Saturday, March 22, 2014

Living With Cancer: The Cost of Trials -

A recent CT scan made me realize that the clinical trial extending my life effectively excludes all but the most privileged cancer patients.

I used to weasel out of scans. Chalk it up to trepidation about radiation and possible kidney damage, along with paranoid suspicions that such scans don't yield definitive pictures. My oncologist and I had agreed to fudge on frequent testing. But the clinical trial did not.

When I registered for the CT, a woman wearing a badge that read "financial navigator" handed me the requisite forms to sign. I explained that the CT should be billed to the Phase I trial, since I was undergoing it so the investigators could measure the efficacy of their drug. Unable to reach the trial administrator by phone, she asked, "Can we put it down as a self-pay since you can change it afterwards?"

The clock was ticking. I would need to start drinking the gallons of what I call Kool-Aid, the drink that people under 140 pounds need to gulp during the two hours before an abdominal CT. I knew that I had to concede but wanted to know how much it would cost. "Oh," she replied, "I couldn't say."

I signed the form and, after receiving the paper bracelet, trudged down to the basement and began the long haul of swilling and waiting. The Kool-Aid — in science-speak, the gastrografin contrast solution — brought to mind my friend Judy, vomiting the barium milkshake she had to ingest in a different hospital. It was impossible to keep down, she reported, but her oncologist insisted on it. I touted the less viscous Kool-Aid and she asked a hospital radiologist who replied, "Sure, you could try that instead." We shook our heads in disbelief at his nonchalance.

Running repeatedly to the bathroom, I thanked my lucky stars that I did not need to take the drugs prescribed for people with allergic reactions to this test. The CT would be brief and painless, I knew, and therefore none of the anxiety of the first few scans plagued me as the technician accompanied me down the hall to the scanner.

"I can't tell when I can get a nurse to access your port," she said, positioning me on the narrow plank facing the gaping mouth of the huge machine. "There were massive cutbacks two months ago. Would you rather wait or have me stick you?"

At least I was fully clothed while making this decision. Praying a vein would work, I eyed the triangular bar hanging from a pulley over my head while the technician established a line and took cover in another room.

The conveyor belt moved me so deep into the bowels of the cave-like mechanism that the overhead metal bar, which I clutched with upraised hands, clanged against it. Only my head remained just outside of the giant doughnut.

"Take a breath and hold," a mechanical female voice said. Did they change it to a male voice for men? I wondered.

Conveyed back out, I heard, "Breathe."

Through the IV line, the technician injected another contrast agent that, she told me, would give me an awful taste in my mouth and make me feel as if I were wetting my pants, and then the process was repeated.

"Take a breath and hold."


After the technician removed the needle in my arm, I limped out of the hospital determined to control my nausea with peppermint. Although I had not eaten for some 20 hours, I asked my husband to stop the car on the way home only to use a gas station restroom.

The nausea I had felt that day returned some time later when I received a bill for $4,567. Because standard practice of care for recurrent ovarian cancer includes a CT every three months, the trial did not cover the cost of this scan. At registration, I had been thinking in terms of the trial paying or me paying. Instead of saying "self-pay," I should have handed the "financial navigator" my insurance cards. Adjustments would have to be made with billing services.

My mistake at registration revealed the exorbitant price of the CT, which otherwise would have been masked by the incomprehensible maze of paperwork sent by providers. The trial exacts large expenses: it requires that people have periodic scans and does not pay for them.

How could patients who are under-insured or not insured at all be included in such a clinical trial? How could people working for the minimum wage afford $18,268 a year for CTs? If the trial were in a remote hospital, travel and lodging would raise that price tag, as would the need to take days off from work for recurrent blood tests.

Now I understand why low-income patients are underrepresented in cancer trials, although they bear a disproportionate burden of cancer mortality. For economic status is of course a barrier not only to trials but also, more alarmingly, to detection and treatment.

I made the call to billing services. I took a breath and got put on hold.

Susan Gubar is a distinguished emerita professor of English at Indiana University and the author of "Memoir of a Debulked Woman," which explores her experience with ovarian cancer.

Wednesday, March 19, 2014

Do psychiatrists think everyone is crazy? – Joseph M Pierre – Aeon

When a psychiatrist meets people at a party and reveals what he or she does for a living, two responses are typical. People either say, 'I'd better be careful what I say around you,' and then clam up, or they say, 'I could talk to you for hours,' and then launch into a litany of complaints and diagnostic questions, usually about one or another family member, in-law, co-worker, or other acquaintance. It seems that people are quick to acknowledge the ubiquity of those who might benefit from a psychiatrist's attention, while expressing a deep reluctance ever to seek it out themselves.

