Fear of litigation

It has long been known that hospital emergency rooms are one of the most expensive places to receive care. There are many reasons why this is so, but the main factor is the inherent nature of emergency care: fast-paced and resource-intensive, with everything to lose if a potentially lethal illness or injury is somehow overlooked or misdiagnosed.

The pressure to overtest and overtreat is enormous, as an Associated Press story recently explained:

The fear of missing something weighs heavily on every doctor’s mind. But the stakes are highest in the ER, and that fear often leads to extra blood tests and imaging scans for what may be harmless chest pains, run-of-the-mill head bumps, and non-threatening stomachaches.

Many ER doctors say the No. 1 reason is fear of malpractice lawsuits. "It has everything to do with it," said Dr. Angela Gardner, president of the American College of Emergency Physicians.

The fast ER pace plays a role, too: It’s much quicker to order a test than to ask a patient lots of questions to make sure that test is really needed.

If you haven’t been following the Associated Press’s "Overtreated" series, I’d urge you to do so. Besides tackling the overall mindset that "more is better," the various installments in the series have addressed back pain, cancer screening, medical imaging and end-of-life care. You also can find a great multimedia interactive tool here.

The concept of overtreatment isn’t something many Americans are accustomed to talking about. Although it’s easy to blame physicians for ordering too many expensive tests or prescribing too many expensive drugs, the fact is that consumers share some of the responsibility. As the AP story points out, patients’ expectations are often high:

Many think every ache and pain deserves a high-tech test.

"Our society puts more weight on technology than on physical exams," Gardner said. "In other words, why would you believe a doctor who only examines you when you can get an X-ray that can tell something for sure?"

Refusing those demands creates unhappy patients. And concern that unhappy patients will sue remains the elephant in the emergency room.

In light of this, it was interesting to come across a newly released study in the Archives of Internal Medicine that found nine in 10 physicians who responded to a survey believed doctors overtest and overtreat to protect themselves from being sued. The survey involved more than 1,200 physicians nationwide and included emergency-room doctors, primary care doctors and surgeons. The vast majority of the physicians who were surveyed said they believed it would help decrease unnecessary testing if physicians didn’t have to fear unwarranted accusations of malpractice.

What we have here is a standoff: fear of litigation and a long-standing philosophy that more medicine is better medicine vs. valid concerns about the cost and potential harms of overtreatment. Until we figure out how to reconcile these opposing beliefs, bringing down the cost of health care in the U.S. will likely continue to be an uphill battle.

The social mission of medical schools

Few would argue that it’s the mission of medical schools in the U.S. to produce trained and qualified physicians who can provide needed health care to the American population. But do medical schools have social responsibilities that go beyond this basic mission? Is it also their duty to help meet the need for primary care doctors? Should they be working to help increase the number of minority physicians and the number of physicians in underserved areas?

An intriguing report, published this month in the Annals of Internal Medicine, takes a look at how medical schools stack up on this issue and concludes that not all institutions are equal:

The contribution of medical schools to the social mission of medical education varied substantially. Three historically black colleges had the highest social mission rankings. Public and community-based medical schools had higher social mission scores than private and non-community-based schools. National Institutes of Health funding was inversely associated with social mission scores. Medical schools in the northeastern United States and in more urban areas were less likely to produce primary care physicians and physicians who practice in underserved areas.

Social mission scores were calculated on the basis of data on medical school graduates from 1999 to 2001. The researchers analyzed information such as race and ethnicity, practice location and the percentage of primary care graduates at each medical school, then came up with rankings for 141 allopathic and osteopathic medical schools in the U.S.

Surprise, surprise: Elite Ivy-League and research-oriented schools such as Johns Hopkins and Harvard Medical School fell near the bottom of the list, while lesser-known colleges – Morehouse College in Georgia, Meharry Medical College in Tennessee and Howard University in Washington, D.C., ranked at the top.

Where does the University of Minnesota – a large research institution with an urban campus in Minneapolis and a smaller campus in Duluth – fit into these rankings? Good question. The U of M Medical School was among the top 25 percent of large research institutions in preparing physicians for primary care. The U also was in the top 25 percent for its overall social mission.

The U is among a handful of the larger, research-focused schools that seem to defy the trend, the study’s authors note: “These findings invite questions about what factors influence graduates of these schools to choose primary care and whether those influences might be transferable to other schools.”

