What Rudy–and Most Americans–Still Don’t Understand about Prostate Cancer

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Presidential candidate Rudy Giuliani recently made the mistake of trying to turn his brush with prostate cancer into a campaign issue: “I had prostate cancer, five, six years ago. My chance of surviving prostate cancer, and thank God I was cured of it, in the United States, [is] 82 percent. My chances of surviving prostate cancer in England, [is] only 44 percent under socialized medicine,” Giuliani declared.

Rudy, of course, was wrong.

Merrill Goozner has done the best job that I’ve see of cutting through to the truth of the matter. In a Nov. 2  post titled “Columnists Miss Chance to Educate on PSA Testing,” he points out that “Paul Krugman’s column in the New York Times and Eugene Robinson’s column in the Washington Post justifiably attack Rudy Giuliani’s misuse of prostate cancer stats, all but accusing him of lying.

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Doc Treats Sheiks, Sells Cars, Hoping to Make Med School Affordable

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Today, I received this e-mail from Dr. Terry Bennett of Rochester, New Hampshire, commenting on my post about the cost of Medical School ("Why Aren’t More Students Applying To Medical School?"). Bennett, who is an alumni of Harvard Medical School, also sent a marvelous story from The Boston Globe (below)

First, Bennett’s comment: "Harvard Medical School, with the  biggest Endowment in the world, refused and still refuses to spend the money on tuition reduction, preferring to make greedy rich white guys richer," says Bennett, referring to the fact that in 2003 two of the money managers at the Harvard Management Company
were paid more than $35 million."The managers of the endowment took home enough money last year to send
more than 4,000 students to Harvard for a year," Bennett said at the time. "The official Harvard ‘greed is good’ mindset, is the mind set all over the USA, essentially.

"On Day one, at Harvard [Medical School] almost every first year student polled ‘wants to do some good in the world, and take care of people.’ By day 365 the same kid wants to be a Dermatologist. The difference? $50,000 in student debt. Average total debt upon graduation $300,000… The tuition is just the beginning.

"We need to cure greed if we are to restore altruists’ interest in becoming a doctor. Sadly, Greed is hard as hell to cure….Who would know better than I, who tried so very hard?? –Terry Bennett MD MPH"

How did Bennett try?  He attached this story from The Boston Globe:   

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Why Aren’t More Students Applying To Medical School?

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Did you know that there are only two applicants for every place in U.S. medical schools?

In Canada, surprisingly, close to four students apply for each opening. The training in the two countries is very similar; indeed, the Association of American Medical Colleges (AAMC) accredits medical schools in both countries.  And, in the U.S., at the high-end, physicians  can hope to earn far more than Canadian doctors.

Why then do so few Americans apply to medical school?

The answer is that we have priced a medical education well beyond the reach of most middle-class students.  In 2004, tuition and fees at a public medical school averaged $16,153. Students who attended a private school paid $32,588 according to a 2005 study published in The New England Journal of Medicine. 

The author, Dr. Gail Morrison, Vice Dean for Education at University of Pennsylvania School of Medicine, tacks on $20,000 to $25,000 a year for living expenses, books and equipment to calculate that the total cost of four years of medical education comes to a heady $140,000 for public schools and $225,000 for private schools.  I’d add that, in many American cities, students would be hard-pressed to cover rent, food, clothing, utilities and transportation for $20,000 a year—let alone books and equipment.

This helps explain why 60 percent of all medical students come from the wealthiest one-fifth of all U.S. families. Another 20 percent come from families lucky enough to be on the fourth step of a five step ladder.

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We Need to Begin A Conversation About “Cost Effectiveness”

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As any policy-maker knows, catering to public opinion, ensuring the public interest, and managing costs can seem an impossible task–especially when what the public thinks it wants is at loggerheads with what it needs. But in the case of health care, there may be an opportunity to do all three at once according to a proposal in the September/October Health Affairs.

