Questions By Pathologist at High Risk for Prostate Cancer

October 11, 2011 - The papers are full of news about a U.S. Preventive Task Force Decision not to recommend routine PSA screening of healthy men for prostate cancer.

About half of men over 50 now receive PSA-screening. It is estimated that 120,000 men die of prostate cancer, the second leading cause of male death after lung cancer, and although 16% of men have the disease but only 3% die of it.

The Task Force essentially said routine PSA screening does more harm than good, because of such things as infections after biopsy, agony over false-positives, over-treatment resulting in impotence and erectile dysfunction, and exorbitant fees for surgery, radiation, and hormonal therapy are unnecessary, especially in men over 75.

Associations of urologists, other doctor organizations, and an oncologist at Harvard disagree, saying prostate cancer, caught early, saves thousands of lives.

To treat or not to treat prostate cancer, based on elevated PSA levels and positive biopsies, that is one question. A second question is, why treat a slow-moving cancer that is not likely to kill the patient, who is five times as likely to die from a disease unrelated to his cancer.

Given this context, I would like my blog readers to answer a series of questions relating to my personal situation. I am a pathologist who in the course of doing hundreds of autopsies, knows that microscopic evidence of focal prostate cancer is present in about 65% of men over 65 and 90% of men over 90. I am in the 65 and over crowd. I am a high risk for prostate cancer for these reasons.

• Men with a family history of prostate cancer are at risk. My brother had his prostate removed at 55 for a PSA-detected prostate cancer without complications, and has been cancer-free for 15 years. My father developed prostate cancer has 75, had his cancer irradiated, and died of a stroke at 91.

• Over the last two years, my PSA has risen from 2.3 to 3.9, with 4.0 considered the outer edge of normality.

My questions are these:

• Should I, an asymptomatic male, go for another PSA?

• If elevated above 4.0, should I undergo a biopsy?

• If the biopsy is positive, should I; one, have the prostate removed; two, undergo hormone therapy; three, have the prostrate treated by conventional radiation or by a 5-day cyberknive therapy.

• Should I be a minimalist, i.e., someone who forgoes PSA-testing and therapy for a positive biopsy, or a maximalist, someone who opts to have the prostate out or treated aggressively by other means.

• Should I trust a federal panel focusing on saving money and doing no harm, advising no PSA-screening over age 65, no treatment over age 75, or on a urologist who will make money on any procedure who may cure me, relieving me of the anxiety of harboring a malignancy.

Not Trivial Questions

These are not trivial questions, given my situation, and given the growing consensus that men over 50 have a 50% chance of having microscopic prostate cancer, men over 60 have a 60% chance, and so on, up to 90% for men over 90.

It isn’t easy being a balls-bearing and prostate-bearing male, especially if one wants to remain upright and functioning into old age.

References

1. Michael Barry, MD, “Screening for Prostate Cancer – The Controversy That Refuses to Go Away,” NEJM, March 20, 2009.

2. Shannon Brownlee and Jeanne Lenzer, “Can Cancer Ever Be Ignored,” NYT Magazine, October 9, 2011.

3. Jennifer Corbett Doreen and Thomas Buxton, “Panel Faults Widely Used Prostate Cancer Test, “ WSJ, October 7, 2011.

4. Jerome Groopman, MD, and Pamela Hartzland, Your Medical Mind, The Penguin Press, 308 pages, 2011.

Tweet: A 65 y.o.+ pathologist at high risk for prostate cancer asks: Should I have a PSA test, and if elevated, should I have biopsy?

Purchasing My Book The Health Reform Maze

October 10, 2011 - Since my essay "Why Doctors Don't Like Electronic Records" appeared in the September 27 issue of Technology Review (MIT Press) and the October 8 edition of The Health Care Blog, I have received numerous requests how to buy copies of my new book The Health Care Blog (Greenbranch Publishing, 2011).

You may purchase copies of the book on Amazon.com or at www. Greenbranch.com.

Thank you for your interest. The book gives a balanced view of the positive aspects of the Health Reform Law and its negative unforeseen consequences.

Tweet: To purchase The Health Reform Maze, my latest book, go to amazon.com or Greenbranch.com

IT As a Halfway Technology --The Secular Gospel Is Not the Holy Grail

October 10, 2011 - In American culture, we tend to look at our bodies as machines - as our salvation and our path to immortality. If the machine face sags, we lift it up; if pipes plug, we unplug them; if joints creak or grind or pain, we replace them. We depend on information technologies to tell us what body organs to fix, remove, or substitute with spare parts.

