Doctor Don’t Do List Grows to 135

It’s not what you do but what you don’t do that counts.

Anonymous

Tell me, Doctor, why didn’t  you do what could have done and should have done to predict  my client’s  heart attack.

Malpractice Attorney

Doctor Groups Unite Against Unnecessary Tests & Procedures

By Richard Knox, NPR News, and  Kaiser Health News

Doctors do stuff — tests, procedures, drug regimens and operations. It’s what they’re trained to do, what they’re paid to do and often what they fear not doing.

So it’s pretty significant that a broad array of medical specialty groups is issuing an expanding list of don’ts for physicians.

Don’t induce labor or perform a cesarean section for a baby who’s less than full-term unless there’s a valid medical reason, say the American College of Obstetrics and Gynecology and the American Academy of Family Physicians. (It can increase the risk of learning disabilities and respiratory problems.)

Don’t automatically do a CT scan on a child with a minor head injury, warns the American Academy of Pediatrics. (Currently half of all such children get them, when simple observation is just as good and spares radiation risk.)

Don’t try to normalize blood sugar in most diabetic patients over 65, exhorts the American Geriatrics Society. (It can lead to higher mortality rates.)

And on and on. The latest list totals 90 tests and procedures that are often unnecessary and potentially harmful, compiled by 17 specialty groups representing more than 350,000 doctors.

The list is the second chapter in a campaign called Choosing Wisely sponsored by the Foundation of the American Board of Internal Medicine. Last year the foundation warned against 45 tests, procedures and treatments that often do patients no good. That list was endorsed by nine medical specialty organizations.

The new don’ts bring the total to 135.

The idea is to curb unnecessary, wasteful and often harmful care, its sponsors say — not to ration care. As one foundation official pointed out last year, rationing is denial of care that patients need, while the Choosing Wisely campaign aims to reduce care that has no value.

The campaign aims to foster the notion, among patients as well as doctors, “that when it comes to health care, more is not necessarily better,” Dr. Christine Cassel of the ABIM Foundation says in a statement abut the latest list, to be officially unveiled at a Washington media event Thursday.

The sponsors promise even more lists of don’ts later this year from a dozen more specialty groups, ranging from the American College of Surgeons to the American Headache Society.

Here are some other notable tests, traditions and procedures to skip:

Don’t use feeding tubes in patients with advanced dementia. Simply assisting such patients to take food by mouth is better.

Don’t perform EEGs (electroencephalography) on patients with recurrent headaches. It doesn’t improve diagnosis or outcomes and simply increases costs.

Don’t perform routine annual Pap tests in women between 30 and 65. Every three years is enough.

Don’t hold back on providing hospice care to relieve pain and distress just because a seriously ill patient is getting treatment aimed at alleviating disease.

Don’t leave an implantable defibrillator turned on if a patient with incurable disease, or his family decision-makers, have elected to forego resuscitation. Currently there are no formal policies on this issue, and implantable defibrillators often fire in the weeks preceding death, causing pain and distress to dying patients and their families.

Don’t use cough and cold medicines in children under four suffering from respiratory illness. They offer little benefit, can have serious side effects and risk accidental overdose.

Don’t do repeat bone scans for osteoporosis more often than every two years. Healthy women over 67 with normal bone mass can go up to 10 years without a repeat bone scan.

Don’t prescribe benzodiazepines, such as Valium, or sedatives and sleep aids to older adults with insomnia, agitation or delirium. They can more than double the risk of motor vehicle accidents, falls, hip fractures and death.

Don’t screen patients routinely for vitamin D deficiency. Over the counter supplements without laboratory testing is sufficient for most otherwise healthy patients.

Don’t screen for cancer in healthy individuals using CT or PET scans. The likelihood of finding cancer is around 1 percent, and the scans are likely to identify harmless findings leading to more tests, biopsies or needless surgery.

Tweet:  American Board of Internal Medicine is sponsoring a campaign to encourage doctors not to do certain tests and procedures with low yields.

 

Notable and Quotable:  ObamaCare Survival Guide, Nick J. Tate, Humanix  Books, 2013

Preface: The following quote is from the paperback book, The Obamacare Survival Guide, which has risen to second place In the  Advice, Miscellaneous Category. The book is an explanation of and an argument against Obamacare.

