In the last couple of weeks there were two interesting articles in the New York Times about patient-physicians communications.

Value of Empathy
In the first  piece, Dr. Pauline Chen discusses an academic article that explored the way physicians communicate empathy to their patients who have serious and life threatening illnesses.  The conclusion of the research, (which looked at the experience of people who had lung cancer), was that physicians miss 90% of the opportunities to connect empathetically with their patients.

The researchers speculated that physicians don’t engage patients empathetically because they are concerned that this would take too much time. However, according to Dr. Chen, the researchers found that “empathy, expressed throughout the patient-doctor encounter, may actually help alleviate problems with time.”  This occured because when empathy was not acknowledged at the beginning of the visit, patients would to try to elicit that type of support from the physician, which could actually extend the time of the visit.

Patients Make a List
The second article was from Jane Brody – a wonderfully gifted health writer – who wrote about ways patients can improve their communications and interactions with clinicians.  Her list had two parts: 6 things to keep written down and bring to your doctor appointments, and 4 tips on how to interact with clinicians.  Her list of 6 things you should keep written down is a good one, and in essence [with my annotations] it is:

1. Questions for the doctor
2. Diary of symptoms
3. List of medicines, supplements and vitamins you take - with name, dosage and how frequently you take them. [Also, please tell your doctor if you are not taking the medicines as instructed for any reason, including if you are having a problem affording any of them.]
4. Your understanding of how you are supposed to be treating your medical problems [Doctors may think that because they told you something at your last visit that you both understood what they said and are following their guidance.]
5. Medical history for yourself and your immediate family
6. Your use of alcohol, tobacco and any drugs not included in #3

The other 4 items on Jane Brody’s list are also valuable:

1. “Be willing to see a physician’s assistant or nurse practitioner for routine care.”  [They will likely be able to spend more time with you on preventive and wellness care issues.]
2. Ask if the doctor uses email for non-urgent issues and questions.   [Some physicians do and some don’t – possibly because they don’t get reimbursed for communicating with patients via email or over the phone.]
3. If the doctor tells you to go to the Emergency Room because of your symptoms, don’t wait.  [Go right away.  Don’t wait for your TV show to be over, for the laundry to finish, or to put on makeup or shave.]
4. If you are told you have a life threatening condition or you need surgery, get a second opinion.

Physicians Use Lists Too
Lists are clearly good things to use so that important things are not forgotten.  People involved with critical, safety-conscious activities like flying airplanes have used lists to make sure that everything is set before takeoff and landing.  After what has probably been too long, such lists are making their way into modern medicine in a more standardized way.

Last December, Atul Gawande wrote in The New Yorker about how such lists are being used to improve the quality of care and save live (and money) in Intensive Care Units.  The first standardized and studied checklist was for putting in a central intravenous line.  The results were remarkable – lowering infection rates in lines that had been in patients for 10 day from 11% to essentially zero.  Peter Pronovost and his collaborators have since developed many other such checklists, (or protocols as they may sometimes be called), and their use has expanded to many, but still probably not most hospitals.

While these lists are clearly beneficial and valuable, like many medical advances, they are first developed and used for the most critically ill patients in hospitals.  This makes sense, because for hospitalized patients a mistake - or action not taken - can mean the difference between life and death.  And hospitals are also places where systematic changes can be implemented and the results measured.

More Use of List by Physicians
Physicians treating patients outside of hospitals often have lists too, but they are often incomplete and are certainly not standardized.  For example, the charts for most patients have problem lists, which list the individual’s medical problems.  However, it is up to the physicians to refer to them, otherwise, the only problem that may be addressed by the clinician will be the one that brought the patient to the office that day – so any needed preventive or wellness care (like an annual eye exam for someone with diabetes) might be overlooked. This is one reason why the list recommended by Jane Brody is so important.

So while physicians may have their own lists, and they know the reason why each patient has come to see them that day, they might be better served by making a list for each patient’s visit so they can make sure to cover all the things that are needed for that individual patient – and of course, that list should also include a reminder to connect empathetically to the patient.  (This is the same concept as having an agenda before any business meeting that not only lists the topics to be covered, but also states an overall objective and concludes with a wrap-up of actions to be taken – a practice I try to follow and force others to do when I’m invited to a meeting.)

