Overkill: America's Epidemic of Unnecessary Care | The New Yorker →

Atul Gawande writing with his usual, uncommon brilliance about unnecessary medical care:

Well, as a doctor, I am far more concerned about doing too little than doing too much. It’s the scan, the test, the operation that I should have done that sticks with me—sometimes for years.

We’re more afraid of doing too little than of doing too much. And patients often feel the same way. They’re likely to be grateful for the extra test done in the name of “being thorough”—and then for the procedure to address what’s found.

Much of the debate on unnecessary tests and procedures has focused on our fee-for-service reimbursement system and doctors profiting from “doing more”. The two quotes above highlight what I think is a much more important pressure on physicians—we don’t want to miss something. We truly want to find a cause for our patients’ complaints and treat them. This is done with the notion that we are providing the best care for them. We dramatically underestimate the consequences of overtesting and overdiagnosis. It is a bias and part of the culture of medicine; we feel like we have to do something.

Right now, we’re so wildly over the boundary line in the other direction [of wasteful care] that it’s hard to see how we could accept leaving health care the way it is. Waste is not just consuming a third of health-care spending; it’s costing people’s lives. As long as a more thoughtful, more measured style of medicine keeps improving outcomes, change should be easy to cheer for. Still, when it’s your turn to sit across from a doctor, in the white glare of a clinic, with your back aching, or your head throbbing, or a scan showing some small possible abnormality, what are you going to fear more—the prospect of doing too little or of doing too much?

This is the ultimate battle, both for doctors and patients. When its your health or your patient’s health on the line, you don’t want to fall on the side of doing too little. This is a struggle I deal with daily in trying to provide the best care for my patients.

Resident burnout – not fixed | MedRants →

Robert Centor:

Burnout generally follows a lack of control. Changing work hour rules, if anything, worsens lack of control.

[...]

The ACGME rules are not helping residents. They are not improving patient safety. They are likely impacting education.

Work hour rules, however, are accomplishing one of their most important goals–giving the public the impression that the ACGME is doing something to keep sleep-deprived residents from harming patients.

As long as they continue to accomplish this goal, I see very little changing.

Google Glass Is Finally Dead. Ish. | Slate →

Will Oremus:

"Moving even more from concept to reality” is a pretty fantastic PR euphemism for discontinuing a product, moving the team to a different division, and going back to the drawing board. While the company promises that there will be future versions of the device, it has offered no timeline.

Some consolation for Google Glass enthusiasts–Tony Fadell, previously at Apple working on the iPod and then started Nest, is reported to be taking over the project.

The most damning part of this announcement is the lack of details or timeline for next steps. If Google didn’t think Glass needed serious work, the next announcement would have been plans for retail sales.

I expect Google Glass to undergo serious changes that will be on a time scale of years not months. I remain bearish on Google Glass, even in medical settings.

The dumpster fire (part 2) | Controversies in Hospital Infection Prevention →

Dr Mike Edmond boldly writing about the crisis in recruiting new ID doctors:

But ethical mentoring now requires that we have frank discussions about the relatively low pay of ID physicians with young physicians who are in the process of career discernment. I tell would-be ID physicians that they need to come to terms with the fact that they will work harder and make less money than their peers who are hospitalists. And the issue isn’t just about money, it’s about how valued you feel.

Many (maybe most) subspecialists maintain their generalist board certifications. Why not trade your overworked, underpaid job for shift work as a hospitalist?

Should Surgeons Keep Score? | Backchannel →

James Somers:

In order for surgeons to improve, they have to know how well they’re doing. In order to know how well they’re doing, they have to know how well their patients are doing. And this turns out to be trickier than you’d think. You need an apparatus that not only keeps meticulous records, but keeps them consistently, and throughout the entire life cycle of the patient.

Great article on the need for performance measurement and feedback. This article focuses on surgeons, but we need this everywhere in medicine. Unfortunately, as stated above, any efforts require meticulous and expansive data. This is one of the promises of electronic medical records, but we are far from that goal right now.

I would love to have a system like this for diagnostic accuracy for myself, especially as I train.

Don’t Homogenize Health Care | NY Times →

Sandeep Jauhar:

We have to get smarter about how we try to improve medical care. I believe the next phase of quality improvement will be a move away from homogenizing care and toward personalizing it, perhaps with the help of genomic research. Neither the old approach, in which seemingly every patient was treated differently, nor the new one, where we try to treat them all the same, has worked well. Medicine needs another way.

