Very nice to read the article, indeed truly shocking and counter intuitive.
But after reading my mind immediately connected to Arnold Joseph Toynbee magnum opus study of history wherein he exhaustively discusses the theory about the law of challenge and response.
Albert Toynbee, in his monumental study of world history, used the concepts of “Challenge and Response” to explain how civilizations rise and fall. By “challenge” Toynbee meant some unpredictable factor or event that posed a threat to the ways in which a group of people had made their livelihood in the past. But “challenge” was not all negative. It carried in it the germ of opportunity. “Response” was the action taken by the same group of people to cope with the new situation.
Similarly rookie cardiologist take the challenge as an opportunity to respond positively in the absence of senior cardiologists resulting in patients with acute life and-threatening cardiac conditions got better when the seniors were absent.
But after reading my mind immediately connected to Arnold Joseph Toynbee magnum opus study of history wherein he exhaustively discusses the theory about the law of challenge and response.
Albert Toynbee, in his monumental study of world history, used the concepts of “Challenge and Response” to explain how civilizations rise and fall. By “challenge” Toynbee meant some unpredictable factor or event that posed a threat to the ways in which a group of people had made their livelihood in the past. But “challenge” was not all negative. It carried in it the germ of opportunity. “Response” was the action taken by the same group of people to cope with the new situation.
Similarly rookie cardiologist take the challenge as an opportunity to respond positively in the absence of senior cardiologists resulting in patients with acute life and-threatening cardiac conditions got better when the seniors were absent.
7
This is pretty contrived and naïve. The fact is that senior experienced doctors will take on the high risk cases that others won't. Obviously higher risk patients will have a higher mortality than lower risk ones. This doesn't mean they got "bad" care it just means that they are a high risk group that will see more mortality - which the younger docs refused to do because in THEIR hands such high risk patients would have a VERY high mortality.
Obviously at some stage a very senior operator will start "losing" it. But here we're not talking about 85 year old docs, we are talking about the difference between a newly minted 35 year old vs. a 50-55 year old. As a cardiac catheterization laboratory nurse, I assure you the new guys are VERY shaky and underconfident and rely a LOT on nurses and technicians to tell them what to do. I'd hate to be getting my stent from them.
Obviously at some stage a very senior operator will start "losing" it. But here we're not talking about 85 year old docs, we are talking about the difference between a newly minted 35 year old vs. a 50-55 year old. As a cardiac catheterization laboratory nurse, I assure you the new guys are VERY shaky and underconfident and rely a LOT on nurses and technicians to tell them what to do. I'd hate to be getting my stent from them.
14
The title is cute but misleading. Of course you want the best doctors. The twist is that the best doctors often aren't who you think they are...
12
A senior cardiologist does not mean you are the best, silly boy, everyone knows to ask the nurses in the hospital who is the best doctor not the colleagues.
7
This seems to be a very bad opinion of cardiologists. What does ACP and ACC have to say?
2
Other factor - when the BIG boss shows up everyone's work gets worst - they hesitant and become overly careful. They second guess themselves and the will not challenge nor argue with the big guy (even when they should)
5
Senior Cardiologists are more likely to more aggressively intervene than recent graduates - sometimes is for better patient care and most times rain making. You just have to find those you trust and the key question is always 'what would you do if it was your Mother / Father / Wife'. You will find that treatment is different along with the outcome.
1
Always remember: To the man with a hammer, everything looks like a nail
2
It would have been nice to have the reference to the article in JAMA Internal Medicine so other physicians could review it.
5
Seniors and their families should be aware that Ezekiel is a leader in the seniors-have-a-duty-to-die-ASAP crowd before following his "friendly" advice.
9
Dying in the hospital is directly linked to how long you actually stay there. Get your stitches, your Band-Aid, your aspirin and get out of there.
5
Well, my heart stopped while in ICU at 2 am...the alarm went off and the and the nurses did their thing as they are trained to do...and here I am...four years later. No need for a cardiologist, although I had one of the top cardiologists in the profession.
2
Emanuel, once again shilling for the POTUS and ACA, to try make ACA more palatable. How much bad advice can one politically motivated doctor be allowed to publish freely in this paper?
3
This is not a surprise. In Palo Alto, when sick, you do NOT go to Stanford Hospital despite the brilliant research. You get your buns ASAP to UCSF. Also great research but brilliant clinically.
So I think this report is skewed by those great research hospitals which are lousy clinically. And then there are those great research hospitals like UCSF which are also good clinically.
Take home is check out the clinical record. And here is a HUGE shout-out to the life saving cardiologists at UCSF. You gave my father 15 extra years.
So I think this report is skewed by those great research hospitals which are lousy clinically. And then there are those great research hospitals like UCSF which are also good clinically.
Take home is check out the clinical record. And here is a HUGE shout-out to the life saving cardiologists at UCSF. You gave my father 15 extra years.
12
This is a very brave article. It strikes at the heart why we are an over-medicate, over-treated, yet sicker country then dozens of others in the "first world."
I once went to see 90 year old patient lying comatose like in her hospital bed. As a "psychiatric consultant" I was asked if one low dose anti-depressant was caused her to have a low blood sodium. SHE WAS ON 19 MEDICATIONS.
I approached her bed, put my hand on her forehead, asked her how she was feeling. SHE STARTED CRYING.
I asked her why she was crying and she said, "You are the first Doctor who has asked me that question."
The kidney doctor, the lung doctor, the liver doctor, the cardiologist (all in cahoots with one another to share referrals so they can bump up their billing), didn't ask her a single question. They looked at her chart and prescribed more drugs.
It is criminal.
I practiced medicine for 40 years and I will tell you this, do not trust any doctor under 40. And do not trust any "superstar" surgeon.
Yep, there are really good doctors, most over 40, burned out and co-opted by the pharmaceutical/insurance/hospital industry couples.
United Health Care recently announced they may abandon the ACA? Why? Not profitable enough. The CEO of United Health care is the 3rd highest paid CEO in the United States.
If you are a doctor dealing with them or a patient begging for help they will do everything they can to deny you.
They are a modern day mafia. And they DO NOT CARE IF YOU LIVE OR DIE!!
I once went to see 90 year old patient lying comatose like in her hospital bed. As a "psychiatric consultant" I was asked if one low dose anti-depressant was caused her to have a low blood sodium. SHE WAS ON 19 MEDICATIONS.
I approached her bed, put my hand on her forehead, asked her how she was feeling. SHE STARTED CRYING.
I asked her why she was crying and she said, "You are the first Doctor who has asked me that question."
The kidney doctor, the lung doctor, the liver doctor, the cardiologist (all in cahoots with one another to share referrals so they can bump up their billing), didn't ask her a single question. They looked at her chart and prescribed more drugs.
It is criminal.
I practiced medicine for 40 years and I will tell you this, do not trust any doctor under 40. And do not trust any "superstar" surgeon.
Yep, there are really good doctors, most over 40, burned out and co-opted by the pharmaceutical/insurance/hospital industry couples.
United Health Care recently announced they may abandon the ACA? Why? Not profitable enough. The CEO of United Health care is the 3rd highest paid CEO in the United States.
If you are a doctor dealing with them or a patient begging for help they will do everything they can to deny you.
They are a modern day mafia. And they DO NOT CARE IF YOU LIVE OR DIE!!
30
There is a cultural, professional, financial, and legal incentive for physicians to perform medical and diagnostic interventions that may not be in the patient's best interest. "Wait and see," may be good medicine but it has become a risky proposition: The patient who watches miracle cures on TV hospital ads expects the doctor to do SOMETHING; the doctor is asked on rounds, "What did you DO for (or to) this patient?"; the insurance company does not reimburse the doctor well for time spent - but pays significantly more if the doctor does SOMETHING; and the lawyer is more likely to sue the doctor for a delay in diagnosis ( frequently even if the outcome would not change) if he didn't do SOMETHING. Even electronic health records prompt doctors with "Best Practice" alerts - and I rarely (if ever) see one that says, "Don't do anything." Maybe doctors and their patients have to change the definition of a "good" doctor to one who has the self-assurance and resiliency to know that doing nothing is doing something.
7
The best mentors I had in medicine always said that your patient should NEVER be on more than four medications at one time!
Meds are prescribed, side effects occur, then MORE meds are prescribed.
Today we have the same lousy mortality rate with heart attacks--about 50% don’t live beyond 6 months. Caths, angios, stents, coronary bypass grafts, the rise of coronary care units--no difference in the long run. Congestive heart failure? No matter what is done, once first diagnosed life expectancy is five years. Period.
I’ve been doing family practice for over 40 years...from the top teaching hospitals to very poor rural clinics to Doctors without Borders.
Here’s what keeps you alive the longest: Good nutrition, moderate exercise--30 minutes 4-5 times a week, living in a country with a long life expectancy---war zones take their toll, and having great genes. If your parents lived to 90, you can expect the same.
Oh yeah. Don’t do stupid things. Most premature deaths are preceded by the words: “Hey watch this!” and even better “Hold my beer, now watch this!”
Live smart, do basic medical prevention--Pap smears, mammograms, colonoscopies after age 50 or at 40 of there is a family history. Don’t smoke. alcohol in moderation--one to two drinks a day at most. Park the car, WALK, so use public transportation, walk up stairs--no elevators or escalators. AND don’t keep a gun in your home--you have a seven times GREATER chance of dying by gunfire with a gun in the house.
Meds are prescribed, side effects occur, then MORE meds are prescribed.
Today we have the same lousy mortality rate with heart attacks--about 50% don’t live beyond 6 months. Caths, angios, stents, coronary bypass grafts, the rise of coronary care units--no difference in the long run. Congestive heart failure? No matter what is done, once first diagnosed life expectancy is five years. Period.
I’ve been doing family practice for over 40 years...from the top teaching hospitals to very poor rural clinics to Doctors without Borders.
Here’s what keeps you alive the longest: Good nutrition, moderate exercise--30 minutes 4-5 times a week, living in a country with a long life expectancy---war zones take their toll, and having great genes. If your parents lived to 90, you can expect the same.
