Stem Cells - Stem Cell Breakthrough More than Skin Deep

When the news broke in Cell and Science, two prestigious scientific journals, that research teams in Japan and Wisconsin had re-programmed skin cells to mimic embryonic stem cells, I thought of Lewis Thomas, MD, renowned pathologist, scientist, and writer (1913-1993).

Thomas was best known for a series of New England Journal of Medicine essays, “Notes of a Biology Watcher. “ The essays ran from 1974 to 1990 and became best-selling books, including The Lives of A Cell. In that book, he made this prophetic statement.


I have been trying to think of the earth as a kind of organism, but it is no go. I cannot think of it this way. It is too big, too complex, with too many working parts lacking visible connections. The other night, driving through a hilly, wooded part of southern New England, I wondered about this. If not like an organism, what is it like, what is it most like? Then, satisfactorily for that moment, it came to me: it is most like a single cell.


Indeed it is. And single cells may transform health care into a curative science.


Thomas said health care progress depended on basic research, such as the Salk polio vaccine. -- on understanding root causes of disease, not on “half-way technologies, “such as renal dialysis or coronary bypass.


Too many current innovations, though they may save lives and restore life style function, don’t root out pr explain basic causes, or reverse progression of underlying diseases.


Say what you will about skin cell re-programming into stem cells, that this re-programming.


defuses the political debate,

frees up funding for free-wheeling research,

eliminates need to destroy embryos


has the potential to cure cancer, heart disease, Alzheimers, paralysis, Parkinsons disease, amyotrophic lateral sclerosis, and diabetes.

But the true meaning of the skin-cell transformation is the triumph of basic science.

Here’s a Chicago Tribune described what has happened,”The potential here is staggering: A few flakes of skin could be turned into your own personal line of stem cells, coaxed to attack illnesses or even create replacement parts like a new organ, all without fear of an attack by the body's immune system. ‘It's just a spectacular, spectacular advance. was the way one prominent stem cell researcher described the findings.’ “

The research defuses political and ethical debate over destroying human embryos to harvest stem cells. This new technique promises an unlimited supply of stem cells without destroying embryos. Technical hurdles remain, but they're probably surmountable.Science and politics may finally get beyond distracting debates and embrace research unlocking potential of stem-cell therapies.

This latest technique won't replace human embryonic stem cells in medical research. Those stem cells are still the "gold standard" by which all other stem-cell lines are measured.

Researchers may soon develop an extensive array of stem cells derived in different ways because some stem cells may work against some kinds of illnesses but not others. It's also possible combinations of stem cells derived in different ways could be most potent against certain illnesses.If the ethical and political turmoil is resolved, and the federal spigot opens wide for research, stem-cell scientists may revolutionize medicine.

The triumph is more than skin-deep. It shows the importance of going back to basic academic research, past the half-way technologies ease symptoms but not cause or progression of disease. Transformed skin cells may not be ready for prime time, but they could be an example innovation becoming revelation.

Physicians and Health Plans - The Physician-Health Plan Tango

“Tango – A highly stylized dance of Latin American origin in 2/4 time in which the steps are punctuated by glides and sudden pauses.”


Encarta World English Dictionary, 1999


In And Who Shall Care for the Sick? The Corporate Transformation of Medicine in Minnesota (Index Medicus, 1988), I described a tango between HMOs and doctors addressing who should control patient care.


I forecast physicians would rebel against HMO micromanagement. They did. But in the meantime HMOs have picked up the tango tempo by implementing pay-from-performance and physician ranking programs to control costs in the name of quality.


In recent weeks, the tango has reached a new level of intensity.


· In Minneapolis on November 19, The Star Tribune announced the Minnesota Medical Association, representing 11,000 doctors, 60% of the state’s practicing physicians, had issued a report complaining the state’s nine different insurers, using different criteria in their pay-for-performance (P4P) programs, had created unnecessary administrative and cost burdens for doctors. The title of the article was “Minnesota Doctors Turn Tables by Ranking Insurers.” The doctors ranked Minnesota’s nine insurers all of whom had implemented P4P programs. The programs give bonuses to doctors who met certain goals, such as ordering mammograms or checking eyes of diabetics. The doctors say bonuses flowing from P4P weren’t large or dependable enough to justify the expense of tracking compliance or effective in making system changes.


Across the U.S, 150 P4P programs exist with bonuses in the 3% to 20% range. Doctor David Sabin, a University of Minnesota family physician and an expert on P4P, commented, “ I worry about raising a generation of future doctors who do what they do because they follow guidelines. Why? Because they follow the money!” Why, some critics complain, should doctors be rewarded for what they should be doing already.


