Saturday, April 30, 2016
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 the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the so-called 'bible of psychiatry', with some particularly vocal critics coming from within the profession.
She didn't recognize herself.
She gazed saucer-eyed at her image, thinking: Oh, is this what I look like? No, that's not me. Who's that in my mirror?
This was in late 2012. She was 69, in her early months getting familiar with retirement. For some time she had experienced the sensation of clouds coming over her, mantling thought. There had been a few hiccups at her job. She had been a nurse who climbed the rungs to health care executive. Once, she was leading a staff meeting when she had no idea what she was talking about, her mind like a stalled engine that wouldn't turn over.
"Fortunately I was the boss and I just said, 'Enough of that; Sally, tell me what you're up to,'" she would say of the episode.
Certain mundane tasks stumped her. She told her husband, Jim Taylor, that the blind in the bedroom was broken. He showed her she was pulling the wrong cord. Kept happening. Finally, nothing else working, he scribbled on the adjacent wall which cord was which.
Then there was the day she got off the subway at 14th Street and Seventh Avenue unable to figure out why she was there.
So, yes, she had had inklings that something was going wrong with her mind. She held tight to these thoughts. She even hid her suspicions from Mr. Taylor, who chalked up her thinning memory to the infirmities of age. "I thought she was getting like me," he said. "I had been forgetful for 10 years."
But to not recognize her own face! To Ms. Taylor, this was the "drop-dead moment" when she had to accept a terrible truth. She wasn't just seeing the twitches of aging but the early fumes of the disease.
She had no further issues with mirrors, but there was no ignoring that something important had happened. She confided her fears to her husband and made an appointment with a neurologist. "Before then I thought I could fake it," she would explain. "This convinced me I had to come clean."
Four years ago, Dave deBronkart spoke at a medical conference, with his face displayed on a giant screen. Afterward, a doctor told him that a spot on his face looked like basal cell carcinoma.
She was right. That cancer was unlikely to spread, but it needed to be treated, and deBronkart's health insurance policy had a $10,000 deductible. Any treatment, then, would come out of his pocket. How would he find the right treatment at the right price?
The reason deBronkart was attending the conference was that he is an advocate for patient involvement in health care. So he decided that, as an experiment, he would invite proposals on his blog, e-PatientDave. He outlined what he was looking for and asked health care providers to bid for his business.
No one did, of course. "I didn't expect to get a response," he said. "Hospitals don't have a 'submit a bid' department. But you hear over and over that patients are the reason for high health costs. I pursued it as far as I could to explore what happened when a patient tries to be a responsible consumer."
He began calling around to hospitals asking the price of various procedures. "The hospitals said 'we don't know; ask your insurance company.' The insurance company said 'we don't know; ask your hospital,'" said deBronkart. "That was when I smelled a great big rat."
After many, many calls, he chose his surgery: excision, total price $868. Today he is fine.
But his point stands: Health care operates very differently from anything else we buy.
"The actual information I needed in order to be an effective, responsible shopper was by policy blocked from me," he said in an interview. "It's not just a matter of lowering costs. It blocks innovation. Somebody does a good job — better quality, better price — but there's no way for people to discover them."
There is practically nothing that we shop for the same way we did 15 years ago. We compare prices online, look at quality ratings and reviews, and read about the experiences of others. We have endless information.
Except in health care. Most of us still buy it blind. We do as our doctor directs — and pray that our portion of the bill will be reasonable. We have very little information about quality and almost none about price. (In contrast to virtually every other field, price and quality are not related in health care.) And we find out the cost afterward.
This is a problem for patients with high deductibles, like deBronkart. It's also a huge problem for the country.
Is the idea of shopping for health care absurd? Well, you're not going to spend an ambulance ride browsing Hospital Compare on your phone. But most of health care is non-emergency and, therefore, shoppable: screenings, diagnostic tests, lab work, doctor visits, professional services such as physical therapy, scheduled surgeries.
This is just starting to happen.
One big reason is the increase in high-deductible plans like deBronkart's. Another factor is the new availability of data, led by the federal Center for Medicare and Medicaid Services. C.M.S. has released utilization and payment data for hospitals, physicians, nursing homes and home health agencies. It has also published quality data, in both raw and user-friendly form.
Thursday, April 28, 2016
SAN FRANCISCO — Helmy Eltoukhy's company is on a roll. The start-up is a leading contender in the crowded field of firms working on "liquid biopsy" tests that aim to be able to tell in a single blood draw whether a person has cancer.
Venture investors are backing Guardant Health to the tune of nearly $200 million. Leading medical centers are testing its technology. And earlier this month, it presented promising data on how well its screening tool, which works by scanning for tiny DNA fragments shed by dying tumor cells, worked on an initial group of 10,000 patients with late-stage cancers.
Just one thing is holding the company back: Guardant Health has yet to get approval from government regulators.
As a tidal wave of new health-related gadgets, apps and tests hits the market, the Food and Drug Administration, the Federal Trade Commission and other enforcement agencies are showing up in Silicon Valley like they've never done before. They have slapped companies such as Theranos, 23andMe, Lumosity and Pathway Genomics with warning letters and fines and opened investigations into products that regulators believe promise more than they can deliver.