That reluctance is understandable. Although most of us crave support, understanding, and human connection, we also worry that if we reveal our true selves, we'll be judged, criticised, or rejected in some way. And even worse – perhaps calling upon antiquated myths – some worry that, if we were to reveal our inner selves to a psychiatrist, we might be labelled crazy, locked up in an asylum, medicated into oblivion, or put into a straitjacket. Of course, such fears are the accompaniment of the very idiosyncrasies, foibles, and life struggles that keep us from unattainably perfect mental health.

As a psychiatrist, I see this as the biggest challenge facing psychiatry today. A large part of the population – perhaps even the majority – might benefit from some form of mental health care, but too many fear that modern psychiatry is on a mission to pathologise normal individuals with some dystopian plan fuelled by the greed of the pharmaceutical industry, all in order to put the populace on mind-numbing medications. Debates about psychiatric overdiagnosis have amplified in the wake of last year's release of the newest edition of theDiagnostic and Statistical Manual of Mental Disorders (DSM-5), the so-called 'bible of psychiatry', with some particularly vocal critics coming from within the profession.

It's true that the scope of psychiatry has greatly expanded over the past century. A hundred years ago, the profession had a near-exclusive focus on the custodial care of severely ill asylum patients. Now, psychiatric practice includes the office-based management of the 'worried well'. The advent of psychotherapy, starting with the arrival of Sigmund Freud's psychoanalysis at the turn of the 20th century, drove the shift. The ability to treat less severe forms of psychopathology – such as anxiety and so-called adjustment disorders related to life stressors – with the talking cure has had profound effects on mental health care in the United States.

Early forms of psychotherapy paved the way for the Mental Hygiene Movement that lasted from about 1910 through the 1950s. This public health model rejected hard boundaries of mental illness in favour of a view that acknowledged the potential for some degree of mental disorder to exist in nearly everyone. Interventions were recommended not just within a psychiatrist's office, but broadly within society at large; schools and other community settings were all involved in providing support and help.

A new abundance of 'neurotic' symptoms stemming from the trauma experienced by veterans of the First and Second World Wars reinforced a view that mental health and illness existed on a continuous spectrum. And by the time DSM was first published in 1952, psychiatrists were treating a much wider swath of the population than ever before. From the first DSM through to the most recent revision, inclusiveness and clinical usefulness have been guiding principles, with the profession erring on the side of capturing all of the conditions that bring people to psychiatric care in order to facilitate evaluation and treatment.

In the modern era, psychotherapy has steered away from traditional psychoanalysis in favour of more practical, shorter-term therapies: for instance, psychodynamic therapy explores unconscious conflicts and underlying distress on a weekly basis for as little as a few months' duration, and goal-directed cognitive therapy uses behavioural techniques to correct disruptive distortions in thinking. These streamlined psychotherapeutic techniques have widened the potential consumer base for psychiatric intervention; they have also expanded the range of clinicians who can perform therapy to include not only psychiatrists, but primary care doctors, psychologists, social workers, and marriage and family therapists.

In a similar fashion, newer medications with fewer side effects are more likely to be offered to people with less clear-cut psychiatric illnesses. Such medications can be prescribed by a family physician or, in some states, a psychologist or nurse practitioner.

Viewed through the lens of the DSM, it is easy to see how extending psychiatry's helping hand deeper into the population is often interpreted as evidence that psychiatrists think more and more people are mentally ill. Recent epidemiological studies based upon DSMcriteria have suggested that half or more of the US population will meet the threshold for mental disorder at some point in their lives. To many, the idea that it might be normal to have a mental illness sounds oxymoronic at best and conspiratorially threatening at worst. Yet the widening scope of psychiatry has been driven by a belief – on the parts of both mental health consumers and clinicians alike – that psychiatry can help with an increasingly large range of issues.

The diagnostic creep of psychiatry becomes more understandable by conceptualising mental illness, like most things in nature, on a continuum. Many forms of psychiatric disorder, such as schizophrenia or severe dementia, are so severe – that is to say, divergent from normality – that whether they represent illness is rarely debated. Other syndromes, such as generalised anxiety disorder, might more closely resemble what seems, to some, like normal worry. And patients might even complain of isolated symptoms such as insomnia or lack of energy that arise in the absence of any fully formed disorder. In this way, a continuous view of mental illness extends into areas that might actually be normal, but still detract from optimal, day-to-day function.

