Gawande on what agricultural reform can teach us…

“America’s agricultural crisis gave rise to deep national frustration. The inefficiency of farms meant low crop yields, high prices, limited choice, and uneven quality. The agricultural system was fragmented and disorganized, and ignored evidence showing how things could be done better. Shallow plowing, no crop rotation, inadequate seedbeds, and other habits sustained by lore and tradition resulted in poor production and soil exhaustion. And lack of coördination led to local shortages of many crops and overproduction of others.

You might think that the invisible hand of market competition would have solved these problems, that the prospect of higher income from improved practices would have encouraged change. But laissez-faire had not worked. Farmers relied so much on human muscle because it was cheap and didn’t require the long-term investment that animal power and machinery did. The fact that land, too, was cheap encouraged extensive, almost careless cultivation. When the soil became exhausted, farmers simply moved; most tracts of farmland were occupied for five years or less. Those who didn’t move tended to be tenant farmers, who paid rent to their landlords in either cash or crops, which also discouraged long-term investment. And there was a deep-seated fear of risk and the uncertainties of change; many farmers dismissed new ideas as “book farming.”

Another inciteful piece showing how far agriculture came in a few short decades by experimenting and scientifically evaluating methods for improvement and the parallels for us in this centuries health reform debate. How does he come up with these?

An Interview With Thomas Russell for Health Affairs

Health Affairs Blog link to full interview.

John Iglehart, one of the Founders of Health Affairs posts an interview with surgeon and retiring Executive Director of the American College of Surgeons. There are quite a few pleasantly surprising moments in the interview, which I’ll bullet here, but you can go read on your own.

Q. I would assume that more than a few surgeons regard such activity as an intrusion into the independent practice of medicine. Is there a generational difference among surgeons in their willingness to cooperate or at least participate in these kinds of initiatives?
Russell: Absolutely. The younger surgeons have trained in an environment in which they to expect that the quality of care they deliver will be measured and evaluated, so they don’t really have any difficulty participating in these activities. It’s some of the older physicians who entered practice in a more autonomous era who struggle with these new forms of oversight.
First, let me say that the surgical community is not homogeneous, and they’re all over the map on reform. The College has a split membership. Some surgeons think that the status quo is just fine and that greater oversight and accountability are unnecessary. They view them as intrusions into the autonomy of a sovereign profession, while others are all in favor of reform.
There is at least one matter on which I think we mostly agree, and that is the fact that we have to do something to fix our broken payment system. So, the number-one change that I would like to see emerge from the health care reform debate is fundamental, long-term improvement in how physicians are paid, so that they really are being paid for providing cost-effective, high-quality services.
Iglehart: Would that mean, according to your vision, an abandonment of the fee-for-service payment model and going to an alternative model, or some kind of a hybrid?
Russell: I recently addressed a large group of surgeons and asked them whether they are paid a salary, and most of them raised their hands. Throughout the nation, more surgeons are becoming salaried professionals. Most academic surgeons as well as those in integrated delivery systems—such as the Mayo Clinic, Geisinger, Kaiser, and many others, including Veterans Affairs—are on salary. So are doctors who are employed by the VA. I think it’s safe to say that more than 50 percent of the nation’s physicians are paid a salary. And, some of the happiest doctors whom I’ve met are the salaried ones because they don’t have to deal with the hassles of malpractice insurance, including the high premiums they pay, or coding, or any of the other administrative burdens that confront physicians who are in private practice and reimbursed through the complicated fee-for-service system.
We also need to look in a very thoughtful, ethical way at rational – I’m not using the word rationing, I’m using the word “rational”–ways to improve end-of-life care.
In addition, the medical and surgical professions need to develop protocols for the best ways to approach diseases. We need policies about when scans, such as a CTs and MRIs, are indicated, and to make sure they are not unnecessarily repeated by another physician. And we must develop standardized ways of treating diseases so that every health care professional involved in coordinating a patient’s care is addressing the condition in the most cost-effective way that follows the scientific evidence.
For instance, I think that the Number One way to help patients avoid frivolous trips to the ER is to educate them about where they should turn to receive appropriate care for nonemergency conditions and to make certain they have access to primary care physicians. [We do a poor job of getting people into PCPs– cmhmd]
Here’s how this maldistribution of surgeons has arisen. About 80-90% of medical school graduates who pursue surgery as a specialty begin their residency training in general surgery. After five or six years of residency, and at ages 32 to 34, many pursue additional training in a fellowship that will allow then to focus on just one type of disease or organ that general surgeons treat and operate on. That is to say, they become super-specialized in breast surgery, minimally invasive surgery, bariatric surgery, cardiac surgery, or cancer surgery. So they’re taking themselves out of the pool of professionals who can perform the broad range of general surgery procedures. And, most of this highly specialized surgery is performed in large cities, so these surgeons are not typically accessible to rural patients.
Organized medicine and many Republican legislators have long argued in favor of capping awards for noneconomic damages, but I don’t believe the nation will ever reach a consensus on that proposal, although a few states have implemented the limits. I think instead more efforts should be made to educate, in this case surgeons, about how to avoid or better manage risk by staying within their scope of practice. Communication with the patient and his or her family throughout the surgical experience is also key to helping these individuals understand why there was a negative outcome. When a mistake is made, apologize, if you practice in a state that has passed legislation providing legal protections for saying, “I’m sorry.”
Very important, too, is for the profession to develop evidence-based best practice protocols and for physicians to follow them closely. In my era, we objected to this form of standardization and called it “cookbook medicine.” But, as calls for accountability have increased, lawmakers should consider setting policies that protect physicians who adhere to professionally developed protocols. In these cases, if a patient sues because of a bad outcome, the physician can respond with a legitimate defense: ”Look, I followed the protocol that we all agreed was best practice. I’m sorry for the bad outcome, but a bad outcome does not equal malpractice. [Except for this and people like Bernadine Healy, who should know better -cmhmd]

