rahul k. parikh's Open Salon Blog

Huffington Post Health Watch: Dr. Dean Ornish's Infomercial

Sun, 8 Nov 2009 09:11:11 -0500

Dr. Dean Ornish seems to be getting too much inspiration from other Huffington Post Living Section bloggers, who appear on the site when they need to promote themselves and their friends.

In what can be described as nothing other than an informercial, Ornish, the Post's Medical Editor, posted "Sharecare Builds a Web 3.0 Bridge to Better Health." In it, Ornish basically talks up a venture that he seems to believe is a cutting edge idea: a website that offers health advice and information to patients.

You can read the ad if you have the stomach for such blatant press self-promotion. Basically, Ornish describes joining forces with the likes of Oprah's Dr. Oz and Deepak Chopra to provide expert advice. In addition:

"Sharecare will include many points of view from people who have similar interests, concerns, and experiences. Peer to peer social networking functions will allow users to talk with one another about common issues, problems and successes within the context of expert content. Being able to communicate directly with others who have gone through the experience of illness not only gives different perspectives but also provides a level of compassion, empathy, intimacy, and shared strength that is itself healing."

Of course, Ornish doesn't exactly describe what he means by "web 3.0." Does he mean social networking and support groups? That's web 1.0-2.0. Revolution Health, founded by former AOL head Steve Case, has been at it for years now.

It's not clear how anybody--whether it be readers, other HuffPo editors, or those who pay for legitimate advertising on the site--can find Ornish's post credible or newsworthy. If anybody at the Post took their journalistic responsibilities seriously, or cared about the information they were peddling to patients looking for serious health answers, then Ornish would probably have been reprimanded for abusing his authority the minute he posted this.

"No one has a monopoly on truth," Ornish ads.

Indeed. So here's the truth for Arianna and company: Ornish's post is a vacuous-self-congratulatory-cliche-littered-plug, one that promotes a venture based on a recycled idea.

The only thing missing is where to mail your check (or does "web 3.0" use PayPal?)

Medical Malpractice Revisited on NPR

Wed, 4 Nov 2009 23:11:56 -0500

I appeared on NPR's Talk of the Nation last Monday to discuss my Salon article on medical malpractice reform. To no surprise, I was on hot seat in the virtual doctor's lounge, as physicians called in with their concerns--and gripes--about my point of view that tort reform will not solve America's health care problems.

I have a few thoughts about the interview, especially about those who called in. First, all three were doctors, and reflected on cases from their experience and point of view.

But medical malpractice is a patients' rights issue as well. The discussion may have been more provocative had we heard from someone who had been injured due to physician negligence. Then, we may have seen how hard it can be to seek redress. Here in California, for example, we have one of the oldest laws capping malpractice payouts at $250,000. The figure hasn't changed since the mid-1970s when the caps were enacted, despite the obvious rise in inflation and the cost of living. That often leaves an injured victim with very little recourse because the cost of fighting for compensation exceeds the payout. So while caps may prevent frivolous suits, they also make it harder for a patient to hold a doctor accountable. For an example of this, listen to my story at the end of the NPR segment or read it here.

Second is the issue of defensive medicine. The callers, and most other doctors, argue they practice defensive medicine to prevent being sued. Consider the comments by one particular caller:

"I think doctors are afraid of being sued, whether they're going to be sued for $20 or $2 million. But the question is, are these cases going to be tried by a jury of inner city people who sympathize more with patients than with the doctors, or are these cases going to be tried in front of professionals who understand the cases?

I think, you know, any data that you have, I completely - I can't possibly think applies to my practice or my husband's practice or what I'm seeing. Every doctor, every day, practices defensive medicine. There's no doubt about it. And I think it's ridiculous that it's not more of an issue in the health care litigation - or health care legislation that's before Congress right now. It should be..."

Let's look at the caller's main points: One, defensive medicine is practiced every day by doctors. Two, that tort reform should be a big part of health care reform due to the impact of defensive medicine on costs.

No doubt we practice defensive medicine. The question is whether tort reform is the cure for it and therefore, a key to lowering health care costs.

The short answer is no. You can look at my references in the Salon article, but let's take another example. I practice in Walnut Creek, Ca, and the caller who made the comments above practices in Baltimore, Md. As I said we have malpractice caps here, as does Maryland. If you believe the caller is right, then health care spending should be lower in both areas where we practice.

But take look at health care spending in both areas, as measured the by the Dartmouth Atlas of Healthcare. What you'll see is that both my county (Contra Costa) in Northern California and Baltimore have very high health care costs (darker green on the map). There are certainly many other factors that account for costs in both areas, to be sure. But there is no effect of caps in curbing spending seems in either area.

That leads to my last point--we doctors don't practice defensive medicine just to protect ourselves from lawsuits. If we did, then the caps would have done the trick.