Optimism for the Future
In the future, more diagnostic and treatment protocols and guidelines will be developed and configured into standardized checklists to be used in the outpatient setting.  Integrating these into electronic medical records (EMRs) – which include prioritized problem lists with links to recommended preventative exams and monitoring tests – will certainly help improve the quality of care and control the growth in costs.  Of course, this is predicated upon the development of EMRs that can provide such information in ways that are easily used by physicians and their associates.  (This too might be an area where the medical IT industry can learn from those designing airplane information systems.)

While physicians have railed in the past about guidelines and protocols forcing them to practice cookbook medicine, I hope that in the coming years they will welcome them as a way to standardize and simplify their practices so that they can actually work to individualize care for every patient, and connect empathically with them as individuals.  In decades past, that was one of the primary functions of the local doctor, and perhaps if that function again rises in prominence, the interpersonal rewards of practicing primary care medicine will help it grow in popularity with graduating medical students and residents.

An article in the July/August Health Affairs about Massachusetts health plans implementing Pay-for-Performance (P4P) incentives for physicians raised more questions than it answered.

The study found that P4P programs from 5 private sector payers “wasn’t associated with greater improvement in quality” compared to the overall upward trend in the factors measured.  But the study didn’t address some overarching questions and basic realities about P4P, such as:

• How the payers P4P incentives to the physician groups was actually translated into incentives for the individual physicians - or smaller groups of physicians inside the larger groups?
• How the P4P incentives compared to the other financial incentives the physicians are facing?  For example, seeing more patients or doing more procedures could increase their income more than meeting the P4P standards. (The Health Affairs article states that P4P incentives for Massachusetts physician groups averaged 2.2% of their income.)
• The quality measures used in the study were all performance based, rather than actual outcomes, e.g. cholesterol screening rates rather than patients’ actual cholesterol levels, HbA1C screening rates in diabetics rather than their actual HbA1C levels, or asthma medication use for children ages 5-17, rather than ER visits or hospitalizations for these same children.  What impact does that has on physicians’ behavior, and the value of changing their actions to meet these process standards?  Would physicians be more responsive to incentives tied to clinical outcomes?

Making Incentive Programs Successful:
While the study concluded that the P4P incentives program instituted in 2002 may not have produced dramatic changes in the HEDIS process measures, that does not mean  they were ineffective or that P4P is not a useful tool.

First, while collecting process measures data is easier, since clinical outcomes are what patients (and their physicians) should really care about, shouldn’t P4P incentives be based upon actual clinical outcomes? Process measures are easier to monitor by using billing data, but as the prevalence of quality electronic medical records systems grows, collecting and analyzing data about clinical outcomes will become much easier.  In addition, measuring a small set of any factors – process or outcome – presents the pitfall of driving physicians to focus on those diseases and measures to the exclusion of other important things.  For example, in the Health Affairs study, there are a number of preventive services in the process measures, but what about flu vaccinations, colonoscopies or smoking cessation?  This “managing what is being measured” behavior is why the number of factors used for P4P incentives should be as broad as possible.  (But this does not mean that they all have to be measured at every interval, or for every compensation period.)

Second, as any psychologist (or parent) will attest, the time between the actions and the reward (or penalty) is very important for changing behaviors. The Health Affairs article indicates that the bonuses are paid to the physicians groups annually.  Having the incentives paid annually, (or even quarterly), would be unlikely to provide adequate feedback to physicians to prompt them to change their behaviors.  An alternative blended methodology would be to provide physicians feedback on their actual performance against many of the possible measures on a weekly or bi-weekly basis, while making the P4P payments on a monthly or quarterly basis.