A great idea except genomic medicine has almost no evidence supporting it. We have excelled at uncovering the genetic components of diseases and physiology. Unfortunately, we have not excelled (so far) at applying that knowledge to changing the practice of medicine.

A quick example, we know that opioids are metabolized with the help of an enzyme encoded by the CYP2D6 gene. We also know that this gene is highly variable in humans. We know how to detect this variability using genetic testing. We do not know what to do with this information [1]. I could have a patient’s CYP2D6 profile in my hands but I would not have a precise estimate of how I should adjust their morphine dosing…because no such studies have been done.

Genomic medicine is likely part of the answer, but we are going to need the translational research first and then guidelines on what to do with that research.

  1. …other than to tell people at the extremes (very poor metabolizers and very rapid metabolizers) they should likely avoid opioids all together.  ↩

Atul Gawande responding to CIA Torture Report | Twitter →

Yesterday morning, Atul Gawande posted a series of 12 tweets detailing and condemning the medical professionals complicit in the CIA’s torture of detainees. The details are appalling and the doctors’ actions reprehensible.

I find it interesting that Gawande used Twitter and a tweetstorm format to publicize this important criticism. While he has over 108,000 followers, he also has access to The New Yorker and The New York Times. With 12 tweets worth of content, clearly he had enough for a longer form [1]. Perhaps this was only the first public debut of his thoughts and we will see more in the next few days in one of those prominent publications.

  1. Maybe we need to hook him up with a tumblr account…  ↩

How residency programs are training doctors to waste money | Vox →

(It’s difficult to link to an article with such a ridiculous title, but here we are.)

An interesting piece written about a new JAMA study that shows residency impacts and continues to impact costs of care for physicians once they are practicing.

I initially read through the Vox article, then read the abstract from the JAMA [1] and came to the conclusion that training in a high-spending region seems to mean that you will have higher costs of care when you go out in practice (regardless of spending patterns in your region).

From the Vox article:

Residents who train in regions with high health care costs (that is, the places that err on the side of more scans and specialists) continue to practice expensive medicine decades beyond graduation — even if they move to low-cost parts of the country.

While proofing my original post, I realized that this is not what the paper says at all [2]. There is never a direct comparison made among residents trained in high-spending areas versus residents trained in low-spending areas. The comparisons (summarized in Table 2) are all made within the training spending levels.

The data (as presented) actually shows the opposite of what Vox concludes. For residents trained in regions with high health costs, their average cost patient expenditure is $9,482 when practicing in a high-spending region versus $7556 when practicing in a low-spending region [3].

The comparison we want to look at is between the high-spending trainees and low-spending trainees and their costs within their specific practice spending strata. So, for a resident trained in a high-spending region who goes to practice in a low-spending region, his average cost is $7,556 (as mentioned above). For a resident trained in a low-spending region who goes to practice in a low-spending region, his average cost is $6,882. This represents a difference of $674—not chump change—but no direct statistical comparison is made, so it is difficult to say if this is a real difference.

This data is correlational and speculative at best. It’s hard to tell the direction of the effect.

Vox concludes:

The JAMA paper suggests a tantalizingly easy way to save money in American health care: train more residents in low-cost areas of the country.

While I don’t think that is a bad idea, I wouldn’t base huge programs to shift residency training to lower-cost regions based on this paper.

  1. I have to jump through about 27 hoops to get a full-text article from JAMA through my institution while at home.  ↩

  2. Which subsequently had to be pulled because it was all sorts of wrong.  ↩

  3. P < 0.001  ↩

Blood, Simpler | The New Yorker →

Theranos and Elizabeth Holmes are utterly fascinating. To develop a diagnostic testing company in complete secrecy over 10 years that is now valued at $9 billion is unreal.

Speaking of Theranos’ valuation:

Investors have valued the company at more than nine billion dollars, comparable to the two major diagnostic labs.

Comparable valuations, but not comparable scale of business:

Quest runs about thirty full-service laboratories around the country; it performs six hundred million tests of all kinds annually—Theranos’s aim is to hit one million blood tests in 2015—and owns four thousand vehicles for picking up samples.

Valuations never make sense to me.

