IN THIS ISSUE
For your health’s sake, don’t let your doctor turn into a medical fossil
When medicine advances, but your doctor lags
How patients can be informed, prepared partners in health care
A little gray can be OK
And what to do for shy patients
BY THE NUMBERS
Estimated time in year 2020 it will take for medical knowledge to double. In 1980, the doubling time was seven years
Time that doctors spend on average with each patient.
Estimated time it would take a typical doctor each day to comply with quizzing of patients just about recommended preventive health measures
Estimated time it typically takes for published medical science to translate into widely used clinical practices.
The latest medical news can be dizzying: Medical scientists regularly push new bounds by, for example, targeting cancer treatments based on individual patient genetics. Doctors are applying supercomputing, artificial intelligence, and algorithms to complex diagnoses and attacking deadly viruses with great success.
But as patients see medicine’s march, a practical concern emerges: How might these advances benefit me? And that question makes for another: How up-to-date are my doctors so they can provide me with the best of both routine and advanced care in a brave new world?
To protect our health, we need to cast off the old passive mindset and take on full partnership in our care. And that means helping our doctors keep current.
For your health’s sake, don’t let your doctor turn into a medical fossil
It’s not your imagination. The pace of change in medical treatment has quickened, exponentially. As Peter Densen, a practicing physician and medical educator, observedl:
“It is estimated that the doubling time of medical knowledge in 1950 was 50 years; in 1980, 7 years; and in 2010, 3.5 years. In 2020 it is projected to be 0.2 years—just 73 days. Students who began medical school in the autumn of 2010 will experience approximately three doublings in knowledge by the time they complete the minimum length of training (7 years) needed to practice medicine. Students who graduate in 2020 will experience four doublings in knowledge. What was learned in the first three years of medical school will be just 6 percent of what is known at the end of the decade from 2010 to 2020. Knowledge is expanding faster than our ability to assimilate and apply it effectively; and this is as true in education and patient care as it is in research. “
This can have big effects on patients like you and me. Consider that just a blink ago:
- Doctors persuaded themselves that pain was such a pervasive problem that they needed to listen to Big Pharma and treat pain aggressively with powerful prescription painkillers. Now, we have an opioid drug crisis that may kill in the next decade as many Americans as now live in Baltimore.
- Surgeons recently thought that two of the most common kinds of cancer — breast cancer in women and prostate cancer in men — too often needed to be treated with extensive screening and invasive therapies. Now, doctors focus on discerning which types of these two cancers are aggressive and demand major responses, including surgeries, radiation treatments, and chemotherapies, and which can be treated less radically, including by “watchful waiting.” This also has meant big changes in the recommended screenings for these cancers.
- Weight loss experts were gung-ho for lap-band surgery for the obese, believing the devices were easier to use and could be removed so the procedure was “reversible.” But after seeing how much follow-up work lap bands required, and after evaluating data that showed they were the least effective weight-loss means by surgery, doctors have mostly abandoned the devices and procedure.
It’s clear that even as medicine advances, its risks to patients’ safety and lives aren’t retreating. They may be growing. Experts at Johns Hopkins and elsewhere estimate that medical errors claim the lives of 685 Americans daily or 250,000 a year ─ more people than die of respiratory disease, accidents, stroke, and Alzheimer’s.
While big-picture statistics may be alarming enough, patients also may be feeling in their smaller, more routine contact with caregivers the corrosive effects of big money in medicine — and how the pressure on doctors to build and maintain practices can make them harried and less careful.
Roughly a third of 19,000 doctors surveyed in 2017 reported that they spend just 13 to 16 minutes with each of their patients, while another third bump the time up slightly, to 17 to 24 minutes. Roughly 40 percent of cardiologists (13 to 16 minutes) and 38 percent of oncologists (17 to 24 minutes) reported brief average visiting times with patients.
Doctors express dissatisfaction with the complex demands of their time-pressed practices. They’re not only trying to deal with patients’ medical issues these days, they’re also having to spend key time recording a lot more data in laptops for electronic health records. They may need to describe what they’re doing in special detail, so their staff can translate the information into insurer billing codes, so they can get paid (more).
Many also may be spending key consultation time trying to learn if patients are depressed, abusing tobacco or other substances, oreating right. They may need to devote their brain power to examining the many drugs patients may be taking and their possible interactions, as well as whether they’re taking supplements. Recent research suggests that doctors could spend 7.4 hours a day just complying with all the recommended preventive questions and measures.