· In New York City on November 20, New York Attorney General Andrew Cuomo announced UnitedHealth Group Inc. (UNH), Group Health Inc. and HIP Health Plan of New York had agreed to adopt a model for physician-ranking programs.

UnitedHealth said it would apply the model nationwide and planned to launch a doctor-ranking program known as UnitedHealth Premium in New York. The agreement also covered Oxford Health Plans Inc.

"We are witnessing the insurance market correcting itself," Cuomo said, "The three largest insurers in the country have now all said they will apply the principles of our model for doctor rankings nationwide. Leaders in the insurance industry are setting the standard for rating doctors by using a model that was created with the input of physicians and consumers."

The model requires companies to ensure their rankings for doctors aren't based solely on cost, to use established national standards to measure quality of care, and to disclose to consumers how their programs are designed and how doctors are ranked.

Wellpoint Inc. (WLP), Cigna Inc. (CI) and Aetna Inc. (AET) recently have agreed to make similar changes to their physician-ranking programs nationwide.

Empire Blue Cross Blue Shield, a subsidiary of Wellpoint, will adopt Cuomo's model for any future program it adopts in New York state.

And so the tango continues across the health care dance floor– with moves and countermoves, rankings and counter-ranking, forward steps and sidesteps, glides and slides, pirouettes and pauses.

Where will the dance partners be when the music stops?

Effect of Culture - Thanksgiving - A Time to Say Thanks

Thank you, whoever and wherever you are, for the privilege of being a doctor.


Thank you for granting me the abilities, , the gifts, and the intelligence to help others.


Thank you for the good fortune to live in a free country, where I can choose the specialty I please, where I can practice where I please as I please, and where I can say what I please.


Thank you for the honor of serving patients – for being available to them, listening to them, comforting them, finding what’s wrong with them, treating them.


Thank you for allowing me to reside in a nation encouraging innovation and rewarding ingenuity for developing medical technologies, devices, and drugs.


Thank you for offering so many options and providing so many flexibilities to pursue what I want and to continue to learn.


Thank you for our political system – the longest standing democracy on the planet.


Thank you for the environment of freedom encouraging expression of honest differences of opinion.


Thank you for permitting to live in this vast nation with its abundant natural resources, stretching from sea to shining sea, from Alaska to Hawaii, and from Canada to Mexico.
.

Thank you for encouraging an open and diverse culture with a common language that attracts more immigrants than any other country and remains the magnet of opportunity for the rest of the world.


Thank you for allowing me to live under the system of capitalism and freedom, which despite its occasional inequities, generates the highest standard of living and best urgent medical care system known to man.


Thank you for the freedom to choose whatever doctor, alternative provider, hospital, or medical facility that suits my intelligence, fancy, convenience, or proximity to home.


Thank you for our medical teachers, now in 125, soon to be 131, medical schools, teaching hospitals, the VA system, and everywhere else teachers and mentors lend a hand up.


Thank you for my colleagues – for the medical sisterhood and brotherhood - who set examples for me, tolerate me, and support me in darkness and light.


Thank you for the ability to state my mind to my local, state, specialty, and national medical societies, to politicians at every level, to the local media, and to whomever else who will listen.


Thank you to wives, husbands, children, significant others, and whoever else listens to us, supports us, and loves us.


Thank you for the warmth and comforts of home and family and the ample food and drink.


Thank you for letting me say this on this Thanksgiving Day in this magnificent country of ours – the home of the Brave, the True, The Free, and the Grateful.

Kaiser - Systems Engineering and Individualism: Is There Room for Both in Health Care?

The question posed in the title isn’t trivial. It’s a very large question. To some, it’s about safety and quality; to others it’s simply unnecessary meddling; to still others, it’s the essence of health reform.

But systems, no matter how well designed, are limiting. Then the question becomes: how much slack, initiative, responsibility, and freedom to act are we going to give the individual? These too aren’t small questions.


Systems engineering promises a systematic, organized, and purposeful approach to minimizing variation, maximizing outcomes, and measuring results. Furthermore, it lends itself to deploying information technologies to guide doctors and inform patients.


The trouble is that system applications may impinge upon individualism – a characteristic that distinguishes America from other cultures. We believe, above all else, in individual autonomy – in the ability of individual patients and individual physicians having freedom to make health care choices.


Systems engineering is an interdisplinary field of engineering. It focuses on developing and organizing complex systems. It disciplines groups into a team effort Systems engineering considers the business and the technical needs of customers to provide a quality product meeting user needs.


Clinical protocols, paying only for care based on scientific evidence, paying -for-performance, measuring process and outcome metrics, and making electronic medical records mandatory are examples of systems engineering. Physicians in independent practice might prefer to the term “social engineering” to “systems engineering” and object to thinking of health care in systems terms because “systems” may violate the freedom-loving Americans.