Thanks to Mr. Iglehart and Dr. Russell for the informative interview.

A Senate Minority Hijacks Health Care – Pittsburgh Post-Gazette

According to the U.S. Constitution, each state is represented by two senators, regardless of population. This arrangement is the legacy of a deal struck in 1787 at the nation’s founding, partly to keep the slave-owning states from exiting the then-fledgling nation. As a result, California, with more than 36 million people, has the same number of senators as Wyoming, with a half-million people.

That disproportional allocation has only gotten worse over time. When the Senate was created, the most populous state had 12 times more people than the least populous state; now it has 70 times more people. In the 1960s, the Supreme Court established the groundbreaking principle of majority rule based on ‘one person, one vote,’ meaning that all legislative jurisdictions must be equal in population. This applied to the U.S. House of Representatives, yet the U.S. Senate completely violates this fundamental principle.

As a result, the 40 Republican senators represent a mere third of the nation, meaning Republican voters have more representation than everyone else. That overrepresentation is bad enough, but it gets even worse. For the United States has added an arcane layer of parliamentary procedure known as the ‘filibuster’ that takes us out of the frying pan and into the fryer.

The Senate’s use of the ‘filibuster’ means you need not a majority of 51 votes, but 60 votes to stop unlimited debate on a bill and move to a vote. So a mere 41 senators can kill any legislation. The 40 Republican senators representing only a third of the nation need to peel away only a single conservative Democratic or independent representing a low-population state like Montana, Nebraska or Connecticut to torpedo what the senators representing two-thirds of the nation want.

Given such a vastly mal-apportioned and unrepresentative Senate wielding its anti-majoritarian filibuster, it is hardly surprising that minority rule in the Senate consistently undermines majoritarian policy. Besides health care, senators representing a small segment of the nation have thwarted renewable-energy policy, sensible automobile mileage standards, cuts in subsidies for oil companies, tougher campaign-finance reform, congressional oversight of national security and war, and more.

Minority rule in the Senate has been with the nation for a long time; in fact, it is widely blamed for perpetuating slavery for decades (between 1800 and 1860, eight antislavery measures passed the House, only to be killed in the Senate). For all these reasons, two of America’s most revered founders, James Madison and Alexander Hamilton, opposed the creation of the Senate, with Hamilton warning in Federalist Paper no. 22 that representation in the Senate “contradicts the fundamental maxim of republican government, which requires that the sense of the majority should prevail.

This was written by Steven Hill, “director of the Political Reform Program for the New America Foundation and author of “Europe’s Promise: Why the European Way is the Best Hope in an Insecure Age,” which will be published in January.”

Evidence Based Medicine and Reform

This week has been very disappointing, with the USPSTF breast cancer screening guidelines coming out and recieving such an intemperate analysis by virtually everyone with access to a microphone or a camera.