Third, many large companies structure their bonuses for their senior managers around a minimum of 20% of compensation.  If incentives for P4P programs only represent a small percentage of physicians’ income, then it would be unlikely to change their behaviors – particularly if they can make up for any lost income by increasing volume.  However, if physicians are being paid a fixed (capitated) amount per month to provide a certain set of services to a patient group – either primary or specialty care – then the volume part of the equation disappears, and P4P programs could be much more effective, even at a lower fraction of their potential income.

And lastly, and most simply, the insurers would not be spending time and money developing and implementing these programs if they didn’t think they provided some benefit – even if it is only financial - so they must be getting some benefits, or at least learning some things to make these programs beneficial in the future.

Conclusions:
18 years ago I wrote a book chapter that focused on structuring incentives for physicians.  Since then it has been hard to move payers and clinicians toward using more focused financial incentive systems.  But the P4P concepts are important, and to be successful they need to be implemented in a way that works for payers, physicians, and patients.  Unless these and other stakeholder groups buy-in to the purpose and practice of such incentives systems, they are unlikely to have the desired effects.  And the result will be more of the same – rising costs, variable quality, and limited access for many patients.

In talking to people about the problems with the US healthcare system, two fundamental truths have become apparent.

First, people really want the type of healthcare that is envisioned in science fiction such as Star Trek, where almost any ailment is treated with a single injection or pill, or a few waves of a healing wand. Unfortunately, medical science hasn’t accomplished that, except in a few instances – antibiotics for a bacterial infection, or perhaps relocating a dislocated finger or shoulder (and those still require weeks to heal and therapy to regain strength and mobility).

And second, the ongoing problem of healthcare literacy and communications may be getting worse as the complexity of medical treatments increases.  Literacy and communications problems impair good healthcare when patients don’t understand what their doctors are telling them, how to take their medicines, or what disease they have.  When this happens  patients have much greater difficulty properly taking care of themselves.  A few examples and data:

• The American Academy of Family Physicians has a Literacy Toolkit which they promote with the twin facts that only 50% of “patients take medications as directed,” and “nearly 90 million American adults have difficulty understanding and using health information.”
• A July 9^th ABC news story reported about an Annals of Emergency Medicine article showing that 78% of Emergency Room patients had some misunderstanding of their doctor’s instructions, but only 20% realized that they didn’t fully understand the instructions.
• More patients are misusing medicines in dangerous ways. The actor Heath Ledger’s accidental overdose was the most recent high profile example of this. And CNN reported Monday about an Archives of Internal Medicine study showing that deaths of this type have increased 700% in 20 years.

Star Trek directly addressed communications challenges in a Next Generation episode, (Darmok and Jilad at Tanagra), where the crew of the Enterprise encounters an alien race whose words are understandable, but none of it makes any sense. It turns out that the alien’s language is based upon metaphors, and since the Enterprise’s crew doesn’t understand the context for the metaphors – the mythology and stories behind the metaphors – communications is nearly impossible….. until of course Captain Picard figures it all out in 60 TV minutes.

Unfortunately clinicians and patients aren’t able to resolve communications challenges like TV characters. When clinicians use words and concepts that their patients don’t understand, patients can’t correctly follow their instructions, and end up relying on what they think they heard or understand.

A classic example of this is that many people think taking antibiotics makes them resistant to antibiotics.  While it is true that antibiotic resistance is an issue of concern, it is the bacteria that become resistant to the medicines – not the patients. But patients who believe that they will become resistant may not take the full dosages of their antibiotics, or for as long as the doctor has prescribed – inactions that can actually increase the rate of bacterial resistance and not adequately treat the patient’s infection – bad outcomes for both society and the individual.

This is just one example of how misunderstanding a disease or a treatment can produce adverse consequences. Similar misunderstandings about diseases like diabetes and high blood pressure also lead to inadequate treatments and poor outcomes. For example, many patients believe they can tell when their blood pressure is high – and only then do they take their medicine. But high blood pressure (or hypertension) is called the “silent killer” because people can’t feel high blood pressure – except sometimes when it is dangerously high.

Which brings us back to Star Trek. One of the great things about the one-dose cure is that the patient doesn’t have to understand their disease or remember to take their medicines for the treatment to be effective, so literacy and communications problems are less of an issue for quality of care.