It’s one of the first times I’ve seen this kind of data-based analysis to examine how medical schools fare at meeting what could be defined as their responsibility toward society. To be sure, social mission is only one aspect of medical training. It’s also important to prepare physicians for specialties and for research and academia.

The study points out, however, that medical schools cannot afford to shirk their social mission:

Evidence increasingly shows that primary care is associated with improved quality of care and decreased medical costs. However, an insufficient number of primary care physicians has hampered efforts to provide expanded health care access in states, such as Massachusetts, and business groups and insurers have begun to speak out about the need for increased access to primary care.

Rural communities have a chronic shortage of physicians, and federally supported community health centers report major deficits in physician recruitment. African-American, Hispanic and Native-American physicians continue to be severely underrepresented in the U.S. workforce.

The report also takes aim at the prestige factor, noting that national rankings of medical schools “often value research funding, school reputation and student selectivity factors over the actual educational output of each school, particularly regarding the number of graduates who enter primary care, practice in underserved areas, and are underrepresented minorities.”

The authors of the study conclude, “Some schools may choose other priorities, but in this time of national reconsideration, it seems appropriate that all schools examine their educational commitment regarding the service needs of their states and the nation.”

Predictably, the study has been met with negative reaction. “Political correctness and social missions have now invaded the world of measuring ‘quality’ in medical schools,” a commenter lamented online at the Chronicle of Higher Education. A statement issued by the American Association of Medical Colleges concludes the study “falls short” by defining the role of medical schools too narrowly.

An interview with one of the study’s authors, Dr. Candice Chen of the George Washington School of Public Health and Health Services, sheds more light on how the social-mission rankings can be viewed. Research is important but social mission needs to be valued as well, she argues:

… Medical schools have to play their role too. They have to maximize those changes. And medical schools can make a difference. They can make a difference in terms of their recruitment and admissions practices. They can make a difference in terms of their curriculum. And just in the very culture that they support. Unfortunately, there are schools out there that have no family medicine department, and it’s hard to imagine that a student is going to pick family medicine when they’re not being exposed to a family medicine department within the school. There are definitely things that schools can do, and we look at it as things have to happen across the continuum.

Is this just an academic discussion of no real interest to the public? I don’t think so. Aside from the fact that tax dollars are helping subsidize part of the medical education system, communities have a stake here too. This is a discussion that has been long overdue and should be welcomed, controversy and all.

Photo: Harvard Medical School, courtesy of Wikimedia Commons

On the night shift

The daily demands at a hospital never truly slow down, not even at night. If you’re a hospitalized patient, nighttime can in fact be one of the riskiest times in the entire 24 hours that make up a day.

The hazards of the night shift came under scrutiny yesterday after a spokesperson for Twin Cities hospitals, which are engaged in contentious labor negotiations with their registered nurses, was quoted as saying patients just “sleep” through the night shift.

Putting aside the overheated atmosphere that accompanies labor disputes, there’s actually a sizable body of evidence that nights are one of the most vulnerable times when it comes to patient safety.

Even though the level of hospital activity – scheduled surgeries, lab and imaging tests, discharge planning – tends to wind down at the end of the day, patients are still sick and in need of care. Babies are still being born. Patients are still showing up in the emergency room. A child’s or elderly person’s condition can crash regardless of what hour of the day it is. The nurses who are managing all of this are fewer in number than during the daytime and often have less access to back-up help from other professionals.

A Wall Street Journal article that appeared a couple of years ago suggested it gives whole new meaning to the term “graveyard shift”:

The risks of seeking after-hour care are well documented. Recent studies show higher death rates for patients who arrive at the hospital with strokes after hours. This is also the case for patients who have a cardiac arrest when they are already in the hospital. And Stanford University researchers who examined close to five million hospital admissions in three states reported [in 2007] that rates of complications are significantly higher on weekends for surgeries including vascular procedures and obstetrical trauma during cesarean sections.

One study that looked at emergency-room nurses who worked the night shift found they were often sleep-deprived, which impaired their performance and made them less likely to catch medication errors or detect signs of deterioration in a patient’s condition. Fatigue is well established as a risk factor for medical error, not only among nurses but among physicians as well – and the stakes are huge, as a blogger with the Joint Commission describes:

If I come to work tired, worn out, stressed out, or a bit under the weather, it’s unlikely that anyone would get hurt. Sure, I might make a mistake, but chances are I will have a chance to correct it before the public sees it.

