EBM is the integration of clinical expertise, patient values, and the best evidence into the decision making process for patient care. Clinical expertise refers to the clinician's cumulated experience, education and clinical skills. The patient brings to the encounter his or her own personal and unique concerns, expectations, and values. The best evidence is usually found in clinically relevant research that has been conducted using sound methodology.
There are serious subtleties in Sackett's straightforward statement. Has the physician, addressing your problem, necessary cumulative experience? How is relevant cumulative experience defined? How do patients judge a physician's total education? How does a patient assess a physician's clinical skills?
What are some of the other important issues? Does the physician have a stable personal life? Is he or she in financial difficulty? Did he or she have a knock-down drag-out fight with his or her spouse or children the night before he or she is scheduled to perform a technically difficult procedure, requiring a sharply focused mind, for you? Does the physician use too much alcohol or is he or she a drug-user? Does he or she have a health problem which affects medical practice and judgment? Is he or she a personal risk-taker and is that a personality characteristic you consider useful in your care?
Is the physician intellectually aggressive and knowledgable? Is the physician energetic or lazy? Is the physician inappropriately fearful or self-defensive? Does he or she seek-out and value the opinions of other physicians in the same specialty or does he or she dismiss those opinions which are inconsistent with his or her views. Does he or she know what evidence is important in your case, obtain that evidence and then carefully review it, integrating it with the available history, physical findings and other medical data about you? Does your physician seek consultation or make referrals or does he or she believe that he or she can "handle it all" even though his or her experience may be very limited?
Does your physician work in isolation? Does he or she test his or her ideas in study groups, professional lectures or other activities? Does he or she read leading medical journals or rely on pharmaceutical company sponsored education programs for updates? Are your physician's extra-curricular activities primarily medical-political, or is he or she focused on activities benefitting the comunity?
Does your physician work in a medical group run or owned by lay people? Are the physicians in the group setting its course or are they only paid employees for whom working conditions, patient volume, practice philosophy, professional standards, office facilities, and financial production numbers are dictated by others? Do the physicians in the group carefully observe each other so that substandard care is addressed and high quality care is rewarded? Is referral outside the group discouraged? What are the ethical standards and practices of the group? What is its mission?
"Evidence" is a single factor in a many-faceted physician-patient relationship. While the preparation, interpretation and value of medical evidence changes rapidly, the physician's wisdom, personal and professional judgment, compassion and competence in addressing life's issues tend to be stable. Don't get hung-up on evidence. Look for the subtleties.
Sunday, November 29, 2009
Friday, November 20, 2009
Your X-Ray & Your Doctor's Computer Monitor
In yesterday's blog, I discussed two physicians' abilities to display and review the same MRI, on their desktop computer monitors (and their different conclusions). On its face, this display technology seems efficient, appropriate, and without any downside.
But there is a downside, which will probably elude anyone who has not practiced medicine collaboratively with person to person discussion between two (and sometimes more) physicians reviewing an x-ray: a radiologist and the physician who ordered the study. When these physicians spend a few moments together to jointly review critical patient information (history, physical findings, lab, clinical impressions), they both benefit professionally because the study is no longer a solo cold intellectual exercise conducted in a dark room or reviewed in another country. The study becomes a source of information enriched by these physicians' collaboration. The radiologist can augment the ordering physician's clinical knowledge and skill, providing input which causes the clinician to modify his or her care of the patient.; the ordering physician can call attention to study findings that the radiologist may not have considered important but are clinically relevant.
While computer monitors on pysicians' desks may show reports and scans, they do not provide the depth of information vital to the care of a patient with serious illness. Computer medical technology may provide the illusion of superior efficiency, but someone needs to study the real cost of this application of non-collaborative technology..