While a continuous view of mental illness probably reflects underlying reality, it inevitably results in grey areas where 'caseness' (whether someone does or does not have a mental disorder) must be decided based on judgment calls made by experienced clinicians. In psychiatry, those calls usually depend on whether a patient's complaints are associated with significant distress or impaired functioning. Unlike medical disorders where morbidity is often determined by physical limitations or the threat of impending death, the distress and disruption of social functioning associated with mental illness can be fairly subjective. Even those on the softer, less severe end of the mental illness spectrum can experience considerable suffering and impairment. For example, someone with mild depression might not be on the verge of suicide, but could really be struggling with work due to anxiety and poor concentration. Many people might experience sub-clinical conditions that fall short of the threshold for a mental disorder, but still might benefit from intervention.

The truth is that while psychiatric diagnosis is helpful in understanding what ails a patient and formulating a treatment plan, psychiatrists don't waste a lot of time fretting over whether a patient can be neatly categorised in DSM, or even whether or not that patient truly has a mental disorder at all. A patient comes in with a complaint of suffering, and the clinician tries to relieve that suffering independent of such exacting distinctions. If anything, such details become most important for insurance billing, where clinicians might err on the side of making a diagnosis to obtain reimbursement for a patient who might not otherwise be able to receive care.

Though many object to psychiatry's perceived encroachment into normality, we rarely hear such complaints about the rest of medicine. Few lament that nearly all of us, at some point in our lives, seek care from a physician and take all manner of medications, most without need of a prescription, for one physical ailment or another. If we can accept that it is completely normal to be medically sick, not only with transient conditions such as coughs and colds, but also chronic disorders such as farsightedness, lower back pain, high blood pressure or diabetes, why can't we accept that it might also be normal to be psychiatrically ill at various points in our lives?

The answer seems to be that psychiatric disorders carry a much greater degree of stigma compared with medical conditions. People worry that psychiatrists think everyone is crazy because they make the mistake of equating any form of psychiatric illness with being crazy. But that's like equating a cough with tuberculosis or lung cancer. To be less stigmatising, psychiatry must support a continuous model of mental health instead of maintaining an exclusive focus on the mental disorders that make up the DSM. If general medicine can work within a continuous view of physical health and illness, there is no reason why psychiatry can't as well.

Criticism of this view comes from concern over the type of intervention offered at the healthier end of the continuum. If the scope of psychiatry widens, will psychiatric medications be vastly overprescribed, as is already claimed with stimulants such as methylphenidate (Ritalin) for attention deficit hyperactivity disorder (ADHD)? This concern is well worth fretting over, given the uncertain effectiveness of medications for patients who don't quite meet DSMcriteria. For example, a 2008 study by the Harvard psychologist Irving Kirsch published in PLOS Medicine found that, for milder forms of depression, antidepressants are often no better than placebos. Likewise, recent research suggests that children at risk of developing psychosis – but not diagnosable just yet – might benefit more from fish oil or psychotherapy than antipsychotic drugs.

In the end, implementing pharmacotherapy for a given condition requires solid evidence from peer-reviewed research studies. Although by definition the benefit of medications decreases at the healthier end of a mental health continuum (if one isn't as sick, the degree of improvement will be less), we need not reject all pharmacotherapy at the healthier end of the spectrum, provided medications are safe and effective. Of course, medications aren't candy – most have a long list of potential side effects ranging from trivial to life-threatening. There's a reason such medications require a prescription from a physician and why many psychiatrists are sceptical of proposals to grant prescribing privileges to health practitioners with far less medical training.

People worry that psychiatrists think everyone is crazy because they make the mistake of equating any form of psychiatric illness with being crazy. But that's like equating a cough with tuberculosis or lung cancer

Pharmacotherapy for healthier individuals is likely to increase in the future as safer medications are developed, just as happened after selective serotonin re-uptake inhibitors (SSRIs) supplanted tricyclic antidepressants (TCAs) during the 1990s. In turn, the shift to medicating the healthier end of the continuum paves a path towards not only maximising wellness but enhancing normal functioning through 'cosmetic' intervention. Ultimately, availability of medications that enhance brain function or make us feel better than normal will be driven by consumer demand, not the Machiavellian plans of psychiatrists. The legal use of drugs to alter our moods is already nearly ubiquitous. We take Ritalin, modafinil (Provigil), or just our daily cup of caffeine to help us focus, stay awake, and make that deadline at work; then we reach for our diazepam (Valium), alcohol, or marijuana to unwind at the end of the day. If a kind of anabolic steroid for the brain were created, say a pill that could increase IQ by an average of 10 points with a minimum of side effects, is there any question that the public would clamour for it? Cosmetic psychiatry is a very real prospect for the future, with myriad moral and ethical implications involved.

