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Out of Control Physicians: Too Many Doctors Doing Too Many Things to Too Many Patients

My father is 92 years old, and I am beginning to wonder whether the best thing for his health would be to stay away from doctors. That’s because well intentioned physicians often expose their elderly patients to harmful and unnecessary services out of habit. That’s certainly the message I absorbed after reading a recent issue of JAMA Internal Medicine that published three studies documenting the worrisome frequency with which internists like me over-test and over-treat our patients. I am going to briefly describe these three studies before laying out some ideas about what’s going on here.

One study explored the use of PSA screening among men with limited life expectancy. The PSA blood test is used to screen men for prostate cancer. The test is controversial, with some groups saying there is no evidence it benefits anyone and others saying it is a crucial way to reduce prostate cancer deaths. Despite this controversy, almost everyone agrees that when people have limited life expectancy–when, because of age and other illnesses, they probably have fewer than five years to live–the PSA test does more harm than good. But some physicians nevertheless continue to order PSA tests, even in men close to the end of their lives.

The study, which analyzed data from Veteran’s Affairs medical centers, found out that patients receiving care from “attending physicians”–more senior physicians–were more likely to receive harmful PSA tests than patients receiving care from physicians still in training. Indeed, 40% of patients expected to live five or fewer years received PSA tests from experienced physicians, versus only 25% receiving care from trainees :

Out Of Control Too Many Doctors Doing Too Many Things To Too Many Patients Fig 2

The second study looked at carotid artery imaging in people 65 years or older. The carotid arteries are the large vessels on either side of your neck, the ones you can feel your pulse on. They are the main supply of blood to the brain. People who get blockages in their carotid arteries are at risk for strokes.

Carotid imaging with tests like ultrasound can identify narrowing of these important arteries, potentially revealing partial blockages in time to fix them before they fully occlude. In the old days, I’d place my stethoscope on a patient’s neck to listen to the harsh sound of blood squeezing its way through these blockages. Upon hearing a worrisome whoosh, I’d send my patient for imaging and then, if my suspicions were warranted, would refer the patient to a neurovascular surgeon, who would decide whether to perform a procedure to open up the artery.

But now, we physicians are being told to be more cautious. The benefits of all these tests and treatments aren’t so clear in many patients. The risks of the surgery can outweigh the benefits in people with no history of stroke or stroke-like symptoms. Nevertheless, many physicians continue to test and treat aggressively.

To read the rest of this article, please visit Forbes.

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What Behavioral Economics Get Wrong About Improving Healthcare

It is notoriously difficult to change physician behavior. When it’s discovered that primary care physicians are, say, prescribing too few cholesterol pills or too many antibiotics, it will not be easy to change those behaviors. Physicians are strong-willed people, with lots of things competing for their attention and with many well ingrained habits.

That’s why I should be excited about several recent studies establishing successful ways of changing physician behavior. One trial, which I wrote about earlier, showed that physicians were less likely to inappropriately prescribe antibiotics after receiving feedback on how their prescribing habits compared to their peers. Another trial, published in the New England Journal of Medicine showed that an intervention combining professional education, informatics and financial incentives reduced how often physicians inappropriately prescribed high-risk medications like pain pills that can cause GI ulcers. Here is a picture of those results, showing a reduction in high-risk prescriptions after the intervention, a reduction that lasted even after the intervention was no longer being implemented:

What Behavioral Economic Interventions Get Wrong About Improving Healthcare 1

And a third study published in JAMA showed that financial incentives informed by insights from behavioral economics increased the likelihood of getting patients’ cholesterol under control.

To read the rest of this article, please visit Forbes.

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Nice Coverage of Our Robot Study

Robot Plays Operation

My student and colleague, Karen Scherr, recently published an excellent article showing that physicians don’t always describe robotic surgery in an unbiased manner. Here is a nice write up of that work:

Author Peter Ubel referred to a study done at four Veterans Affairs medical centers of men making decisions on how best to treat their prostate cancer. As part of their report, the researchers recorded clinical interactions between patients and surgeons discussing the pros and cons of robotic surgery for treatment of their prostate cancer. 

The study found that some surgeons had access to robotic surgery while others did not. Those who used robotic surgery were more positive about the outcomes using the robotic surgery. The study determined that those surgeons who didn’t have a robot available “downplayed its advantages.” 