For health care providers, matters are different. An “off day” can have a long-term impact on a patient’s life and health. Fatigue poses a serious threat to patient safety and impairs human performance.

There’s been a lot of research on how to make night shifts easier for health care workers to handle. Working a permanent night shift vs. a rotating shifts seems to help; allowing nurses to take short naps during their shift at night also is thought to be helpful.

But working a night shift is hard on the human body, period. Health care workers do it because it comes with the territory. Even when all their patients are supposed to be sleeping, the need to provide care around the clock never rests.

Photo: Wikimedia Commons

On a technical note…

… changes are ahead. At some point in the next few weeks, Forum Communications is moving all its Area Voices blogs, including this one, to the WordPress platform. This blog will look different. It will probably have a new URL as well. I’m told that older postings will continue to be accessible one way or another.

That’s all I know for now. I’ll update readers when I get more information.

The pet prescription

Six dogs, three months, 50 visits. Those are the statistics from January through March of this year for the new pet therapy program offered by Rice Hospice. The numbers will probably grow, now that 15 more volunteer dogs and handlers recently completed their training. (That’s Jade in the picture above; doesn’t she look like a wonderful dog?)

The value of companion animals to human physical and emotional health is well accepted these days. Oh, sure, there are a few hard-hearted wretches skeptics out there who are impervious to the joys that can be wrought by a pet, but for the most part pet therapy is considered pretty much in the mainstream.

It can be easy to forget that for many years, animals were not welcome in health care settings. They were considered hairy, germy, rambunctious and unpredictable. Gradually, however, most of these barriers have been overcome. Protocols have been established for safely bringing animals into hospitals on visits, allowing them to live in nursing homes, and using them as a furry form of therapy with patients young and old. A healthy, well-behaved pet who’s supervised by his handler is now regarded as a benefit rather than a potential liability.

It says something about the human-animal bond to see so many people volunteer for the Rice Hospice pet therapy program. The program isn’t even a year old yet, but already it has 21 dogs and handlers plus a waiting list.

Not everyone makes the cut. Some dogs are weeded out during a preliminary round of temperament testing. The dogs must be able to pass both the AKC Canine Good Citizen test and a Therapy Dogs Inc. three-day training workshop that includes on-site observation of the dog and handler with residents at local nursing homes. Only if they pass all these hurdles can they officially be registered as a therapy dog. As for the handlers, they not only must be able to work successfully with their dog but they also have to undergo training of their own – 12 hours of Rice Hospice volunteer training and another four hours of general hospital volunteer training.

It’s clearly a substantial commitment, and it doesn’t end with the initial training. Each year additional training will be required to ensure the dogs and their handlers are still up to snuff.

These volunteers are doing this because they want to, and because they believe it will make a difference for someone. Many things in medicine can be costly, unpleasant or painful for the patient, and might not ultimately confer any benefit. Not so with pet therapy, which is about as straightforward as it comes.

The folks at Rice Hospice have waited a long time to be able to offer this program. Now they finally can, and it’s a real addition to how the community cares for dying patients and their families.

West Central Tribune photo by Ron Adams

The perils of the hand-off

One of the more vulnerable places on the health care continuum is the point at which patients make the transition from one provider to another – switching from the daytime staff to the night shift at the hospital, for instance, or leaving the hospital to go home or to a skilled nursing facility.

It’s known as The Hand-Off, and it’s a time when things can frequently go wrong. Sometimes important information isn’t communicated, or incorrect assumptions are made. Sometimes there’s simply a failure to think far enough ahead to anticipate potential problems.

One of the latest case studies posted on the Agency for Healthcare Research and Quality’s online morbidity and mortality rounds illustrates how easy it can be for a transition in patient care to go awry.

An anesthesiologist has trouble removing a spinal drain from a patient who has undergone surgery. After consulting with a neurosurgeon, it’s agreed to remove the catheter under general anesthesia in the operating room. But this information isn’t passed on to the anesthesiologist who is on call for the night, nor does the anesthesiologist look at the patient’s chart. Instead, she attempts to remove the spinal drain in the preoperative area while the patient is awake. The catheter breaks, leaving a portion inside the patient and necessitating surgery to remove it.