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Tuesday, March 18, 2014

Ten types of emergency room patients - Slate

You're sitting in the waiting room, icing your sore ankle. The teenager to your right is moaning and clutching his belly. The woman to your left is coughing into her mask. A stretcher rolls by with a man yelling at the top of his lungs. An ambulance arrives. You see paramedics performing CPR.

You wonder, with all this chaos around you, how can you make sure that your emergency room doctor will address your concerns?

Along with primary care physicians, we emergency providers are the frontlines of medical care. We see people with every imaginable issue. Some ER patients are critically ill—from trauma, heart attack, or severe infection. These patients will get seen immediately and have the full focus of ER staff. Other patients are not critically ill but still have needs that must be tended to.

As an emergency physician and patient advocate, I've met many patients who are frustrated by their medical care. I wish I could have given them advice before they came to the ER.

I see some of the same missed opportunities and miscommunications again and again. Categorizing the clusters of difficulties can help to identify and fix the problems. Here are my suggestions for 10 types of ER patients. I don't intend to stereotype or imply that every patient falls into one of these categories. If you recognize yourself in one of these categories, you may benefit from some guidance to help us best help you.

No. 1: The Repeat Customer. Often, ER docs will see a patient who's had headaches for 10 years or foot pain for even longer. If you have a chronic, ongoing issue, explain why today is the day you came to the ER. Help us understand why you're here. Maybe your symptoms have changed. Perhaps your sister just got diagnosed with cancer and you're worried. Please tell us the truth. If there is truly nothing new and you have a primary care physician, please consider making an appointment with her. We can take care of acute pain, but you will need someone to follow you for ongoing medical problems.

No. 2: The Second-Opinion Seeker. You've had months of troublesome symptoms. Nobody—not your primary care physician, not the five specialists you've seen—has given you a satisfactory answer. We understand that you're concerned, but it's unlikely that in the ER, with limited time and resources, we can give you the in-depth investigation you deserve. Ask your regular doctor for referrals and further testing. Keep in mind that we have finite resources; if you're in our emergency MRI for your chronic knee pain, that means the patient with the possible stroke needs to wait.

No. 3: The Googler. The Internet can be a powerful tool for empowering patients, but please use it responsibly. Looking up your symptoms yourself might turn up that you have a brain tumor when you have food poisoning or that you are pregnant when you have belly pain (and you're a man). Use the Internet to help you understand your diagnosis and treatment and to come up with questions—not to diagnose yourself.

No. 4: The "Pain All Over" Patient. We call it the "positive review of systems" when you say yes to everything we ask. Headache? Chest pain? Shortness of breath? Fatigue? Muscle aches? Yes, yes, of course, yes. Some illnesses really affect many parts of the your body, but more often than not, patients will say yes to convince us they are ill. We know you aren't well, so tell us the truth. (If you don't, you run the risk of undergoingunnecessary testing.) If everything hurts, try to tell us your story. When did you last feel normal and well? What happened then? And please don't exaggerate. If you say that your pain is 15 out of 10, but you're eating lunch and texting on your iPhone, it's hard for us to calibrate your symptoms.

No. 5: The "Totally Healthy" Person. I can't tell you how often a patient will tell me he is healthy with no medical problems, then mention to his nurse that he gets insulin shots and takes "some white and blue pills." Please give us the full information about your health. Few visits to the ER are truly such an emergency that you don't have time toprepare in advanceCarry a card with you of all your medical conditions, past surgeries, allergies, and current medications and dosages. Don't forget vitamins and herbal supplements. Let your doctor know you're coming; she can call in and let us know, or she might say you can see her that day instead of going to the ER.

No. 6: The Forgetter. Often, I'll ask patients what brought them to the ER, and they'll look at me blankly. "I don't know," they'll say. Going to the ER is stressful, especially if you're ill and already not feeling well. While you're waiting for the doctor, write down your symptoms and key concerns. Bring a family member or friend with you who can help you speak up. There is limited time to see the doctor, so you have to make use of that time and tell us why you are here. If you brought a loved one to be seen, stay with the person—this isn't the time to go shopping and leave granny alone in the waiting room.