This brings me to my theme: halfway technologies, whether of the mechanical or informational sort, will not ward off our final ending. We will continue to have a finite life span.

Others have said this better than I. As I write, I am thinking of two of my heroes.

• One is a literary hero - Lewis Thomas, MD (1913-1993), a pathologist who wrote “The Technology of Medicine,” in Lives of a Cell (Viking Press, 1974), a compilation of essays that first appeared in the New England Journal of Medicine under the rubric “Notes of Biology Watcher.” Thomas articulated the doctrine of halfway technologies, what we do after the disease horse has left the barn.

"Halfway technology represents the kinds of things that must be done after the fact, in efforts to compensate for the incapacitating effects of certain diseases whose course one is unable to do very much about. By its nature, it is at the same time highly sophisticated and profoundly primitive... It is characteristic of this kind of technology that it costs an enormous amount of money and requires a continuing expansion of hospital facilities... It is when physicians are bogged down by their incomplete technologies, by the innumerable things they are obliged to do in medicine, when they lack a clear understanding of disease mechanisms, that the deficiencies of the health-care system are most conspicuous... The only thing that can move medicine away from this level of technology is new information, and the only imaginable source of this information is research. The real high technology of medicine comes as the result of a genuine understanding of disease mechanisms and when it becomes available, it is relatively inexpensive, relatively simple, and relatively easy to deliver."

• The other is a technologic hero – Steve Jobs, who died on October 5, 2011 at age 56 of pancreatic cancer. In a Stanford University commencement address in 2005, he said this:

"No one wants to die. Even people who want to go to heaven don't want to die to get there. And yet death is the destination we all share. No one has ever escaped it. And that is as it should be, because Death is very likely the single best invention of Life. It is Life's change agent. It clears out the old to make way for the new. Right now the new is you, but someday not too long from now, you will gradually become the old and be cleared away. Sorry to be so dramatic, but it is quite true."

"Your time is limited, so don't waste it living someone else's life. Don't be trapped by dogma — which is living with the results of other people's thinking. Don't let the noise of others' opinions drown out your own inner voice. And most important, have the courage to follow your heart and intuition. They somehow already know what you truly want to become. Everything else is secondary."

Commonalities

My two heroes share a belief that technology, however wondrous, will not save us from death. Most of us would not deny this reality, but that is exactly what many of us expect, what we want, and what we demand. But, alas, half-way medical technologies - organ replacements , dialysis, stents, wonder drugs , stem cell transplants, and IT telling us how to prevent disease, cure disease, and stay well – will not provide immortality any time soon. These technologies may keep us upright and functioning to the very end, but the end will come to us all.

Yet we Americans will continue to worship at the altar of technology, particularly information technology. Technology offers us hope of another and better day.

In a October 8 WSJ piece, “ Steve Jobs, Secular Prophet,” Andy Couch, also author of Culture Making: Recovery for Creative Calling, explains why information technologies have become secular gospel.

"Steve Jobs’ most singular quality was his ability to articulate a perfectly secular form of hope. Nothing exemplifies that ability more than Apple's early logo, which slapped a rainbow on the very archetype of human fallenness and failure—the bitten fruit—and turned it into a sign of promise and progress."

"That bitten apple was just one of Steve Jobs's many touches of genius, capturing the promise of technology in a single glance. The philosopher Albert Borgmann has observed that technology promises to relieve us of the burden of being merely human, of being finite creatures in a harsh and unyielding world. The biblical story of the Fall pronounced a curse upon human work—"cursed is the ground for thy sake; in sorrow shalt thou eat of it all the days of thy life."

"All technology implicitly promises to reverse the curse, easing the burden of creaturely existence. And technology is most celebrated when it is most invisible—when the machinery is completely hidden, combining godlike effortlessness with blissful ignorance about the mechanisms that deliver our disburdened lives."

"Apple made technology not for geeks but for cool people—and ordinary people. It made products that worked, beautifully, without fuss and with great style. They improved markedly, unmistakably, from one generation to the next—not in the way geeks wanted technology to improve, with ever longer lists of features (I'm looking at you, Microsoft Word) and technical specifications, but in simplicity."

"Press the single button on the face of the iPad and, whether you are 5 or 95, you can begin using it with almost no instruction. It has no manual. You cannot open it up to see its inner workings even if you want to. No geeks required—or allowed. The iPad offers its blessings to ordinary mortals."