Could this have been prevented? There were probably several steps that could have been taken to ensure better communication, the case reviewers concluded:

Fundamentally, handoffs should become a sacred ritual, as common as the checklist in a cockpit, in which the incoming provider also asks questions to elicit potentially undocumented or unusual circumstances. The basic question should be: “Is there anything unusual I need to know about this patient or procedure or what’s going on currently that might impact what I do or how I do it?” This sounds so simple. But when things generally go well, and when production pressure is routine, providers can become complacent about risks.

Achieving a smooth hand-off is harder than it looks. A couple of years ago the Harvard Risk Management Foundation devoted an entire issue of its quarterly patient safety publication to the pitfalls of the handover and strategies to help make it safer.

One particular form of the handover – discharge from the hospital – is getting a lot of attention these days. Hospital readmissions have become a big deal, not only for their cost but also for their impact on patients. Increasingly, readmission rates are being viewed as a key indicator of quality of care. Just last week, the New Jersey Hospital Association announced a year-long, statewide initiative to reduce the number of patients with congestive heart failure who are readmitted to the hospital within 30 days.

Obviously there are multiple reasons why someone might end up back in the hospital, and a certain number of readmissions are probably inevitable. There could likely be fewer of them, however, if there were a better hand-off process at the time of discharge.

Patients and families might think they have little influence over the handover but they’d be wrong. There are a lot of things they can do, starting with being more assertive and involved. An article last week in the New York Times lays out some of the tactics, including the need to take charge:

In the hospital, multiple people may have been involved in supervising a patient’s care: a surgeon, a nurse, an attending fellow and a discharge planner.

That means it’s up to patients and their advocates to make sure discharge plans are sound and to challenge any information that doesn’t add up.

(I’d add that while most of the discussion about discharge planning and handovers centers on elderly patients, you don’t have to be old to fall through the cracks during a hospital hand-off; young patients can get into trouble too with a hand-off that’s perfunctory or incomplete.)

Unfortunately, many people are unaware of the perils of the hand-off – unaware, that is, until they or someone in their family is hospitalized and things deteriorate because of a badly managed transition. It’s a tough lesson that perhaps hasn’t been emphasized for consumers as much as it should be. When people know transitions in care are an important and vulnerable time, they can be better prepared to help make the handover go more smoothly.

Fill out your disability form? That’ll be $25, please

If you can’t get by on the fees you collect for providing a service, start tacking on extra charges: $25 for the paperwork, $10 for the administrative overhead, $5 for copies of documents, another $25 for retrieval of said documents, etc. etc. etc.

Businesses and government do it all the time. Now the concept is being adopted by doctors as well. The practice doesn’t appear to be widespread, but according to a recent article in USA Today, it’s starting to look more and more attractive to physicians who can’t make ends meet on insurance reimbursement alone. From the article:

The extra payments include no-show fees of $30-$50 for missed appointments, widely varying charges for filling out health forms for school, work and athletic teams, and annual administrative fees of $30-$120 or more to simply be a patient in some practices, medical associations and doctors say.

"It’s not unlike the airlines," said William Jessee, president of the Medical Group Management Association, which generally advises against extra fees that may anger patients or run afoul of insurance contracts. "They’ve gone from all-inclusive to a la carte. That’s what you’re seeing with physicians."

Doctors who charge extra fees are in the minority, he said. Some have done it for years, but more are joining them because they say they need the fees to offset the rising costs of practicing medicine.

Is it fair or reasonable to charge extra? Or are services such as filling out forms and refilling prescriptions just part of the doctor’s cost of doing business?

An Atlanta mom has to fork over $10 every time the family pediatrician fills out a form, and she doesn’t like it. "It’s part of their job," she told USA Today.

Judging from the 800-some comments posted by readers in reaction to the story, there’s a lot of resentment over the concept. "Any doctor that tacks on fees will not be getting my business," one person wrote. "They are just greedy theives (sic). And on top of it they are whining greedy theives (sic)," fumed someone else.

Grousing aside, it’s valid for people to ask where the line should be drawn between the normal cost of doing business vs. uncompensated burden. A teacher who commented at USA Today wondered, "Should I be compensated extra for my student-teacher conferences? Or for having to fill out forms regarding a child’s poor behavior? What about the extra hassle of speaking on the phone with a parent who is worried about their child? Isn’t this all ‘administrative’ stuff?? Yes, but it comes with the territory."