No. 7: The Narcotic Seeker. This is the patient who says he has chronic pain and is out of his narcotic medications; for some reason, he cannot contact his primary care physician, and his pills have all been "stolen." The United States has an epidemic of prescription drug abuse, and we in the ER inadvertently become detectives. We want to be careful to identify patients who have real pain and real need, but we also don't want to feed addiction and even criminal behavior of those who abuse the system. If you have a real need, explain what happened and why you cannot see your regular doctor. If it's a different pain than usual, tell us clearly—perhaps there is an underlying new problem that we have to investigate.

No. 8: The Small Talker. We want to talk to you; we really do. Actually, the greatest pleasure of my work is getting to know people, and I would love to sit and chat. Unfortunately, there are 20 other patients waiting to see me, and my job is to help you and them. So please tell me about your health, and ask me as much as you want about that. I don't want to be rude, and I appreciate your interest in me, but please help me help you by focusing on your health.

No. 9: The Yeller. You've been waiting for hours. You're in a tiny room; the TV doesn't work. We are sorry about this; we truly are. Our ER may have 50—100—patients in it, and we have to take care of everyone in order of severity. Screaming and shouting doesn't help, nor does threatening to call your lawyer, the hospital CEO, or the local news station. Please be assured that we are working very hard and are trying to take care of you as quickly and as well as possible. If something has changed and you are feeling worse, please let us know. If you want to help the ER improve, there are often opportunities to do so by joining patient advisory committees.

No. 10: The Apologizer. "I'm so sorry to come in for this. You have a lot of other patients who look worse than me." It's possible that other patients may be sicker, but you came because you weren't feeling well. Help us understand what prompted you to come in today. We know it's hard to know when it's necessary to come to the ER and when it's not. And there's no need to feel sorry for us. We chose this job because we want to treat all patients, regardless of who they are and what conditions ail them. We are proud to have the privilege of caring for you.

A Surgical Procedure's Risks, Unmentioned -

Many patients assume that, like prescription drugs, surgical procedures 
and instruments undergo extensive testing and must be government-approved. It's not necessarily so.

Developers, of course, do test new instruments, and practitioners often train with an expert before using them unsupervised to treat patients. And the Food and Drug Administration must confirm an instrument's safety and effectiveness before it can be marketed — but only if the device is deemed significantly different from others already approved.

Surgical techniques, however, are not subject to the stringent approval process that drugs go through. And as with drugs, problems with new procedures may not become apparent until after they have been used many hundreds or thousands of times.

Such is the case with a popular treatment for a very common medical problem: uterine fibroids. The technique, called electric or power morcellation, has widespread appeal for both surgeons and patients. It is used during laparoscopic or robotic-assisted operations that are fast and effective, require only a tiny incision or none at all, and involve less pain, a shorter hospital stay and a quicker recovery. In most cases, these operations are safer than traditional surgery.

As recent reports have shown, however, power morcellation can also cause serious and sometimes life-threatening complications. Experts say that prospective patients are often not told about these risks before consenting to the operation.

The technique involves insertion of a tiny instrument with a rapidly rotating blade, the morcellator, that breaks up the fibroid so that it can be sucked out through the small opening of a laparoscope. But problems can arise months or years later if pieces of tissue escape into the pelvic cavity and seed themselves on other organs.

This problem is all the more serious if the fibroid that was morcellated happens to have contained a hidden cancer. Although the overwhelming majority of fibroids are benign, there is no certain way to tell before their removal if they harbor a cancer, which happens in 1 in 400 to 1 in 1,000 cases.

One such case involves a 41-year-old Bostonian, Dr. Amy J. Reed, an anesthesiologist and a mother of six, who now has a Stage 4leiomyosarcoma after undergoing uterine morcellation. It is a rare but particularly aggressive uterine cancer. Dr. Reed and her husband, Dr. Hooman Noorchashm, a cardiothoracic surgeon, are waging a campaign through to halt use of the technique.

Despite several preoperative tests, neither Dr. Reed nor her surgeon suspected that cancer lurked within the fibroids that were removed. If she had had a traditional operation in which the fibroids were cut out or the entire uterus removed intact, it is highly unlikely that the cancer would have spread.

From 1983 through 2010, 13 unexpected uterine sarcomas were reported after uterine surgery on 5,666 patients. Among 1,192 women who underwent morcellation, two developed sarcoma that spread within the abdomen.

