Friday, April 30, 2010

Study Details the ‘Invisible’ Work Burden of Family Doctors -

A new study detailing the uncompensated work burden on family doctors points to the need to change how they are paid, medical experts say — particularly as the new health care law promises to add millions more patients to the system.

Family doctors make up the embattled front line of the nation's health care system. They earn about half the money of specialists who focus on treating particular ailments or parts of the body. That is a reason less than 10 percent of medical school graduates choose so-called primary care, which includes general internists and pediatricians.

Worsening shortages of family doctors were being predicted even before the recent health care legislation, which opened the door to an estimated 30 million newly insured people who will begin making appointments for checkups and other care.

"There is already enormous pressure on primary care, and more is coming," said Dr. Thomas Bodenheimer, a professor of family medicine at the University of California, San Francisco.

Comparatively modest salaries and rising patient numbers are part of the challenge, medical experts say. But so is the breadth of the unpaid work performed by family doctors. A study published on Wednesday in the New England Journal of Medicine measured that problem precisely, using computerized patient records and reporting systems to track all the tasks done in a five-physician practice over a year.

Family doctors are paid mainly for each visit by patients to their offices, typically about $70 a visit. In the practice in Philadelphia covered by the study, each full-time doctor had an average of 18 patient visits a day.

But each doctor also made 24 telephone calls a day to patients, specialists and others. And every day, each doctor wrote 12 drug prescriptions, read 20 laboratory reports, examined 14 consultation reports from specialists, reviewed 11 X-ray and other imaging reports, and wrote and sent 17 e-mail messages interpreting test results, consulting with other doctors or advising patients.

The article is the statistical answer to its title, "What's Keeping Us So Busy in Primary Care?" The study, Dr. Bodenheimer said, "really quantifies the huge amount of invisible work in primary care."

The study, medical experts say, also suggests the direction of changes needed if family practices are to flourish and more effectively improve the health of patients and contain costs. It starts, they say, with compensating doctors for work other than patient visits. Such work includes preventive care and helping patients manage chronic illnesses like diabetes, heart disease, cancer and asthma, which account for most of the nation's health care spending.

The new health care legislation includes Medicare payments for preventive health and programs intended to encourage family doctors to assist patients in improving their overall health. And last year's economic stimulus package included $19 billion in financial incentives for doctors and hospitals to accelerate the adoption of electronic health records.

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Thursday, April 29, 2010

Legal fears thwart doctor's bid for ‘liberation' from MS pain - The Globe and Mail

Paulette O'Leary already had an IV in her arm when the lawyers arrived.

The 41-year-old Toronto doctor and mother of two had flown to Pennsylvania over the weekend to undergo a controversial "liberation" treatment she hoped would alleviate the symptoms of multiple sclerosis that have plagued her for 22 years. On Sunday night, she and her husband went out for dinner on the instructions of the doctor who would perform the surgery – he was so confident it would work, he had instructed her to celebrate.

But on Monday, the same doctor, a vascular radiologist named Joseph Bonn, sat at her bedside at Lankenau Hospital outside Philadelphia and informed her that he had just been ordered by lawyers to cancel her procedure, as well as those of countless other MS patients who had booked his surgery time solid through to October.

"I was in shock, because I was so pumped up," Dr. O'Leary said Wednesdaybefore flying back to Toronto. "It's going to be awful when I arrive back at the airport because my daughter's expecting me to run to her, and she's going to see me still walking with a cane."

Dr. O'Leary, a researcher with the University Health Network in Toronto, had paid $18,000 (U.S.) to be just the fifth MS patient, and first Canadian, to be treated by Dr. Bonn.

Since an Italian vascular surgeon named Paolo Zamboni released a study suggesting MS was connected to chronic cerebrospinal venous insufficiency (CCSVI), patients in Canada and around the world have been desperately seeking out doctors who will perform procedures to unblock their veins.

But in the U.S., hospitals are beginning to ban the procedures for MS patients until more research is done, as fears of legal liabilities surface. Dr. O'Leary and others in the MS community worry that this reluctance will force the treatment underground, with people lying about why they need an angioplasty or paying large amounts to receive the treatment overseas.

"People are willing to mortgage their houses for this," Dr. O'Leary said.

A statement released by Lankenau on Wednesday said that while CCSVI "may offer a breakthrough" in the treatment of MS, the hospital is suspending the unblocking treatments until they are approved by its Institutional Review Board.