More regulatory scrutiny is probably coming. Venture capital investments in life sciences hit a record high in 2015, with $10.1 billion invested in 783 deals, and total start-up funding is approaching levels of the last dot-com bubble — a development that has some industry observers worried that pseudoscience is being confused with innovation.
But even as some companies push back against federal agencies' reach — contesting which rules, if any, apply to their work — there's now recognition that the government can be a powerful ally rather than a brake on progress. And its stamp of approval can take firms from being worth multimillions to multibillions.
Ethan Weiss, a cardiologist at UC San Francisco, spends long hours at the hospital treating patients. But between shifts, he takes calls with health-technology entrepreneurs to offer them advice and feedback.
As Weiss explains, it's not about the money. He does the majority of this advisory work for free or in exchange for a tiny chunk of equity. It's also not about prestige: He doesn't speak publicly about the startups he's consulting with. So why does he bother?
For one thing, it makes for a stimulating break in the day. "I have an intense curiosity and I like novel things," says Weiss.
It's a challenge to quantify the exact number of doctors moving into health tech; even if a large physicians' group like the American Medical Association (AMA) tried to keep track, it would need to determine whether to include doctors that advise startups but still practice one or two days a week, or just those who have left medicine altogether. I suspect that the former category is much larger. Suffice it to say, though, that Weiss is far from alone—the migration of doctors into the health tech space is noticeable.
It is now fairly common for well-funded health-tech startups to have medical directors, physician founders, or chief medical/health officers on their team. Some high-profile examples include Collective Health, Sherpaa, Startup Health, Doximity, Aledade, and AthenaHealth. And the AMA tells me it is proactively forging partnerships in Silicon Valley and beyond to help doctors "work in tandem on the innovative tech solutions that promise to change health care."
To understand why doctors are dabbling in startups or even changing careers, I recently polled MDs involved with startups (very informally) on Twitter to gauge whether they were motivated by money, prestige, fun, or altruism. Of 45 respondents, 44% were motivated by "fun." But it runs deeper than that. Weiss, for instance, has other motivations. He is concerned that much of the $4.5 billion in venture capital raised by digital health companies in 2015 will be spent on the next "Uber for health care," or the 10th next-generation stethoscope, rather than on solving patients' most pressing needs. "A lot of startups are peddling really cool technology in search of a problem," he told Fast Company.
Need knee replacement surgery? It may be worthwhile to head for Tucson.
That's because the average price for a knee replacement in the Arizona city is $21,976, about $38,000 less than it would in Sacramento, Calif. That's according to a report issued Wednesday by the Health Care Cost Institute.
The report, called the National Chartbook on Health Care Prices, uses claims and payment data from three of the largest insurance companies in the U.S. to analyze how prices for procedures vary from state to state, and city to city.
Health care prices are crazy.
"There doesn't seem to be a systematic pattern with respect to what's high and what's low," says David Newman, HCCI's executive director. Newman is lead author of an article published Wednesday online in the journal Health Affairs that accompanied the release of the Chartbook.
The reports compare average state prices for 242 medical services — from primary doctor visits to coronary angioplasty to a foot x-ray — to the national average price for those services. It shows that states such as Minnesota and Wisconsin have higher than average prices while others, such as Florida and Maryland, were cheaper overall.
Monday, April 25, 2016
Some do it to get into heaven, and some do it to get into medical school. Some do it because everyone else is doing it. Whatever the motivation, the number of health care volunteers heading from developed to developing countries has soared in recent years, with commentators straggling behind debating the merits of the stampede.
The reasons to applaud are self-evident: All the old epidemics are compounded by all the new ones, and the health-related fallout of wars and natural disasters never ends. If both skilled and unskilled labor can help, then surely those who provide such labor should do good, feel good and learn much.
Not necessarily, critics say. Some would concur instead with an opinion published by a Somali blogger in The Guardian in 2013 and quoted by the sociologist Judith Lasker in "Hoping to Help: The Promises and Pitfalls of Global Health Volunteering" — "The developing world has become a playground for the redemption of privileged souls looking to atone for global injustices by escaping the vacuity of modernity and globalization." (Read an excerpt.)
And indeed, as Dr. Lasker watched groups of American and Canadian volunteers in matching T-shirts surging through the Port-au-Prince airport two years after Haiti's disastrous 2010 earthquake, she was reminded of nothing so much as "the weekly Saturday turnover at American time-share vacation resorts."
Sunday, April 24, 2016
"A cardiologist puts someone on good, evidence-based medications for his heart," said Dr. Alexander, co-director of the Johns Hopkins Center for Drug Safety and Effectiveness. "An endocrinologist does the same for his bones."
And let's say the patient, like many older adults, also uses an over-the-counter reflux drug and takes a daily aspirin or a zinc supplement and fish oil capsules.
"Pretty soon, you have an 82-year-old man who's on 14 medications," Dr. Alexander said, barely exaggerating.
Geriatricians and researchers have warned for years about the potential hazards of polypharmacy, usually defined as taking five or more drugs concurrently. Yet it continues to rise in all age groups, reaching disturbingly high levels among older adults.
"It's as perennial as the grass," Dr. Alexander said. "The average senior is taking more medicines than ever before