That means that are a whole host of other reasons we play defense, ones that tort reformers never mention, and ones that have nothing to do with fear of litigation. One of those reasons is profit: in fee-for-service medicine, more tests and referrals mean more revenue for you and your specialist colleagues down the street. Another reason is time pressure: many times, doctors don't have the time to sit down with their patients and get a good history of their illness. Ordering tests saves time and allows us to move onto the next patient. Finally, there's customer service: many of us believe that our patients want more, and so to please them, we prescribe and refer more. Tort reform won't impact any of these reasons for playing defense.

Health Reform Should Be About More Than Money

Wed, 7 Oct 2009 10:10:15 -0400

There is plenty to criticize in our bungling trek toward health reform. Leaders on the right, left and at 1600 Pennsylvania Avenue have sidestepped the crucial conversation of controlling the cost of care, in favor of partisan rhetoric about "death panels" and "rationing care." Worse, the entire focus of reform has centered on spending billions of dollars on technology solutions that will only make marginal changes in the cost and quality of care Americans get.

I want to refocus the debate on what matters most: relationships. Let's reinvest in the sitting down with, listening to, empathizing with and touching patients.

America has the most advanced healthcare system in the world. But in our haste to research, develop and invest in high-tech medicine, we have lost sight of the very basics of good doctoring. The first things we learn in medical school are: ask, listen and touch. Doctors do not do enough of this any more.

As has been made painfully clear, most doctors are rewarded for doing all manner of procedures. This is true from the earliest moments of our career . As a resident, even when faced with the most basic medical problems, I was grilled by my attending when I didn't order the full battery of tests, or contact all the specialists available to consult on a patient. Thus, over-testing and over-treating becomes a knee-jerk response from the get go.

This is how doctors practice medicine today. Some of us do it this way because it's how we get paid. Some of us refer our patients to specialists because we don't have time to sit down with them ourselves. Some of us rely on tests and procedures because we're fearful of malpractice lawsuits. And most of us have just lost sight of the most powerful tools in the doctor's arsenal: our hands and our minds.

I'll illustrate this with an example. Once while still a medical student, author Dr. Sandeep Jauhar evaluated a man with chest pain whose lab tests and EKG suggested he was having a heart attack. The patient was admitted to the ICU. Hours later, the patient was in severe pain and his blood pressure had dropped. The resident in charge ordered another EKG and prepared to intubate and place a central line in the patient.

In the midst of this, Jauhar took the patient's blood pressure. For reasons then unclear to him, the resident instructed Jauhar to repeat the exercise -- on the patient's other arm. Jauhar tried, but above the din of beeping monitors and barking doctors, he couldn't hear the pulsing sounds through his stethoscope. Jauhar "shrugged and let it go."

Sometime in the night, the patient underwent a CT scan. The next morning Jauhar learned his patient hadn't suffered a heart attack, after all. Instead, it was an aortic dissection - a tear in the wall of his aorta, leading to severe internal bleeding. Worse, with the time lost to the misdiagnosis, the dissection was now inoperable. The patient died later that day.

I use this example because the diagnosis ultimately confirmed by a $1,000 high-tech CT scan would have been evident from the low-tech hands-on procedure Jauhar shrugged-off. A discrepancy in blood pressures between the right and left arm is a classic indicator of aortic dissection, and easily distinguishes the condition from a heart attack.

Consider that a blood pressure cuff costs just a few dollars, compared with the hundreds of thousands of dollars in sophisticated ICU and ER equipment that the medical team employed trying to solve the riddle of the patient's condition. These same high tech tests and procedures also led the medical team down the wrong path. So much for the certainty we believe technology gives us.

If Jauhar had employed the basics of physical exam might the patient have lived? Possibly. In my own recent experience, I saw a young boy whose mother told me he seemed to be clumsier than other children his age. She had mentioned this to previous doctors, as well. When I examined him, I noted very brisk reflexes and an unusual flapping motion in his feet. This is called ankle clonus. I referred the mother to a pediatric neurologist. I learned shortly thereafter that her son wasn't just clumsy. He has cerebral palsy. This is a diagnosis that must be made clinically; oftentimes an MRI or a CT scan cannot detect CP because there are no discrete visible findings. The happy ending is that physical and occupational therapy can ameliorate the boy's symptoms.

My point is that not all of the system's ills can be solved with high technology - nor should they be. If you believe that reforming health care is essential for our country's future - and if you're at all mindful of our fiscal state -- then you've got to be open to other strategies besides throwing billions of dollars at the problem.

We can start by leveraging the basics. For doctors like me, this means re-learning value of the patient history and the head to toe physical exam. It means weaning ourselves off our dependence on technology, tests and procedures.