From the physician’s point of view, though, it’s becoming increasingly difficult to stay solvent while managing the flood of unreimbursed paperwork. Dr. Toni Brayer lamented the situation in a guest post at Kevin, MD:

As a physician who has practiced for over 20 years, I can tell you that the demands of filling out forms for everything from work questions and school physicals to handicapped stickers and travel vouchers, dealing with insurance companies, reviewing tests ordered by other doctors, overseeing and coordinating patient care, talking with pharmacists, filling prescriptions and then redoing the work when a patient switches pharmacies, e-mailing and countless other tasks that are "free" make it near impossible to remain in private practice.

If health care was like other industries, it could simply raise its prices to cover the increased cost of doing business, or drop services that don’t pay for themselves. But health care doesn’t function like other businesses. For one thing, there’s limited room for negotiating reimbursement rates with third-party payers. In the case of Medicare, there’s no negotiation; providers either have to accept what Medicare is willing to pay them or opt out of Medicare altogether. For another, insurance contracts usually place restrictions on charging extra for services already deemed to be covered. In view of the fact that physicians only make money by seeing patients and/or doing procedures, administrative fees are one of the few viable options left for bringing in more revenue to subsidize their overhead costs.

I personally wouldn’t mind paying extra fees, as long as they were reasonable. (And I’m gonna add here that doctors aren’t alone in disliking all the forms they have to fill out on behalf of patients; most patients don’t like it either.) There are patients, though, who won’t be able to afford the extra fees – what then? And does it make sense to add more spending to a health care system that already consumes billions of dollars each year?

The irony in all of this is that it’s not doctors and patients who are the real problem. The real problem lies in how physicians are paid and how third-party payers set their reimbursement rates. If both these things could be changed, the burden for physician practices might be eased and administrative fees would no longer be necessary. As usual, though, doctors and patients are paying the price for the brokenness of the health care system, and until there’s a substantive fix, add-ons such as extra fees constitute little more than a Band-Aid.

The online sport of provider-bashing

I belong to an online community where the hot topic last week was doctor-bashing – more specifically, whether it’s OK to name names when patients are criticizing an individual physician or institution.

The discussion started innocently enough with a posting from someone who wasn’t happy with the care a relative received at a large hospital somewhere on the East Coast. Then things escalated. Accusations were made about only telling one side of the story. Names were named. Folks got angry. A moderator stepped in and started editing names out of posts, resulting in cries of censorship.

I’m not sure the argument was resolved to anyone’s satisfaction. But it points to a thorny modern-day issue: the use of online forums to exchange recommendations (or warnings) about individual providers and the ethics of truth-telling vs. smear campaigns.

It seems to be human behavior to compare notes about health care providers. Even the Neanderthals probably sat around the fire and griped about the caveside manner of their local shaman. To the degree that interactions with a health care provider often are highly individual and tend to be colored by emotion, it’s logical that people would want to know if others have had the same experience. Similar experiences can help validate people’s perceptions that Dr. X or Hospital Z is [insert failing of your choice].

It’s one thing, though, to grouse among a small circle of friends and family, and quite another to broadcast your dissatisfaction online where the whole world can see.

There are plenty of Internet forums where this takes place. At RateMDs.com, you can see the good, the bad and the ugly – mostly neutral to good reviews but also more than a few that are negative and even scathing. Healthcare Scoop, a Minnesota site, is a little more sedate (it has its own code of conduct) but has a similar purpose in giving consumers a place to swap stories and information.

Yes, names are named – otherwise what’s the point? No, there’s no way to verify whether commenters are actually being truthful or whether they’re biased or telling only part of the story.

Physicians and, to a lesser extent hospitals, often feel threatened by this, and rightfully so. It’s hard for them to defend themselves against anonymous online comments, and in any case they’re generally barred by privacy regulations from responding. Some attorneys have gone so far as to suggest that physicians ask their patients to sign a contract agreeing not to comment online about the doctor. Sometimes, physicians fight back with a lawsuit, as a Duluth neurologist recently did after being criticized by a patient’s son for his bedside manner (although this particular case apparently didn’t involve online commenting).

The larger question, it seems to me, is whether consumers truly benefit from sharing personal stories and experiences, good or bad, that they’ve had with health care providers. There are plenty of caveats, to be sure. A rating site might contain only one or two reviews of an individual physician – hardly enough information with which to draw any conclusions. If a patient or family member is upset about the care they’ve received, you don’t know how accurate their perceptions might be. Sometimes people misunderstand a situation, or their emotions simply are running a little too high. Under these circumstances, does it unfairly tarnish someone’s professional reputation if names are named?