"Steve Jobs was the evangelist of this particular kind of progress—and he was the perfect evangelist because he had no competing source of hope. He believed so sincerely in the "magical, revolutionary" promise of Apple precisely because he believed in no higher power. In his celebrated Stanford commencement address (which is itself an elegant, excellent model of the genre), he spoke frankly about his initial cancer diagnosis in 2003. It's worth pondering what Jobs did, and didn't, say:

"This is the gospel of a secular age. It has the great virtue of being based only on what we can all perceive—it requires neither revelation nor dogma. And it promises nothing it cannot deliver—since all that is promised is the opportunity to live your own unique life, a hope that is manifestly realizable since it is offered by one who has so spectacularly succeeded by following his own "inner voice, heart and intuition."

"Perhaps every human system of meaning fails or at least falls silent in the face of these harsh realities, but the gospel of self-fulfillment does require an extra helping of stability and privilege to be plausible. Death is "life's change agent"? For most human beings, that would sound like cold comfort indeed."

"The world—at least the part of the world in our laptop bags and our pockets, the devices that display our unique lives to others and reflect them to ourselves—will get better. This is the sense in which the tired old cliché of "the Apple faithful" and the "cult of the Mac" is true. It is a religion of hope in a hopeless world, hope that your ordinary and mortal life can be elegant and meaningful, even if it will soon be dated, dusty and discarded like a 2001 iPod."

"It is said that human beings can live for 40 days without food, four days without water and four minutes without air. But we cannot live for four seconds without hope."

"Whatever the limits of Steve Jobs's secular gospel, or for that matter of Dr. King's Christian one, our keen sense of loss at his passing reminds us that the oxygen of human societies is hope. Steve Jobs kept hope alive. We will not soon see his like again. Let us hope that when we do, it is soon enough to help us deal with the troubles that this century, and every century, will bring."

Halfway technologies offer hope, but they cannot deliver biological immortality.

Tweet: Modern medical technologies and information technologies may help you in the short run but they merely delay the inevitable.

Latest Statistics on Presidential Election and Obamacare

October 9, 2011 - I’m a sucker for statistics. Statistics give a sharper picture of the state of U.S. affairs than mere words and opinions.

Here the latest statistics.

• From Realclearpolitics.com, which publishes average results of national polls.

--President Obama job approval 42.1%, disapproval 51.4%, Spread -9.3%

--Congressional job approval 13.0%, disapproval 82.3%, Spread, -69.3%

-- Generic Congressional vote, Republicans, 41.8%, Democrats, 41.5%, Spread, +0.3%

- Obamacare, Oppose, 50.0%, Favor, 38.6%, Spread, -11.4%

--Repeal of Obamacare, favor, 49.0%,oppose 40.3%, Spread, -8.7%

• From Intrade.com, which publishes predictions of those placing bets on national events.

--Mitt Romney to be Republican presidential nominee in 2012 - 61.9% chance

--Rick Perry to be Republican presidential nominee in 2012- 18.7% chance

--US economy to go into recession in 2012 – 65.0%

-- President Obama to be re-elected President in 2012 – 47.9%

-- Marco Rubio to be Republican VP in 2012 – 20.1%

--Republicans to control Senate in 2012- 67.1%

What These Statistics Mean for Obama and Health Reform

For the moment, these statistical snapshots mean President Obama and his health reform law are in trouble. His election will hinge on two issues – the state of the economy and the Supreme Court decision on the constitutionality of the individual mandate and perhaps of the whole health law.

According to an article in today’s October 9 Sunday New York Times, “An Ugly Forecast That’s been Right Before, “ the Economic Cycle Institute in New York City, which in the past has invariably picked chances of a recession, the economy will go negative by end of the first quarter of 2012. And conventional wisdom has it that the Supreme Court will rule Obamacare unconstitutional with Judge Anthony Kennedy casting the decisive vote in a 5/4 decision.

It is, of course, a long, long way from here to November 2012, and the mellifluous President Obama has the Bully Pulpit and the elite media on his side. I would not discount his chances for re-election. But if a double-dip recession and the Supreme Court intercedes, it is likely Obamacare will lie in tatters, whether or not President Obama wins re-election.

Why Doctors Don't Like Electronic Health Records

October 7, 2011 - The following article of mine ran in the Technology Review, an MIT Press publication, on September 27. The Health Care Blog, the most widely read health blog, reprinted it on October 9, and it immediately drew 26 responses.

A physician argues that electronic patient records raise costs, decrease patient visits, and make poor communication tools.
·
Why are doctors so slow in implementing electronic health records (EHRs)?

The government has been trying to get doctors to use these systems for some time, but many physicians remain skeptical. In 2004, the Bush administration issued an executive order calling for a universal "interoperable health information" infrastructure and electronic health records for all Americans within 10 years.