“While ObamaCare has angered a significant portion of the American people (especially seniors), the anger among doctors is palpably strong.  In a poll conducted in 2010 for the Physicians Foundation, 40 percent said they would ‘retire, seek a non-clinical job in healthcare or seek a job unrelated to healthcare” during the next three years. Fears of an acute doctor shortage, which existed prior to ObamaCare, have only been exacerbated by the new late.  The anger of doctors in understandable as ObamaCare reduced their earning potential, by, for instance, putting new restraints on payment s rates in Medicare.   In a large sense, the law represents an ideological assault on the current fee-for-service system – the foundation of most doctors’ earnings. New payments system like Accountable Care Organizations (ACOS) might not hurt doctors financially, but there is a big risk they will, leaving them with lower incomes to pay off medial school student loan debts that are among the highest in the world.

Critics of Obamacare assert that the new law will decrease the quality and number of American doctors, and do so at a time when their services will be more in demand than ever before.  If their prediction comes, true, the consequences for healthcare in the United States would be disastrous.  Not only would it become much harder to find a doctor, the price you have to pay for their services could risk significantly.

While it’s unlikely that four out of every 10 doctors will actually leave their profession because of Obamacare (survey claims about future behavior  rarely match reality), some departures  might occur. If even one of 10 doctors decided they don’t want participate in the new system it will be a low to quality and availability of healthcare in the United States.”

Tweet: According to the book  ObamaCare Survival Guide, American doctors are angry at the new law and significant numbers may cease practice.

Health Reform: Who’s in Charge Here? Hint: It’s Not The Patients and It’s Not the Doctors

Over the past decade, we’ve enriched the labs, drug companies, medical device makers, hospital administrators and purveyors of CT scans, MRIs, canes and wheelchairs.   Meanwhile, we’ve squeezed the doctors, who don’t own their own clinics, who don't work as drug or device consultants or who don’t otherwise game a system that is so gamable. And of course, we’ve squeezed everyone oufside the system who stuck with the bills.

Steve Brill, “Bitter Pill: Why Medical Bills Are Killing Us,” Time Magazine,  February 20, 2013

Who is charge of the health system? 

It depends on who you ask. 

·         If you ask the business community, they will say the government, who under Obamacare is increasing their cost of covering employees by 20% to 30%. 

·          If you ask health plans, they will say something similar,  for they view Obamacare as a vehicle for raising their expenses while cutting their profit margins in the same order of magnitude, that is, by 20% to 30%.   

·         If  you ask the government,  it will say it is the medical-industrial complex,  that is, the health care markets, which keeps coming up with new technologies that cost more without any appreciable increase in efficiency or outcomes.

·         If you ask suppliers of health care services and  purveyers of medical technologies,  they will say they like government incentives just fine.    Their revenues have doubled  in the last five years are so.  AllScripts and Epic, who supply electronic medical record systems, are an example. For the last decade,  government has insisted a national interoperative data system  is imperative and has budgeted $30 billion to make it happenm and revenues of these electronic records systems giants have doubled.

·         If you ask physicians,  they will say it is a combination of government and private health plans,  which are intent on systematically lowering their reimbursements  and handcuffing them with regulations and codes that restrict what they can order and what they are paid.

·         If you ask patients, they are likely to say they have not idea but it isn’t them.    All they know is  tht they are faced with ever increasing premiums, unforgettable and unfathomable bills, catastrophic bills for catastrophic illnesses,  and a health reform law they do not understand  and that has so far cost more, lessened access, and caused them to lose employer coverage.

And so, the Great Debate over the future of government-provided  and free-market health cae rages on, without immediate resolution.

Writing today in Reuters, U.S. editiron,  Douglas Holtz-Eakin and Avik Roy, a couple of conservative economists say choosing between the two great forces – government which pays for 50% of heath costs, and private markets – who pay for care for most of us - is a false choice.  It is possible to have both with lower costs and more coverage.

They point to Switzerland.

While most Americans view their healthcare system as “free-market,” Switzerland actually has the most market-oriented healthcare system in the West. It translates into universal coverage and low entitlement costs. Swiss government entities spent about 3.5 percent of gross domestic product on healthcare in 2010, compared to 8.5 percent in the United States. That’s a difference of more than $5 trillion over 10 years: real money, especially relative to our $16 trillion debt.

