First published on on Nov. 18, 2013

[In response to the question: “If you could change one aspect of the Affordable Care Act, what would it be?”]

Similar to the old comedy straight-line, “When did you stop beating your wife?” this question has a built-in assumption.  From their first day on the wards, medical students are taught never to ask such questions, because they bias a patient’s response.

Instead, phrasing the question as “What would you do to improve healthcare or its delivery in the United States?” would elicit equivalent answers, without bias.

I’m not saying the ACA is the pinnacle of mankind’s legislative accomplishments.  But it’s clearly not the monstrous cancer that loud voices proclaim it to be.  Let us take the energy directed against the ACA and try turning it positive.  Let’s try to make the Act work, and bring healthcare insurance to the tens of millions of Americans who don’t now have it.

First published on on June 20, 2013

Short answer: Yes, of course.

Longer answer: There is no new thing under the sun. Physicians in the 1920s debated whether they should use telephones to communicate with their patients. We know how that turned out.

The issues debated, then and now, are not too different, e.g. the loss of information and nuance when two people cannot see each other, or when the physician cannot examine the patient. And just as they did with telephones, physicians will have to learn what topics are effectively handled by email and which are not.

Even the vexations are similar. Insurance companies are just as unwilling to pay physicians for email messaging as they are for telephone consultations. Many physicians, however, are already emailing patients. A salaried friend loves it.

As technology evolves, the next debate will ask whether texting is appropriate for physicians. Are 140 characters enough to have a clinically meaningful conversation? Let’s give it a try:

(PT = Patient, MD = Physician)

PT: “Hurting”

MD: “Where?”

PT: “Chest.”

MD: “Describe”

PT: “Squeezing”

MD: “Bad?”

PT: “Elephantweight!”

MD: “Call 911”

< crickets >

MD: “Now”

< crickets++ >

MD: “Hello?”

< ominous crickets >

MD: < expletive >

< anguish >

MD: “Hello?!!”

PT: “Here.”

MD: “Alive!”

PT: “Batterycrumped.”

MD: “Call 911”

PT: “Text 911?”

MD: “CALL 911”

PT: “Ok”

MD: “Now”

PT: “Ok”

< disconnect >

MD: “Yeow.”

All technologies carry their own frustrations.

First published on on June 19, 2013

In 1905 Dr. William Osler – the great co-founder of Johns Hopkins Hospital, who was cursed with a terrific sense of humor – jokingly proposed that all men over age 60 should be euthanized. Unfortunately for Osler, the newspapers took him seriously. A gigantic controversy erupted, and Osler spent the rest of his time in America trying to explain himself, before fleeing to Oxford.

Being a man not far from the aforementioned age, let me be clear: I do not support any form of mandatory euthanasia as a method of reducing physician workload. There are much better ways.

I think that physicians should do only physicianing. The trends in medicine, however, are exactly the opposite: physicians are wasting increasing amounts of time doing un-physiciany things. They are being de-professionalized.

Two art works that Dr. Abraham Verghese of Stanford University, likes to compare, illustrate one such erosive trend.

The painting, titled “The Doctor,” appeared in 1891. The sick child commands every ounce of the doctor’s attention and concentration. The drawing, untitled, appeared in 2012. The sick child, who is also the artist, sits on an examination table, amid family. The physician is at the left margin, his head down, the hospital information system commanding every ounce of his attention and concentration.

If you talk to physicians today, every single one of them will begrudge the time they spend feeding the gaping, information-eating maw of insurers and medicine-practiced-by-teams. Some may admit there are benefits, but every single one will talk about the costs, which are all too obvious.

If Dr. Leonard “Bones” McCoy were among us, he would rightly and indignantly remind Captain Kirk that, dammit, he’s a doctor, not a stenographer.

First published on on June 18, 2013

This sounds like an “If I were King” question, so I’ll answer it that way.

If I were King, I would want all my subjects to die at age 120, by accidentally falling into an ice crevasse while descending from the summit of Mt. Everest. At night. In this kingdom, physicians are paid according to how close they come to achieving that outcome for each patient.

The incentives in this system are perfect: both the physicians and patients want exactly the same thing. Implementation is tricky, however. Naive approaches would spur physicians to cherry pick healthy patients and then spend lavishly to keep the patient alive and well.

Suppose, however, that each patient is treated, financially, like a public corporation. Each would have a fixed number of shares, and each share would pay an annual dividend based on the improvement in the patient’s health status over the past year. Referrals to other physicians would dilute the holdings of the referring physician, forming a financial disincentive to excessive care that must be balanced against the goal of keeping the patient healthy and vigorous. Perfect.

Aiming the healthcare delivery system squarely at outcome improvements would encourage a long-term outlook, preventive care, and close follow-up of patients. It would transform medically underserved areas into the most lucrative places to practice, ultimately erasing disparities in health. Administering such a system would be data-intensive, but that heavy burden is already upon us.

In this kingdom, healthcare reimbursement derives from clear, results-oriented goals, with inherent checks and balances on spending. Our real-world system is, alas, far from that – it is deranged.

First published on on June 17, 2013

I’m going to dodge the “American” part and go global. I’m doing that because researchers have very carefully documented what the absolute worst disease in the entire world is.

Can you guess?

It’s hypertension.

And this means that you should slash your salt intake.

Hypertension, also known as “high blood pressure,” is today the leading risk factor for death on planet earth, according to the gigantic Global Burden of Disease Study, published last December.

This finding is related to diet because hypertension is a new disease for human beings. Studies in the 20th century showed that humans living in undeveloped, primitive societies simply did not get hypertension, nor even the mild age-related rise in blood pressure that your doctor would label “normal.”

With the coming of civilization, however, blood pressures rise, because salt intake rises. Salt is the sine qua non of food preservation, which is itself a signal characteristic of civilized life that appears much earlier than automobiles or drops in physical exercise.

Modern medicine is still debating the benefits of salt-restricted diets. I suspect that one reason is because even highly restricted diets today are still much saltier than our stone age physiology is tuned for. I do not think it’s too much of an exaggeration to say that one restaurant meal in America will give you more salt than your ancestors 200 generations ago ate in a month.

And, of course, salt is a fellow traveller with fat in today’s diets, so drastically cutting salt will likely cut your fat intake as well – also a good thing. The dangers of excess calories are not news to anyone.

NB: If you have high blood pressure, please take your pills. You can work on dietary changes once the pressure is well controlled.