In a better system, doctors won't be rewarded for doing everything. Instead, they will be rewarded for doing the right things. They'll use their heads and hands to decide how to spend our healthcare dollars - and I can promise you they'll spend less of them in the process.

This is how we could do it. This is how we should do it. Simply by re-prioritizing medicine's hands-on basics we can make great strides toward improving healthcare, without spending a dime on more technology.

Regina Holliday & The Art of Health Reform

Tue, 29 Sep 2009 10:09:28 -0400

If you want to get insights into the problems of our health care system, you should certainly listen to policy makers like Peter Orzag, browse economist Uwe Rhinehardt's blog, or read Atul Gawande's recent article in the New Yorker.

But you should also look at a mural by Washington DC resident Regina Holliday. Holliday is a 37-year old mother of two and an art teacher. Last summer, her husband, Fred, died from kidney cancer at the age of 39. The Hollidays' experience is a case study in the ugliest, most festering problems of American health care. To share that horror story and to advocate for change, she began painting a portrait of a health care system that is fragmented and insensitive. It is a system where caregivers like Regina have to unfairly shoulder many bureaucratic burdens and one that needs to treat people better than the way it did her husband.

The Death of Fred Holliday:

Regina stated her story by telling me about what happened to her husband. Fred Holliday developed the early symptoms of his disease-fatigue, weight loss and occasional blood in his urine-before he had health insurance. In late 2008, his insurance kicked in after he got a job at American University teaching film studies. Last January, he developed low back pain. He went to see his doctor multiple times. Each time, she prescribed pain medication, but his pain worsened. Regina wondered: if Fred just had muscle pain, then why the night sweats? Why the blood tinged urine? Why didn't his clothes fit him anymore? Still, Fred's doctor didn't reconsider her diagnosis and treatment.

His pain worsened. In March, Regina demanded more. Fred's doctor ordered an MRI of his back. Three days later, they got a call telling them that he had "shadowing over his kidneys." What that meant wasn't entirely clear, but the next thing Fred and Regina knew, they were in the office of a Maryland oncologist, who admitted them to Holy Cross Hospital in Silver Spring for further tests.

On Friday, March 27 around 11 am, Regina was at work when Fred called. He was crying. "I think the doctor just told me I have cancer," he managed to tell her.

What exactly did the doctor say? Fred remembered being told that he had a growth on his kidneys. Regina rushed into see the doctor, but he had left town for the weekend. They had to wait until the next day before another doctor (not an oncologist) tried to clarify his diagnosis: it looked like he had stage IV metastatic renal cell carcinoma. That jumble of words didn't make any sense. Regina went onto the Internet. Wikipedia turned out to be more helpful than Fred's doctors.

When their oncologist returned, he was curt and often distracted by his cell phone. He didn't like Regina's detailed questions, telling Fred that, "If Miss type-A personality wants me to answer her questions, she can come to my office hours."

In retrospect, Regina believes that if Fred's doctor had been clear about his prognosis from the beginning, he may have made the decision to stop fighting sooner. Instead, he informed him of how he could fight: surgeries, radiation, and chemotherapy. So he decided he needed more advanced care than what Holy Cross could provide.

Patient transfers between hospitals are normally the responsibility of doctors who work there. Holy Cross doctors, however, told her they had not been able to find another center willing to accept him. So Regina contacted her own internist, who sat on the board of directors at Suburban Hospital in Bethesda. After hearing Fred's story, he pulled strings and arranged a transfer.

The Hollidays arrived at Suburban four weeks after Fred's diagnosis. The first thing they learned was that he needed surgery to repair a broken hip-which happened after an orderly at Holy Cross bumped him into a wall while he was moving Fred on a gurney. Fred had been complaining of severe hip pain for two weeks, but nobody at Holy Cross had followed up on it. All it would have taken was the x-ray he got when he came to Suburban.

After surgery, his new oncologist ordered a chemotherapy drug called Sutent. While his health insurer approved the drug, Fred's doctor told Regina that the pharmacy refused to order it. At $40,000 for a 28 day supply, it was too expensive. "Sometimes this happens," Fred's doctor told her. So Regina had the drug mailed home, picked it up, tucked it safely into a fanny pack, and dispensed a dose to her husband each day.

Fred's cancer advanced. He still couldn't walk. He had become incontinent. The doctors decided to transfer him to a rehabilitation center with the goal of getting him to walk again. Once he was there, Regina's duties as his caregiver intensified. She learned where the center's storage closets were so she could collect fresh sheets and change them herself. She emptied his trash, and changed and disposed of his bedpans.

While he was in the hospital, Fred required blood transfusions every 10-14 days. Regina knew when he needed them because he would begin to get very tired, eat, move, and talk less. One afternoon, this is just what happened. At Surburban Hospital, it was easy to ask the nurse to get a blood test to know just how low his counts were. In the rehab center, they only did blood tests once every morning, no exceptions. So Fred suffered until morning came and his test confirmed what he and Regina knew the day before.