There is no “public option” in Switzerland. Instead, citizens qualify for means-tested, sliding-scale subsidies and choose among a variety of regulated, private-sector insurance products. The Swiss have the freedom to choose their own doctors, as Americans do, and access to the latest medical technologies. They also have short waiting times for appointments.

Maybe it is possible to have the best of two worlds – private markets with government oversight and subsidies.

Think of health reform  as a huge and growing $2.8 trillion bitter lemon.  Government and health care industry is squeezing out the juices and leaving the hide to patients and doctors.

Tweet:  Who’s in charge of  paying for and causing high costs.  It’s a combination of government and the health care industry. It’s not patients and doctors.

Americans and Their Medical Machines Revisited

Obsession with medical technologies and machines characterizes American’s cultural expectations. We tend to think of our bodies as perpetual motion machines, to be preserved in perpetuity. If the face of our machines sag, we lift its faces up. If our pipes clog, we roto rooter them out or stent them. If impurities gum up our machinery, we filter them out. If our joints give out or lock up, we replace them. If we want to remove something in the machine’s interior, we take it out through a laparoscope. If the fuel or metabolic mix is wrong, we alter the mix or correct the metabolic defect with drugs If anything else goes wrong, we diagnose it and rearrange it electronically

R. Reece, MD, “Americans and Their Medical Machines,” Medinnovation blog, May 9, 2010

February 20, 2013 – When will critics of medical high tech ever learn?  Critics complain high tech machines should not be marketed or used until randomized control led studies prove their worth – until proven outcomes can justify their costs.

Yet American hospitals, physicians, and patients rush to try high tech  machines before study results are in.  This has been the case for CT and MI scans and PET imaging, for laporoscopic procedures, and now robotic surgeries.

The case in point for this blog post is the fast-growing, exploding use of da Vinci Surgical systems, where the surgeon site sits behind a console and operates four robotic arems that manipulate miniaturized tools inserted into the patient though tiny incisions. A study in the Journal of the American Medical Association doubts the value of robotic surgery.

Yet the number of  de Vinci robot surgeries is exploding – by a factor of 10 or more in the last 5 years.   Today 85% of prostates are removed  robotially.  And robotic surgeries have spread to surgery on the heart, lung, pancreas, abdomen, and gynecological region.

The average total cost for a robotic hysterectomy is $8,868,  compared to $6,679 for the laporoscopic procedure, and $6,651 for open surgery.  Patients may ask, why quibble about price when someone else in paying the bill?

Advocates maintain  robotic procedures require smaller incisions, and produce less scarring,  less pain,  fewer complications , shorter hospitals stays, and much faster recoveries.

So why not robotic?  Why not indeed?   Last year 1370 U.S. hospitals purchased at least one robotic system, and   robots performed 1.5 million procedures worldwide.  Besides, hospitals like robots  to show they are on the cutting edge.  Robots are great hospital marketing tools.  Surgeons like them. Their use attracts more patients and show they are masters of technology.  Patients swear by them because of  smaller incisions,  less pain, and faster recoveries.

What’s not to like? In the minds of hospitals,  surgeons, and patients, these very human factors outweigh lack of randomized controlled studies.  This may be unfortunate and non-scientific, but it is reality.

Should we surprised? I think not.  One of my most visited blog posts is “Americans and Their Medical Machines,” written over 2 years ago. And John Naisbitt, Author of the 1982 classic,  Megatrends. wrote:

“High tech/high touch is a formula I use to describe the way we have responded to technology.  What happens is that when a new te4chnology is introduced into society there must be a counterbalancing response, that is, high touch – or the technology is rejected .  The more high tech, the more high touch.”

The da Vinci surgical system is high tech, the faster recovery with less pain is high touch.

Tweet:  da Vinci  surgical robots for performing surgeries is catching on fast, though they cost more and are unproven to produced better outcomes

Doubts about Obamacare As Major Issue During Second Term Erased

If a man will begin  with certainties, he shall end in doubts, but if he will be content to begin with doubts he shall end in certainties.

Francis Bacon (1561-1626), The Advancement  of Learning

Any doubt  I had about Obamacare being a major issue during President Obama’s second term  were erased when I received today’s Wall Street Journal. The Journal  has the largest circulation of any American newspaper.  It does not publish things with considering the impact of its reporting.

In today’s edition,  the Journal has a special report, a six page spread on “Squaring Off on Health Care, “ on five issues it considers “big issues.”