Lessons for Healthcare Reform
The lessons here for health reform are twofold: First, producing one-shot cures will require a lot more research and development – which needs to occur at the same time as we are improving the healthcare delivery system. And second, a fundamental area for improving healthcare delivery is communications and literacy. If patients don’t understand their disease, how to take their medicines, or modify their lifestyle, etc., then that is not their fault – that is the fault of the healthcare delivery system, and we should be able to find ways to fix it because this is not a new problem.

What’s the point of vacations?  As a consultant that’s something I often ask myself since with the internet, cell phones, etc., it seems almost impossible to really “get away” and not be connected to work.

So what’s the value of vacations?  I think I’ve found the answer at the poker table.  As Ricky Ricardo used to tell Lucy, “Lemme splain!”

The point of vacations is to recharge by being in a different environment that presents a new context for viewing our normal “reality.”  A great practitioner of this principle was Teddy Roosevelt.  He would travel to the wildest and most dangerous parts of the world, and hunt the largest of animals. After these experiences he probably came back to Washington DC and the political world, and said to himself, “Hey, this jungle and these animals really aren’t so bad or ferocious.”

As a consultant, I often find my vacations are pieced together days, (or pieces of days), that often include work “time-outs.”  For example during a recent 5 day trip to visit family in Seattle, aside from the many emails, I had two 8 am conference calls, and a 6 am telephone presentation.  Trips like this have forced me to schedule “vacation” time like I schedule exercise time – in 2-6 hour chunks.  The challenge is making these mini intra-day vacations count.

Which brings me to the poker table.  I had gone with some friends to play at a local casino a few months back, and we all had a good time.  I also found that while playing I could completely focus on the game, and not keep drifting back to ongoing work projects.  I later realized that this was a mini-vacation which provided a refreshing break from the work mindset – a cranial reset if you will.

But there is more to it than just a diversion, because a good movie provides that same 2 hours of alternative focus.  What the poker table provides is an intellectual and rather fast-paced set of interpersonal interactions.  This is when I realized the two connections between poker and clinical medicine:

First, playing cards for many years has helped me learn how to read people – an essential skill in poker, and very useful in clinical medicine where non-verbal communications are a big part of the clinician-patient relationship.  This is similar to teaching medical students about art as a way to improve their observational-diagnostic skills.

And second, while playing poker I get the most gratification not from winning a hand, but from tossing down a hand I had started to play but then decided was probably not going to win.  This latter “skill” is essential to playing good poker, and is also related to good diagnostic skills.  Lemme splain.

In clinical medicine, the diagnostic process starts with gathering the first round of information – by talking to the patient, reviewing their chart, and doing a physical exam.  (This is like looking at the first cards you are dealt.)  Then, as more testing and inquiry are done, you and the patient learn more about their medical problem.  (In poker this information comes in the additional cards in the hand.) And then, as the patient tries different treatments, even more is learned about their condition and how best to treat them.  (This is similar to what happens with the betting in poker – each bet tells you something about the other players and their cards.)

Thus, by seeing the cards as they are dealt and the other players’ bets, (and their responses to my bets), I learn about how my cards stack up against theirs.  And with this additional information I can make a better diagnosis – and decide whether or not my cards are likely to win.  By correctly folding my cards in the middle of a hand, I have in essence made the right diagnosis – which is the ultimate goal of any clinician.  It is an essential step for helping patients – and at the poker table, for limiting losses from that hand.  Conversely, winning or losing a hand – no matter how big the pot – doesn’t carry the same thrill since the intellectual options have been exhausted and all that’s left is to get ready for the next hand – or get back to work.

The clinical analogy to staying in until the end of the hand is that the patient has no more options; every test has been done and treatment considered, and either a treatable or controllable condition has been diagnosed – or not. Medical research strives to expand these options by providing patients and clinicians with more and better diagnostic tests and treatments.  Successful research gives patients the opportunity to draw more cards and play more hands.  And just to come full circle here, medical research is very much like poker in that the skill to correctly fold research spending on an experimental compound or diagnostic test is very valuable – hundreds of millions of dollars valuable.