But there is a downside, which will probably elude anyone who has not practiced medicine collaboratively with person to person discussion between two (and sometimes more) physicians reviewing an x-ray: a radiologist and the physician who ordered the study. When these physicians spend a few moments together to jointly review critical patient information (history, physical findings, lab, clinical impressions), they both benefit professionally because the study is no longer a solo cold intellectual exercise conducted in a dark room or reviewed in another country. The study becomes a source of information enriched by these physicians' collaboration. The radiologist can augment the ordering physician's clinical knowledge and skill, providing input which causes the clinician to modify his or her care of the patient.; the ordering physician can call attention to study findings that the radiologist may not have considered important but are clinically relevant.
While computer monitors on pysicians' desks may show reports and scans, they do not provide the depth of information vital to the care of a patient with serious illness. Computer medical technology may provide the illusion of superior efficiency, but someone needs to study the real cost of this application of non-collaborative technology..
Thursday, November 19, 2009
When To Find A Different Doctor
Today's blog reflects personal recent experience. I hope that it will help my readers.
Recently I visited several physicians concerning a medical problem. My internist recommended selecting two highly competent physicians in the relevant specialty (he did make recommendations). I had long ago learned how difficult it is for patients to evaluate the competency of physicians to whom they are referred (even when they are, themselves, physicians), so I went about the process methodically, checking with other respected physicians, friends and academic leaders, as well as with the Medical Board of California's web site where I could verify credentials and freedom from serious disciplinary action.
I chose two doctors, one in a well-known group practice (my internist's) and the other at a nearby university medical center.
The first physician briefly reviewed my history (he had a computerized medical record), examined me, and with me and my wife, reviewed the abnormalities on an MRI which had been performed 6 months earlier. He told me that he could not help me with the presenting pain symptom because the presumed responsible condition was not sufficiently severe to be its cause. He did not discuss several other abnormalities on the MRI, other than to note that they were there and they were not treatable by him because there was no evidence-based literature to support his specialty intervention.
The second physician also took a history, examined me, and reviewed the abnormalities on the MRI (on his computer screen) done earlier and agreed with the first doctor that the MRI demonstrated that the presenting diagnosis did not warrant surgery. But he went further to analyze and discuss the other abnormalities in the scan, which were not significantly addressed by the first physician, and to ask the question "why are these abnormalities here and what causes them?" He then, citing applicable professional standards of practice, sent me for lab, x-rays and an additional MRI after dictating a clinical note in my presence.
When the first doctor showed the abnormalities on his computer screen, I was surprised that he did not give them more than cursory attention and comment. But I decided that if he had little interest or comment about them, I would recognize his professional limitations and demand more interest, attention, analysis and discussion from the second doctor. I didn't have to: the second doctor demonstrated interest, attention, analytical ability and the capacity to ask "why?"
My suggestion to readers is that if your doctor, hearing of an abnormality on taking a medical history, or seeing an abnormality in a laboratory test, x-ray or scan, doesn't ask "why," he or she is the wrong physician for you. The physician who instinctively reaches for the prescription pad or gives a simple reassuring answer to what may be a serious clinical danger signal may not be providing competent care. Find yourself another doctor who is less anxious to limit choices or exercise professional intellect. Find a doctor who asks "why."
Sometimes doctors make mistakes. Sometimes patients are wrong, too. But you can protect yourself by asking your doctor "why?"
Recently I visited several physicians concerning a medical problem. My internist recommended selecting two highly competent physicians in the relevant specialty (he did make recommendations). I had long ago learned how difficult it is for patients to evaluate the competency of physicians to whom they are referred (even when they are, themselves, physicians), so I went about the process methodically, checking with other respected physicians, friends and academic leaders, as well as with the Medical Board of California's web site where I could verify credentials and freedom from serious disciplinary action.
I chose two doctors, one in a well-known group practice (my internist's) and the other at a nearby university medical center.
The first physician briefly reviewed my history (he had a computerized medical record), examined me, and with me and my wife, reviewed the abnormalities on an MRI which had been performed 6 months earlier. He told me that he could not help me with the presenting pain symptom because the presumed responsible condition was not sufficiently severe to be its cause. He did not discuss several other abnormalities on the MRI, other than to note that they were there and they were not treatable by him because there was no evidence-based literature to support his specialty intervention.