Here is a very thoughtful analysis for those who are interested, but I’m really writing this because of what it says about us as Americans and our love-hate relationship with science.

So, researchers at USPSTF have made an evaluation and recommendations that fly in the face of “common sense.” Common sense in America being that more is always better, whether it be testing or surgery or whatever. You can’t be overtested, there are no downsides to excessive intervention. Except when there are. I will not go into the downsides of overtesting and overdiagnosing, but it really bothers me that we look to science to advance medicine, to make breakthroughs, to guide treatment and yet, we get a recommendation that falls outside of what we “know” to be true, we flip our collective gaskets.

Apparently, sensing opportunity, Glen Beck had on Bernadine Healy, whom I remember becasue she was in a position of responsibilityin Medicine (she was the Director of NIH from 1991-93), and she apparently doesn’t care much for scientific thinking. She trotted out the old saw about prostate cancer survival being better here in America than in the UK because, obviously, the British hate their citizenry.

I have this debunking on the blog here, and it is basically that screening finds things that don’t need treatment, but treating all of these cases as if they are life threatening makes our numbers look good. For a better estimate of how the US really does in saving people for dying from preventable causes, go here to see we have the distinction of being 19th out of 19.

But hearing about Ms. Healy being on glen beck reminded me that I had a letter published in US News (that’s what the editor told me, though I never actually could find the link – ah, well), after she wrote an article praising anecdote above evidence based medicine. HCRenewal has an analysis here, and here is my letter:

To the Editor:

Healy castigates the practice of evidence based medicine in her polemic as if it were anathema to medical science, and, more particularly, to the individual physician’s practice of medicine. Hippocrates knew that “Experience is delusory.” “Experience,” or anecdote, is sometimes helpful in medicine, but often harmful, because we physicians often internalize our experience into hard rules about treating patients. This often leads us down dangerous paths.

Evidence based medicine is long overdue counterweight to this kind of medical practice. EBM, when evidence is available, makes us think hard about our practices: Are we doing this because that’s the way we’ve always done it, or because we have scientific research to back up our decisions? Sadly, it is too often the former, because the evidence is just not there or has not yet been synthesized into a useful form, or, most commonly, not yet reached the physicians “in the trenches.” EBM is not discarding or devaluing physician judgment,” as Healy argues, it is rather an attempt to make our judgment more rational.

I find it astonishing that Healy trumpets the jury awarding damages against a physician who did not order a PSA test based upon the best evidence available to him. Every physician should howl in protest at this outcome. Using this standard, we should all have monthly full body high speed CT scans and massive blood testing to search for every possible disorder that comes to the mind of the physician or the patient. But we do not practice this way because it is, yes, I’ll say it, stupid!

Evidence based medicine is not a “straightjacket”, but a means to an end: providing the best care based on the best scientific evidence we have.

So are we a scientifically based medical community and society, or are we thinking irrationally and letting fear mongers lead us over a cliff?

Don’t answer that.

Intellectual conservatism, RIP – Salon.com

Neoconservatism – Salon.com

I was once a young neoconservative. The word meant something different then, before it was hijacked by extremists by Michael Lind

A nice article on the history of neoconservatism – not what I thought – but I brought it here for this great quote:

Ultimately Milton Friedman and other free-market ideologues did far more damage to America than the carnival freaks of the counterculture.

Love it!

AMA – AMA votes to continue commitment to health system reform

AMA – AMA votes to continue commitment to health system reform:

AMA votes to continue commitment to health system reform
Outlines details to guide efforts toward making the health system better for patients and physicians
For immediate release:
Nov. 9, 2009
HOUSTON – The American Medical Association (AMA) House of Delegates today voted on health system reform policies, reaffirming the AMA’s commitment to health system reform. The AMA’s House of Delegates is the nation’s broadest, most inclusive assembly of physicians and medical students. Delegates representing every state and medical specialty debate and vote on behalf of their physician peers.
“Now is a defining moment in the history of the AMA,” said AMA President J. James Rohack, M.D. “In a democratic process, the AMA House of Delegates today voted to continue AMA’s commitment to health system reform for patients and physicians. The time to make health system reform a reality is now.”
The AMA reaffirmed its support for health system reform alternatives that are consistent with AMA policies concerning pluralism, freedom of choice, freedom of physician practice and universal access for patients. It also outlined specific elements it will actively and publicly support and oppose as the health system debate continues.
The AMA’s support for H.R. 3962 and H.R. 3961 remains in place.
“H.R. 3962 is not the perfect bill, and we will continue to advocate for changes that help make the system better for patients and physicians as the legislative process continues,” Dr. Rohack said.”