After reviewing the medical records of more than 1,000 women who received morcellation for fibroids, specialists at Brigham & Women's Hospital in Boston found a ninefold higher rate of unexpected sarcoma than is now quoted to patients considering the procedure.

"These data suggest uterine morcellation carries a risk of disseminating unexpected malignancy with apparent associated risk of mortality much higher than appreciated currently," the researchers wrote in the journal PLOS One in 2012.

Even benign uterine tissue, when it is spread to other parts of the abdomen during morcellation, can grow in places it doesn't belong and cause pain, infection or bowel obstruction.

There is a technique that could make morcellation safer: encasing the tissue to be removed in a bag before it is broken up. But thus far, the procedure is infrequently used, and few surgeons are skilled in the technique.

Other established ways to treat bothersome fibroids are free of this potential risk, though complications like wound infection are possible.

Fibroids are extremely common, affecting half or more women during their reproductive years, when hormones foster their growth. They develop from the smooth muscle tissue of the uterus, ranging in size from tiny to huge, and often shrink after pregnancyand menopause.

Most women with fibroids are unaware they have them, but others can experience symptoms like prolonged heavy periods, bleeding between periods, pelvic pressure, constipation, frequent urination, backaches and anemia. They can sometimes cause infertility ormiscarriage.

Fibroids are typically detected through a pelvic exam, sonogram orM.R.I., sometimes with saline solution or a dye used to better define their size and location.

Nothing needs to be done about a fibroid that causes no distress. Large, bothersome fibroids can often be shrunk by several months of treatment with medications that block estrogen andprogesterone, causing temporary menopause and its attendant symptoms.

The drug mifepristone (RU-486) also can shrink fibroids, andEvista may do likewise, but only in postmenopausal women. Sometimes a low-dose oral contraceptive is used to reduce bleeding caused by fibroids without shrinking their size.

Noninvasive ultrasound surgery under M.R.I. guidance can be used to heat and destroy a fibroid without damaging the uterus. A fibroid also can be destroyed by injecting small particles into uterine arteries to cut off its blood supply.

Fibroids can be removed laparoscopically or robotically without damaging the uterus. If the fibroid is contained within the uterus, it can often be removed with surgical instruments inserted through the vagina and cervix. Some fibroids may be destroyed by applying heat or electric current to the uterine lining.

Very large, multiple or deep fibroids may require more traditional surgery, called an abdominal myomectomy, that spares the uterus, or with a hysterectomy, a more serious operation involving removal of the entire uterus, ending a woman's menstrual periods and ability to bear children.

If you are contemplating treatment for symptomatic fibroids, your doctor should answer several important questions before you choose a method:

What is the nature of the problem, and how necessary is it to treat it?

What procedures are known to be effective, and what are the risks and benefits of each?

What is the approach you recommend, and how much experience do you have with it?

What are its possible complications, and how often do they occur?

Without a clear understanding of treatment options, their potential hazards as well as their effectiveness, it is not possible to for you to give informed consent.

The Unworried Unwell -

She is an organized, punctual patient who makes appointments and keeps them. He drops in whenever he feels like it. Her visits are short and organized; his seem to drag on forever. The two have nothing in common — except that they both leave the office empty-handed.

Most people leave a medical encounter with something to show for it, whether tangible (prescriptions, referrals) or ephemeral (good advice). These two patients accept nothing, especially not the advice.

They both feel fine, although neither could be called well. For her, the problem is blood pressure, with readings so far into the "malignant" zone that we compulsively recheck her with different cuffs, trying to blame the equipment.

No such luck: Her results are permanently stroke-making, kidney-ruining, eyesight-threatening. She declines any form of medication. At first, we figured she was just politely taking her business elsewhere, but no, she keeps coming back. "Just want to see how I'm doing," she says. She is always doing the same.

His problem is a rapidly accelerating H.I.V. infection. His blood tests are as alarming as her blood pressure, and as suggestive of imminent catastrophe, but he has no interest in any of the ways we propose to avert it. "Just want to see how I'm doing," he says every few months as he saunters away, lab report tucked into his pocket.

There aren't many medical situations where doctors' imaginations trump those of their patients. In fact, when it comes to chronic illness, doctors are notoriously shortsighted, seldom perceiving the seismic effects pain and disability can exert on all aspects of a patient's personality and family life. The medical problems may be clear, but their context often remains obscure.

For people who feel fine, though, the situation can be just the reverse: It is the patient with feet of stone firmly planted in the here and now, while medical personnel spin wild tales of coming catastrophe, full of verbs conjugated in the future probable.

