic to a new eye cream I bought to stave off the effects of aging -- not in need of pricey and invasive tests for a rare tropical disease.

Sunday, November 8, 2009

Marcia Angell, M.D.: Is the House Health Care Bill Better than Nothing?

Well, the House health reform bill -- known to Republicans as the Government Takeover -- finally passed after one of Congress's longer, less enlightening debates. Two stalwarts of the single-payer movement split their votes; John Conyers voted for it; Dennis Kucinich against. Kucinich was right.

Conservative rhetoric notwithstanding, the House bill is not a "government takeover." I wish it were. Instead, it enshrines and subsidizes the "takeover" by the investor-owned insurance industry that occurred after the failure of the Clinton reform effort in 1994. To be sure, the bill has a few good provisions (expansion of Medicaid, for example), but they are marginal. It also provides for some regulation of the industry (no denial of coverage because of pre-existing conditions, for example), but since it doesn't regulate premiums, the industry can respond to any regulation that threatens its profits by simply raising its rates. The bill also does very little to curb the perverse incentives that lead doctors to over-treat the well-insured. And quite apart from its content, the bill is so complicated and convoluted that it would take a staggering apparatus to administer it and try to enforce its regulations.

What does the insurance industry get out of it? Tens of millions of new customers, courtesy of the mandate and taxpayer subsidies. And not just any kind of customer, but the youngest, healthiest customers -- those least likely to use their insurance. The bill permits insurers to charge twice as much for older people as for younger ones. So older under-65's will be more likely to go without insurance, even if they have to pay fines. That's OK with the industry, since these would be among their sickest customers. (Shouldn't age be considered a pre-existing condition?)

Insurers also won't have to cover those younger people most likely to get sick, because they will tend to use the public option (which is not an "option" at all, but a program projected to cover only 6 million uninsured Americans). So instead of the public option providing competition for the insurance industry, as originally envisioned, it's been turned into a dumping ground for a small number of people whom private insurers would rather not have to cover anyway.

If a similar bill emerges from the Senate and the reconciliation process, and is ultimately passed, what will happen?

First, health costs will continue to skyrocket, even faster than they are now, as taxpayer dollars are pumped into the private sector. The response of payers -- government and employers -- will be to shrink benefits and increase deductibles and co-payments. Yes, more people will have insurance, but it will cover less and less, and be more expensive to use.

But, you say, the Congressional Budget Office has said the House bill will be a little better than budget-neutral over ten years. That may be, although the assumptions are arguable. Note, though, that the CBO is not concerned with total health costs, only with costs to the government. And it is particularly concerned with Medicare, the biggest contributor to federal deficits. The House bill would take money out of Medicare, and divert it to the private sector and, to some extent, to Medicaid. The remaining costs of the legislation would be paid for by taxes on the wealthy. But although the bill might pay for itself, it does nothing to solve the problem of runaway inflation in the system as a whole. It's a shell game in which money is moved from one part of our fragmented system to another.

Here is my program for real reform:

Recommendation #1: Drop the Medicare eligibility age from 65 to 55. This should be an expansion of traditional Medicare, not a new program. Gradually, over several years, drop the age decade by decade, until everyone is covered by Medicare. Costs: Obviously, this would increase Medicare costs, but it would help decrease costs to the health system as a whole, because Medicare is so much more efficient (overhead of about 3% vs. 20% for private insurance). And it's a better program, because it ensures that everyone has access to a uniform package of benefits.

Recommendation #2: Increase Medicare fees for primary care doctors and reduce them for procedure-oriented specialists. Specialists such as cardiologists and gastroenterologists are now excessively rewarded for doing tests and procedures, many of which, in the opinion of experts, are not medically indicated. Not surprisingly, we have too many specialists, and they perform too many tests and procedures. Costs: This would greatly reduce costs to Medicare, and the reform would almost certainly be adopted throughout the wider health system.

Recommendation #3: Medicare should monitor doctors' practice patterns for evidence of excess, and gradually reduce fees of doctors who habitually order significantly more tests and procedures than the average for the specialty. Costs: Again, this would greatly reduce costs, and probably be widely adopted.

Recommendation #4: Provide generous subsidies to medical students entering primary care, with higher subsidies for those who practice in underserved areas of the country for at least two years. Costs: This initial, rather modest investment in ending our shortage of primary care doctors would have long-term benefits, in terms of both costs and quality of care.

Recommendation #5: Repeal the provision of the Medicare drug benefit that prohibits Medicare from negotiating with drug companies for lower prices. (The House bill calls for this.) That prohibition has been a bonanza for the pharmaceutical industry. For negotiations to be meaningful, there must be a list (formulary) of drugs deemed cost-effective. This is how the Veterans Affairs System obtains some of the lowest drug prices of any insurer in the country. Costs: If Medicare paid the same prices as the Veterans Affairs System, its expenditures on brand-name drugs would be a small fraction of what they are now.

Is the House bill better than nothing? I don't think so. It simply throws more money into a dysfunctional and unsustainable system, with only a few improvements at the edges, and it augments the central role of the investor-owned insurance industry. The danger is that as costs continue to rise and coverage becomes less comprehensive, people will conclude that we've tried health reform and it didn't work. But the real problem will be that we didn't really try it. I would rather see us do nothing now, and have a better chance of trying again later and then doing it right. -- Help us build our Web site!

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