Oh yeah. Don’t do stupid things. Most premature deaths are preceded by the words: “Hey watch this!” and even better “Hold my beer, now watch this!”
Live smart, do basic medical prevention--Pap smears, mammograms, colonoscopies after age 50 or at 40 of there is a family history. Don’t smoke. alcohol in moderation--one to two drinks a day at most. Park the car, WALK, so use public transportation, walk up stairs--no elevators or escalators. AND don’t keep a gun in your home--you have a seven times GREATER chance of dying by gunfire with a gun in the house.
42
I am a cardiologist.
Both reasons given are valid
Younger cardiologists are more closely involved in care as they are building a new career. They have to keep safety a very high priority due to patient satisfaction and reporting requirements.
Second senior cardiologist may attempt more complex procedures (not necessarily more stenting) which naturally have higher complication rates.
Another very important thing I have done in my office and hospital practice is DRASTICALLY DECREAED the no. of medications for sicker and older patients.
BUT I am regularly penalized by insurance and Medicare automatic algorithms for not prescribing standard of care meds.
If doctors don't prescribe these meds they are almost forced to. Hospitals are severely penalized for not giving at least 4 class of meds to every heart attack patient.
And that comes straight from top doctors like Dr Zeke and CMS
Both reasons given are valid
Younger cardiologists are more closely involved in care as they are building a new career. They have to keep safety a very high priority due to patient satisfaction and reporting requirements.
Second senior cardiologist may attempt more complex procedures (not necessarily more stenting) which naturally have higher complication rates.
Another very important thing I have done in my office and hospital practice is DRASTICALLY DECREAED the no. of medications for sicker and older patients.
BUT I am regularly penalized by insurance and Medicare automatic algorithms for not prescribing standard of care meds.
If doctors don't prescribe these meds they are almost forced to. Hospitals are severely penalized for not giving at least 4 class of meds to every heart attack patient.
And that comes straight from top doctors like Dr Zeke and CMS
53
As a few commenters know, I find countless OpEds that lead to simple question (SQ) number 1, have you, the writer or the NYT Editor, taken a moment to ask SQ number 2?
SQ 2: Can we put the subject before us in perspective by considering experience in a country or countries outside the USA?
Answer to SQ 2: Yes, almost always.
General example: In Universal Health Care the heart or other patient does not choose the physician. So E.J. Emanuel might just wonder why, if Swedish patients cannot choose, how do Swedes, seen statistically, manage to live so long?
Anecdotal example: I had a cardiolite stress test at UVM Cardiology Center, Burlington VT about 10 y ago. Surprise, they said, images consistent with diagnosis stunned myocardium. Took the images back to my Valla Vårdcentral Clinic, Linköping, Sweden. Soon after received a letter (kallelse): Check in at Linköping University Hospital, there are stent(s) in your future. Polish interventionist put 2 in LADA and a month later Swedish interventionist put no. 3 in circumflex. Results good, will run slowly later today in my forest.
Sorry to report that the two Swedish Verifieds seem to be no longer active, they might provide details.
Only-NeverInSweden.blogspot.com
Dual citizen-USA-SE
201511220756
SQ 2: Can we put the subject before us in perspective by considering experience in a country or countries outside the USA?
Answer to SQ 2: Yes, almost always.
General example: In Universal Health Care the heart or other patient does not choose the physician. So E.J. Emanuel might just wonder why, if Swedish patients cannot choose, how do Swedes, seen statistically, manage to live so long?
Anecdotal example: I had a cardiolite stress test at UVM Cardiology Center, Burlington VT about 10 y ago. Surprise, they said, images consistent with diagnosis stunned myocardium. Took the images back to my Valla Vårdcentral Clinic, Linköping, Sweden. Soon after received a letter (kallelse): Check in at Linköping University Hospital, there are stent(s) in your future. Polish interventionist put 2 in LADA and a month later Swedish interventionist put no. 3 in circumflex. Results good, will run slowly later today in my forest.
Sorry to report that the two Swedish Verifieds seem to be no longer active, they might provide details.
Only-NeverInSweden.blogspot.com
Dual citizen-USA-SE
201511220756
2
Is this the same Ekekiel Emanuel who also recommended that we skip our annual physicals and also wrote something about not really wanting to live to be over 75?
I love your articles, Dr. Emanuel, and this one made me laugh, but - you're talking about people who really want their mother, father or dear relative to live. Shouldn't having a qualified cardiologist around be of some help? Or are you just trying to keep your friends from calling you when someone they know gets sick?
I love your articles, Dr. Emanuel, and this one made me laugh, but - you're talking about people who really want their mother, father or dear relative to live. Shouldn't having a qualified cardiologist around be of some help? Or are you just trying to keep your friends from calling you when someone they know gets sick?
6
Oh, Dr. Zeke, "you're a man after my own heart", as they say.
My new mantra (at age 75, a retired R.N. & enjoying good health), is NOT, "Don't just stand there, do something" but IS, "Don't just do something, stand there".
I've completed my healthcare proxy, advanced directives, body donation forms, scanned them into my E.M.R. & had a "conversation" c all of the people involved.
Now that that's done, I can relax & enjoy life.
My new mantra (at age 75, a retired R.N. & enjoying good health), is NOT, "Don't just stand there, do something" but IS, "Don't just do something, stand there".
I've completed my healthcare proxy, advanced directives, body donation forms, scanned them into my E.M.R. & had a "conversation" c all of the people involved.
Now that that's done, I can relax & enjoy life.
4
So the Republicans were right all along?!
The best solution to our vexing medical coverage problem is to ask people to just walk it off? :-)
The best solution to our vexing medical coverage problem is to ask people to just walk it off? :-)
2
It's kinda hard to know what to do with this information.
"Mr. Notlob, there's nothing wrong with you that an expensive operation can't prolong." - Monty Python
6
" Are Good Doctors Bad for..."
What exactly is a "good doctor?" A doctor with the most titles- Department Chair, endowed position- ? These are the types of doctors who almost never attend to patients in emergency rooms.
Maybe you should stop making generalized statements based on correlational studies.
What exactly is a "good doctor?" A doctor with the most titles- Department Chair, endowed position- ? These are the types of doctors who almost never attend to patients in emergency rooms.
Maybe you should stop making generalized statements based on correlational studies.
5
Too many cardiac catheterizations! Reminds me of the Porsche license plate that belonged to a cardiologist at my hospital - "FLIPPR" - as in clot flipper. They need to cool it with excessive procedures.
1
Thank you so much. I agree. And I have found that, the more famous and renowned the institution, the less likely it is that the doctors are interested in and open to new solutions, new treatments. If you tell the prestigious doctors something worked they think you are deluded. If you want someone interested in new developments and new ideas look elsewhere.
1
I had a parrot in Paris and decided to get his sex determined (African Grays are monomorphic). I took him to the Paris zoo's bird specialist vet. The guy that wrote the book in France on exotic bird care. My bird was dead the next day. Reaction to anaesthesia. I had been assured the laproscopic procedure was safe. So yeah, I can see that the experts don't always get it right. This was a long time ago....
1
I read this article 2 hours ago when there were 4 comments - and, I have reread the article, and there are still only 4 comments. The problem with this article is that it has two great ideas, but is poorly written. I think the author should have said that best doctors are those who have recently finished their residency, know newest procedures and treatments, whereas the more "senior" docs are a little sloppy. The 2nd great idea comes out of Israel, and that is that many of the elderly folks are over medicated and do best with less drugs. Better yet - Zeke should come up with ideas and let other people write them....
1
I'm glad Dr Emanuel wasn't around when it was clobbered with cardiac ischemia in 2011. I'm glad a skilled interventional cardiologist was around at 3 am to immediately implant two stents within 45 minutes of the heart attack. Ten days later I was hitting tennis balls. If there had been all the yakking and kvetching he recommends I'd be long dead by now.
4
Let Dr. Zeke be his own guinea pig then. He makes some good overall points but the correlation sounds a bit nebulous.
2
Only one problem with your argument. Stents clearly saves lives when it comes to heart attacks. Your argument holds true for patients with chronic stable angina. Don't let facts, however, get in the way of your narrative.
2
So many people being doctored to death.
2
I wonder if Colonoscopy at age 50- with no health problems- is a good idea? Seems like a waste.
1
Part of the problem is defining who is the "best". Is it the most senior or most famous, someone quoted in the Times? Is it who has the best quality data, hedis scores. Or maybe someone who does basic evidence based care, not too much and communicates well.
4
This might have been an excellent opportunity to spread the word about Choosing Wisely - google it - more patients, families, health care professionals and administrators will benefit when these evidence-based guidelines are widely discussed. In 2012 the ABIM Foundation launched Choosing Wisely® with a goal of advancing a national dialogue on avoiding wasteful or unnecessary medical tests, treatments and procedures.
Choosing Wisely centers around conversations between providers and patients informed by the evidence-based recommendations of “Things Providers and Patients Should Question.” More than 70 specialty society partners have released recommendations with the intention of facilitating wise decisions about the most appropriate care based on a patients’ individual situation.
Choosing Wisely centers around conversations between providers and patients informed by the evidence-based recommendations of “Things Providers and Patients Should Question.” More than 70 specialty society partners have released recommendations with the intention of facilitating wise decisions about the most appropriate care based on a patients’ individual situation.
3
Few other Western countries would think of making healthcare for-profit!
2
No doubt teaching hospitals are generally better, but if you have a heart attack you need to be first taken to the nearest hospital that can catherize your arteries for blockages and stent one or two arteries to keep blood flowing to your brain. For open heart surgery, you can then be airlifted to a teaching hospital.
Acute care surgeons are trained to advise patients of their options. And you definitely want to consult with a younger acute care specialist who isn't going to be wedded to the notion of some senior surgeons that they are capable of prolonging life regardless of the pain and suffering of patients.