Perhaps the most ardent proponent of systems engineering in health care is George Halvorson, CEO of Kaiser. Halvorson pushes the idea of electronic medical records to achieve consistency, standardization, quality tracking, and diagnostic support for following patients outside the exam room to see if they’re complying with instructions and improving outcomes. The key to this, says Halvorson is e-support – e-visits, e-scheduling, e-reminders, and e-care.


Halvorson feels we can overcome our system’s lapses and improve “systems” thinking. By systematically applying data, we can organize teams to provide answers, tamp down variables, strive for zero defects, coordinate everyone through e-systems and put all relevant data at physicians’ fingertips in the exam room.”


Halvorson maintains room exists for both systems engineering and individualism, and the final clinical judgment rests with the individual physician.


Does the health system need the discipline of systems engineering? Or is it simply an unnecessary clinical impediment? Let me know what you think.

Book Reviews - Reece's Pieces - Occasional Notes and Comments

I. Schools of Thought


Source


Fixing American Healthcare: Wonkonians, Gekkonians, and the Grand Unification Theory of Health Care, Publisher or Perish Publishers, 2007


“Government regulators, politicians, public health officers, political liberals (wonks, in other words) espouse the Wonkonian school of thought.”


“The insurance industry, healthcare executives, many physicians, and most free market proponents espouse the Gekkonian school of thought, named for Gordon Gekko, the character in the movie Wall Street, who said greed is good. “


Note


It’s hard to choose between those who make money at the expense of patients and those who exercise power by spending other people’s money.


Comment

Would you rather be an idealistic Wonk,
Or an realistic Gekko who’s not a Monk?
Would you rather rule from top-down,
Or wear a mercenary merchant’s crown?
Either way you’ll learn from the school of hard Knonks.


II. Faith in Doctors

Source Grooks, “My Faith in Doctors,” Piet Hein

“My faith in doctors is immense.
Just one thing spoils it;
their pretenceof authorized
omniscience.”


Note


An English, American, and Russian surgeon are boasting of their greatest deeds. The English says he performed a brain transplant on a mute who has never stop talking since. The American claims he performed a heart lung transplant without anesthesia. The Russian says, “I did a tonsillectomy.” “What’s so great about that,” chimed in the other two. “Well,” said the Russian, “in my country people are afraid to open their mouth, so I had to approach it in a different direction.” The moral is” no miracles among follow professionals, please.


Comment


Two cheers for my fellow physicians,
Why not three cheers for clinical magicians?
Because no matter how resolute.
Nothing is ever absolute,
Under all conditions.


III. Generalists and Specialists


Source: “Too Many Specialists, Not Enough Primary Care Doctors, Worry Health System Experts, ” Newspaper headline


Note


Edward DeBono, MD, a world class expert on thinking based on London, once wrote that there are two kinds of thinkers - those who survey the landscape laterally and those that dig ever and ever deeper vertical holes. At the bottom of each hole, you will find a world-class expert. The problem is: the holes don’t connect.


Comment


There are those of us who are generalists.
More of us consider ourselves specialists.
Generalists think laterally,
Specialists think vertically,
As for me, I think bilaterally.

Medicare Offers Savings Accounts for First Time

From Greg Scandlen, president of Consumers for Health Care Choice, an organization favoring consumer driven care fueled by HSAs, comes this November 15 message:


“With Open Enrollment starting yesterday (November 15) and going to December 31, Consumers for Health Care Choices has released a new paper alerting beneficiaries to a new option -- Medical Savings Accounts.”


“For the first time ever Medicare is making Medical Savings Accounts available to virtually all beneficiaries during the current open enrollment season. The program could be a huge boon for beneficiaries because it eliminates the need for MediGap coverage, provides a way of paying for non-Medicare covered services, limits out-of-pocket exposure, and offers the opportunity to save-up for future expenses. Beneficiaries should be sure to check it out.”

“This paper explains some of the advantages and lets readers know how to find information on the CMS web site.”

“Consumers for Health Care Choices is a national membership organization of citizens devoted to putting the consumer in the driver's seat of the health care system. It was organized two years ago and is growing quickly as more people realize the future of health care rests with empowered consumers. The Board Chair is Daniel (Stormy) Johnson, Jr., MD, a radiologist in Metairie, Louisiana, and former president of the American Medical Association.”

Comment: This message has enormous implications in that it might eliminate need for Medigap coverage, a huge source of revenue for the nation’s health plans. For more information, access or contact Website: http://www.chcchoices.org , Greg Scanlen, Consumers for Health Care Choices, greg@chcchoices.org, 301-606-7364