Naming names can have another impact that’s not as readily recognized: undermining the confidence of someone who has chosen a particular hospital or physician and causing them to question whether they’ve in fact made the right choice. At the very least, it might prompt patients and families to search for faults that aren’t really there, and thus unwittingly erode the relationship.

But there’s another side to this: the value of honesty and disclosure. As one of the participants in my online group said, "Why would we have a double standard – OK if people have something nice to say and not OK if they have something critical to say? There are times when patients/families really need to hear an honest opinion."

Despite the growing prevalence of online ratings for physicians and hospitals, word of mouth remains a significant force in helping people choose a provider. Online ratings don’t always capture nuances that might matter to patients. One or two bad reviews don’t necessarily constitute a trend, but consistently low or lukewarm ratings can help signal deeper issues – for instance, a physician who’s not a good communicator, or a hospital that’s not responsive to problems that crop up during a patient’s stay. To many consumers, this is important to know.

For the record, I’m not a fan of bashing. If you have something negative to say, you can say it without resorting to insults or anger. There’s nothing inherently wrong, however, with criticism. If providers are too thin-skinned about it, they risk losing an opportunity to identify areas that need improvement. Inevitably, it sometimes means names are going to be named, and the responsibility that comes with this applies to both sides of this particular fence.

Photo: Wikimedia Commons

What’s my line?

On more than one occasion, I’ve had the experience of dealing with a health care professional whose identity wasn’t very clear.

Is the person checking your blood pressure at the medical clinic a nurse or a medical assistant? Is the person in your hospital room a registered nurse, a nursing assistant, a social worker or a respiratory therapist? Are you being seen by the doctor or by a physician assistant or nurse practitioner?

Health care personnel are generally trained to introduce themselves to patients and families with their name and title. The Joint Commission, which accredits most of the hospitals in the U.S., actually requires organizations to identify anyone coming into the facility, a measure that can extend to hospital visitors as well as employees. ID badges are supposed to be worn both for identification and security purposes.

Impostors are rare, although fakers do tend to pop up from time to time, such as the recent case of a woman in Tampa, Fla., who allegedly pretended to be a doctor and charged $60 an hour to unsuspecting patients. Of more concern to the average patient, though, is when bona fide health care professionals get a little too casual about identifying themselves.

Sometimes they don’t state their name, or they offer a vague disclaimer that they’re “from the lab” or “from X-ray.” Presumably they’re wearing an ID badge, but what if it isn’t visible or isn’t legible? I don’t know about anyone else, but I have a hard time trying to decipher someone’s name and title from a little piece of plastic clipped somewhere near their collar or dangling at hip level from their scrubs, especially if they don’t stand still long enough for my eyes to actually be able to focus on the lettering. As for those strings of initials denoting someone’s professional certification, they might mean something to other health care professionals but not to most laypeople.

Should it matter, as long as they’re properly credentialed, skilled and competent? If patients are going to be expected to be informed consumers, then yes, it does matter.

The proliferation of mid-level and allied health professions has been good in many ways, but it also has generated a certain amount of confusion, an issue that was blogged here recently. The increasing practice of using medical assistants in doctor’s offices, for instance, can leave patients unsure – or unaware – whether it’s a nurse who’s taking their vital signs or whether it’s some other kind of professional.

While this distinction might not seem important from a clinical standpoint, the fact is these are two different professions, each with its own type and amount of training and its own scope of practice. The waters get muddied even further when it comes to physician assistants and nurse practitioners, who are qualified to undertake a level of patient care almost similar to what a physician would offer.

The vast majority of professionals wouldn’t dream of misrepresenting their credentials. As far as most patients are concerned, though, everyone wearing scrubs tends to look the same. It’s not a question of skills or professional authority; it’s a question of clarity. Patients should know who’s taking care of them, and they shouldn’t have to play detective games to find out.

The bottom line for the public is that people need to be aware that health care professionals come in different flavors. A medical assistant isn’t the same as a licensed practical nurse isn’t the same as a registered nurse isn’t the same as a nurse practitioner. There’s a difference between technicians and technologists, between anesthesiologists and certified registered nurse anesthetists. Ideally, the professionals with whom you’re dealing will tell you up front who they are, or at least be wearing an easy-to-read ID badge. If patients and families aren’t sure, they should ask.