Acute care surgeons are trained to advise patients of their options. And you definitely want to consult with a younger acute care specialist who isn't going to be wedded to the notion of some senior surgeons that they are capable of prolonging life regardless of the pain and suffering of patients.
1
A useful article which reinforces the need to use a hands on, state of the art trained doctor for the best results. A prestigious "administrator" who lectures and attends elite conferences may not be your best bet, and when it comes to your heart, you may not get another chance to bet.
1
Well, I looked up the article. Contrary to Dr. Emanuel story here, there is absolutely nothing there about stratifying senior and junior cardiologists at teaching hospitals going to meetings. It is possible that the best clinicians at the teaching hospitals did not go to the meetings, perhaps they care more about taking care of patients. It is also possible that the teaching hospitals were understaffed and were not accepting the higher risk patients (it is difficult to capture the entire story from bird's eye view inherent to these kinds of studies).
Dr. Emanuel, you are telling sick patients to conduct sophisticated data analysis. Meanwhile, you are unable to communicate data without contaminating it with your own narrative. That is bad science, bad medicine, and bad journalism. It may be that your narrative is actually correct, but retelling the data to fit the narrative is wrong.
Dr. Emanuel, you are telling sick patients to conduct sophisticated data analysis. Meanwhile, you are unable to communicate data without contaminating it with your own narrative. That is bad science, bad medicine, and bad journalism. It may be that your narrative is actually correct, but retelling the data to fit the narrative is wrong.
12
I would add a fifth question to Dr. Emmanuel's four: "If we forego this treatment/drug at this time, under what circumstances would we initiate/restart it?" One of the best teachers in my medical internship said, "I'm a minimalist, but if you're going to be a minimalist, you have to articulate the conditions under which you *would* do something; that's the difference between being a minimalist and doing nothing."
6
Confirms results in Dawes et al (1989) "Clinical versus Actuarial Judgement", Science and review by Dan Kahan, Yale Law Shool, The Cultural Cognition Project: The greater the cognitive capability the greater the cognitive bias.
1
I had to go Mass General a while back and you are totally right - teaching hospitals are the best. I woke up to the senior doctor gently stroking my hand walking me through what was happening, two newbies who looked like they could have been your prom date and one who looked as terrified as me.
To hear the doctor explaining the situation to a group of four made the experience so less scary. I don't believe in trickle down economics but I do believe in trickle down humanism. In my limited stay I saw a doctor teaching young doctors how to make people suffering feel at ease. It was extremely powerful for me and better than any pill!!!
To hear the doctor explaining the situation to a group of four made the experience so less scary. I don't believe in trickle down economics but I do believe in trickle down humanism. In my limited stay I saw a doctor teaching young doctors how to make people suffering feel at ease. It was extremely powerful for me and better than any pill!!!
4
What a mess we've made of the medical industry. The common refrain,' we have the best health care in the world' has become a cruel joke.
3
I’m glad that I can read the true story about treatments in hospitals. I have scarcely gone to the doctor. I have not taken any medicine for almost ten years. My colleagues in their 50teens and 60teens tend to go the doctor speedily when they feel something wrong and accept the diagnosis of his doctor obediently. One of my colleagues said, “There was something wrong with the result of my cardiogram. There was nothing wrong with the second test of cardiogram. But my doctor said that it would be better for me to have an operation on my heart. It is not a serious operation that will be undergone next week so let’s go to drink two weeks later.” I told him why he would have an operation so easily. I advised him that he should have a diagnosis of another doctor.
It is true that patients do not think over the risk of operations and the side effect of medicines so much.
It is true that patients do not think over the risk of operations and the side effect of medicines so much.
1
Zeke,
The reason why there is a higher mortality in the patients of top cardiologists, if they are indeed tops in their field, can be no other than the fact that the best cardiologists are assigned the gravest (and therefore, highest mortality) cases. Or do you really believe the opposite?
The reason why there is a higher mortality in the patients of top cardiologists, if they are indeed tops in their field, can be no other than the fact that the best cardiologists are assigned the gravest (and therefore, highest mortality) cases. Or do you really believe the opposite?
6
While I have not experienced serious, life-threatening health problems (to date), the points of this article ring true to me. However, would it be possible for authors of such articles to include specific access information of studies cited? I can access JAMM Internal Medicine, but I am also interested in the source of the Israeli study of "over-medicating", especially of the elderly. Specific references to studies cited would be helpful to readers, and can go at the end of an article.
2
I wish zeke would be prevented from publishing in the times. First he takes over healthcare, then every article is about spending less now that it's coming out of his program.
9
The question that should be asked in this op-ed article's title is: Is too much medical intervention bad for your health? And the answer, given what Dr. Emanuel has said here, is yes, too much medical intervention IS bad for your health. I found it especially interesting that stopping most of an elderly person's multiple medications actually made them healthier. Hmmmm.
2
I wish my orthopedic doctor was out of town when I had my knee replaced. A year later and I still can't walk without a walker.
This article confirms my primary criteria for selecting a new doctor: is he/she at a teaching hospital. I've found that doctors at teaching hospitals are simply more curious. They want to get to the root of your medical issue, and treat it appropriately using the scientific method. In contrast, I've found doctors affiliated with non-teaching hospitals very transactional -- process the patient fast, give them the "right treatment", and if it doesn't work, "oh well".
3
It has for a good while, maybe since I was young and healthy enough to be interesting as a test subject, been my opinion that R&D is a highly discretionary and certain way to increase the high cost of medical care and an area of investment that is arguably no less beneficial when it produces negative results than when a marketable (FDA approved?) drug or clinical procedure is obtained. Protect us at all costs please.
In the virgin forests, the gardens of mother earth have been decimated by the once profitable foraging of the coal and mining interests. Thus, we can not afford to direct "seed money" to small entrepreneurs because the well run dry.
So it is with available health care options. Many just are not available to me or my neighbor. Maybe in another part of town.
But this is just an example of how this expose is directed at such a small sample. How much fits onto a specimen slide? Many people are persuaded of validity when individual examples, cases, are described more so than when highly impersonal, impossibly distant and exotic studies are quoted to substantiate a hypothesis already of limited value to anyone but the idle rich.
interesting information presented maybe. My doctor might not agree to take me off any little drug. Most important to me: Better treatment means Less treatment. More treatment means get a different provider while you still can.
In the virgin forests, the gardens of mother earth have been decimated by the once profitable foraging of the coal and mining interests. Thus, we can not afford to direct "seed money" to small entrepreneurs because the well run dry.
So it is with available health care options. Many just are not available to me or my neighbor. Maybe in another part of town.
But this is just an example of how this expose is directed at such a small sample. How much fits onto a specimen slide? Many people are persuaded of validity when individual examples, cases, are described more so than when highly impersonal, impossibly distant and exotic studies are quoted to substantiate a hypothesis already of limited value to anyone but the idle rich.
interesting information presented maybe. My doctor might not agree to take me off any little drug. Most important to me: Better treatment means Less treatment. More treatment means get a different provider while you still can.
1
The public is not privy to many other variables at work that motivate "good doctors".
1. What difference will it make? To the patient, of course? "Ruling out" competing diagnoses, identifying a diagnosis not considered, establishing a baseline are among the variables that impact the patient that are "self evident" to the clinician, are a routine, or are casting about in the dark. To the physician? A habitual choice, "defensive medicine", a preference of the service, research group, or hospital, remuneration are also variables.
2. Improvement of prognosis, prolong life, prolong quality of life? Conflict is evident in that life takes precedent over quality of life. To the patient quality may be paramount and it falls on patients and their surrogates to clearly describe their goals. The public does not consider the fact that life may be on a ventilator, dependent, or vegetative.
3. How severe are the side effects? What are the symptoms of the side effects? How long will they last? What remedies for side effects are there and what are the side effects of the remedies?
4. Is the hospital a teaching hospital? The benefits of teaching hospitals may be diminished by higher infection, decubitus ulcer, and wound dehiscence rates as compared to non teaching hospitals. At a minimum, hospital Patient Safety Indicators (the measure of harm to patients) must be a factor.
These are good questions. They should be coupled with a frank detailed discussion with PMD immediately.
1. What difference will it make? To the patient, of course? "Ruling out" competing diagnoses, identifying a diagnosis not considered, establishing a baseline are among the variables that impact the patient that are "self evident" to the clinician, are a routine, or are casting about in the dark. To the physician? A habitual choice, "defensive medicine", a preference of the service, research group, or hospital, remuneration are also variables.
2. Improvement of prognosis, prolong life, prolong quality of life? Conflict is evident in that life takes precedent over quality of life. To the patient quality may be paramount and it falls on patients and their surrogates to clearly describe their goals. The public does not consider the fact that life may be on a ventilator, dependent, or vegetative.
3. How severe are the side effects? What are the symptoms of the side effects? How long will they last? What remedies for side effects are there and what are the side effects of the remedies?
4. Is the hospital a teaching hospital? The benefits of teaching hospitals may be diminished by higher infection, decubitus ulcer, and wound dehiscence rates as compared to non teaching hospitals. At a minimum, hospital Patient Safety Indicators (the measure of harm to patients) must be a factor.
These are good questions. They should be coupled with a frank detailed discussion with PMD immediately.
1
It's not clear to me why the Times published this article. The data are unclear as to why the difference in mortality rates is "not trivial" -- so are we, the readers, supposed to speculate as to why that might be? If the experts don't know why, the commenters here taking guesses are only going to be correct by accident. Unfortunately, given no explanation, the article only serves to make people fearful of the one thing they probably shouldn't be fearful of: expert care.
3
Why do we always demand action as opposed to contemplation? Other than in bona fide emergency situations, contemplation is the superior method for obtaining an accurate diagnosis & establishing treatment. Unfortunately, our for-profit medical-industrial complex prefers action because it generates greater profit with little regard for positive outcomes for the patient.
