Vacations – Poker – Diagnostic and Research Skills

July 21, 2008 / Michael D. Miller MD / Clinician-Patient Relationships, Innovation, Miscellaneous / No Comments

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.…

E-Prescribing – Good? E-Dispensing Bad!!

July 10, 2008 / Michael D. Miller MD / Access to Healthcare, Clinician-Patient Relationships, Delivery of Healthcare, FDA, Information & Communications, Miscellaneous, Public Health, Quality of Care & Safety / 1 Comment

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. …

Updates on Vitamin D

June 27, 2008 / Michael D. Miller MD / Clinician-Patient Relationships, Innovation, Nutrition, Public Health / No Comments

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. …

Cracking Down on Fake Cancer Cures

June 17, 2008 / Michael D. Miller MD / Clinician-Patient Relationships, FDA, Public Health, Quality of Care & Safety / No Comments

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.…

Nature v. Nurture – Smoking and Other Complex Problems

June 4, 2008 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Miscellaneous, Public Health / 3 Comments

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.…

Baseline and Goals of Treatment

May 20, 2008 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Information & Communications / 3 Comments

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.…

End of Life Issues: Clinical and Cost Considerations

May 16, 2008 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Economics & Financing / No Comments

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.…

People in Clinical Trials: Patients or Subjects?

May 8, 2008 / Michael D. Miller MD / Clinician-Patient Relationships, FDA, Innovation / 1 Comment

Are people who participate in clinical trials patients or subjects? This may seem like a minor rhetorical difference, but I believe it has tremendous implications for health and biomedical research policy. Let me explain why –

Clinical trials are experiments to discover new knowledge. Their intent is to see if a new way of treating a specific disease or condition is better than, the same as, or worse than, another option – either a placebo or an established treatment. Therefore, when people agree to participate in a clinical trial they are participating in this experiment, and their fundamental goal for participating should be to help future patients by expanding biomedical and/or clinical knowledge.…

The Stressed and Strained Health Care Workforce

April 15, 2008 / Michael D. Miller MD / Access to Healthcare, Clinician-Patient Relationships, Delivery of Healthcare, Medicaid, Medicare, Public Health / 2 Comments

The Institute of Medicine put out a report yesterday titled “Retooling for an Aging America: Building the Health Care Workforce.” The report discusses how the aging of the baby-boom generation will create greater needs for health care providers (of all types) who are trained in caring for the elderly with chronic conditions. The report’s recommendations fall into three categories: training, system transformation and financing. Like many reports about health system improvement, their recommendations all make sense – particularly within the context of the three categories. However, like many IOM reports, the writing by Committee process is a bit evident in that, (at least from the Executive Summary), it doesn’t seem to describe a complete plan, nor does it prioritize any of its recommendations – either in terms of funding or which actions should be done first.…

Information Can Change Medical Practice, Patient Behaviors, and Kill Kids

April 10, 2008 / Michael D. Miller MD / Clinician-Patient Relationships, Comparative Effectiveness, Delivery of Healthcare, FDA, Information & Communications, Public Health, Quality of Care & Safety / 1 Comment

Medical information can change how clinicians treat patients, how patients care for themselves, and how healthcare payers promote or prevent the use of treatments and diagnostic tests. However, this information can act as either a broad sword or a scalpel, and produce good or bad outcomes.

A recent report from a Canadian new service about an article from the Canadian Medical Association Journal describing the outcomes from warning about the use of anti-depressants in children brings this issue down from a general concept to being very specific. This news report stated:

Two years after Health Canada warned about prescribing anti-depressants to children, the number of children and teens who died by suicide increased 25 per cent after years of steady decline, major new Canadian research shows.

…

Ensuring Enough Primary Care Clinicians

April 8, 2008 / Michael D. Miller MD / Access to Healthcare, Clinician-Patient Relationships, Delivery of Healthcare, Economics & Financing, Health System Reform, Politics / 3 Comments

Like many complicated problems in the US healthcare system, setting a goal can be easy, but achieving it can be hard. In recent years there has been a number of proposals for increasing the use of primary care clinicians to help patients with chronic diseases (like diabetes) manage their care and avoid long-term complications – and to presumably lower long-term healthcare spending. For example, the “Patient Centered Medical Home” proposal supported by a dozen organizations, (including companies and family practice and pediatrics associations), doesn’t specifically use the term “primary care,” but it gets to the same result – heightened relationships and communications between patients and a particular clinician or clinic.…

E-Health – A Medical Information Miracle or Mess?

February 26, 2008 / Michael D. Miller MD / Clinician-Patient Relationships, Economics & Financing, Health System Reform, Information & Communications, Politics / 3 Comments

Information technology tools has been touted for years as a cornerstone for improving the quality of healthcare and reduce spending. While, clearly this has not been achieved, many e-health initiatives are being launched, and it is unclear how successful or efficient these will be. I am often concerned about the effect e-health systems have on the health care quality when my own physician spends so much time looking into and typing on his laptop. But to avoid discussing the challenges of e-health based upon my n of 1, below are 4 perspectives that are more expansive and analytical:

The Commonwealth Fund recently released a report about 27 state governments’ e-health activities in 2007.…

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