Ubel, who wrote about the study with colleagues Angela Fagerlin, Karen Scherr, John T. Wei and Lillie D. Williamson, said he did not believe the surgeons were willfully misleading the patients. While he does think most physicians do believe the robotic surgery is better, they want to reassure patients that they will still receive state-of-the-art care without the use of a robot. 

He also noted that in the case of the Veterans Affairs doctors they were not promoting the use of the robotic surgery for financial gain because there is no financial incentive for surgeons at the VA medical centers to choose one procedure over another. 

In an abstract describing the VA medical centers study, the researchers noted they performed a content analysis of the physicians’ descriptions of robotic surgery for prostate cancer during 252 appointments at four facilities. They found the doctors were more likely to describe the robotic surgery as superior if it was available at their center.

The researchers also provided evidence that the physicians were shaping how they described the treatments “in an effort to manage patients’ emotions and demands for the robotic technology.” 

They conclude that treatment availability does influence how the doctor describes the pros and cons of alternatives, “which has important practical implications for patient empowerment and patient satisfaction.” 

To read the rest of this story, please visit Health Care Business Daily News.

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Three Things to Know about Future Healthcare Spending

For my entire life, a half century and counting, healthcare spending in the U.S. has almost always risen faster than inflation. Sometimes it’s relatively slow, sometimes it’s relatively fast, but no matter the time, healthcare spending is climbing. Getting healthcare spending under control is really important for us to do if we hope to have any money left in this country to spend on other important things. You know–like food, shelter, education. That kind of stuff.

So are we in the process of getting healthcare spending under control? A couple recent studies shed light on this question.

The first comes from the Bureau of Economic Analysis, an agency within the Department of Commerce. Using a new measure, researchers at the Bureau were able to break down healthcare spending by disease, or at least by a general category of health conditions: cardiology care, for instance, versus cancer care. They looked at two time periods: 2000-2005, a time period of high growth in spending, and 2006-2010, a time of slower growth. They tried to figure out what explained the slower growth in that time period.

Their biggest finding was that the slowing of growth did not occur primarily because fewer people got sick. Growth didn’t slow down, for example, primarily because cholesterol treatment reduced the number of people experiencing heart attacks. Instead, spending slowed mainly because the cost of treating people with problems like heart attacks stopped rising so quickly, what the researchers called the “cost per case” of treatment. Here’s a picture showing that result, with the cost per case line essentially flattening out between 2006 and 2010:

Three Things to Know About Future HC Spending 1
This slowdown in cost per-case spending wasn’t uniform across health conditions. Between 2006 and 2010, care for circulatory conditions grew less than half as quickly as it did between 2000 and 2005. By contrast, the rise in the cost of cancer care didn’t slow one iota over that latter time.

To read the rest of this article, please visit Forbes.

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Industry Shenanigans?

I know, I know: correlation does not mean causation. But it is still suspicious that when industry employees join as co-authors in medical journals, the randomized trials they are writing about are more likely to show positive results – results that make industry products look good. At least that was the finding from a study published in JAMA Internal Medicine:

Photo Credit: JAMA Internal Medicine

Photo Credit: JAMA Internal Medicine

It is becoming increasingly clear that the key to balanced science in clinical medicine is to utilize prospective registries, where we commit to laying out study design hypotheses up front, so the world doesn’t learn only about the trials that work out the way industry hopes them to.

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How Supermarkets Influence Shoppers

Here is a great graphic from the Center for Science in the Public Interest laying out how supermarkets lay out food to encourage impulse purchases:

Photo Credit: Center for Science and Public Interest

Photo Credit: Center for Science and Public Interest

So much for “free” markets!

 

 

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The Healthcare Efficiency Myth – What Really Happens When Doctors And Hospitals Join Forces

For much of the history of U.S. medical care, hospitals and physicians have existed as separate financial entities. Physicians in the U.S. have typically been self-employed, as solo or group practitioners and not as hospital employees. An internist like me might have admitting privileges to several local hospitals. When we admit patients to one of those hospitals, we bill insurance for our services. The hospitals send insurers separate bills for hospital related expenses. Physicians and hospitals have depended on each other to conduct their business, but they have done so while largely maintaining their financial independence.