Fred would have to be re-hospitalized. The nearest one was, literally, across the parking lot from where he was. But rules and regulations prevented an employee from wheeling him over on a gurney. So Regina picked up the phone and arranged for an ambulance to take him across that parking lot. To accomplish this, she had to beg the rehab staff there to provide her with the proper medical records so the hospital would take Fred.

Fred continued to deteriorate. It quickly became a question of how much longer to fight. On May 19th, he was moved to hospice care to get his pain under control and on June 11th, he went home. On June 17th, less than three months after he was diagnosed with cancer, Fred Holliday died at home. Ironically, this was the same day that the United States Senate began debating health care reform.

Turn onto Connecticut Ave, Not Pennsylvania Ave

These days you'll find Regina Holliday on NW Connecticut Ave, painting her mural on the side of a gas station across from a CVS Pharmacy and near Politics and Prose bookstore. It's called 73 Cents, named after the price patients have to pay to obtain copies of their medical records--$0.73 per page.

My colleague, Dr. Ted Eytan, recently took some photos of 73 Cents and posted them on Flickr. At the center of photo is Fred Holliday lying sick-a note in his hand that's telling Regina to "go after them" when he was at Holy Cross, after doctors wanted to send him home.

In front of Fred is Regina. She has two faces: the bright one of the caring, loving wife juxtaposed against the ashen one of the exhausted, frantic caregiver. She is secretly grabbing medical records from the nurse standing at his bedside. That nurse is looking at a blank computer screen, symbolic of a closed information loop of each hospital, which prevents doctors from sharing information freely. In contrast, a computer behind Fred in another room is being used by a nurse not to provide care, but rather to surf a social networking site, like Facebook.

In the far right corner of the mural sits a family friend, the one visitor who came to see Fred. The extra space between figures in the painting is something Holliday did on purpose-distance is a medical motif, be it strict visiting hours for family or the masks, gloves and gowns providers to prevent infections. Central to that theme is Fred's doctor, his first oncologist, who keeps physical distance as he stands near the foot, and not the head of the bed, and that cell phone glued to his ear. His cold countenance-which nurses who work with him tell Regina she got just right-captures is emotional distance as well.

Symbols abound in the picture-one that stands out is the little girl dressed in the Stars and Stripes holding the caduceus staff. Holliday told me that she represents the status quo and the fear of change-exemplified in the real work by angry town hall meetings and anti-reform rallies that demand we protect Medicare, yet rail against a government takeover of medicine.

73 Cents is compelling advocacy, the exact opposite of what we've seen from our leaders over on Pennsylvania Ave. Regina Holliday isn't sure whether her story and her mural will move the rudders in our National Debate over health care. She told me a few people have screamed at her over her art. She's also had many fans, including Howard Dean, who reportedly came over and admired it. Regina's work has also persuaded a few angry but more civil folks opposed to reform to look, think and chat with her. An eye-opening but civil dialogue about health care-now there's an accomplishment Regina Holliday should get credit for.

What does Joe Wilson really believe about health care?

Mon, 14 Sep 2009 20:09:18 -0400

Like most people, I had never heard of Joe Wilson until his angry outburst in the biggest town hall of them all, the U.S. Congress. Unfortunately for him, it's hard to see Wilson beyond anything other than a symbol of everything that's wrong with modern American political life.

Still--to be fair to Wilson--we ought to take a look at his record on health care:

Wilson does have some official positions on health care you can find at Project Vote Smart. What we find is nothing short of a legislator who toes his party's line. Among his positions are his support for health savings accounts, the right to purchase insurance across state lines to increase competition, medical malpractice reform, and increasing the use of information technology in health care:

Wilson, like most of his Republican colleagues, voted against expansion of health care for kids (SCHIP) and for expansion of health care for seniors (Medicare). He voted against a 2007 bill that would have given the government the power to negotiate lower drug prices with pharmaceutical companies. He also voted for medical malpractice liability reform.

Finally, in recent comments on the floor of the House, Wilson noted his second largest contribution to current reform efforts (the first being his temper tantrum last week):

"During consideration of the over 1,000-page bill in the Education and Labor Committee, I successfully got an amendment passed that would provide that Congress Members who vote in favor of government-run health care would enroll in the plan themselves. The American people should monitor that this provision is kept in the bill."

In his speeches on the house, Wilson rails against a government takeover of health care over and over again. Yet Wilson himself voted for the biggest government entitlement this generation has seen--the Medicare Modernization Act. Ironically, Section 1011 of that bill authorized $250,000 annually to reimburse hospitals for treatment of illegal immigrants.