1
In the case of a cataract operation, the patient and his or her near and dear have plenty of options to choose an eye surgeon since the operation concerned doesn't need immediate operation but not so in the case of heart attack. The patient needs to be immediately rushed to the nearby hospital with the best or even adequate facilities available there. Under the circumstances the near and dear have no option but to seek the services of the available cardiologist and then hope for the best, then where is the question of raising a number of questions.
We were in America from January 2007 till May 2012. We never fell sick but visited our family doctors, Internal Medicine, for regular checkup every two to three months. I am diabetic and also have high B.P. My wife has high B.P. I was asked to undergo ECG, 2D Echo, stress test etc from time to time for which I have no complaint. My complaint is that the opinion of a Cardiologist was sought by my family doctor as expert. Luckily our insurance was good enough to cover the expenses. What I mean to say is that if the clinic were to have a cardiologist, I could have approached him directly so that expenses could have been much lesser especially it would have helped those, who don't have adequate insurance coverage.
Even though we never fell sick, our family doctors always had to claim the money from insurance as if we were sick. I don't think this way of claiming is correct. It could have been better as " reqular checkup " claim.
We were in America from January 2007 till May 2012. We never fell sick but visited our family doctors, Internal Medicine, for regular checkup every two to three months. I am diabetic and also have high B.P. My wife has high B.P. I was asked to undergo ECG, 2D Echo, stress test etc from time to time for which I have no complaint. My complaint is that the opinion of a Cardiologist was sought by my family doctor as expert. Luckily our insurance was good enough to cover the expenses. What I mean to say is that if the clinic were to have a cardiologist, I could have approached him directly so that expenses could have been much lesser especially it would have helped those, who don't have adequate insurance coverage.
Even though we never fell sick, our family doctors always had to claim the money from insurance as if we were sick. I don't think this way of claiming is correct. It could have been better as " reqular checkup " claim.
1
The flaw in the study is that most cardiologists practice in groups rather than solo - this is certainly true for "famous, senior cardiologists". It is also most likely that the "famous" cardiologists are at teaching hospitals and not at non-teaching hospitals.
Furthermore, in an emergency setting you get whoever is on call for the group and that cardiologist is your cardiologist for the duration of your hospital stay. Senior cardiologists are less likely to be on call than the junior members of a group (who are often the ones away at conferences, for educational purposes granted by contract).
A study like this requires more follow-up and confirmatory studies before it can be taken at face value.
Furthermore, in an emergency setting you get whoever is on call for the group and that cardiologist is your cardiologist for the duration of your hospital stay. Senior cardiologists are less likely to be on call than the junior members of a group (who are often the ones away at conferences, for educational purposes granted by contract).
A study like this requires more follow-up and confirmatory studies before it can be taken at face value.
3
First of all , this is an OP-ED, where the author of the OP-ED himself is providing the interpretation. Don't go rushing into all kinds of conclusions based on ONE study whose details the readers have not reviewed. For the record, I am a physician, an internist, so I do not feel the need to defend my cardiology colleagues. However, since I have not read the study I will reserve judgment until I have personally examined the methodology. Nevertheless, some points are valid regardless. Being more senior, more " famous" does not mean you are a better clinician, nor a " top " doctor( which is one reason you should take with a grain of salt any Top Doctor list you see). Those who practice on the frontlines have known this forever. Medicine is as political as any other endeavor in society. Connections, seniority, ability to go along with the " establishment ", who started the practice etc influence leadership positions in medicine which due to lack of objective data often being available are sometimes translated to mean " better " doctor. However, do not make the mistake to interpret what this article says to mean that clinical experience is not a valid and useful criterion in selecting a physician. A very " junior " doctor's more limited experience could in certain situations affect his/her clinical judgment adversely and he/she may also lack sufficient number of encounters to have optimal proficiency. High level of clinical skill and competency is a composite of many factors.
6
Article is provocative but let us not take one JAMA article to lay the foundation of who the good doctors are and if good care is only in teaching hospitals. Cardiologists who are famous, holding prominent leadership positions, listed in "Best Doctors" list , and attending big national meeting circuits may not be in the prime of their career. I think as interventional cardiologist you are at your prime between fifteen to twenty five years of practice. You get over "fix all" attitude and get humbled by the knowledge that enemy of good is better. Trusting relationship between patient and doctor is most important. All the data, mumbo jumbo and questions cannot make the decision. That has to come from doctor. Each situation is unique and data is only generic. I would suggest apply "my family test". Will I do this procedure if it was my family. That keeps my thinking process fairly straight.
Community hospitals have a huge role and they also have very many excellent doctors practicing medicine. They may not be publishing heavy duty research and may not be on lecture circuit but they are doing the bread and butter, every day clinical medicine which is more relevant to care of the patient. Mortality rates of hospitals have issues of measurement, documentation of risk profiles of patient and other issues relating to how the data is defined.
Community hospitals have a huge role and they also have very many excellent doctors practicing medicine. They may not be publishing heavy duty research and may not be on lecture circuit but they are doing the bread and butter, every day clinical medicine which is more relevant to care of the patient. Mortality rates of hospitals have issues of measurement, documentation of risk profiles of patient and other issues relating to how the data is defined.
1
"It is surprising how uncomfortable some physicians get when you ask these questions. No one likes to ... have to justify their decisions. "
If it is my body, why shouldn't I be able to question what my physician prescribes for me?
This quote also shows why there is this problem with senior physicians. I admire and care very much for the many physicians who welcome questions. They are the backbone and treasure of the medical profession. But the ones who feel they should not be questioned, more often senior doctors, have become arrogant and cold as they gained prominence and power. That this is the cause of the problem is amply supported by a NY Times article "Empathy Is Actually a Choice” published July 10, 2015, which shows that the more of a certain kind of power a person feels he or she has, the less the empathy that person will choose to feel.
Many of the doctors I have been treated by were both highly competent and respectful. In the meantime, what we can do as to certain other physicians is to be more demanding that they stop falsely believing they are better than other people, and that they never stop seeing their patients are just as deserving of respect as they are. Otherwise, as this article indicates, there will be more unnecessary deaths.
If your physician does not welcome questions get one who will!
If it is my body, why shouldn't I be able to question what my physician prescribes for me?
This quote also shows why there is this problem with senior physicians. I admire and care very much for the many physicians who welcome questions. They are the backbone and treasure of the medical profession. But the ones who feel they should not be questioned, more often senior doctors, have become arrogant and cold as they gained prominence and power. That this is the cause of the problem is amply supported by a NY Times article "Empathy Is Actually a Choice” published July 10, 2015, which shows that the more of a certain kind of power a person feels he or she has, the less the empathy that person will choose to feel.
Many of the doctors I have been treated by were both highly competent and respectful. In the meantime, what we can do as to certain other physicians is to be more demanding that they stop falsely believing they are better than other people, and that they never stop seeing their patients are just as deserving of respect as they are. Otherwise, as this article indicates, there will be more unnecessary deaths.
If your physician does not welcome questions get one who will!
1
A good geriatrician knows the adage, "do no harm." Unfortunately, there are under 7000 of us in the U.S. and the number is dropping every year. Making matters worse, most physicians, trained with Medicare funds, are taught and expensive, aggressive, high tech approach to care of older adults with chronic conditions. Geriatricians practice a high touch, often low tech approach and have excellent outcomes. Until with address this issue, we will continue to be saddled with the health care system that we have today. No number of bandaids, in the form of government regulations and programs, will reeducate or newly educate doctors and other clinicians.
2
As others have pointed out; it is more often the junior-mid level attendings (and senior residents) who attend conferences (they are building their careers), than the senior level attendings.
The assumption it is "top doctors" or senior doctors only who leave for conferences is unjustified and this undermines the whole article/Op-Ed. But I doubt these hastily written op-eds really try to consider alternate explanations in their rush for exposure. This is why we leave critical analysis for careful peer reviewed studies.
The assumption it is "top doctors" or senior doctors only who leave for conferences is unjustified and this undermines the whole article/Op-Ed. But I doubt these hastily written op-eds really try to consider alternate explanations in their rush for exposure. This is why we leave critical analysis for careful peer reviewed studies.
3
I have great respect for Zeke Emanuel's knowledge of the health system. So, I will take on faith that the "What" documented by the studies is valid. But, Dr. Emanuel is speculating about "Why" cardiac mortality (30 days post discharge) is higher during cardiology conventions. Readers should realize that when he used terms such as "possible explanation", "possibly", etc. That intriguing observation sets up his discussion of the risks of over treatment and what patients should do to protect themselves.
Dr. Emanuel could have pointed out an additional source of information - rating systems for hospitals - that would have been more specific and accurate than his statement that teaching hospitals have better outcomes. That may be true in general, but is not true in many locals. Services such as Healthgrades use massive databases on hospitalizations to provide risk-adjusted comparisons of in-hospital complication and mortality rates, as well as the mortality rate 30 days post discharge. In many geographies non-teaching hospitals may have superior outcomes or may have equally good outcomes at much lower cost. http://www.healthgrades.com/find-a-hospital
Or, Google "hospital quality ratings" to find other rating systems.
Dr. Emanuel could have pointed out an additional source of information - rating systems for hospitals - that would have been more specific and accurate than his statement that teaching hospitals have better outcomes. That may be true in general, but is not true in many locals. Services such as Healthgrades use massive databases on hospitalizations to provide risk-adjusted comparisons of in-hospital complication and mortality rates, as well as the mortality rate 30 days post discharge. In many geographies non-teaching hospitals may have superior outcomes or may have equally good outcomes at much lower cost. http://www.healthgrades.com/find-a-hospital
Or, Google "hospital quality ratings" to find other rating systems.
Absolute rubbish. This is the kind of sloppy, post hoc ergo propter hoc that a scholar should be loathe to perpetuate. The study doesn't say that senior docs were away, or that any given patient had a different treatment. There are hundreds of reasons why there might be differences - the most likely is the play of chance. Meanwhile, if this is what "data mining" and big data are giving us in medicine, it is heading down the wrong path. Dr. Emmanuel should share his clinical outcomes but then again, he stopped seeing patients 20 years ago.