The second physician also took a history, examined me, and reviewed the abnormalities on the MRI (on his computer screen) done earlier and agreed with the first doctor that the MRI demonstrated that the presenting diagnosis did not warrant surgery. But he went further to analyze and discuss the other abnormalities in the scan, which were not significantly addressed by the first physician, and to ask the question "why are these abnormalities here and what causes them?" He then, citing applicable professional standards of practice, sent me for lab, x-rays and an additional MRI after dictating a clinical note in my presence.
When the first doctor showed the abnormalities on his computer screen, I was surprised that he did not give them more than cursory attention and comment. But I decided that if he had little interest or comment about them, I would recognize his professional limitations and demand more interest, attention, analysis and discussion from the second doctor. I didn't have to: the second doctor demonstrated interest, attention, analytical ability and the capacity to ask "why?"
My suggestion to readers is that if your doctor, hearing of an abnormality on taking a medical history, or seeing an abnormality in a laboratory test, x-ray or scan, doesn't ask "why," he or she is the wrong physician for you. The physician who instinctively reaches for the prescription pad or gives a simple reassuring answer to what may be a serious clinical danger signal may not be providing competent care. Find yourself another doctor who is less anxious to limit choices or exercise professional intellect. Find a doctor who asks "why."
Sometimes doctors make mistakes. Sometimes patients are wrong, too. But you can protect yourself by asking your doctor "why?"
Monday, November 16, 2009
Does China Benefit From America's Health Care Reform?
Aside from the dubious benefit of turning $300+ per hour physicians into minimum-wage data input clerks, as they waste their time in entering computer data into terminals rather than spend their time actually talking to, examining and thinking about patients, there are other problems with the push to computerizing health care records.
Most of the computer equipment that I see these days has Chinese origin.I don 't fault Chinese engineers and entrepreneurs from developing their computer system production capacity and quality, but I do believe that a big chunk of the "computerized medical records" budget will not lower America's health care costs, will not create jobs in the health care industry and will not improve health care. But it will result in a huge American demand for Chinese-origin computer systems which will funnel money right out of American health care and into China's coffers, aggravating our economic recovery, unemployment and America's trade deficit with China. Not only will the push to computerize America's health records weaken our dollar, but as the New York Times points out today, "Little Benefit Seen, So Far, in Electronic Patient Records".
Most of the computer equipment that I see these days has Chinese origin.I don 't fault Chinese engineers and entrepreneurs from developing their computer system production capacity and quality, but I do believe that a big chunk of the "computerized medical records" budget will not lower America's health care costs, will not create jobs in the health care industry and will not improve health care. But it will result in a huge American demand for Chinese-origin computer systems which will funnel money right out of American health care and into China's coffers, aggravating our economic recovery, unemployment and America's trade deficit with China. Not only will the push to computerize America's health records weaken our dollar, but as the New York Times points out today, "Little Benefit Seen, So Far, in Electronic Patient Records".
Sunday, November 15, 2009
A Day At The Races
After passing crowds of people patiently lined-up in front of the building and noting the "Racetrack" sign which told me I was in the right place, I parked and then reported for assignment at 7:30 AM. We were told (and the deputy sheriffs and security people with whom I shared the lunch table verified) that the lines to receive the H1N1 flu vaccine had begin to form at 1 AM on a cold fall night. Even the Santa Clara County Fairgrounds Exhibition Hall was cold and I wondered how well my stiff fingers would accomplish the job ahead and how I would stay warm in my cotton and Dacron tan public health uniform. My worries proved unnecessary.
It was clear that the Santa Clara County Public Health Staff had paid lots of attention to vital organizational details and logistics. Vaccinators (like me) wore distinctive orange jackets and logistics people, security, administrators, greeters, guides and translators each had distinctive garb. The enormous hall had serpentine Disney World-like crowd handling lanes. Tables and chairs lined each side of the hall and at each table were three vaccinators, supplies of syringes and vaccine and alcohol swabs and adhesive bandages and cotton balls and every other item which we would need to do our jobs throughout the day. After a quick breakfast and a few organizational instruction meetings (i.e. - "don't get dehydrated," "drink water," be sure to take your 10 minute breaks," and be sure to stop for lunch") we set out for our tables.