Some people see our visions even more clearly than we do, accepting all offered preventives and asking for more. Most of the rest take our word for it and resignedly go along with the program. A few say thanks but no thanks, and saunter away.

And it is that last little group — including him with his virus and her with her blood pressure — who hold the key to the way future generations of doctors will be practicing medicine.

Medical care is all about prevention these days: locating and disarming invisible swords of Damocles before they drop. In the process, of course, we are creating whole lists of "pre-illnesses," situations likely to lead to actual illness over time — or, in the case of "prehypertension" (blood pressure that is almost too high), situations likely to lead to situations likely to lead to illness. People who opt to have their DNA analyzed by a commercial lab see their future spelled out in the vaguest possible terms: the risks of various diseases compared to the average.

Soon, it seems, we will do little but talk to our pre-patients about all their various pre-diseases. And we still have exactly no idea how best to conduct those conversations.

There is the reasoned numerical approach ("30 percent of people with your problem of X will develop Y"). Many studies (and all casinos and lotteries)illustrate how abysmal is the average person's understanding of risk when couched in mathematical terms.

There is the in-your-face approach, like the one taken by a series of antismoking advertisements featuring harsh close-ups of painfully moribund smokers. No one likes those. "Couldn't get the TV off fast enough," said one smoker I know.

There is the blunt "it's your funeral" approach: doctors who indicate by word or deed that they have no time for you till you are ready to knuckle under and behave the way a pre-patient should.

And there is the fallback "beat your head against the wall" approach, with the same dire predictions enunciated over and over again, a millstone ground by a plodding ox. This particular routine enervates doctor and patient alike: The future probable is a pretty dull tense, summoning none of the adrenaline that attends acute fix-it-up care.

Sometimes we forget, though, that medicine is fundamentally all about the thankless art of prognosis, a practice only a few little data-filled footnotes away from prophecy. In fact, our future of treating pre-illness will simply catapult us right back to a priestly past, as we offer up misty visions of the future and encourage the masses to see with us and act accordingly.

We have said many things over the centuries to those who, for whatever reason, cannot see what we see. Of them, I suspect that by far the best, most effective and most important has always been "See you next time."

Monday, March 17, 2014

The Doctor Will See You Onscreen - New Yorker

One night last summer, when I was working as a medical student in an emergency room, a woman pulled me aside. Her left eye was pink and looked painfully irritated. She had been waiting for hours to get it checked but would have to leave soon to catch a train home. How much longer, she asked, before she could be seen?

A doctor was able to evaluate the patient before she dashed out the door, but her dilemma struck me. We buy groceries, trade stocks, and chat with friends across the globe without getting out of bed. Yet seeing a doctor remains a fantastically old-fashioned routine: minutes of medical attention can cost hours spent in transit or in a waiting room. When the price of losing that time gets too high, we might not even bother to be seen.

There's a potential solution to this problem: using technology to deliver health care remotely. That approach, known as telemedicine, involves locating available doctors over the Internet and connecting with them, at a moment's notice, using video chat. Telemedicine lets you see a doctor whenever and wherever you want, freeing you to choose a doctor based on merit rather than location. It can also improve the quality of medical care and reduce costs.

Telemedicine works especially well for urgent care, which deals with issues that need prompt attention but can be diagnosed and treated without an in-person exam—respiratory illnesses or urinary tract infections, for example. But it has many other possible uses. A study published last month in Health Affairs focussed on an off-hours telemedicine service in a chain of Massachusetts nursing homes. When residents got sick, an outside physician could use two-way video-conferencing equipment to see them instead of going to the facility in person or transferring patients to a hospital. Homes that used the service regularly sent a smaller portion of residents to the hospital than those that didn't. The cost savings for Medicare, which would have had to pay for those hospital visits, far exceeded the cost of the telemedicine service.

In 2010—around the time that the nursing-home study was being conducted—telemedicine seemed on the verge of a breakthrough. Milt Freudenheim wrote, in the Times, that telemedicine was "gaining traction as never before"; Bernard A. Harris, Jr., a venture capitalist, told him that Americans were arriving at "a gold rush of new investment in telemedicine."