6
Does the average senior cardiologist consider being first to test a new procedure or new drug on patient more important than guaranteeing as much as possible that patient's safety ? That's the impression get reading this.As to many of the prescription drugs,usually their advertisement mostly consist of warnings of the many ways they can make worse,and even kill us,until by the time the is finished I forget the good reason to ask my doctor about it.
When the "senior" cardiologists are at their annual meetings, patients with life threatening cardiac conditions have better outcomes. Dr. Emanuel suggests some reasons. Is it possible that the new drugs and new interventions presented at these meetings are actually not always better than the procedures younger residents are trained to know well. New does not equate with better. We have the most expensive healthcare in the world but rank last in outcomes, quality and access when compared to countries that have single payer government funded healthcare. We need to get rid of the "fee for service" model which only encourages more unnecessary testing and procedures. We need to rid the FDA of corporate influence and approve drugs that are truly beneficial. We need to investigate the racketeering of drug companies that, for example, can raise the price of a vial of ACTH from $50 to $28,000. We need to elect a congress that is not corrupted by drug and insurance companies. And we need to elect a President. like Teddy Roosevelt, who was first to advocate for a single payer healthcare system.
6
Were the RESEARCHERS asking the right question?
Perhaps there were other (non-obvious) factors
other than the senior cardiologists being absent?
When the top doctors were not available,
did the patients in the worst condition go elsewhere?
Similar studies have found that
Monday is the worst day for surgery.
Why should that be?
Researchers assumed that it was
because surgeons were not at their best on Mondays.
But a more reasonable explanation emerged:
The most complicated surgeries are scheduled for Mondays
because of the longer time needed for follow-up and recovery.
The rest of the medical staff would be at full strength
during the regular work-week but not on the week-end.
Surgeries are not randomly scattered over the week.
And the more complicated cases (schedules for Mondays)
have a higher rate of failure.
Bottom line for researchers:
Look for non-obvious factors
that might explain the differences.
Perhaps there were other (non-obvious) factors
other than the senior cardiologists being absent?
When the top doctors were not available,
did the patients in the worst condition go elsewhere?
Similar studies have found that
Monday is the worst day for surgery.
Why should that be?
Researchers assumed that it was
because surgeons were not at their best on Mondays.
But a more reasonable explanation emerged:
The most complicated surgeries are scheduled for Mondays
because of the longer time needed for follow-up and recovery.
The rest of the medical staff would be at full strength
during the regular work-week but not on the week-end.
Surgeries are not randomly scattered over the week.
And the more complicated cases (schedules for Mondays)
have a higher rate of failure.
Bottom line for researchers:
Look for non-obvious factors
that might explain the differences.
6
These results appear to be a genuine correlation. This truly bears more examination and study. But it is still correlation without any explanation. As I look through the comments, there are a number of guesses as to why this happens. It's because of greedy doctors and hospitals who do procedures to make more money. It's because of ivory tower docs who don't really practice medicine anymore. It's because often these docs are the ones who take care of the sickest patients. It's even because there isn't a definition of what a "good doctor" is. Because, of course, a good doctor isn't the same as an academic expert.
What I would really love to see is research that compares PATIENT perception of whether they have a "good" doctor or not, and how outcomes compare. This type of article calls academic specialists "good" doctors. As the Gershwins said, "It Ain't Necessarily So".
What I would really love to see is research that compares PATIENT perception of whether they have a "good" doctor or not, and how outcomes compare. This type of article calls academic specialists "good" doctors. As the Gershwins said, "It Ain't Necessarily So".
Good doctors are not bad for your health. The problem is that too many good doctors practice medicine with unexplained variances in their practice patterns. Almost all physicians and nurses I know acknowledge these variations. My most vivid memory of these variances was from an office nurse who worked with five physicians. The patients were of similar economic class, insurance, complaints and ages. Yet the office nurse who floated to each of the physicians noted wide differences in lab orders, time spent with patients, instructions, etc. What factors contributed to these practices patterns? Surely the patient's clinical condition was the dominate factor. But also the physician's personal economic status was a factor. For example, a divorce, a child in college and other personal economic factors. Only a few types of physician organizations are able to address this type of very discrete dis-incentive. Insurance companies and government are marginally effective practice influencers.
1
It's bad now, but wait till you see what's coming (and is already begun) with accountable care organizations
Part of the problem is that cardiologists have moved into the traditional territories of thoracic and vascular surgeons, who are better trained and equipped for certain conditions.
Why?
Money. Purely money.
I have a friend who went into a local, nationally ranked hospital for cardiology. They decided she needed a stent ... and tore her aorta.
In my experience, the very best, most knowledgeable physicians are slow to recommend surgery;
Part of the problem is that cardiologists have moved into the traditional territories of thoracic and vascular surgeons, who are better trained and equipped for certain conditions.
Why?
Money. Purely money.
I have a friend who went into a local, nationally ranked hospital for cardiology. They decided she needed a stent ... and tore her aorta.
In my experience, the very best, most knowledgeable physicians are slow to recommend surgery;
1
Not terribly useful. How the heck is the family to know what the doctors should do? If the senior cardiologists are messing up that is the responsibility of the hospital or the other doctors. Not being in on these interactions I sure don't know what is wrong. Someone must, perhaps the author. Could he share his thought on what is happening?
2
Ann older study showed the same thing, more generally. Mortality rates went down in Israel during a physician strike.
I estimate between knowledge and skills, you're best off with a Fellow or an attending no more than five years after Fellowship. But the more unsettling thought is you might be better off without a doctor at all. There must have been someone manning the ER during the strike: EMTs? Nurses? They can't all be better than attendings, but I'm sure we often underestimate the value of their opinions, and skills.
I estimate between knowledge and skills, you're best off with a Fellow or an attending no more than five years after Fellowship. But the more unsettling thought is you might be better off without a doctor at all. There must have been someone manning the ER during the strike: EMTs? Nurses? They can't all be better than attendings, but I'm sure we often underestimate the value of their opinions, and skills.
1
Very good point. Of course, now I want to read up more on this topic, starting with the JAMA article mentioned. It bugs me that the exact reference is not provided, nor the lead author, nor the date of publication. Pubmed search with JAMA heart failure teaching hospital will give you the article, but the the reference should be included as standard practice.
2
The question that should be asked in this op-ed article's title is: Is too much medical intervention bad for your health? And the answer, given what Dr. Emanuel has said here, is yes, too much medical intervention IS bad for your health. I found it especially interesting that stopping most of an elderly person's multiple medications actually made them healthier. Hmmmm.
Lyndon Johnson famously insisted on having the chief resident - - and not the chief of Surgery - - perform his operation.
3
sources and data, please
I'm not just going to take your word for it.
Medicine should not be a "cult of personality" enterprise.
Maybe the same logic also applies to articles: it is better to read your own medical journals than to rely on the interpretation of a big shot.
I'm not just going to take your word for it.
Medicine should not be a "cult of personality" enterprise.
Maybe the same logic also applies to articles: it is better to read your own medical journals than to rely on the interpretation of a big shot.
2
Zero surprise. Ask any young house officer about the early lesson-- protect your patients from the senior faculty.
The second study is not surprising, either. Even though most medications are added with a clear indication and the best of intentions-- once you have a soup of 5-7 medicines bubbling away in someone's system-- you really don't have any idea what's going on.
The second study is not surprising, either. Even though most medications are added with a clear indication and the best of intentions-- once you have a soup of 5-7 medicines bubbling away in someone's system-- you really don't have any idea what's going on.
3
I don't believe the spin Dr. Ezekiel put on the JAMA article, and question the validity of the JAMA's analysis. The summary of the JAMA article did not include any description of which cardiologists at teaching hospitals went to the meetings. The absence of chief residents or young attendings in the Cardiology departments may have resulted in the seasoned professionals taking over during the annual cardiology meetings.
4
It always helps not to have some ego-maniacical power junkie looking over your shoulder.
This report is not surprising at all.
This report is not surprising at all.
I haven't read this paper, but somehow I don't believe it, or at least that the conclusions are correct - maybe it's worth examining this paper more carefully before advertising it widely in the NY Times. Part of the reason I don't believe it is that the senior research oriented cardiologist are not likely to take care of very many patients even when they are in town. Senior faculty at teaching hospitals are typically more involved with teaching or leadership positions than actual patient care, which is often left to the residents anyway. If this observation is correct, you have to argue that the senior cardiologist is somehow inhibiting the residents and junior faculty from doing a good job. And given that their jobs are to TEACH these people at these TEACHING hospitals where they work, you'd have to argue that the best teaching hospitals have the worst teachers if they cause so much trouble.
4
As I recall, when President Reagan needed a chest tube after being shot, the secret service demanded that the head of surgery put it in. And were told that the interns =s and residents ALWAYS do it and the head has not done one in years.
That little vignette supports this article.
That little vignette supports this article.
4
Is this like being treated for cancer by a famous oncologist who doesn't spend much time in clinic anymore?
2
The United States and New Zealand are the only countries in the world that allow "ask your doctor" television and radio advertising by Big Pharma. This is one of the major causes of over-prescribed medication, and must be stopped.
5
When a former President needed an emergency procedure on his coronary arteries, the Cardiology Chief was out of town, within 100 miles. He was called in to treat a V.I.P. who could not be named. The Chief replied that if the V.I.P. was not named, he would not come in to the hospital.The next day, a younger but excellent cardiologist on his staff was named on TV and in newspapers around the world for his important role in operating successfully upon the former President.
Morton Linder, M.D., Mount Kisco, NY
Morton Linder, M.D., Mount Kisco, NY
4
Vice provost, eh? Could it be that the policy entrepreneur stuff isn't working out as well as you had hoped?
Banging on other docs always gets the amen chorus going. Hey Zeke, how about putting down the pen and putting on the stethoscope again? Or is that just too much work?
Banging on other docs always gets the amen chorus going. Hey Zeke, how about putting down the pen and putting on the stethoscope again? Or is that just too much work?