The introductions at our table were brief. I worked with two paramedics who throughout the day did not waste words, motion, vaccine or supplies. At 9:30 AM when our first patients appeared, one of the paramedics had pre-filled syringes with vaccine and we were ready to go. We worked steadily throughout the day.
Each time we had an empty chair, we signaled a volunteer who directed individuals, and families, to us. Mothers, fathers, grandparents, young and older children of all character and description presented for H1N1 vaccine. They seemed well-informed (thanks to the people who were assigned to work the lines to provide information to the potential vaccine recipients) and almost always came with the paperwork which assured us that their vaccination experience would not involve unnecessary risks. The noise level was high because of screaming children, but because of the educational effort directed to the potential vaccine recipients, they were well-informed and relatively relaxed, which was reflected in most of their kids' simply accepting the injection or the nasal flu vaccine.
The hours passed quickly, Our stocks of vaccine dwindled. And the last vaccine recipients were cared-for. Unlike the iffy world of horse-racing, there no question about the benefit received by thousands of people whom we vaccinated, some of whom might otherwise be sickened or die from H1N1 influenza.
Public health prevention is better than trying to treat the complications of a preventable disease.
It was clear that the Santa Clara County Public Health Staff had paid lots of attention to vital organizational details and logistics. Vaccinators (like me) wore distinctive orange jackets and logistics people, security, administrators, greeters, guides and translators each had distinctive garb. The enormous hall had serpentine Disney World-like crowd handling lanes. Tables and chairs lined each side of the hall and at each table were three vaccinators, supplies of syringes and vaccine and alcohol swabs and adhesive bandages and cotton balls and every other item which we would need to do our jobs throughout the day. After a quick breakfast and a few organizational instruction meetings (i.e. - "don't get dehydrated," "drink water," be sure to take your 10 minute breaks," and be sure to stop for lunch") we set out for our tables.
The introductions at our table were brief. I worked with two paramedics who throughout the day did not waste words, motion, vaccine or supplies. At 9:30 AM when our first patients appeared, one of the paramedics had pre-filled syringes with vaccine and we were ready to go. We worked steadily throughout the day.
Each time we had an empty chair, we signaled a volunteer who directed individuals, and families, to us. Mothers, fathers, grandparents, young and older children of all character and description presented for H1N1 vaccine. They seemed well-informed (thanks to the people who were assigned to work the lines to provide information to the potential vaccine recipients) and almost always came with the paperwork which assured us that their vaccination experience would not involve unnecessary risks. The noise level was high because of screaming children, but because of the educational effort directed to the potential vaccine recipients, they were well-informed and relatively relaxed, which was reflected in most of their kids' simply accepting the injection or the nasal flu vaccine.
The hours passed quickly, Our stocks of vaccine dwindled. And the last vaccine recipients were cared-for. Unlike the iffy world of horse-racing, there no question about the benefit received by thousands of people whom we vaccinated, some of whom might otherwise be sickened or die from H1N1 influenza.
Public health prevention is better than trying to treat the complications of a preventable disease.
Wednesday, November 11, 2009
Make The Call
Whether you are a Republican, Democrat, or an independent, call your U.S. Senators' offices and ask:
1. How much campaign money have (he,she, they) raised from pharmaceutical companies?
2. How much money have (she, he, they) raised from insurers and insurers'associations?
3. How much money have (they, he, she) raised from hospital associations?
The fact that you called and raised these questions will make a difference. Just do it.
1. How much campaign money have (he,she, they) raised from pharmaceutical companies?
2. How much money have (she, he, they) raised from insurers and insurers'associations?
3. How much money have (they, he, she) raised from hospital associations?
The fact that you called and raised these questions will make a difference. Just do it.
Thursday, November 5, 2009
"I Want My Doctor"
Recently, my television screen has been filled with pictures of angry protestors, standing up against health care reform imposed by the federal government. Prominent among the statements was a single refrain: "I want my doctor."