Meantime, there are risks when doctors dash from examining room to examining room: A medical malpractice insurance firm analyzed more than 10,000 claims filed between 2013 and 2017, finding that a third of them resulted from errors made in patient diagnosis — with 36 percent of these claims resulting from settings outside of hospitals, i.e. in outpatient situations like doctor offices and labs.
Misdiagnosis is a major medical bane that can result in patient harm and death, and as the malpractice insurer study reported: “Clinical judgment can be impaired for a variety of reasons, not the least of which is that the [process] can be a lonely, rushed, and sometimes overly confident affair.”
Patients need to invite themselves into their own care, including helping their doctors treat them better and in the best and most current ways.
When medicine advances, but your doctor lags
Surely, patients should expect their doctors to stay up to date in their own profession. To their credit, many doctors put a lot of work into being up to date.
But, at the same time, doctors can be stubborn and slow to adopt clinical improvements — even when these are evidence-based, carefully researched, and widely publicized. Researchers have estimated that it takes 17 years for findings from a valid, published medical study to become part of accepted medical practice. Vinay Prasad and Adam Cifu, two doctors and medical educators, have criticized their colleagues and profession for resisting “medical reversals,” situations in which new, rigorous research contradicts existing clinical practice — and the old ways stay. They cite, for example, women’s experience with doctors’ insistence on hormone replacement after menopause to fight heart disease. Clinical trials, however, showed this therapy increased heart attacks and breast cancer in women.
Practitioners shouldn’t blow with the wind, of course. It isn’t helpful when doctors seem to wax and wane on basic benchmarks like blood sugar levels for diabetics and acceptable blood pressure ranges for all of us.
But the New York Times reported on an extreme: The resistance by emergency room doctors to administering a well-accepted clot-busting drug to stroke patients within a crucial window of a few hours to “save brain.” Neurologists and neurosurgeons have pushed for the use of the clot-busting drug, based on rigorous, extensive clinical trials and other studies.
Some ER docs, though — influenced by prominent practitioners in their field, anecdotal information, and cherry-picked data from studies not directly on point — not only won’t give the clot-busting drug, they also don’t tell stroke patients or their loved ones about this treatment. The clot-busting treatment known as tPA is so standard and accepted, by the way, that its availability is one measure for hospitals winning a special designation for stroke care. Doctors are calling for its expanded use beyond the spare few hours in which it once was thought to be effective.
The newspaper story noted in passing this distressing information about younger ER doctors and how Dr. Edward C. Jauch, a medical professor in South Carolina, observed they were keeping up with best practices — and getting negative clinical influences: “The way information and opinion is now communicated to the younger generation of physicians is much more through [the] web and social media and less through peer review journals, journal clubs or live debates.”
Milton Packer, a physician, heart failure expert, and medical educator, has echoed the newspaper’s reporting that fewer doctors than ever, especially young practitioners, don’t take in published medical scienceas they need to. Or, as his provocative blog post headlined the matter: “Does anyone read medical journals anymore?”
To be sure, doctors must show they’re staying current to keep their licenses and specialty credentials. The continuing medical education or CME practices vary by state, with the District of Columbia, Virginia, and Maryland, for example, requiring doctors to amass at least 50 credits (hours) every two years by participating in certified classes, online sessions or bona fide professional improvement programs. The requirements for medical specialists have become more extensive, angering doctors who have battled “maintenance of credential” or MOC requirements.Critics contend the MOCs are excessive, costly, and ineffective.
Patients who poke around a little in the traditional ways that doctors keep current may be unhappy to see, again, how big money undercuts good medicine.
Doctors, for example, once devoted time to reading respected medical journals to try to keep pace with important and useful developments to benefit patients. But with the rise of the internet and the ease of getting information out online, medical science “publishing” has exploded. Canadian researchers estimate 2.5 million new scientific papers get published annually, and, that by 2009, more than 50 million scientific papers had been published since 1665.
Scholars reported in 2005 that their scrutiny of Medline, the “largest and most widely used index of the medical literature,” found that it published 8.1 million journal articles between 1978 and 2001. In recent years, the annual number of Medline articles “increased 46 percent, from an average of 272,344 to 442,756 per year, and the total number of pages increased from 1.88 million pages per year during 1978 to 1985 to 2.79 million pages per year between 1994 to 2001.”
