Atul Gawande gave the commencement speech at Stanford’s School of Medicine this year. Below, the speech, which was published in the New Yorker http://www.newyorker.com/online/blogs/newsdesk/2010/06/gawande-stanford-speech.html    

Summary:  In his speech, Gawande congratulated the class for ignoring their elders: “You come into medicine and science at a time of radical transition. You have met the older doctors and scientists who tell the pollsters that they wouldn’t choose their profession if they were given the choice all over again. But you are the generation that was wise enough to ignore them: for what you are hearing is the pain of people experiencing an utter transformation of their world.”

Most people do not enjoy radical change that turns their world upside down—and doctors are no exception.  “Doctors and scientists are now being asked to accept a new understanding of what great medicine requires,” Gawande explains. “It is not just the focus of an individual artisan-specialist, however skilled and caring.

 “The volume and complexity of what doctors need to know has grown beyond our capacity as individuals,” he warns. “Diagnosis and treatment of most conditions require complex steps and considerations, and often multiple people and technologies . . . . We’ve been obsessed in medicine with having the best drugs, the best devices, the best specialists, but we’ve paid little attention to how to make them fit together well.”  And because our system is not well coordinated, “more than forty per cent of patients with common conditions like coronary artery disease, stroke, or asthma receive incomplete or inappropriate care in our communities.”

He tells the story of a patient who lost all of his fingers and all of his toes because each doctor thought that another doctor involved in his care had given him the vaccine he needed.

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Accreditation Group’s Proposal on Resident Physician WorkHours Do Not Measure Up to Institute of Medicine Recommendations

Summary: As regular HealthBeat readers know, resident sometimes work 30 hours shifts. In 2008, the Institute of Medicine (IOM) recommended capping shifts at 16 hours, saying that longer shifts are unsafe for patients and residents themselves. Sleep deprivation is likely to lead to errors; residents acknowledge that lack of sleep has caused them to make mistakes that harm, and sometimes even kill patients. Exhaustion also affects how they feel about their patients. I have posted about this here. The IOM also noted that in some cases, residents need better supervision. I told the story of what happened to 15-year-old Lewis Blackman earlier this month.

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Speaking at a Third Way event earlier this week, House Majority Leader Steny H. Hoyer (MD) had this to say about the deficit:

“On the spending side, we could and should consider a higher retirement age, or one pegged to lifespan; more progressive Social Security and Medicare benefits; and a stronger safety net for the Americans who need it most. “

On the face of it, lifting the retirement age makes sense. Americans are living longer, so they could retire later and still enjoy their golden years.

Except—only some of us are living longer.

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As Congress once again wrestles with “the doctor fix”—yet another postponement of the 21% cut in Medicare reimbursement that went into effect this month—the media has been swirling with stories warning of a mass exodus of doctors out of the federal program. The reason: In 2008 Medicare paid doctors 78% of what they get from private insurers; with the 21% cut they fear that their income will drop even lower.

The reports hit their peak late last week—USA Today wrote that “[t]he number of doctors refusing new Medicare patients because of low government payment rates is setting a new high,” while the American Medical Association announced that 31% of primary care doctors are restricting the number of Medicare patients they take. In a recent survey, the American Academy of Family Physicians found that 13% of respondents didn't participate in Medicare last year, up from 8% in 2008 and 6% in 2004. Chic Older, executive director of the Arizona Medical Association told the Seattle Times ; "If the 21 percent cut goes into effect, we're going to have a very severe problem in the state of Arizona."

The question is: Will Medicare beneficiaries really face a shortage of providers and restrictions on their access to care? Or is this a scare tactic being used for political reasons?

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As regular HealthBeat readers know, I’ve been writing about the risks of PSA testing for early-stage prostate cancer since I launched this blog in 2007. 

The American Cancer Society does not support routine PSA testing for prostate cancer. Testing often leads to unnecessary treatment which, in turn, leads to life-changing side effects—namely incontinence and impotence. Moreover, early detection does not guarantee a cure. See these posts on HeathBeat: here and here. Finally, see this very informative NYT story that I posted about in 2008.

Nevertheless, The New York Daily News has once again launched a campaign urging men to take advantage of FREE PSA testing. (Of course the treatment that follows won’t be free, but that’s another story.)

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Summary: Opponents of reform will continue to pretend that at some point in the future, “Obama-care” will mean drastic across-the-board cuts in reimbursements to doctors who take Medicare patients, forcing many to abandon their patients. The Senate’s bi-partisan action on Friday should serve as a reminder that this just isn’t true. Congress never has and never will implement the blind cuts that the SGR formula calls for. The SGR has nothing to do with the reform legislation President Obama signed in March. In fact, the Affordable Care Act hikes payments to many physicians.