6
A better approach would be for every individual to have a physician who is solely responsible for the _management_ of his or her health. Not to treat, but to review past treatments and diagnoses for efficacy, to check for interactions, to review overall progress and call for a change of course.
Today, a doctor sees you, makes a call, "treats" you, and leaves you with a regimen -- and usually a prescription. And you may never seen him or her again. Few other doctors will question the prescription. Why should they? They're seeing you to treat you for something else. So a thick crust of physician "guesses" over time build up in the medicine cabinet and body.
We won't have this until medicine is truly reformed. I probably won't see it.
Today, a doctor sees you, makes a call, "treats" you, and leaves you with a regimen -- and usually a prescription. And you may never seen him or her again. Few other doctors will question the prescription. Why should they? They're seeing you to treat you for something else. So a thick crust of physician "guesses" over time build up in the medicine cabinet and body.
We won't have this until medicine is truly reformed. I probably won't see it.
1
Great piece, thanks.
This prompts my recollection of being on a rock climbing trip with a friend of mine several years ago. My friend started complaining of fatigue nausea. It was a sweltering hot day, and so at first I wrote it off to first stages of heat exhaustion and told him he should sit for 20 minutes to see if he felt better. Both my friend and our third companion were EMT trained, while I was/am not. After resting, my friend stood up and walked around and immediately felt badly again. I said 'you are having a heart attack and we need to get you some aspirin before you take a step further'. Neither of the other two concurred, and my friend was incredulous that I would come to that conclusion. Eventually, we got an aspirin into him, but we called an ambulance as well. Four EMT's came up the trail and 'checked' him with a portable EKG machine. I said 'I don't care what the machine says, he's having a heart attack'. The EKG showed nothing unusual, and he got up and we all walked out, me protesting that we should be carrying him. Six EMT's opinions, and me, the only non-EMT saying otherwise.
They took him to the hospital and he had a quadruple bypass less than 24 hours later. They said he was having he widow-maker and was lucky to be alive.
So much for EMT training.
This prompts my recollection of being on a rock climbing trip with a friend of mine several years ago. My friend started complaining of fatigue nausea. It was a sweltering hot day, and so at first I wrote it off to first stages of heat exhaustion and told him he should sit for 20 minutes to see if he felt better. Both my friend and our third companion were EMT trained, while I was/am not. After resting, my friend stood up and walked around and immediately felt badly again. I said 'you are having a heart attack and we need to get you some aspirin before you take a step further'. Neither of the other two concurred, and my friend was incredulous that I would come to that conclusion. Eventually, we got an aspirin into him, but we called an ambulance as well. Four EMT's came up the trail and 'checked' him with a portable EKG machine. I said 'I don't care what the machine says, he's having a heart attack'. The EKG showed nothing unusual, and he got up and we all walked out, me protesting that we should be carrying him. Six EMT's opinions, and me, the only non-EMT saying otherwise.
They took him to the hospital and he had a quadruple bypass less than 24 hours later. They said he was having he widow-maker and was lucky to be alive.
So much for EMT training.
7
I remember not long after the Bernard Mitchell Hospital was dedicated at the University of Chicago, Bernard Mitchell --THE Bernard Mitchell--was hospitalized there and died. When I asked someone I knew at the U of C what had kicked him, my friend said, "Staffitis." Not initially understanding, I asked, "Staff Infection?" But my friend explained that no, it wasn't staphylococcus, but TOO MANY HOSPITAL STAFF trying to save their VIP patient that had ultimately done in Mr. Mitchell. I wasn't able to verify this, but I made a mental note to stay anonymous and poor when seeking medical care. I also heard in regard to another Chicago area teaching hospital that it was a great place for transplants or other risky procedures, but that they would kill you if you came in with a hangnail. I made another note: Find a local doctor and hospital with a good reputation for care, but no super stars, please. I've done just fine since then.
5
What does one do in New York City when the ambulance arrives and takes you to the Next Scheduled Hospital, and will not take you to the teaching hospital, the nearest hospital, but only the one the dispatcher says you're going to?
8
"While senior cardiologists are great researchers, the junior physicians — recently out of training — may actually be more adept clinically"
I would argue this is the real take-away from this article. The first ten years out of residency is likely the time when evidence based medicine and clinical experience are perfectly balanced.
I would argue this is the real take-away from this article. The first ten years out of residency is likely the time when evidence based medicine and clinical experience are perfectly balanced.
20
Perhaps the most important health care article NYT has published. My suspicion, after helping care for multiple elderly, is that the periodic suspension of drugs to determine effect suggests the most potential beneficial outcome. Carl.Portland
1
It would have been nice if the author had provided the reference to the JAMA Internal Medicine article so it could be reviewed.
1
Give me back the good old-fashioned family doctors who actually touched a person and physically examined them, and asked questions along the way, before they prescribed anything or ordered tests. Pay that family doctor more than surgeons or other "specialists". America will be a healthier nation and average Americans will save BILLIONS of $$$ in health care costs.
6
I searched for years to find a great internist at our teaching hospital and have relied on her direction in getting great care from specialists. She knows who are the most effective Doctors.
1
A new book titled "Ending Medical Reversal" is worth reading and reinforces some of the implications and inferences of this article.;
1
This is definitely a 1%-er problem. Only rich connected and supremely entitled people would demand "the best cardiologist" in Miami on their way to the ER. The other 99% take what they can get and just pray they are really covered by their insurer.
11
As a physician I know my particular field very well, but i will never know any patient as well as they know themselves. So a successful encounter requires that we negotiate an exchange of information; you exercise your expertise about you and I exercise what I know about medicine and you. I invite questions and I feel a need to explain myself in plain English. I wish to negotiate an agreed-upon plan, or at least explain why I can't support the plan you'd prefer.
Still, that's not how we are going to act if you are having a heart attack. It requires a different approach.
Still, that's not how we are going to act if you are having a heart attack. It requires a different approach.
2
Dr. Emanuel's article echoes an important message that I took away from reading a fine, thought-provoking book, Being Mortal, by Dr. Atul Gawande.
As a woman getting up in years, I'm grateful for the wisdom and guidance I found in both of them.
As a woman getting up in years, I'm grateful for the wisdom and guidance I found in both of them.
3
While the reaearchers teated various scenarious to isolate the likeliest factor contributing to the observed decrease in mortality, they seem to have missed a very important one -- what happens when the senior cardiologista ar the community hospitals are away?
Isn't it quite conceivable that the key issue with senior academic cardiologiats may be that, on average, they are simply not such good practitioners relative to the junior staff? After all, with all the reaearch and administration that they are involved in, the time they spend in the OR can be rather limited. So the problem could simply be a matter of rusty fingers...
Isn't it quite conceivable that the key issue with senior academic cardiologiats may be that, on average, they are simply not such good practitioners relative to the junior staff? After all, with all the reaearch and administration that they are involved in, the time they spend in the OR can be rather limited. So the problem could simply be a matter of rusty fingers...
2
A fifth question should be, "what will the quality of life be and does the patient want to be resuscitated?" At 81, I do not!
2
Amen ! I'm with you.
I've had a good life, and I want a good death.
But like all things in life, you must plan and work for your final exit.
I've had a good life, and I want a good death.
But like all things in life, you must plan and work for your final exit.
Often there is pressure for doctors to do something. Wheather from well intentioned non-physician staff , guidelines or even insurance companies. Often the best course, for examine, not is not prescribing medications,. However this is quite hard at times.
3
We had that general practitioner whose philosophy was basically "do nothing." So he missed my avascular necrosis leaving me years of pain before the new one sent me to the orthopedic specialist for a hip replacement. He also missed my young adult child's Grade IV brain tumor which would surely have killed him had I not taken him to the neurologist on my own. So doing nothing is not always the wisest course.
Since a physician's and the hospital's income typically increases with the number of procedures and is typically unrelated to the patient outcomes, should overtreatment not be expected?
8
An apple a day keeps the doctor away. -- Ben Franklin
I'd probably go to the doctor more often, but I've found their offices are usually full of sick people.
I'd probably go to the doctor more often, but I've found their offices are usually full of sick people.
5
Perhaps we should take treatment adjustment more seriously, although don't expect the drug companies to take the lead. Both my parents became colder, weaker, prone to falling, and prone to frequent napping as they aged; while their dosage of beta blocker, ACE and diuretic remained unchanged. Mom had a routine BP of 100/67 just before her sudden death episode.
2
Several years ago my mother was a resident at the Hewrew Rehab Centre in Boston. She had chronic renal failure, and congestive heart failure. After a "visit" to the Beth Israel, where the Residents and Fellows treated her with exceptional medical and personal care, she decided that she would not return to the hospital. She was 91 at this time. All kinds of well meaning physicians and medical staff at the Rehab centre at various times pleaded with her to return to the hospital. Her decision was final. She lived another wonderful two years, only receiving oxygen care. Had she succumbed to the advise of "experts," I am convinced that her tenure at the Hebrew Rehad Centre would have been shortened.
More was not better; I doubt that will change.
More was not better; I doubt that will change.
9
How could she live 2 years with renal failure?
Who would get better medical attention than one of the greatest surgeons of all time, Dr. Debakey? The overwhelming chaos and mayhem by his doctors, and indeed even his own repeated self misdiagnosis in his final days is laid out in this great story from a few years ago.
This is what the best medical attention in the world, at any price, looks like:
http://www.nytimes.com/2006/12/25/health/25surgeon.html?pagewanted=all
This is what the best medical attention in the world, at any price, looks like:
http://www.nytimes.com/2006/12/25/health/25surgeon.html?pagewanted=all
3
I've learned first hand how doctors really don't know. I was born in a teaching hospital. The doctor has a group of interns feel for a hernia on both sides that he had to fix. Each intern explained they felt them both except one who said he felt only one. He cut both sides to fix them both, but sure enough I had only one.
3
You unfortunately experienced the care of a bad doctor, which does not generalize to all doctors.