One, Should all women over 40 get annual mammograms?

YES: Catching early improves odds of  beating it.

NO:  The benefits are small, but the costs can be high.

MY COMMENT : Obamacare’s proposed comparative outcome studies  are likely to side with the “NO” side because of the statistically insignificant outcome gains.   Women do not think of themselves are “statistics.”

Two, Should medical residents be required to work shorter hours?

YES: Long hours are harmful to both patients and doctors.

NO: More work hours mean more opportunities to learn.

MY COMMENT:  Shorter work hours mean more costs for hospitals, who may have a tough time paying because of the 40% reduction in  Medicare reimibursements over the next 10 years.

Three, Should states opt out of the health law’s Medicaid expansion?

YES:  It represents bad welfare – and health – policy.

NO:  It offers cost-efficient care for the most needy.

MY COMMENT :  This is huge issue,  literally a make-or-break issue for Obamacare,  for states who say they can’t afford Medicaid expansion.   and for patients who will have a hard time finding physicians who accept Medicaid patients.

Four, Should employees get insurance discounts for completing wellness programs?

YES:  Financial incentives can be a good motivational too.

NO:  It could lead to higher costs for all.

MY COMMENT:  Wellness programs will lead to higher premiums for those at-risk, who are already seeing health premiums rapidly increase because of provisions in Obamacare.

Five: Should healthy people have their genomes sequenced online at this time?

YES: For patients, knowledge can be a powerful tool.

NO:  The information is too difficult to interpret  - for now.

MY COMMENT:  This is not, to my knowledge, an Obamacare issue because gene sequencing comes out of  patients’ pockets. However, at this stage of the genome art,  a little knowledge can be a dangerous thing.

OP-ED: “Coming Failure of Accountable Care”

The  three Harvard-based authors of this piece  argue that Accountable Care Organizations, the centerpiece of Obamzcare's efforts to “save” Medicare money by herding doctors into common organizations that bundle billing, as administered by government, are unrealistic and destined to fail  because of three flawed assumptions.

One , ACOs will succeed.

They won’t  because they require a major change in doctors’ behaviors, which they are unlikely to make.

Two, ACOs will succeed.

They won’t  because they require a major change in patients’ behavior  which patents are unlikely to understand or appreciate.

 

Three, ACOs will “save” money. 

The Congressional Business Office estimates ACOs will “save” $1.1 billion in first five years. This is unproven and speculative. Further, it is  insignificant in face of current Medicare budget of $468 billion due to increase each year for next 5 years to over $1 trillion by 2018/

The authors’ conclusion:

Accountable Care Organizations over the long haul may ease the path to slightly lower reimbursements or redistribute physician compensation among specialties. But what ACOS most assuredly will not do is deliver the disruptive innovation that the U>S. health-care system urgently needs.

Tweet: ACOs  are likely to fail. They require major changes in physician and patient behavior and will not save a significant among money

Health Technology’s ‘Essential Critic’ Warns Of Medical Mistakes

Preface:  This article is from Kaiser Health News.   KHN encourages its readers to use their original material.  I  have long been a skeptic of electronic health records as the Holy Grail for improving health care, eliminating errors, and preventing duplications.  EHRs are a tool not a solution. EHRs are capable of doing great harm quickly without the knowledge of the patient or the physician.

"Computer mistakes like the one that produced incorrect prescriptions for thousands of Rhode Island patients are probably far more common and dangerous than the Obama administration wants you to believe, says Drexel University’s Dr. Scot Silverstein.

Flawed software at Lifespan hospital group printed orders for low-dose, short-acting pills when patients should have been taking stronger, time-release ones, the Providence-based system disclosed in 2011. Lifespan says nobody was harmed.

But Silverstein, a physician and adjunct professor of healthcare informatics who is making a name for himself as a strident critic of electronic health records, says the Lifespan breakdown is part of a much larger problem.

“We’re in the midst of a mania right now” as traditional patient charts are switched to computers, he said in an interview in his Lansdale home. “We know it causes harm, and we don’t even know the level of magnitude. That statement alone should be the basis for the greatest of caution and slowing down.”

Use of electronic medical records is speeding up, thanks to $10-billion-and-counting in bounties the federal government is paying to caregivers who adopt them. The consensus among government officials and researchers is that computers will cut mistakes and promote efficiency. So some 4,000 hospitals have or are installing digital records, the Department of Health and Human Services said last month.