 Friday, June 18, the Senate aproved a plan that blocks a 21 percent cut in Medicare payments to physicians; the axe was scheduled to fall that day. Leadership on both sides of the aisle pushed for the reprieve; it will remain in place for six months. The measure will now need to be considered by the House, which in May approved a fix that would last longer. If the House agrees that the cut should not be implemented–and it is all but certain that it will–the 21 percent cut wil be replaced with a 2.2 percent pay hike. The bill will not add to the deficit. The proposal is fully offset by changes in Medicare billing regulations, antifraud provisions and the tightening of some pension rules, eliminating Republican objections that it would push the federal government deeper into debt. The only question is whether the House will demand a full repeal of the SGR formula which calls for a 21 percent cut, or at least, a much longer repreive.

In six months, Congress will have to consider the matter once again, just as it has ever year since 2003.  This is the third time this year that Congress has averted Draconian cuts to physician’s payments. What, you might wonder, is going on?  Here is the back-story:  in 1997, Congress enacted a so-called "sustainable growth rate" (SGR) mechanism to keep Medicare physician reimbursement rates in check. Congress has never allowed the full cuts called for under the SGR formula to take effect and it never will.

Why don’t legislators simply repeal the cuts to doctors’ fees that they have been postponing for years?  Why just put off the measure for another six months? 

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Summary:  Deficit Hawks want to slash both Medicare and Social Security, and they seem to be in control of the President’s National Commission on Fiscal Responsibility and Reform. Hovering in the wings, aging mogul Pete Peterson is eager to help them do the job.

The irony is that cutting domestic spending is exactly what we shouldn’t do in the midst of this economic crisis. As George Soros explains, when you’re skidding you have to turn into the skid.

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Both liberals and conservative critics have charged that the health reform legislation that President Obama signed this spring focuses mainly on insurance coverage, and does little to rein in the spiraling cost of health care. This isn’t true. But the legislation is dense– and, as usual, the truth is more complicated than a lie. There is no single “fix” that will “break the curve” of health care inflation. The Affordable Care Act (ACA) contains multiple provisions that open the door to cost containment in myriad ways.

 In today’s issue of The New England Journal of Medicine (NEJM), Peter Orszag, director of the White House Office of Management and Budget (OMB) and OMB special health advisor Zeke Emmanuel explain how the bill will make Medicare more affordable:   “Perhaps most fundamentally,” they write, “the ACA recognizes that reform, particularly changing the delivery system, is not a one-time event. It is an ongoing, evolutionary process requiring continuous adjustment. The ACA therefore establishes a number of institutions that can respond in a flexible and dynamic way to changes in the health care system.”

What is most exciting is that under the new legislation, Congressional lobbyists will not be able to block the process: “The secretary of health and human services (HHS) is empowered to expand successful pilot programs without the need for additional legislation.”

Below excerpts from their “Perspective” in the June 16 NEJM:

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Last week, the New York Times asked me to write an opinion piece for its “Room for Debate” section.

Here is the topic that the Times asked participants to discuss:

“An article in the Times this week focuses on a 5,000-member clan in Colombia that has an unusually high incidence of early-onset Alzheimer’s disease. A medical study of this large family, which lives in one Andes region, is being planned to see if giving treatment before dementia starts can lead to preventing the disease. In that traditional society, the heavy burden of caring for the ill falls on siblings, spouses, children and other family members.

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Children have become the new growth industry for
prescription drug makers. A study released last month by the pharmacy benefit
manager Medco found that 26% of kids under 19—almost
30% of those aged 10 to 19—are now taking prescription medications for a
chronic condition. Meanwhile, spending on prescription drugs for children
increased by almost 11% last year, the largest increase experienced by all
segments of the market, including the elderly. Although asthma drugs are the
still the most commonly prescribed therapeutics, kids are increasingly being
prescribed drugs that are decidedly uncommon for such young patients: atypical
anti-psychotics, diabetes drugs, anti-hypertensives, cholesterol medications
and heartburn drugs—expensive therapeutics that in the past were rarely used
outside of adult populations.

The Medco figures are alarming first of all because
intuitively it just feels wrong that so many children are downing prescription
pills along with their morning multivitamin and orange juice. Kids are supposed
to be healthy, full of energy, free spirited. But increasingly, this is not the
case. More than 17% of adolescents (10-19 year olds) are now classified as
obese: in fact, a whopping one out of three kids is considered overweight or
obese. And obesity brings with it a raft of formerly adult chronic
conditions.  According to a fact
sheet provided by the Institute of Medicine, in one population-based sample some 60% of obese children aged 5 to 10 years
had at least one cardiovascular disease risk factor—including high levels of
total cholesterol, triglycerides, insulin, or high blood pressure—and 25
percent had two or more of these risk factors.

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