In December, Stanford University in California also ordered vascular specialist Michael Dake to stop performing a procedure to open the veins of MS patients. Although many of his patients reported improvements in their symptoms, one woman died of a brain hemorrhage on the way home from the treatment, and another patient required surgery after the stent installed to open his jugular vein broke free and floated into his heart.

Since then, other U.S. doctors who had been quietly performing the procedure – their names spread swiftly by online MS support groups – have been ordered to stop by their legal departments.

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Sunday, April 25, 2010

Editorial - Faltering Cancer Trials -

The nation's most important system for judging the clinical effectiveness of cancer treatments is approaching "a state of crisis." That is the disturbing verdict of experts assembled by the National Academy of Sciences to review the performance of clinical trials sponsored by the National Cancer Institute.

Unless the shortcomings are remedied, some of President Obama's ambitious health care reforms will be jeopardized and his audacious goal of finding "a cure for cancer in our time" will have almost no chance at all.

The most shocking deficiency highlighted by the report, issued by the academy's Institute of Medicine, is that about 40 percent of all advanced clinical trials sponsored by the Cancer Institute are never completed. That is an incredible waste of effort and money, and a huge obstacle at a time when researchers are developing promising new therapies that must be rigorously tested.

These large, government-sponsored studies are supposed to be the gold standard — and very different from the narrow, occasionally biased studies sponsored by manufacturers seeking approval of a new drug.

The government-sponsored trials can be invaluable in comparing one therapy against another (manufacturers rarely want to put their products up against a competitor's), combinations of therapies, or therapies for rare diseases with little commercial potential.

So it is especially worrying to hear the experts say that the system — run by the Cancer Institute at the National Institutes of Health — is so mired in cumbersome procedures that it needs to be completely overhauled.

The Cancer Institute funds clinical trials primarily through 10 "cooperative groups" of experts. They generate ideas for testing new therapies and conduct the trials through networks of cancer centers and community oncology practices. More than 25,000 patients, 3,100 institutions and 14,000 patients participate each year.

Yet a series of reviews in recent years found that the testing operation is mired in bureaucracy and poorly coordinated. A typical trial must navigate past dozens of overlapping reviews by different boards and agencies that must approve the original concept for the trial and then the protocol that will govern how it is conducted before the investigators can start enrolling any patients.

The average time between developing the concept for a study and getting it started is about 2.5 years. The longer a study takes to get started, the more likely it is to become scientifically out of date, and the less likely it is that doctors or patients will want to participate.

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Mind Over Meds -

One day several years ago, I was reaching the end of my first visit with a patient, J.J., who had come to see me for anxiety and insomnia. He was a salesman for a struggling telecommunications company, and he was having trouble managing the strain on his finances and his family. He was sleeping poorly, and as soon as he opened his eyes in the early morning, the worries began. "I wake up with a list of things to worry about," he said. "I just go through the list, and it seems to get longer every day."

A psychiatric interview has a certain rhythm to it. You start by listening to what your patient says for a few minutes, without interrupting, all the while sorting through possible diagnoses. This vast landscape of distress has been mapped into a series of categories in psychiatry's diagnostic manual, DSM-IV. The book breaks down mental suffering into 16 groups of disorders, like mood disorders, anxiety disorders, psychotic disorders, eating disorders and several others. As I listened to J.J. (a nickname that he agreed I could use to protect his privacy), it was clear to me that he had one of the anxiety disorders, but which one? In order to systematically rule in or rule out the disorders, I asked J.J. dozens of questions. "Do you have panic attacks?" "Do you get fearful in crowded situations?" "Have you ever experienced a traumatic event that later caused flashbacks or nightmares?"

Each of J.J.'s answers provided me with a clue, closing off one possibility while opening up others. At its best, when you are working with an intelligent, insightful patient, the process is fun, involving a series of logical calculations, much like working a Sudoku puzzle. Finally, toward the end of the hour, I felt confident that I had arrived at J.J.'s diagnosis. "I think you have what we call 'generalized anxiety disorder,' " I told him. It may start with a defined series of causes, as was true for J.J., but then it spirals outward, blanketing the world with potential threat. J.J. worried about what the future would bring and experienced a predictable series of physical symptoms: insomnia, muscle tension, irritability and poor concentration.

"I'm going to write you a prescription for a medication called Zoloft," I said, picking up my prescription pad. He asked what was causing his anxiety, and I began one of the stock neurochemical explanations that psychiatrists typically offer patients about low serotonin levels in the brain. The treatment involved "filling up the tank" by prescribing a medication like Zoloft, Celexa or Paxil.