Now that the American Society of Anesthesiology has voted to support the House Bill, we now have an AMAZING NINE OF of the TEN largest physicians organizations supporting reform.

Even if you take out the AMA and AOA as a friend suggested because they are multispecialty groups, we have 8 of the ten largest physician specialty organizations supporting reform. The American College of Radiology is still against it, the American College of Emergency Physicians (# 9) has still not committed and the American College of Cardiology ( which I’m pretty sure is # 10) is on board.

That’s about as close as you can get to running the table with physicians groups.

How to reform the broken medical malpractice system. – By Darshak Sanghavi – Slate Magazine

For many doctors, the malpractice case against a family physician named Daniel Merenstein epitomized how the broken medical liability system drives up costs. In 1999, Merenstein, then a resident, saw a 53-year-old man for a routine checkup and discussed with him the dubious value of a blood test to screen for prostate cancer. Since the test leads to many false positives and pointless treatments that can cause impotence and other harm, neither the American Cancer Society nor U.S. Public Health Service support its routine use. Presented with the data, the patient chose not to get the test.

When the man later developed prostate cancer, he sued Merenstein and the residency training program and ultimately won $1 million. According to the plaintiff’s attorney, the doctor should have ignored the evidence-based national guidelines and not even have given the patient the choice to refuse the test.

This is the same story told on This American Life last month, and it is quite disturbing. In my “to-do list” for health care reform, medical liability reform is relatively low on my list*, but this story gives me pause.

I hope we can address this and make following guide lines in good faith a reason to dismiss a lawsuit. For more information on guidelines and Comparative Effectiveness Research in action, go here.

*Caps are not even on my list, but there are many other things we can do that benefit patients AND physicians, as outlined in this Slate article, and by the AMA.

House Bill Effects on Physician Income

I had a piece in the Pittsburgh Post-Gazette today on physician support of health reform.

A sadistic friend posted it on Sermo. Weee!

The subject of the effect on physician income came up on our Doctors for America and I said:

I often ask my colleagues who 1.) complain about Medicare rates and 2) say all care for the uninsured should be via charity by physicians , “Wouldn’t you rather get paid a bit less and have everyone covered so you have more paying patients?”

I doubt anyone has done an analysis of what the net effect of this would be, but perhaps the net effect would be neutral or positive, I don’t know. BUT as the NEJM survey said, most of us find it acceptable to take lower reimbursements if everyone is covered.

Our terrific Media Mogul, Mandy Krauthammer-Cohen, MD, of course, had a great bit of information:

Some additional food for thought. If you look at the Lewin group analysis….which does have a conservative bias given it is owned by United Health…physicians will actually make more money under health reform with a public option.

Testimony by Lewin states: “In the first year of the program (when public option is only opened to small businesses with less than 10 employees), physician income would increase by $10.9 billion. This reflects the reduction in uncompensated care for uninsured people as well as increased health services utilization for newly insured people. It also reflects the House bill provisions that would increase Medicaid reimbursement for primary care services to Medicare payment levels. Thus, the reductions in payment for people who shift to the public plan are outweighed by increases in reimbursement for Medicaid, reductions in uncompensated care and revenues from increased service use for newly insured people. Average net-income per physician wouldincrease by $15,237 in 2010 under this scenario.”

Read the whole testimony here.

T.R. Reid: Can We Really Fix U.S. Health Care?

From the Commonwealth Club of California Podcast is here.

Friday, September 18, 2009, 12:34:52 PM

T.R. Reid, Correspondent, The Washington Post; Commentator, National Public Radio; Author, The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care

For 100 years, U.S. presidents have unsuccessfully strived to provide universal health coverage. When LBJ created Medicare in 1965, he thought the program would gradually be extended – to people over 60, then 55, then 45, etc., so that everybody would have government health insurance by 2000. Decades later, the Clinton plan failed. George W. Bush created Medicare Part D. Barack Obama says we have the best chance ever this year to fix our health-care system. Is he right? Reid weighs in and reveals what we can learn from health-care models across the globe.

This program was recorded in front of a live audience at The Commonwealth Club in San Francisco on September 14, 2009.

A very good listen. Excellent tid bits about health promotion in Britain, insights into the minds of Canadians and more!