But there was a problem: many health-care providers weren't on board. In the nursing-home study, for example, two of the facilities barely used their telemedicine services. Not surprisingly, their hospitalization rates were similar to those of facilities that didn't have telemedicine capabilities. "Simply making off-hours telemedicine coverage available does not guarantee that nursing homes will use the service," the study's authors wrote. In this instance, the staff had no incentive to learn a new system. Avoiding unnecessary hospitalizations didn't save them money—in fact, it cost them money. "As long as nursing homes pay for the service and Medicare realizes the savings that result, we suspect that the use of the service will be limited," the authors wrote.

In the wake of the Affordable Care Act, the outlook may be changing. Health-care providers are forming Accountable Care Organizations, large groups that win bonus payments from the government for meeting certain standards of quality and efficiency but lose money if their costs exceed target levels. Bundled payment schemes pay providers a fixed amount to manage a given medical condition, in contrast to the traditional model that reimbursed a la carte for each service. "In the past, we were paid for the process rather than the outcome," Thomas Nesbitt, the associate vice-chancellor for technology at the University of California Davis Health System, told me. Now, doctors have an added interest in improving their patients' health efficiently. That makes telemedicine newly attractive. "Physicians see that they can manage their chronic-disease patients on a regular basis and achieve better outcomes, and get financial rewards for that," Nesbitt said.

Policymakers are also warming to telemedicine. Medicare, which previously only paid for telemedicine in rural locations, extended its coverage this year to "the fringes of metropolitan areas," according to the American Telemedicine Association. The number of states making telemedicine coverage mandatory for private insurance plans has also grown—from five in 2000 and twelve in 2011 to nineteen as of early March.

Interest and opportunity, of course, aren't enough. There is also the question of execution—how to schedule virtual patients, document encounters, and ensure that health-care providers get paid. To simplify logistics, the U.C. Davis Health System has a telemedicine clinic that provides technical, operational, and billing support. "The physicians just show up," Nesbitt said. But he acknowledged that, "eventually, if we want telemedicine to be more widespread, incorporating it into the normal workflow process is a barrier we will need to overcome."

Meanwhile, for-profit telemedicine companies, which compete with hospital systems for business, are gaining momentum. "Since the A.C.A., we're seeing a lot of interest in the area," Bob Kocher, a venture capitalist at the firm Venrock, told me. Kocher, who is also a physician and a former special assistant for health care in the White House, recently took part in Venrock's investment in a telemedicine company called Doctor on Demand, which launched in December of 2013. Startups like Doctor on Demand have the potential to offer what Clayton Christensen, a professor at Harvard Business School, calls "disruptive innovation"—innovation from smaller firms at the "bottom" of a market. Eventually, these firms can displace industry leaders.

In his book "The Innovator's Prescription," Christensen proposes that telemedicine can be disruptive if it is used to "extend care into areas of nonconsumption, where the alternative is no health care at all." If competing against nonconsumption is telemedicine's best bet, the people to woo are not payers, providers, or policymakers, but patients. That may be why Doctor on Demand is marketing its services directly to consumers. One of the company's founders is Jay McGraw, the son of Phil "Dr. Phil" McGraw and the creator and executive producer of "The Doctors," a daytime talk show about health and medicine. On his show, Dr. Phil recently demonstrated how the service might work. "If you wanted to see my throat…could I show it to you?" he asked a Doctor on Demand physician via video chat, aiming an iPhone camera at his open mouth. "What if you just need a prescription refill?…What about something like"—he feigned a cough—"Viagra?" The audience laughed and clapped.

As gimmicky as these tactics seem, Doctor on Demand may have tapped into a psychological truth: behavior change is as much about emotion as it is about reason. Simply recognizing the benefits of telemedicine isn't enough; patients must want to use it. "It's like going from buying clothes in the store to online," Pat Basu, the chief medical officer of Doctor on Demand, told me. "The user experience needs to be good, or they won't do it."

Perhaps the user experience will never be good enough to replace face-to-face medicine entirely. Skeptics say that there is no substitute for human touch. In his 2011 TED Talk, titled "A Doctor's Touch," Dr. Abraham Verghese warned against losing the physical exam, stating, "We're losing a ritual that I believe is transformative, transcendent, and is at the heart of the patient-physician relationship."

Then again, as care becomes more accessible, the patient-doctor relationship could change for the better. By turning occasional encounters into ongoing dialogues, telemedicine could enhance, rather than diminish, the human capacity for connection. "A lot of people think it's about the technology," Nesbitt said. "But it's really about a new model of care that the technology facilitates."

Rena Xu is a student at Harvard Medical School and Harvard Business School. She has written for the Web site of the Atlantic and for the New England Journal of Medicine.