Even the most voracious reader of medical journals would be hard pressed to keep pace with the publication torrent. As doctors try to pore over published, peer-reviewed studies — especially reports on the gold-standard “randomized clinical trials” — they need not only to thrash through a thicket of technical language but also to be wary of frauds and conflicts of interest. Internet trolls have burgeoned in online medical and scientific publishing, creating sites and pseudo journals that infuriate serious researchers and that pollute the web with false — even dangerous — information.
At the same time, well-known and respected medical journals are struggling as never before with scandal, fraud, and conflicts of interest, including debacles like the anti-vaccination calamity that hit the respected Lancet medical journal two decades ago and still poses problems today. The foibles of medical-scientific publication have become so rife they support online publications like the respected site “Retraction Watch.”
Meantime, as the opioid crisis has underscored, Big Pharma and its pill pushers barrage doctors with drugs of dubious use and claims of treatment advance. Doctors should be hugely skeptical of their “free” samples, branded swag, “friendly” lunches, and other meals, as well as speaker and consulting fees. Alas, research shows this relentless Big Pharma advertising and promotion is all too persuasive with supposedly well-educated and highly trained doctors and nurses. Some academic medical centers have given drug hucksters the boot from their facilities, and some states have passed laws restricting the compensation doctors can get from drug companies.
Medical-device makers also have sales people out in force. Some surgeons allow some of these product pushers into operating suites to “advise” on the latest procedures with new devices.
Big Pharma and the device makers also root themselves in doctors’ ears and minds early, with medical academics warning that these contacts, even if well disclosed, foster a career of too easy access and excess credibility by sales people to medical practitioners. CME programs themselves are under fire for failing to disclose conflicts of interest among “experts,” notably their ties to Big Pharma and big device makers.
Doctors also may be unduly susceptible to the Bigfoot phenomenon as they consider patient care and best current practices. From their earliest medical education, doctors are steeped in a hierarchical system in which it is rare and impolite, at the least, for those with lesser education, experience, or accomplishment to question a more senior practitioner. This “etiquette” persists, even at peril to patients, and it can turn into unacceptable, unprofessional intimidation and bullying. Some hospitals have sought to change the medical culture, giving nurses, for example, greater support and leeway to speak out when doctors err, even if they fail basic hygiene rules by not washing their hands.
But if Dr. Big Name and Important at a major hospital decrees that a medical treatment or procedure will be done his way, it can be difficult for others to disagree, even if rigorous evidence and research backs them up on a newer, better option.
How patients can be informed, prepared partners in health care
Here’s what you need to know, but many doctors and nurses might not tell you: In modern medicine, patients rule.
One of your fundamental, critical rights is informed consent — the duty of every health care provider to ensure that you know fully your treatment options and that you decide what path to take, without strong-arming or scare tactics from the person in the white coat.
You might want to start your job as health care partner by getting, reading, and understanding your own medical records. This should be Task 1 for informed consumers, as I made clear in my book, The Life You Save: Nine Steps to Getting the Best Medical Care, and Avoiding the Worst. Reading your own records makes you an informed patient, helps doctors correct misunderstandings about your history, and ensures that you don’t get expensive duplicative tests.
When you get to see your doctor, approach her in a way that you’d appreciate if the tables were turned, so she understands how engaged you hope to be in your own care.
With the economics of medicine existing as they do, you may need to prepare extensively for every doctor contact, aiming to wring the most out of every moment and to improve your health. The New York Times has published a “how to” piece on a successful doctor visit. It details well the items you may wish to muster — and your need to edit these down — before seeing your doctor.
Before your visit, do make notes about items important to you that you want addressed during your consultation.
The internet, of course, may be a double-edged resource for you as you try to see not only accepted medical therapies and procedures that might benefit you but also what may be changing. Be careful online, and that means being skeptical. Over-testing and over-treatment add billions of dollars in needless costs to the nation’s medical tab, and the excesses can be harmful and even fatal.
My firm and I try to provide you with useful, timely information to consider, with both a patient safety blog and this monthly newsletter. In addition, there are credible sites that you may wish to examine, including:
- The Medical Letter, a longtime objective source of non-biased info on drugs and therapeutics, which is free of Big Pharma funding.
- Uptodate.com, a site that enlists independent doctors to do comprehensive reviews of therapies.
- Cochrane reviews, a site originally out of Britain, which does state-of-the-art meta-analyses of studies to prove what works and what doesn’t.