If I take my car to a tire and brake shop to repair a tire, and the shop recommends all new tires brakes and shocks, I can easily decline the unnecessary repairs (I know their condition) and save a thousand dollars, although those repairs would present no risk to the car. In a hospital, I will agree to those "repairs" often with significant risk, not to mention exorbitant costs.
Take the profit out of medical care!
Take the profit out of medical care!
15
You are not a car
It's becoming abundantly clear that we need to tabulate and reveal the 4 clinical outcomes (preventative, medical, surgical and palliative) manufactured and produced by physicians, institutions, therapists and technologies in health care according to all variables in order to discern what are the best diagnostics and treatments and who are the best physicians and hospitals for which diseases and more importantly why they're the best.
Clearly, when it comes to clinical outcomes in healthcare in America: The Emperor Has No Clothes! https://www.linkedin.com/pulse/health-care-marketing-emperor-has-clothes...
Clearly, when it comes to clinical outcomes in healthcare in America: The Emperor Has No Clothes! https://www.linkedin.com/pulse/health-care-marketing-emperor-has-clothes...
4
"Clinical Outcomes" aside (Preventative, Medical, Surgical and/or Palliative), we may be forgetting to discuss the "frequent flyer", who may have a "clinic/hospital/healthcare provider dependency" problem.
They may experience a "reward" (perhaps subliminal), from "failure to comply" and/or multiple surgical procedures.
They may not "hear" the best healthcare teaching in the world.
They may experience a "reward" (perhaps subliminal), from "failure to comply" and/or multiple surgical procedures.
They may not "hear" the best healthcare teaching in the world.
1
It is more likely than not that the difference is due to patients who are not severely ill but only marginally so, in whom the benefit of a more aggressive approach might be doubtful.
Also, I am not convinced that the authors could demonstrate that all the "senior cardiologists" were away at conferences - this is a presumption that may be unwarranted. It may be just as likely that the junior cardiologists were away, sent for education at a major meeting, leaving a cadre of senior cardiologists to handle the most dire cases.
Moreover, the nature of study had to require analysis of insurance data, which is always fraught with ambiguities and never tells the complete story.
I would take this study with a grain of salt.
Also, I am not convinced that the authors could demonstrate that all the "senior cardiologists" were away at conferences - this is a presumption that may be unwarranted. It may be just as likely that the junior cardiologists were away, sent for education at a major meeting, leaving a cadre of senior cardiologists to handle the most dire cases.
Moreover, the nature of study had to require analysis of insurance data, which is always fraught with ambiguities and never tells the complete story.
I would take this study with a grain of salt.
3
typical md response.... go ahead and challenge any suggestion that your bottom line is what drives your decisions when it comes to patient care.
I agree. Even time I go to a specialist, like my dermatologist or orthopedist, the aide takes my blood pressure for no reason (except to bill the insurer). It's just business...the kind of business that drives up costs. Doctors like to make money. Medical practices today are generally profit-driven like law firms. If a doctor wants to get ahead, become partner, I assume they have to be profit-centers. Patients' needs are not primary. We are just a shoulder, a mole or a spleen to a typical medical specialist.
26
That's one interpretation. Another would be that specialists taking blood pressure is a good thing because many patients are rarely seen by a doctor, so this is an opportunity to identify underlying treatable disorders (such as hypertension) that can have catastrophic consequences (stroke, heart attack) when left untreated.
Blood pressure readings are important to know when prescribing drugs.
And if the insurer -including Medicare- decides that extra bill is an overcharge,we patients are required to pay,rather than the Dr. or medical facility having to absorb the loss by not getting paid ,period,by anyone.
My experience as a General Surgeon is that good hospitals follow routines for diagnosis and treatment. As soon as somebody, not seldom VIPs get inferior treatment because they want the Chief Specialist to intervene. The Chief Specialist is pushed to deviate from the routine which causes delays in treatment and the treatment might end up being something not tested before.
1
I hate studies like this for 2 reasons. The first is that they are based on arbitrary and vague ideas like "star" doctors. Suppose I define a star doctor to be one whose patients have shown a high probability to recover. Then, of course, you would want to go to one.
Secondly I seriously doubt is the authors of the studies know enough about probability to know that random data can exhibit non-random phenomenon if you select it carefully. The best example of that is:
The Texas Sharpshooter:
A drunken Texan one evening went out and shot up the side of a barn and then passed out. Since he was shooting randomly the bullet holes were all over the place, but there were some places where they clustered together. When he awoke the next morning, he looked at the barn and drew bull's eye targets around the clusters. Then he told everybody what a good shot he was even when he was drunk.
A fancy selection fallacy.
Secondly I seriously doubt is the authors of the studies know enough about probability to know that random data can exhibit non-random phenomenon if you select it carefully. The best example of that is:
The Texas Sharpshooter:
A drunken Texan one evening went out and shot up the side of a barn and then passed out. Since he was shooting randomly the bullet holes were all over the place, but there were some places where they clustered together. When he awoke the next morning, he looked at the barn and drew bull's eye targets around the clusters. Then he told everybody what a good shot he was even when he was drunk.
A fancy selection fallacy.
I ask what physicians to avoid and what hospital has the best outcomes for whatever medical condition presents.
These are statistics and people individual health histories govern. Obviously, over treatment is to be avoided but that has never been my experience. Getting any diagnostic test has been more of an issue.
These are statistics and people individual health histories govern. Obviously, over treatment is to be avoided but that has never been my experience. Getting any diagnostic test has been more of an issue.
Maybe that's why at M&M conferences when a VIP comes in bad things seem to happen more often because they often dictate their care and demand certain docs who they think are the best. The best docs are the ones who are not flashy and work the most. The ones with the great reputations may spend more time cultivating a reputation and less time working clinically.
2
This past year, I had my first heart attack brought on by an AFib. I wound up in the local hospital under the care of a fine cardiologist. It annoyed me at the beginning when he would explain what was happening, what he wanted to do, what he suggested as the right treatment and then asked if I wished for him to proceed with every step he was taking. When he was preparing me for a pacemaker implant, he insisted that I understand I could refuse, that I would certainly live without the pacemaker, that it would involve taking a blood thinner that I might not be totally comfortable with.
He drove me nuts. IMO, he was the expert and I was the patient. But, apparently, to this highly recommended cardiologist, I was the one who had to make the decisions for my health and he would carry them out.
I'm healthy, my heart is fine, my pacemaker scar is barely visible, and I still hate taking medications but I made the choice to do so as he keeps telling me I can quit them if I insist.
He drove me nuts. IMO, he was the expert and I was the patient. But, apparently, to this highly recommended cardiologist, I was the one who had to make the decisions for my health and he would carry them out.
I'm healthy, my heart is fine, my pacemaker scar is barely visible, and I still hate taking medications but I made the choice to do so as he keeps telling me I can quit them if I insist.
You are now an active participant in your medical care. Be pleased.
2
I wonder if there is any correlation with a star doctor's arrogance? The famous physicians are less available and tend to delegate. Getting an appointment with one of them can be like trying to personally talk to a movie star. I'm sure this is not true of all of them, but people who are practically worshipped can develop characteristics that reflect the saying "power corrupts."
1
Juding by his op eds in the Times, Ezekial Emanuel appears to revel in anything that disparages physicians and thrills at the idea of further regulation of medical practice.. But the take home from the study he cites may be that the teaching rounds that fill so much time when senior academic faculty are on service actually impede patient care, using time better spent in expeditious management of illness. As a senior administrator at Penn, of course, Emanuel is one of those responsible for sustaining that enterprise.
3
Yep, of course more often does not equal better. But patients want more, they want to eliminate uncertainties which represent a 1% chance of complications or diagnosis failure, so more testing and procedures are done. And of course the lawyers stand ready to punish less medicine with more lawsuits should that 1% event occur ! And the government reinforces this paradigm with the legal system, the reimbursement system, and now a new mandate : physicians will be graded and reimbursed on how they please the patients. So forget cost control, NYT, just forget it.
5
Since Dr Emanuel is familiar with JAMA, I would like to direct his attention to an article in the Nov 19, 2014 issue that examined CDC data on heart disease mortality. It shows that death rate for coronary heart disease delined annually by 5.1% between 2000 and 2010. It does not seem like all these pills, stents and defibrillators are killing many patients.
As for the effect of conferences, many of the megastars spend more time attending meetings and giving lectures so they are not as good technically anymore. Finally, asking for a teaching hospital makes sense if you are in a big city. Not if you happen to be more than an hour away by helicopter from the closest community hospital.
As for the effect of conferences, many of the megastars spend more time attending meetings and giving lectures so they are not as good technically anymore. Finally, asking for a teaching hospital makes sense if you are in a big city. Not if you happen to be more than an hour away by helicopter from the closest community hospital.
3
Defibrillators save lives. Nephrologists should inform their patients about defibrillators, and should recommend implantation, because dialysis can and does cause cardiac arrest, especially in older patients. Assuming one values the older patients enough to want them to live, one should encourage ways to save their lives. Of course, that's may be an optimistic assumption...
Another point is that in teaching hospitals there may be pressure for the hospital to perform procedures on patients in order to provide learning opportunities for residents. This places pressure on the hospital to recommend procedures for patients where the potential benefits are marginal, at best.
2
While Ezekiel Emanuel is entitled to his opinion, it is worth noting that he is neither board certified in internal medicine or medical oncology. Board certification is required in reputable hospitals to practice medicine and to see patients. Thus, his opinions should be taken as those of a member of the public with a medical degree, rather than those of an active, practicing physician.
10
Why would being in active practice improve the objectivity or scientific competence of someone? The way that practitioners used remedies which are now totally discredited such as bloodletting for thousands of years demonstrates they they (and patients) are incapable of judging how effective treatment is, when the result is not absolutely unambiguous. The true cause of infectious disease was discovered by Pasteur, who was a chemist, not a physician.