Seventy percent of doctors surveyed in September by research firm CapSite said they had switched to digital data.

But the notion that electronic charts prevent more mistakes than they cause just isn’t proven, Silverstein says. Government doesn’t require caregivers to report problems, he points out, so many computer-induced mistakes may never surface.

He doesn’t discount the potential of digital records to eliminate duplicate scans and alert doctors to drug interactions and unsuspected dangers.

But the rush to implementation has produced badly designed products that may be more likely to confound doctors than enlighten them, he says. Electronic health records, Silverstein believes, should be rigorously tested under government supervision before being launched into life-and-death situations, much like medical hardware or airplanes.

Silverstein “is an essential critic of the field,” said Dr. George Lundberg, editor at large for MedPage Today and former editor of the Journal of the American Medical Association. “It’s too easy for those of us in medicine to get excessively enthusiastic about things that look like they’re going to work out really well. Sometimes we go too far and don’t see the downside of things.”

A growing collection of evidence suggests that poorly designed software can obscure clinical data, generate incorrect treatment orders and cause other problems. Cases include the Lifespan glitch; a data-entry error that led to the 2010 death of a baby at Advocate Lutheran General Hospital in Illinois; and computers at Trinity Health System, a major Midwest chain, that logged doctors’ orders on the wrong patients’ charts.

Computer mistakes voluntarily reported to the Food and Drug Administration include those that researchers said were linked to 44 injuries and six deaths at unidentified institutions. Those problems included tiny fonts causing caregivers to click on the wrong medication; flipped images that led a surgeon to operate on the wrong side of a patient’s head; and lost or misdated test results that caused unnecessary surgery or delayed treatment.

The FDA’s Dr. Jeffrey Shuren has said that such cases “likely reflect a small percentage of the actual events that do occur.”

At conferences and working from home on the Health Care Renewal blog, Silverstein chronicles digital failures and criticizes hospitals in the same dogged way that he applied himself to building the 1970s-era Heathkit computers he still keeps in his home, say people who know him.

“His message has been consistent: [health IT]provides far less benefit than is claimed by its proponents and opens new — sometimes potent — routes to failure,” said Dr. Richard I. Cook, a medical error expert at the University of Chicago who sat on a panel examining electronic record safety at the authoritative Institute of Medicine. “No one wants him to be visible. But his message and tone have not wavered.

The HIMSS Electronic Health Record Association, an industry group, declined to comment on Silverstein. A spokesman for the HHS’s Office of the National Coordinator for Health Information Technology, the administration’s proponent of digital records, said: “It’s important to listen to all the voices” in the discussion of the subject.

Trained as an internist and in medical info-tech as a Yale postdoc, Silverstein, 55, served as Merck’s director of scientific information in the early 2000s and then as a full-time Drexel professor, shifting in recent years to part-time teaching and working on medical liability cases for plaintiff attorneys. His insistent warnings about digital health risks over more than a decade have effectively barred him from a lucrative career at a hospital or software vendor.

“I’m sure Scot would be better off by keeping his mouth shut and getting a job with a hospital that’s just put in a big effing system,” said Matthew Holt, a Silverstein critic and co-chairman of Health 2.0, which organizes health technology conferences.

Many say he comes on too strong. Even admirers cringed when he began blogging about the 2011 death of his mother, which he blames in a lawsuit on a computer error that allegedly caused Abington Memorial Hospital to overlook a key medication. (Both he and the hospital said they couldn’t comment on a pending suit.) Personalizing his campaign, some thought, made him seem less objective.

“His refusal to temper his message makes it sometimes difficult to hear,” said Ross Koppel, a University of Pennsylvania sociologist and digital health record skeptic.

But Silverstein says his position today is the same as it has always been. He believes in the potential power of electronic records for good, he says. But any doctor who feels bound by the Hippocratic oath’s injunction to “first, do no harm,” he adds, should balk at what’s going on.

“Patients are being harmed and killed as a result of disruptions to care caused by bad health IT,” he said. “I’m skeptical of the manner and pace [of implementation], not of the technology itself…. My only bias is against bad medicine. And my bias is against people with complacent attitudes about bad medicine.”  "

 Tweet:  Digital technologies in the form of electronic health records are capable of doing harm as well as good.