With two notable government actions in the last couple of weeks there has been significant movement towards increasing the use of e-prescribing.

DEA Proposed Rule
The Drug Enforcement Agency (DEA), proposed regulations on June 27th that would make it possible for controlled substances to be prescribed electronically. Interestingly, this was released right after a National Journal article on this topic.

The DEA’s proposed rule is very important, because while it is appropriate to place stronger safeguards on medicines that are likely to be abused (which is the criteria for being a DEA scheduled medicine), having controlled medicines prescribed by pen and paper while all other medicines are e-prescribed would be a logistical problem and obviate many of the potential benefits of e-prescribing.  And technologically, if banks and others can provide secure login systems and other security measures, I would think that e-prescribing systems could be similarly secure to make sure that unauthorized people aren’t electronically writing themselves prescriptions for thousands of narcotics pills using a legitimate doctor’s DEA number.  (See more about this in the e-quackery section below.)

Medicare Bill Contains Carrots and Sticks for E-Prescribing
The Medicare bill which passed Congress yesterday included a provision to increase the incentives for physicians to use e-prescribing technologies.  These incentives are a small percentage add-on to allowed Medicare charges for physicians who are e-prescribing starting in 2009, and a cut to payments for allowed Medicare charges starting in 2011 for physicians who are not e-prescribing.

Movement in a Good Direction
Together these actions move the US healthcare system towards greater e-prescribing, something that if done right, should increase efficiency (with lower administrative costs), and improve quality of care and patient safety by creating a better system for detecting and preventing adverse drug reactions from known drug allergies and drug-drug interactions.  The use of computerized prescription order systems for patients in hospitals has been shown to accomplish both of these improvements, but how e-prescribing will work in the outpatient world remains to be seen.

Challenges to Making E-Prescribing Increase Efficiency and Improve Quality
There are many challenges for e-prescribing in clinicians’ offices.  Like electronic medical records, they have to buy and install the systems, learn how to use them, and then keep them updated – since new prescriptions keep getting approved etc.  Because of these challenges, it is estimated that only about 6-7% of physicians’ offices are currently using e-prescribing systems.

Optimally e-prescribing systems should be an integrated part of the office’s electronic medical records system so that it could identify potential problems with drug allergies, or the need to alter dosages for patients with impaired kidney or liver function.  And at a minimum, a free standing e-prescribing system should be able to keep track of each patient’s prescriptions to flag drug-drug interactions, otherwise it may become nothing more than a sophisticated fax machine – which some could argue (but I wouldn’t) is a rudimentary form of e-prescribing.

While, e-prescribing systems should provide alerts about drug-drug interactions,  potential allergic reactions, and the need for dosing adjustments, systems that constantly flash up reminders for such things when they’re not relevant, leads users to ignore them altogether. I take a lesson about this hazard from my brother who works on designing aircraft information systems. Clearly pilots need to know certain things at the right time, but I doubt any pilot would fly better or more safely if they kept getting an alert about it being unsafe to land the airplane because the wheels were up – even with the plane at 30,000 feet.  OK – that may be a bit of an extreme example, but if the e-prescribing system doesn’t know anything about the patient, it may send similarly useless alerts and lead those using it to ignore all alerts – which could be worse than having no alerts at all, since it having them pop-up and be ignored could provide a false sense of security.

This illustrates what most people involved with healthcare reform recognize - improving the quality and efficiency of healthcare in the US requires making the systems work better since our practitioners are generally already pretty good.  But giving these good people flawed systems won’t help them, their patients (i.e. us), or our overall healthcare system.

This brings me to one last point.  How many e-prescribing systems will each clinician’s office need?  I certainly hope that every pharmacy chain/group won’t require their own version of an e-prescribing system, nor will each payer, insurer or regulator require a different electronic or paper output of the prescription information for reimbursement or quality auditing purposes.  If that becomes the case, then e-prescribing will face even greater hurdles.