"So Dr. Freud, the causes are all in the brain? Isn't there some explanation in my childhood?" It was a good-natured tease.

"I specialize in prescribing medications," I said with a smile. I was a psychopharmacologist and specialized in medication rather than psychotherapy. "I can refer you to a good therapist in the area if you'd like."

After J.J. left my office, I realized, uncomfortably, that somehow, over the course of the decade following my residency, my way of thinking about patients had veered away from psychological curiosity. Instead, I had come to focus on symptoms, as if they were objective medical findings, much the way internists view blood-pressure readings or potassium levels. Psychiatry, for me and many of my colleagues, had become a process of corralling patients' symptoms into labels and finding a drug to match.

Leon Eisenberg, an early pioneer in psychopharmacology at Harvard, once made the notable historical observation that "in the first half of the 20th century, American psychiatry was virtually 'brainless.' . . . In the second half of the 20th century, psychiatry became virtually 'mindless.' " The brainless period was a reference to psychiatry's early infatuation with psychoanalysis; the mindless period, to our current love affair with pills. J.J., I saw, had inadvertently highlighted a glaring deficiency in much of modern psychiatry. Ultimately, his question would change the way I thought about my field, and how I practiced.

I originally became interested in psychiatry primarily because of my father: he is a psychiatrist practicing in San Francisco. But there was a darker side to my career choice. My mother suffered severe mental illness, with debilitating depressions and paranoid thoughts. One autumn day during my junior year in college, she committed suicide. Psychiatry then became personal, a way for me to come to terms with her illness.

I majored in psychology at U.C. Berkeley, and at U.C. San Francisco I labored through medical school's rites of passage in order to qualify for a psychiatric residency. Eventually, on a steamy July day in 1992, I stood on a Boston street, far from home, gazing at Massachusetts General Hospital (known as M.G.H.), where I was about to start my training.

This was a momentous time at M.G.H. Prozac was introduced four years earlier and became the best-selling psychiatric medication of all time. Zoloft and Paxil, two similar medications, were in the pipeline, and many of the key clinical trials for these antidepressants were conducted by psychiatrists at M.G.H. who were to become my mentors. M.G.H. and other top programs were enthralled with neurobiology, the new medications and the millions of dollars in industry grants that accompanied them. It was hard not to get caught up in the excitement of the drug approach to treatment. Psychopharmacology was infinitely easier to master than therapy, because it involved a teachable, systematic method. First, we memorized the DSM criteria for the major disorders, then we learned how to ask the patient the right questions, then we pieced together a diagnosis and finally we matched a medication with the symptoms.

But learning the formal techniques of therapy was like navigating without a compass. While I learned how to form an alliance with my patients and begin a good dialogue, becoming a skillful therapist requires much more practice than busy psychiatry residencies allow.

When my father did his residency at U.C.S.F. in the 1950s, he learned therapy well, because, with few medications available, it was the main treatment psychiatrists could offer their patients. Psychiatric residencies focused on therapy, and many residents extended their training further by enrolling in postgraduate psychoanalytic institutes. When modern medications came on the scene, my father adapted by incorporating them into his therapy practice, as did many of his colleagues. I call this the "golden" generation of psychiatrists, those currently approaching retirement age, who were skilled at offering the full package of effective psychiatric treatments to patients.

The newer generation of psychiatrists, who graduated in the 1980s and afterward, trained in programs that were increasingly skeptical of therapy and that emphasized a focus on medications. M.G.H. was by far the most influential of these modern programs. Graduates of the M.G.H. program and its sister program at nearby McLean Hospital have fanned out throughout the country, becoming chairmen of departments and leaders of the National Institute of Mental Health.

A result is that psychiatry has been transformed from a profession in which we talk to people and help them understand their problems into one in which we diagnose disorders and medicate them. This trend was most recently documented by Ramin Mojtabai and Mark Olfson, two psychiatric epidemiologists who found that the percentage of visits to psychiatrists that included psychotherapy dropped to 29 percent in 2004-5 from 44 percent in 1996-97. And the percentage of psychiatrists who provided psychotherapy at every patient visit decreased to 11 percent from 19 percent.

While it is tempting to blame only the biologically oriented psychiatrists for this shift, that would be simplistic. Other forces are at work as well. Insurance companies typically encourage short medication visits by paying nearly as much for a 20-minute medication visit as for 50 minutes of therapy. And patients themselves vote with their feet by frequently choosing to see psychopharmacologists rather than therapists. Weekly therapy takes time and is arduous work. If a daily pill can cure depression and anxiety just as reliably, why not choose this option?

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