And yet, in 2011, only a fraction of doctors use electronic patient records.

In an effort to change that, the Obama economic stimulus plan promised $27 billion in subsidies for health IT, including payments to doctors of $44,000 to $64,000 over five years if only they would use EHRs. The health IT industry has gathered at this multibillion-dollar trough, but it hasn't had much more luck getting physicians to change their ways.

What is wrong with doctors that they cannot be persuaded to adopt these wondrous information systems? Everybody knows, after all, that the Internet and mobile apps, powered by Microsoft, Google, and Apple and spread by Facebook, Twitter, YouTube, and the iPhone and iPod, will improve care and cut costs by connecting everybody in real time and empowering health-care consumers.

I suspect the answer may lie partly in something essayist E. B. White said about humor. "Humor," said White, "can be dissected as a frog can, but the thing dies in the process, and its innards are discouraging to any but the pure scientific mind." Similarly, humanity withers when it is dissected and typed into an EHR. As Jerome Groopman, a Harvard internist, wrote in How Doctors Think, "Clinical algorithms can be useful for run-of-the-mill diagnosis and treatment ... but they quickly fall apart when doctors need to think outside their boxes, when symptoms are vague, or multiple and confusing, or when test results are inexact."

The computer is oversold as a tool to improve health care, implement reform, cut costs, and empower patients. The reasons are obvious to anyone who treats patients. You cannot look a computer in the eye. You cannot read its body language. You cannot talk to an algorithm. You cannot sympathize or empathize with it.

We physicians are not Luddites or troglodytes. We are savvy about using the Internet, technology applications, and social media. For us, medicine mixes art and science. What we seek from patients are clues, constellations of signs and symptoms, and stories. We choose not to be reduced to data-entry clerks sorting through undigested computer bytes.

A string of numbers containing demographic, laboratory, and other patient information, no matter how systematically assembled or gathered, is not narrative. It does not tell a story. It contains "just the facts," as Sergeant Joe Friday used to say.

That is why an ophthalmologist told me that when he gets an EHR summary, he ignores it: "It does not tell me the patient's story. It does not tell me why the patient is here, what troubles the patient, and what the referring doctor wants me to do."

There are also more mundane reasons why physicians, particularly in small practices, do not cater to EHRs or to their private enthusiasts and government backers. EHRs, you may hear physicians argue:

· are sold by so many companies—more than 100 at present—that no one knows how to separate the good from the bad and survivors from non-survivors.
· slow productivity.
· show negative investment returns.
· don't speak to one another.
· distract from patient time.
· require total reorganization of practices.
· conceal a strategy for monitoring, controlling, and dictating practice activities.
· can be misused or hacked to invade privacy, reveal sensitive information, and threaten the security of patient and doctor alike.
· raise practice costs.

A word on the final point. It is not only the $40,000 that software vendors charge to install an electronic records system and the $10,000 to $15,000 for annual maintenance. It is the hassle factor and the often prohibitive cost of hiring staff to enter the data and to comply with new rules and regulations. When added to the time and effort already required to deal with Medicare, Medicaid, and health insurance plans, EHR requirements are the final straw.

Many doctors are seeking refuge from bureaucratic demands by retiring, closing practices to new Medicare and Medicaid patients, or seeking hospital employment.

This is ironic, since many physicians believe that new apps, such as better speech recognition or systems that translate data into narrative, will make EHRs easier to use. "Free," government-subsidized, or cheaper models will enter the market; clinical algorithms, based on demographic and patient-entered historical information, will make diagnosis, treatment, and management faster and better.

But these features must evolve from below rather than being imposed from above. EHRs won't be useful and physician-friendly until physicians themselves have more input into their design.

The digital revolution, and all the improvements in health care that are promised, will remain promises until the EHR is more useful—in medical and economic terms—for doctors.

Richard L. Reece is a retired pathologist and the author of The Health Reform Maze: A Blueprint for Physician Practices. He blogs about health reform, medical innovation, and physician practices at medinnovationblog.blogspot.com

The American and The Spaniard – Two Wild and Crazy Guys in Search of Physician Entrepreneurship

A Wild and Crazy Guy

1978 Album by Steve Martin, American Comedian

October 7, 2011 - I have just returned from Spain, where I saw my son ordained as an Episcopal Priest in Madrid and where I met with Luis G. Pareras, MD, PhD, MBA in Barcelona.