Since they do good work in this area, I also want to include the eHealth Initiative’s  summary of the challenges for e-prescribing systems:

• Financial burdens – Physician practices face varying financial burdens related to e-prescribing, including covering the implementation, training and maintenance costs.
• Workflow changes and change management – Although e-prescribing efficiencies and time savings are gained in the long run, introducing e-prescribing, and electronic health records (EHRs), can be difficult, time consuming, and requires adequate planning, training, and support, particularly in the beginning.
• Continued needs for greater connectivity – The infrastructure exists for connectivity among pharmacies, physician practices, payers and pharmacy benefit managers (PBMs), but some pharmacies, payers/PBMs and mail order pharmacies are not yet connected.
• Medication history – Although e-prescribing is an improvement over relying on paper medical records and patients’ memories, the information that is available may not always be comprehensive or accurate and therefore tools to adequately reconcile medication histories from multiple sources are needed.

E-Dispensing – Bad!!  And E-Quackery – Bad Too!!!
One of the other challenges for e-prescribing may be the practical and policy interactions between physicians’ e-prescribing and internet sites that sell medicines directly to a patient without a prescription.  While e-prescribing potentially can improve efficiency and quality, e-dispensing can lead to bad fiscal and clinical outcomes from patients getting fake, adulterated or dangerous pills and potions.

Information on the worst examples of e-dispensing is in a recent report from Columbia’s National Center on Addiction and Substance Abuse (CASA).  Their recent annual report found that the number of web-sites selling controlled medicines without a prescription has decreased from the start of 2007 to the start of 2008 - from 581 to 365.  The CASA report also found, “Of those sites not requiring prescriptions, 42 percent explicitly stated that no prescription was needed, 45 percent offered an “online consultation,” and 13 percent made no mention of a prescription.”

I’m not sure if anyone knows what the total number of patients using these sites is, or the number of prescriptions they are filling, so it’s unclear if this reduction represents a real decline in the “industry,” or just its consolidation and maturation.  What CASA also found - and that I find especially worrisome - is “an emerging practice of Internet sites selling prescriptions for controlled drugs that can be filled at local pharmacies. The report also found sites selling online “medical consultations” which enable Internet users to get controlled drugs online without a proper prescription.”  I call this e-quackery, because this is physicians acting inappropriately, or non-physicians acting in the role of a physician and practicing medicine without a license by writing prescriptions.

Other notable findings from the CASA report include:

• Of the few sites that require prescriptions, half permit the prescription to be faxed, allowing significant opportunity for fraud.
• Benzodiazepines (like Xanax and Valium) continue to be the most frequently offered drugs for sale with 90 percent of sites selling them; followed by opioids (like Vicodin and OxyContin) at 57 percent of sites, and stimulants (like Ritalin and Adderall) at 27 percent of sites.
• According to DEA estimates, in 2007 eleven percent of prescriptions filled by traditional pharmacies were for controlled substances compared to 80 percent of prescriptions filled by Internet pharmacies.
• There are no controls blocking access to these sites by children and teens.

Conclusions
Just to bring things full circle – clearly e-dispensing and e-quackery are bad, so perhaps the greater use of legitimate and appropriate e-prescribing will help to clamp down on these illegal and dangerous activities.  And from a personal perspective, I can also only hope that it will reduce the ongoing flow of spam emails for on-line medicines - and the similar onslaught of spam blog comments to this blog that you never see because I delete them, but which like spam emails, just chew up time from every day.

p.s. Sorry about the long post – but this is an important and complicated topic.

Since I wrote about the importance of Vitaim D a few weeks ago, some new information has come out.

A report was released this week from researchers in Australia about Vitamin D reducing the risk of all causes of death.  The study was in the Archives of Internal Medicine, about their evaluation of 3,258 men and women scheduled to have a angiogram of their heart arteries.  They found that the people who had below average Vitamin D levels had about twice the risks of dying than those with levels in the highest 25% of the group.

While looking for the report of the Austrlian study, I found another study from a group of reserachers in Boston, that looked at 18,225 men who had no diagnosed heart disease.  This study found that during 10 years of follow-up, the men who were deficient in Vitamin D (15 ng/mL) were about twice as likely to have a heart attack as those considered to have sufficient levels of Vitamin D (30 ng/mL).