The proposal argues for cost-effectiveness analysis (CEA) “to set priorities for Medicare coverage of new or costly interventions” through a citizens’ council made up of “a cross-section of users” who can provide leadership with “well-considered social-value judgments.” This citizens’ council model is borrowed from the UK, where a group of 30 men and women advise the National Institute for Health and Clinical Excellence (NICE) on behalf of the public.

The British experience shows that there are likely to be practical complications with implementing a citizens’ council, but it’s still an idea that’s on the right track. We need to turn “cost-effectiveness” from a bad word into a public interest issue in the US.

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The Ten Most Overused Medical Tests and Treatments

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I often write about how difficult it is to evaluate the quality of health care.  There is no Consumer Reports (CR) for healthcare, I argue, because while CR can rate mid-priced refrigerators briskly and clearly, in a way that makes comparisons easy, it is often all but impossible—even for a physician—to be positive of the relative benefits of a great many medical treatments. 

But if it’s hard to sort out the “best” healthcare, it may be easier to spot both negligent and unnecessary care.  As a hospital CEO once told me, “Our patients know whether they like the food, and the views, and whether the nurses are pleasant. They really have no way of knowing whether they are getting very good care or mediocre care . . . Though,” he added, “they are more likely to be able to tell if they are getting bad care.”

With that thought in mind, it might be worth taking a look at Consumer Report’s list of the 10 most overused medical tests and treatments. Thanks to  Gary Schwitzer of the University of Minnesota’s  School of Journalism and Mass Communication for calling attention to this list on his always interesting Schwitzer Health News Blog.
As Schwitzer points out, “You can quibble with the list, but you can’t help but commend CR for raising public awareness about the medical arms race.  And this list is just part of a broader special section on overspending on overtreatment.”

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Foreign Doctors—A Question of Equity

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Consider these two facts:

  • Close to 25 percent of U.S. doctors are foreign-born.
  • Each year, developing nations spend $500 million to educate health care workers who leave to work in North America, Western Europe and South Asia.  As the most recent issue of the Journal of the American Medical Association (October 24-31) puts it:  “developing nations are subsidizing healthcare in wealthier nations.”

According to JAMA, “These unchecked flows of health workers leave regions with the greatest health care needs with the fewest workers .  .  . 37% of the world’s health care workers live in the Americas, predominantly in the United States and Canada, yet these countries carry only 10% of the global disease burden. In contrast, Africa is home to only 3% of the world’s healthcare workers, yet it has 24% of the global burden of disease.”

On the other hand, according to the American Medical Association, some
35 million Americans live in areas where there are not enough doctors.
Nationwide, primary care doctors are in short supply, in large part
because they are paid so much less than specialists. Medical students
who know that they will graduate with tens of thousands of dollars in
loans say that they don’t feel that they can afford to become
internists or family doctors.

Moreover, the Kaiser Family Foundation reports that “the
nationwide physician shortage is affecting rural and inner-city
residents the most,” and following 9/11, “restrictions put in place on
foreign doctors who want to practice in the U.S.” have made the
situation worse.

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Patients Managing Chronic Diseases: Not Your Average Consumer

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In his new book, Health Care Reform Now!, Kaiser Permanente President George Halverson points out that when you look at the 10 percent of patients running up 70 percent of the U.S. health care bill, you find that most are suffering from one of five chronic diseases: diabetes, congestive heart failure, coronary artery disease, asthma and depression.

These diseases can be expensive because if they are not monitored properly, they can quickly lead to avoidable hospitalizations—and, in the case of diabetes, avoidable amputations.  One of the most pressing questions health care reformers face today is this: How can we better manage these very expensive diseases—and how can the patient participate in self-management?

Recently, Maggie handed me a Bulletin on Aging and Health from the National Bureau of Economic Research, which includes a synopsis of a paper (penned by James P. Smith of the RAND Corporation) which focuses on one of these chronic diseases—diabetes. Smith’s goal is to explore the relationship among diabetes, socioeconomic status, and the patient’s ability to self-manage treatment.

Of particular interest is Smith’s emphasis on education—which, he concludes, is a major factor in determining first, whether a patient is likely to suffer from diabetes, and secondly whether he or she can successfully self-manage. It’s this second point that I want to address, in part because it provides a good example of how a consumer-based approach to medicine distorts the complexities of health care. 