Peraras The Man

Peraras is Director of Innovation and Entrepreneurship at the Barcelona Medical Association. He is a neurosurgeon and a venture capitalist, did his residency in the U.S., holds a Global Executive MBA degree, frequently visits our country, and has dedicated his life to helping physicians analyze and launch new health care start-ups.

The Steve Jobs Connection

Two days after our meeting on October 3 , Steve Jobs , founder of Apple Computer, died in California . He was 56 years old. I mention this because Jobs was a wild and crazy guy. Peraras leads off his book Innovation and Entrepreneurship in the Healthcare Sector with this quote from Think Different, Apple, 1998.

“Here’s to the crazy ones, the misfits.
The rebels. The trouble makers.
The round pegs in the square holes.
The ones who see things differently.
They’re not fond of rules and
They have no respect for the status quo.
You can quote them, disagree with them, glorify, or vilify them.
But the only thing you can’t do
Is ignore them.
Because they change things.
They push the human race forward.
And while some may see them as
The crazy ones, we see genius
Because the people who are
Crazy enough to think
They can change the world.
Are the ones who do.”

Inscription in Book

After our two hour meeting, Peraras honored me by inscribing this note in my copy of his book,

“To Dick,
Because from the very first minute of our meeting I knew you were one of these… the crazy ones, the rebels.”

Takes One to Know One

It takes one to know one. In some ways, we were an odd couple – a 6’2” 230 pound bald white haired American and a 5’7” black –haired 150 pound Spaniard. But we shared certain things in common. I was the author of 10 books, he of 20. We had a common publisher – Nancy Collins of Greenbranch Publishing in Phoenix, Maryland. My last book The Health Reform Maze spoke of the American health reform law, PPACA, and its obstacles to innovation. His book told of how to overcome innovation obstacles. We were both pragmatists promoting wild ideas rather than ideologues conforming to any social system.

I suspect both of us would agree with Margaret Thatcher, The British Prime Minister, who said, “I have a deep skepticism about the ability of politicians to change the fundamentals of the economy or society; the best thing they can do is to create a framework in which people’s talents and virtues are mobilized not crushed.”

I thought of Ronald Reagan’s famous statement, “Government is not the solution, it is the problem.” True, government can set the tone for social consciousness. True, It can serve as a catalyst for innovation, but it is too inefficient and clumsy to innovate. The American and the Spaniard believed in “bottom-up” solutions rather than “top-down” solutions. The latter stifle innovation, rather than promoting it.

Meaningless of Term “Innovation”

The American and the Spaniard agreed the term “innovation” had become meaningless through overuse. It was a catch phrase lacking specificity. They preferred the word “entrepreneurship,” for it implied human ingenuity at its best. The Spaniard defined innovation, and its stepchild entrepreneurship, as “knowledge turned into money,” requiring specific ideas, business plans, teams of like-minded partners, marketing analyses, and venture capitalists. Entrepreneurs require more than ideas. They need money. Money may be a dirty word in socialist circles, but it is an essential incentive for social and health care success.

The American and the Spaniard were keenly aware of the profound differences between the U.S. and Spain. The Spanish health system was 80% socialist, the Americans 50% capitalist. Yet America was becoming more socialistic, and Spain more capitalistic. The Spaniard deeply understood these differences, having received much of his medical and business training in America. Perhaps that is why his book reads as if written by an American, and why most of his book’s references are to papers written by American MBAs.

The Spaniard has worked for years in the venture capital trenches and sat on the board of venture capital companies. The American was merely an observer of what start-up companies could do The Spaniard said he could listen for 5 minutes to a presentation of new idea, and he knew immediately if the idea had legs. As he put it, workable ideas spread from specific problems in search of a solution; unworkable ideas tended to be solutions in search of a problem.

Courage Rather than Analysis

The Spaniard’s remark brought to mind this quote from Peter Drucker’s 1966 book The Effective Executive,

“Courage rather than analysis dictates the truly important rules for identifying priorities:

• Pick the future as against the past;

• Focus on opportunity rather than problem;

• Choose your own direction – rather than climb on the bandwagon; and

• Aim high, aim for something that will make a difference, rather than for something that is ‘safe’ and easy to do.”

America The Innovative

The Spaniard liked Drucker’s rules so much he wrote them down. Our conversation turned towards what he thought of America. He said repeatedly “America is a great country.” He admired our freedom to choose between modes of health delivery. He thought government should encourage private venture capital and discourage innovation-killing regulations. He admired the Silicon Valley ethos and America’s great universities and health centers. He said he would perhaps like to live in America some day to help bring the fruits of our innovation to the rest of the world, including his beloved Spain.