It may be coincidence that both studies found a 2:1 effect from high/normal v. low levels of Vitamin D, but there seems to be growing interest and consensus that Vitamin D is important for overall health.  What do you think?

The FDA announced today that they have sent letters to 25 companies to stop selling fake cancer cures. That is, things that the companies claim cure cancer, but have never been tested, or approved by the FDA. The FDA has a web-site with more information about this, and a sub-page that lists 125 Fake Cancer Cures.

I know the FDA gets lots of flack for not doing enough - and not doing it fast enough - I applaud the FDA for taking this action, and encourage them to do more because I have found the advertisement and selling of these non-medicines troubling for a long time.

Cancers are serious diseases by anyones definition, and real medical science is making great strides in developing better treatments and cures, and in overall improving the lives of people living with cancer - both through traditional drugs and biologics, as well as with complementary therapies. But those profiting from selling fake medicines are selling false hope.

I would like the FDA go after more of these people who are profiting from selling fake medicines marketed as cures for other diseases and conditions - particularly ones that may be for symptoms of serious conditions. For example, every time I see the plastic-faced grinning guy on TV hawking a non-FDA approved “natural male enhancement” product, I wonder about all the men who may still be too embarrassed to talk to their physician about their erectile dysfunction problem - which unknown to them is being caused by a serious medical problem, like cancer. And of course for men who are buying this stuff who don’t have ED, then it would be nice if they could talk to their physician about therapy to address the route causes of their feelings of sexual inadequacy.

But of course, the FDA currently has insufficient resources to cover all of it’s multiple priorities - which is why Congress and the Administration are discussing how to provide more funding. Until that happens, I hope the FDA continues being vigilant and stops as many of these purveyors of false hope as they can - at least so these people don’t get the idea that because the FDA’s resources are stretched a bit thin, that the FDA won’t bother them.

A long-standing debate in the life sciences has been the role of nature versus nurture in determining individual characteristics. For example, how much of an individual’s height is determined by their genes and how much by their nutrition – both in childhood and prenatally?

In the last few decades advances in our understanding of genetics has shifted this dichotomy to describe it in terms of genetics versus environmental factors, and expanded our appreciation for the role nature/genetics play in causing all manner of human diseases. For example, it was discovered that genetically determined slow serotonin transporters in the brain can predispose individuals to developing depression. However, the more we learn about genetics, similarly exciting discoveries are being made into how environmental factors influence the activity of genes, and thus affect an individual’s health.

Thus - like many things with multifactorial causes - the pendulum swings one way and then the other, i.e. between nature/genetics and nurture/environment.

But what has also become clear is that genetics and environmental influences are not  separable - they interact in important ways, and both can cause health problems and be routes to solutions too.

What recently caught my eye in the nature versus nurture debate were two studies about smoking cessation that came out in the last couple of weeks. The first, by Nicholas Christakis published in the New England Journal of Medicine (and reported in the May 22nd New York Times) describes the importance of social factors for people trying to quit smoking. This study demonstrates how an individual’s social environment plays a dramatic role in their ability to stop smoking, and how people can help each other stop smoking as a collective activity.

On the nature side of the equation, NIH researcher George Uhl led a study that shows how genetic markers can predict which of two smoking cessation treatments will be more likely to work for an individual. From these two studies it is also possible to postulate that individuals may have genetic predispositions that effect the ability of social networks to help them to stop smoking – or possibly to start smoking in the first place. (Didn’t we call this peer-pressure in junior high?)

I find both these studies very interesting because for years smoking has often been described in terms of individual choice (or weakness), and as such something that is completely separate from genetic or environmental factors. These studies refute that popular myth, and more generally illustrate the fundamental point that most illnesses and healthcare problems are complex, and that the solutions to these problems need to be similarly sophisticated. This also reminds me why I cringe a bit when someone says to fix a healthcare problem, “all we need to do is…….”