The U.S. government is trying to change that. The Medicare program is encouraging healthcare providers to consolidate forces into entities like accountable care organizations, in hopes that such integration will increase healthcare efficiency. These hopes exist because some of the most respected healthcare institutions in the country – places like the Kaiser Permanente system and the Mayo Clinic – have long integrated their physicians with hospitals. Indeed, some contend that this integration creates more efficient care.

Such integration could end up costing lots of us lots of money. When hospital and physician practices join forces, healthcare prices often rise.

That’s certainly the conclusion of a study published in JAMA Internal Medicine, led by Hannah Neprash out of Harvard Medical School. Neprash and colleagues explored what happened to healthcare spending when physicians and hospitals integrated. They discovered that outpatient spending rises as physicians gain market power through their hospital alliance. The spending increases are due almost entirely to price increases. Here is a picture of their findings. The main thing to note is that the taller bar, in each pair of bars, is the increase in healthcare prices while the shorter bar is the increase in utilization, following consolidation of physician practices and hospitals:

The Healthcare Efficiency Myth 1

The tall bar on the left reflects a large increase in outpatient spending after hospitals and physicians integrate. The shorter bar right next to it reflects a modest, and statistically insignificant, increase in outpatient utilization at the same time. Spending rises while utilization stays flat – that can only happen because the price of services has gone up.

To read the rest of this article, please visit Forbes.

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Single-Payer Health Care: Love It, Hate It, Love It, Hate It…

One reason our healthcare system in the United States is so messed up is that so few Americans understand much about it. For that reason, their attitudes towards various healthcare reform proposals veer left and right depending on how they are asked for their opinions. Here’s great evidence of that phenomenon, as reported by the Kaiser Family Foundation:

Photo Credit: Kaiser Family Foundation

Photo Credit: Kaiser Family Foundation

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Guess Who Is Struggling to Pay Their Medical Bills!

Here is a picture from the Kaiser Family Foundation showing which Americans were most likely to report problems paying medical bills last year. The sad news is that just about any way you divide it, a hell of a lot of Americans are having a heckuva time paying these bills:

Photo Credit: Kaiser Family Foundation

Photo Credit: Kaiser Family Foundation

 

 

 

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Doctors Can’t Be Trusted to Tell Patients Whether They Should Receive Robotic Surgery

Patients often rely on physicians for information about their treatment alternatives. Unfortunately, that information is not always objective.

Consider a man with early stage prostate cancer interested in surgical removal of his tumor, but uncertain whether it is better for the surgery to be performed with the help of robotic technology. He asks his surgeon for advice, and the surgeon explains that, while robotic surgeries have some advantages (smaller incisions, less blood loss), the advantages are “tiny and unimportant.” And besides: “You do have some smaller incisions with the robotic, but if you added up all the incisions from all the ports and from the incision to remove the prostate itself, it ends up equaling about the same incision length.”

Can that physician’s description of robotic technology be trusted?

My friend and colleague Angie Fagerlin led a study of prostate cancer decision-making that took place across four Veterans Affairs medical centers. As part of that study, she audio-recorded clinical interactions between patients and their surgeons. In some of these interactions, patients asked about the pros and cons of robotic surgery.

As it turns out, some urologists worked at VAs that had access to robotic equipment and others did not. In an analysis lead by Karen Scherr (an MD/PhD student at Duke), our research team discovered that surgeons who had access to the robot were more generous in describing its advantages over standard “open” surgery. When no robot was available, physicians downplayed its advantages. This is illustrated in the following figure, showing the percent of statements physicians made indicating that robotic surgery was inferior, equivalent or superior to traditional surgical approaches:

Doctors Can't Be Trusted Robotic Surgery

Importantly, I do not think physicians are willfully misleading patients about the pros and cons of robotic surgery. Instead, I think most physicians believe the robot is better (in the right hands) but when it is unavailable, doctors try to reassure patients that they will still receive state-of-the-art care. For example, one patient expressed anger that the robot was not available at his VA Hospital: “you see, that’s what’s so stupid about the VA!” The physician tried to assuage his concerns: “If you look at long-term outcomes related to cancer and cancer recurrence,” the surgeon said, “there has really been no difference. That’s why the VA system has not really invested in the robot.”

To read the rest of this article, please visit Forbes.

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