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Hospitals & Nurses: Behind the Scenes

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Recently I’ve begun reading allnurses.com, a website that offers an eye-opening window on conditions in U.S. hospitals.  (I found the site when allnurses reprinted my post about the nursing shortage).

Clearly nurses and doctors know more than virtually anyone else about what is going on in our hospitals, but they also realize that they risk reprisals if they speak out. When I was writing Money-Driven Medicine, I was surprised by how many physicians returned my phone calls. The great majority did not know me; I expected responses from perhaps 20 percent. Instead four out of five called back. To a man and a woman, they were most passionate about what many saw as the declining quality of healthcare. “We want someone to know what is going on,” explained one prominent Manhattan physician as he described how much care had deteriorated in many of New York City’s major hospitals. “But please don’t use my name,” he added. “You have to promise me that. In this business, the politics are so rough–it would be the end of my career.”

Nurses are in an even more vulnerable position. I could not find any who were willing to be interviewed. I e-mailed quite a few, promising anonymity, but not one responded.

On allnurses.com, however, nurses speak freely, knowing that their identities are protected and that their audience is composed of other nurses.  Here is what I have learned from some of the polls and forums on the site:

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Shared Decision Making

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In my last post, I talked about the uncertainties of medicine, and suggested that the relationship between doctor and patient must be built on trust.  (See “A Transaction Based On Trust”). I argued that this is why the consumer-driven model of medicine doesn’t work. It assumes that the doctor is a retailer selling his services and that as his customer the consumer must demand the best quality care at the lowest price. Immediately the relationship between buyer and seller begins to sound adversarial, just as it is in the commercial marketplace where “caveat emptor” always applies. 

But the health care market is not like other market places, and the doctor is not a retailer. He or she is a professional who has taken a pledge to put the patient’s interests ahead of his own interests.  For the transaction to go forward, the patient has to believe this. Who would go under the knife, or submit to any painful or invasive procedure if he didn’t trust the doctor? 

At the end of that post, I asked, “But what about the uncertainty of medicine. Does this mean that the patient must simply trust that his doctor has “the right answer?”

Not at all. The relationship between patient and doctor must be based on mutual trust. Just as the patient trusts the doctor to act as a professional, the doctor needs to trust the patient enough to be open with him about the uncertainties of the patient’s condition and the pros and cons of the treatments that they are considering.

Sometimes—but not always—the doctor must tell the patient: “In this particular case I can’t be sure what the best treatment would be. But here are the options and here are the risks and benefits of each.”    

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Disease Mongering By Way of Restless Legs

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Yesterday during lunch I saw an ad for Mirapex, a “prescription medicine used in
the treatment of moderate to severe primary restless legs syndrome (RLS).” The
fact that there was such thing as a restless leg syndrome seemed odd to me, so
I did some sleuthing. (Maggie, who has in fact discussed RLS over at the Health Care Blog, has some great
thoughts on the issue as well.)

 RLS is a “medical condition that is described as an urge to
move the legs”—simple enough. The Mirapex website offers a list of question
designed to help you diagnose yourself:

  • Do you feel a strong desire to move your legs from time to time, often when they make you uncomfortable?
  • Do those sensations in your legs occur or get stronger when you are inactive?
  • Does moving around or stretching help ease those uncomfortable sensations in your legs?
  • Do those uncomfortable sensations feel their worst at night?

Boehringer
Ingelheim Pharmaceuticals, the manufacturer of Mirapex, is considerate enough
to translate these symptoms into layman’s terms:

People often use words like
"burning," "creeping," "crawling,"
"aching," "tingling," and/or "tugging" to try and
describe their symptoms. Many people with restless legs syndrome have
difficulty explaining the odd sensations they feel, even when talking to their
doctor.

So far it seems that I may have RLS if my (1) legs get uncomfortable after
sitting for a while and (2) I have trouble articulating this sensation. By
these criteria, most anyone who has uttered the phrase “my leg feels weird”
qualifies as an RLS sufferer.

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