The bottom line for health care professionals is that they can’t assume their clientele knows all of this without needing to be told. A little proactive truth in advertising goes a long way.

Image: Guatemalan folk masks. Courtesy of Wikimedia Commons

Health care’s not-so-brave new world

I was back in high school when I first read “Brave New World,” Aldous Huxley’s cautionary parable of a future society in which everyone is genetically programmed for their station in life, the natural world is something to be held at bay, and people are kept happy and obedient with the help of pharmaceuticals.

The underlying message: Be careful how you engineer the future, because the results might shape humanity in ways we neither intend nor want.

Biotechnology has accomplished amazingly wonderful things. If you had been among the audience at a meeting last week on future opportunities for local angel investors, you would have heard about many of the leading-edge developments in the life sciences: personalized medicine, direct-to-consumer digital health information, nanotechnology and continuing advances in medical imaging, diagnostics, electronic health records and medical devices.

It all sounds so promising, but is it really going to be the brave new health care world it’s cracked up to be?

At the very least, the future might not arrive as quickly as we thought. Take the Human Genome Project, which completed the first sequencing of the human gene 10 years ago this month. Although it revealed a trove of information, it hasn’t exactly resulted in a flood of new drugs, the New York Times reports:

A decade ago, drug companies spent billions of dollars equipping themselves to harness the newly revealed secrets of human biology. Investors bid the stocks of tiny genomic companies to stratospheric heights.

That “genome bubble” has long since popped. And not only has there been no pharmacopeia, but some experts say the Human Genome Project might have at least temporarily bogged down the drug industry with information overload.

As the head of Novartis’s pharmaceutical business lamented in 2000, “Data, data everywhere, and not a drug, I think.”

Indeed, even though research and development spending by major pharmaceutical companies has roughly doubled in the decade since the genome project was largely completed, reaching $46 billion last year, the number of new drugs approved each year has stayed about the same.

As we saw only last week, progress in targeted therapies for cancer has been achingly slow and often filled with setbacks and disappointments.

The story sounds similar on a variety of other fronts. Although the electronic health record is touted as the wave of the future, medical providers have been slow to adopt this technology and it has come at a considerable financial cost. Implementation of useful online tools for patients to store their health information and communicate with physicians has been slow to happen.

At the same time there seems to be increasing specialization and fragmentation of all the gadgetry designed to help people achieve or maintain better health. Maybe I’m behind the times or maybe I’m just a skeptic, but I have a hard time working up a ton of enthusiasm for everything that’s new and kewl, such as these iPhone health-related apps that allow you to measure the temperature of your food or collect performance data while pedaling your bicycle. There could well be a market for this, but how large is it?

Meanwhile, very real concerns have been raised about the cost vs. the benefit of all this brave new biotechnology. Should we be offering cancer treatments that cost thousands of dollars but fail to extend life by more than a couple of months? Has the promise of technology ratcheted up people’s expectations to a level that’s both unrealistic and unsustainable? Is it deepening the divide between health care’s haves and have-nots, and is this a direction in which we want to go?

This is not to say that it’s all doom and gloom. On balance, we’re clearly far better off than we were a decade ago. We can’t afford, though, to overlook the human element and the possibility of unintended consequences.

In this vein, it was intriguing to read this commentary, by a medical apps guru, about the potential pitfalls of a new iPhone app, called iTriage, that allows patients to locate a physician, check out his or her rating on HealthGrades, and obtain information about symptoms, diseases and costs of treatment. Satish Misra ponders whether consumers are truly getting objective information and whether it will help them make better decisions. There’s always the risk of self-diagnosis and delayed treatment, he writes:

In difficult economic times especially, all people (including patients) will try to minimize unnecessary costs. The difference between dodging a physician visit and a shopping trip, though, can be the difference between life and death. The last thing anyone wants is a patient looking up “abdominal pain” on this app, deciding it’s gastritis instead of appendicitis, and becoming septic two days later.

As resources like this become more common, “it will become incredibly important for patients and physicians to have strong, trusting relationships,” Misra writes. “Physicians need to talk to patients about appropriate use of these kinds of resources, risks/benefits, and emphasize regular follow-up care.”

Exactly. Even the best ideas come with a down side that needs to be weighed. New things can often be good, but the mere fact that they’re new doesn’t automatically mean they’re useful or valuable, or that they come with an immediate payoff. The sign at the entrance to the brave new world of health care always reads, “Proceed with caution.”