When I first read about Theranos earlier this year, the proposition—hundreds of laboratory tests from a few drops of blood obtained by finger-stick—seemed too good to be true. Conversely, why not? Why do we have to draw so much blood?

I am not a pathologist and definitely not qualified in any way to answer that question. I think the juxtaposition between Theranos’ promise and the eventual reality is what makes it such a fascinating company. As mentioned several times in the article, transparent peer review needs to be conducted before we can fully buy into Theranos’ promise. Comparison to 23 and Me is quite apt; Theranos will undoubtedly go through growing pains which will include government oversight.

I can’t wait to see what happens. I would prefer, both for my patients and myself, easier diagnostic testing, but it has to live up to current standards for accuracy.

Surgeons and GPs more likely to cause car accidents than other workers | The Guardian →

Difficult to judge the validity of this study, but the results are chilling nonetheless:

For every 1,000 surgeons who drive a car, 361 made an at-fault claim in the past five years, compared with just 3.5 building society clerks, the research found.

I think about this whenever I drive home from the hospital late at night after a long day. Be safe on the road.

E is for...Enterovirus 68 | HAI Controversies →

Eli Perencevich:

Never a dull moment. Just as facilities have begun wrapping up their Ebola preparation plans, there’s gathering evidence that several US states may be facing large clusters of acute respiratory illness associated with human enterovirus 68 (EV68).

Great post on the recent enterovirus outbreak (including a discussion of a Morbidity and Mortality Weekly Report from 2011 discussing an outbreak of EV68).

I have been working in the ED during this period and we have certainly been very busy.

What bothers me is the lack of information about the extent of this outbreak. Our current understanding is limited to what individual hospitals and health departments are investigating on their own. We have invested billions of dollars in health information infrastructure, yet there is no easy way for an entity like the CDC to quickly pull microbiology data from hospitals [1]. At a bare minimum, all decent sized academic medical centers run their own micro labs and organize patient data in databases—if not full EMRs—and we should be able to link those together and query them.

Unfortunately, we probably won’t know the full extent for quite some time as we use proven, but antiquated epidemiological tools.

Enterovirus–68-like Respiratory Virus Sickening Children Across the US | NEJM Journal Watch

  1. At least not that I’m aware of and nothing has been reported from such a system.  ↩

Doctors Raise Concerns Over Apple HealthKit | Forbes →

An interesting and nuanced analysis of the possible impact of HealthKit for doctors.

I will propose a more mundane and broad analysis: HealthKit won’t matter.

Doctors won’t trust the data and won’t know what to do with most of it. Additionally, the data will remain siloed within patient’s phones despite high-profile partnerships with EMR companies because most physicians don’t use those EMRs and even those that do often run outdated versions.

The current pursuit is novel ways to collect data. Apple has taken the next step and is trying to collate and organize it. However, the crucial step—one that will require research [1]—is making sense of the data and providing actual guidance. So far, nobody seems to be taking this step (at least not at scale).

  1. Yes, research (!), that long and nasty process of trying to understand something.  ↩

Should Twitter be Regulated at Medical Meetings? | 33 charts →

Bryan Vartabedian MD:

We don’t need our meeting dialog subjected to legislation.

Using terms like “regulation” and “legislation” creates a straw man. Of course we don’t want meeting organizers to formally control the use of social media at meetings. However, we should be careful in our use of social media at meetings.

The biggest danger I see is the public broadcasting of non-peer reviewed research that may be deeply flawed.

Scientific meetings are the beginning of the vetting process for research findings. Meeting organizers do a cursory review of research prior to accepting it for presentation at a conference. This review is based on submitted abstracts and mostly involves ensuring the research is relevant to the conference; it does not involve scientific review. Thus, when a researcher stands at the podium promulgating their conclusions, few people have had a chance to critically review their methods and findings.

In contrast, research published in scientific journals has been through a formal peer review process and found fit for public distribution.

We are also in danger of over-simplifying complex research findings in our dash to encapsulate a speaker’s words in pithy 140-character snipits. We tend to broadcast select conclusions that reflect our own biases and may misrepresent the researcher’s own thoughts. 140 characters does not allow for qualification or explanation of a result.

While I agree with Doctor V that “regulation” or “legislation” are wholly unnecessary, I would implore conference attendees to think twice about what they tweet at meetings.