- U.S. Preventive Services Task Force, an independent panel of national experts in prevention and evidence-based medicine. The Task Force works to improve the health of all Americans by making evidence-based recommendations
about clinical preventive services such as screenings, counseling services, and preventive medications.
- Choosing Wisely, a campaign by Consumer Reports, the ABIM Foundation, and leading physician and specialist groups to help patients avoid costly, potentially harmful, and unnecessary medical tests, treatments and procedures.
You may find it useful to look at Journal Watch, a page highlighting medical-journal offerings and posted by the editors of the New England Journal of Medicine, or the medical journal services offered through the National Institutes of Health at PubMed and MedLine.
Healthnewserview.org is worth a web page bookmark so you get a skeptical, informed scrutiny of mass media stories on medical and health matters.
Many MDs look daily at MedPage Today for information on developments in the field. You also may wish to consult any of the many taxpayer-supported government sites with invaluable health and medical information, including the federal Centers for Disease Control and Prevention, the Food and Drug Administration, and the various arms of the NIH.
By the way, while you’re being skeptical and careful in your internet research, you may want to think hard about available evidence about online symptom checkers and their diagnostic accuracy versus experienced internists. British researchers tested the net-based, free evaluations for patients by WebMD, the Mayo Clinic, and Britain’s Isabel Symptom Checker. The results, from various scripted vignettes also provided to more than 200 internists, gave a considerable edge to human MDs: They were deemed correct 72 percent of the time, versus just 34 percent for the online apps.
Keep that in mind before you decide your doc isn’t as up to speed as you’d like, and you decide to give him the boot for yourself and a machine.
A little gray can be OK
When you’re thinking about how up-to-date your doctor may be, does age matter? Research shows that patients don’t necessarily fare worse with older, more seasoned physicians — but only if they’re keeping up larger, robust practices. In an observational study of hospitalists, who are medical specialists caring for patients in hospitals, the 30-day mortality rates crept higher as the doctors were older, rising the most for MDs 60 and older. This wasn’t true, however, for older doctors treating relatively large numbers of patients.
The researchers controlled for variables to add to the accuracy of their results. The hospitalists studied were assigned patients of varying ages and severity of illness, so, for example, the older doctors weren’t just treating frail, very sick, and elderly patients. But the older doctors also may have reckoned with their lessening skills, reduced their caseloads, and ended up not keeping up with the best, most current, evidence-based practices that most benefited their patients.
Experience can be important for doctors, especially surgeons. Practitioners may brag about how they’re innovators and state-of-the-art with their techniques and equipment. Research shows, however, that volume matters, and doctors who perform more of certain surgeries and do so more often can have better patient outcomes. This is an issue you should delve into with any doctor who will be operating on you.
Doctors for shy patients
What happens if you’re on the shy side? Or what if for some other reason, you’re not a great thinker or communicator or self-asserter? Some of us were raised to respect those in white jackets stoically and almost without question.
It may be a good idea to enlist a loved one or knowledgeable friend to accompany you to your doctor visit to provide support, give counsel, and be your advocate.
You, your medical companion, and your doctor will need to agree on the appropriate lines for a spouse, family member, or friend to participate in your medical visit and care. Unless you’ve made and invoke special legal arrangements, such as adurable power of attorney, aka a health care power of attorney, you will retain your legal right to speak for yourself and to make your own decisions about your care.
But a concerned, careful, and thoughtful extra set of eyes, ears, and memory can be critical for patients, especially if they are ill, may have some memory impairment, or may be receiving complex, detailed, and tough medical information from a doctor.
Preventive care reminders
Don’t be an April fool: You resolved just a few short months ago, at the New Year, that you would exercise more, eat better, lose weight, drink less alcohol, and, if you were smoking, give it up.
How go those 2018 health vows?
No nags, just facts: Weight problems are, in a word, huge for Americans. The New York Times and others have put out helpful information about healthful eating, nutrition, and diet.
You might want to re-inspire yourself and ready your body more for, if for nothing else, warm weather and the hectic, energetic Spring and Summer ahead by clicking on these how-to guides:
- What we know (and don’t know) about how to lose weight
- The last conversation you’ll ever need to have about eating right
- How to stop eating sugar
Don’t forget that, as this newsletter reported to you at the year’s beginning, small steps could take you a big way to a healthier 2018. The year’s flying by — let’s get busy and stick with your best health plan!
HERE’S TO A HEALTHY (REST OF) 2018!
Patrick Malone & Associates