What are your favorite examples of interacting genetic and environmental factors, or where simple solutions have gone awry when used for complex problems?

While watching the Red Sox-Milwaukee baseball game on TV last Saturday, the announcers were discussing Julio Lugo, the Red Sox shortstop who had missed 5 games with a concussion. One of them noted that the team had done baseline neuroimaging testing on all the players so if they had a concussion during the season they would have a baseline to compare to their post-concussion tests. I assume that they also did non-imaging neurological testing, such as reflexes and memory, etc., and this was an extension of all the other evaluations the players went through.

The reason I found this interesting is that it highlights the importance of having an understanding of both a patient’s baseline and their goals. For example, the ability of someone to play the piano after a hand injury is healed depends upon whether or not they could play the piano before the injury. (Sorry – that’s from a very old joke.)

Obviously after a professional baseball player has a concussion, the important factors include reflexes and visual focus since hitting a 90+mph fastball and catching a rocketed ground ball requires precise physical abilities. But for the rest of us - and overall healthcare quality - baseline functioning and goals are important because they are different for every patient, and should be a crucial component of the conversation between a patient and their clinical team. Only when the clinician understands what the patient’s abilities were before the illness or injury, can they work with the patient to develop a treatment plan that they hope will get the patient to their goals.

This may all sound silly or simplistic, but too often I have heard stories about patients who complain that their physician has given them the treatment plan without considering their desires or perspectives - as in “this is what where going to do.” Unfortunately, physicians sometimes only see one reasonable treatment course. But patients are as different as baseball parks – and I mean globally from sandlots to Yankee stadium – and their perspectives, concerns and treatment goals really are just as diverse.

I’m ready for blasts from physicians and others on this one, so let me know what you think.

At a policy related forum for medical residents at the Massachusetts General Hospital last week, one of the questions was about end of life care. The other panelists and I answered from a clinical perspective - and I also put a plug in for the Kenneth B. Schwartz Center which does educational programs for clinicians about strengthening patient-caregiver relationships and communications.

However, during the informal discussion after the panel, a number of the residents raised questions about how much of our healthcare spending goes for treating people at the end of life. In talking with them about this, I recalled three things having looked at this issue several years ago: First, there is a lot of public misunderstanding and misrepresentation of information about this topic. For example, percentages of Medicare spending turning into percentage of total healthcare dollars, or spending in the last year of life being reported as spending in the last month of life. Second, the percentage of healthcare spending in the last 6 months of life has not changed in decades. And third, people agree that if a patient’s life expectancy was clear, then it would be easy to reduce spending at the end of life. This last point was one of the reasons for hospice care, which attempts to both improve clinical care and reduce costs. Hospice has been a big clinical success since - unlike hospitals and general home care services - it is designed to fit the needs of the patient and their family.

So what about costs at the end of life? I did a quick (and admittedly non-comprehensive) search for more information, and found that:

• As of the late 1990s, care in the last year of life consumed about 27% of Medicare’s spending and this percentage hadn’t changed in 20 years. These costs represent 10-12% of total healthcare costs, and 30-40% of this spending occur in the last month of life.
• There is great variability of costs incurred during the last 6 months of life across the country – with up to a 250% difference. But this might also reflect the overall variability in healthcare costs by location.
• A 2007 study found that hospice use reduced Medicare’s costs in the last year of life by 23%, but a 2004 study found that savings from hospice were only with younger patients with cancer, and that overall, hospice enrollment cost Medicare more money.
• A great 2002 article reviews the literature and the issues about end of life care – including how Medicare financial incentives may contribute to more intensive care and higher costs.

So what are my conclusions? Any focus on reducing spending on end of life care as the solution for our rising health care costs is misplaced. These costs are significant, but they are only part of the problem since their growth reflects the overall rise in healthcare spending. And Buntin and Huskamp’s conclusion in their 2002 article, that we have “critical gaps in our knowledge about how to design a better end-of-life care system for Medicare beneficiaries,” is right on target.

What are your thoughts about end of life care, hospices, and educational organizations for clinicians like the Schwartz Center?