Sorry, but perhaps you haven't noticed. The people who took your doctor away were not monstrous federal officials, but health insurance company executives. They did that by selling health insurance plans to a company, then jacking up the premiums so that the company (whose employees had become a few years older and a greater insurance risk) would find another company. Each company had its own contracted doctors in its network and when employers moved from one company to the next, they lost "my doctor" and replaced him or her with a new "my doctor." The demoralizing effect on physicians was severe, as physicians came to realize that they were merely pawns in the insurance game, that the patient who sang their praises on December 31 would be moving to another doctor on January 1st, and that the historic physician-patient relationship no longer existed. And those health insurance companies did something else: they negotiated rates of payment to the doctors which were actually less than the Medicare rates of payment, leading the most qualified doctors who provided high quality care, to drop out of some of the plans, retire or leave town, so that you couldn't see "my doctor" under any of the plans provided by the health insurers and your employers. Or of you did get to see "my doctor" it was not to spend the 15 or 20 minutes with you as was the doctor's customary practice, it was a 5 minute visit because that was what the health insurer, financed by you and your employer, was paying for. You may have also noticed that some of the new doctors in the network provided by your health care insurer and your employer weren't quite as well trained or qualified as your old "my doctor" who you couldn't see any more. Lots of reasons for that but you can imagine most of them.
So let's do away with the mythology that the big ugly federal givernment bureaucrat is taking away "my doctor." That was done by health insurers, your employers, your unions and you. Sorry.
Sorry, but perhaps you haven't noticed. The people who took your doctor away were not monstrous federal officials, but health insurance company executives. They did that by selling health insurance plans to a company, then jacking up the premiums so that the company (whose employees had become a few years older and a greater insurance risk) would find another company. Each company had its own contracted doctors in its network and when employers moved from one company to the next, they lost "my doctor" and replaced him or her with a new "my doctor." The demoralizing effect on physicians was severe, as physicians came to realize that they were merely pawns in the insurance game, that the patient who sang their praises on December 31 would be moving to another doctor on January 1st, and that the historic physician-patient relationship no longer existed. And those health insurance companies did something else: they negotiated rates of payment to the doctors which were actually less than the Medicare rates of payment, leading the most qualified doctors who provided high quality care, to drop out of some of the plans, retire or leave town, so that you couldn't see "my doctor" under any of the plans provided by the health insurers and your employers. Or of you did get to see "my doctor" it was not to spend the 15 or 20 minutes with you as was the doctor's customary practice, it was a 5 minute visit because that was what the health insurer, financed by you and your employer, was paying for. You may have also noticed that some of the new doctors in the network provided by your health care insurer and your employer weren't quite as well trained or qualified as your old "my doctor" who you couldn't see any more. Lots of reasons for that but you can imagine most of them.
So let's do away with the mythology that the big ugly federal givernment bureaucrat is taking away "my doctor." That was done by health insurers, your employers, your unions and you. Sorry.
Monday, November 2, 2009
Keep Your Eyes On The Ball
During the Reagan era, as a board member of the National Health Lawyers Association (which subsequently morphed into the American Health Lawyers Assocation) I learned of the enormous power vested in House-Senate conference committees, where proposed legislation may be rewritten and the vote for the rewritten, often very different bill than that originally passed by the house or senate, is straight up and down.
Instead of getting excited about the political hoopla surrounding health reform, I suggest my readers keep their eyes on the ultimate conference committee and its rewrite of health reform. That's where deals will be made, the decisions hammered out, and health reform will either be gutted or given the muscle that it needs to work. Take a look at Ezra Klein/Jim Horney's analysis of conference committee functions for insight into this legislative powerhouse.
Instead of getting excited about the political hoopla surrounding health reform, I suggest my readers keep their eyes on the ultimate conference committee and its rewrite of health reform. That's where deals will be made, the decisions hammered out, and health reform will either be gutted or given the muscle that it needs to work. Take a look at Ezra Klein/Jim Horney's analysis of conference committee functions for insight into this legislative powerhouse.
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