4
Even if we consider Dr. Ezekiel Emanuel as man with a Medical degree, he is more than competent to express his opinion about practicing doctors when compared with the common man since he has studied medicine and also might have observed how the hospitals, doctors and senior doctors in particular handle the patients right from his college days. Can't he give his opinion on the basis of his observation and also interaction with others, he surely can.
1
His vitae shows his is a diplomate (Board Certified) both in Internal Medicine and Medical Oncology.
1
When an older person enters the state run California Veterans Homes, one brings no medication. Instead, one is subjected to a week of thorough medical screening and then the elder patient receives only enough medication for a healthy, happy and long residency. I am convinced it added two years to my father's life.
If I asked for the "best" cardiologist, I would, of course, mean the one with the best outcomes given patients of similar starting conditions. It would never occur to me to ask for the most famous or the most senior.
2
Another factor in all of this is athe quality of nursing care and the staffing ratios of nurse to patient. In a teaching hospital there are more MD's involved in care than nurses. How does this impact a patient?
I would also like to see the study results on death rates around holidays and major changes in medical staffing in teaching hospitals such as the first week in July when newly minted Md's are starting.
I would also like to see the study results on death rates around holidays and major changes in medical staffing in teaching hospitals such as the first week in July when newly minted Md's are starting.
Since so many patients need not medication, but lifestyle changes, what if they are given a "refrigerator prescription"? It's not to go to the pharmacy, but put up where the patient can see it every day. A prescription for diet changes, exercise, and stress reduction techniques. The patient will go away with a prescription, and to have something in writing may help them with follow through.
7
Be a little careful about the teaching hospital you use. Ours became so dysfunctional and decrepit with such a high rate of infection from lack of state funding for renovations that it was recently sold to a private company. As always, living where there are higher taxes and adequately funded community services leads to a healthier environment. Privatization is not the answer in medicine as these studies seem to show.
2
Yet another possibility could be time. When the senior cardiologists are in town, the junior physicians may have to wait until they get approval for whatever treatment seems appropriate. If the senior cardiologist is busy with other patients, which is likely, that could take a while. If the senior cardiologist is away, junior staff may make the decisions--usually, though not invariably, the same decisions--and get on with it. So the patient receives treatment that much sooner. Increased efficiency of case analysis, staff contact and decision-making could improve outcomes when the senior cardiologist is there--plus furthering the error-avoidance that higher expertise is geared to offer.
1
And then there is the other reason why you don't want the most experienced or department head doctor: They will just get the diagnosis wrong. Older, so called experts may simply become complacent in the face of a problem they have apparently seen before or regard as non-life threatening. They will assume there is no treatment is necessary or that the problem is "all in the patient's head". Simply put, they are not diligent as they should be.
I wouldn't say this happens often, but it has happened to me. When a doctor forgets which tests or images he ordered, that's a sign that they are not paying attention. Mistakes like this can also happen at the triage, when urgent cases are ignored or never followed up because the doctor has too many other priorities like running after research money.
I wouldn't say this happens often, but it has happened to me. When a doctor forgets which tests or images he ordered, that's a sign that they are not paying attention. Mistakes like this can also happen at the triage, when urgent cases are ignored or never followed up because the doctor has too many other priorities like running after research money.
Perhaps a bad analogy, but mine would be chef vs sous chef. It is a generalization, as I'm sure this paper is (what research is not other than solid qualitative, which most people simply do not comprehend, presuming they even consider it "real" research (which is so very ignorant, but I digress)), but the gist of my point is: a chef is no longer focused upon just good food, but he/she must also focus upon that horror of horrors, public opinion. Yes, yes, if food is outstanding people will be happy, right? No. In fact, hardly ever because the public expects to be coddled, stroked, and otherwise treated as royalty before exclaiming that they ordered their steak cooked "medium, but no pink."
The sous chef focuses upon running the kitchen, which means cooking food properly and efficiently. Even a good chef knows that if you enjoyed the food, you enjoyed the work of the sous chef.
So yeah, I can understand the 'truth' of this study. Not surprising, but good to have verified.
The sous chef focuses upon running the kitchen, which means cooking food properly and efficiently. Even a good chef knows that if you enjoyed the food, you enjoyed the work of the sous chef.
So yeah, I can understand the 'truth' of this study. Not surprising, but good to have verified.
Cardiac problems are often experienced as sudden. But usually they are not sudden but a long building problem. Coronary artery disease takes years to build up the conditions to create a heart attack.
A good solution would be for primary physicians to ask the questions considering risk factors for cardiac disease and to carefully assess symptoms at annual wellness visits: such as "Do you ever feel short of breath? If so, what were you doing when you were short of breath?" Simple questions, important answers.
If a patient has been assess for cardiac disease before the sudden heart attack, there is a much better chance that the physician in the hospital will do a good job, especially if the hospital and physician's practices are connected on the computer.
A good solution would be for primary physicians to ask the questions considering risk factors for cardiac disease and to carefully assess symptoms at annual wellness visits: such as "Do you ever feel short of breath? If so, what were you doing when you were short of breath?" Simple questions, important answers.
If a patient has been assess for cardiac disease before the sudden heart attack, there is a much better chance that the physician in the hospital will do a good job, especially if the hospital and physician's practices are connected on the computer.
2
This is not necessarily a surprising finding given that the Medical Industrial Complex is akin to the Military Industrial Complex; highly interventional and not all that effective, resulting in extensive collateral damage.
As per Gilbert Welch MD, "Less Medicine, More Heath" Seven Assumptions Drive too Much Medical Care.
1. All Risks Can Be Lowered, Disturbing truth (DT):Risks can't always be lowered-and trying to creates risks of it's own
2. It's Always Better to Fix the Problem, DT: Trying to eliminate the problem can be more dangerous than managing one
3. Sooner is Always Better, DT, Early diagnosis can needlessly turn people into patients
4. It Never Hurts to Get More Information, DT: Data overload can scare patients and distract the doctor from what's important
5. Action is Always Better Than Inaction, DT: Action is not reliably the right choice
6. Newer is Always Better, DT: New interventions are typically not well tested and often wind up being judged ineffective or harmful.
7. It's All About Avoiding Death, DT: A fixation on preventing death diminishes life
Also read, "Over Dosed America" by John Abramson MD, The Broken Promise of American Medicine. (How the pharmaceutical companies are corrupting science, misleading doctors and threatening your health)
And "Being Mortal" by Atul Gawande, for a sane and sober reflection on end of live care.
Link showing excesses of American Medicine- Caveat Emptor.
http://www.nytimes.com/2010/12/06/health/06stent.html
As per Gilbert Welch MD, "Less Medicine, More Heath" Seven Assumptions Drive too Much Medical Care.
1. All Risks Can Be Lowered, Disturbing truth (DT):Risks can't always be lowered-and trying to creates risks of it's own
2. It's Always Better to Fix the Problem, DT: Trying to eliminate the problem can be more dangerous than managing one
3. Sooner is Always Better, DT, Early diagnosis can needlessly turn people into patients
4. It Never Hurts to Get More Information, DT: Data overload can scare patients and distract the doctor from what's important
5. Action is Always Better Than Inaction, DT: Action is not reliably the right choice
6. Newer is Always Better, DT: New interventions are typically not well tested and often wind up being judged ineffective or harmful.
7. It's All About Avoiding Death, DT: A fixation on preventing death diminishes life
Also read, "Over Dosed America" by John Abramson MD, The Broken Promise of American Medicine. (How the pharmaceutical companies are corrupting science, misleading doctors and threatening your health)
And "Being Mortal" by Atul Gawande, for a sane and sober reflection on end of live care.
Link showing excesses of American Medicine- Caveat Emptor.
http://www.nytimes.com/2010/12/06/health/06stent.html
1
I believe that older patients need to have a patient's advocate overseeing their medical care. Lucky are the seniors who happen to have competent children overseeing the care they are receiving from various doctors.
My wife has likely saved her fathers life by keeping an eye on prescribed medications- without her there'd be no one really studying the big picture of various medications being prescribed and the side affects he has sometimes suffered.
My own mother happens to be living close to my veterinarian sister who keeps an eye on the somewhat complicated care she is receiving as a relatively healthy 93 year old.
I actually believe that a new category of medical professional needs to be established- a patient advocate that looks at all treatments and their effects on a patient. This is particularly important for our elderly.
My wife has likely saved her fathers life by keeping an eye on prescribed medications- without her there'd be no one really studying the big picture of various medications being prescribed and the side affects he has sometimes suffered.
My own mother happens to be living close to my veterinarian sister who keeps an eye on the somewhat complicated care she is receiving as a relatively healthy 93 year old.
I actually believe that a new category of medical professional needs to be established- a patient advocate that looks at all treatments and their effects on a patient. This is particularly important for our elderly.
1
But you are your own advocate
The author really wants to make a point that there is over utilization of medical testing and procedures. The study apparently does not make that conclusion. Ezekiel says "another possible explanation" is over treatment when senior cardiologists are present. He then continues to beat this straw man for the remainder of the piece. As they say, we are all entitled to our own opinion, but not our own facts.
Further there is no mention of the statistical significance of the results. There is a possibility that this is just a chance result. It must be reproduced before major policy changes are considered.
This is the type of half baked stuff that has already gotten the country into the woeful state it is in. A little bit of intellectual rigor and honesty should even make it to the editorial page.
Further there is no mention of the statistical significance of the results. There is a possibility that this is just a chance result. It must be reproduced before major policy changes are considered.
This is the type of half baked stuff that has already gotten the country into the woeful state it is in. A little bit of intellectual rigor and honesty should even make it to the editorial page.
2
As this article illustrates, it would be nice if more Science was brought into the practice of medicine. And what I mean by that, is too often doctors are going by anecdote, or the seat of their pants, or something they were taught in medical school decades ago, or erroneous text books, whereas treatment regimes based on statistical evidence about their efficacy are what is needed. Ultimately, I believe computer assisted diagnosis would be better than what we have. The spectrum of symptoms and test results would be compared to a global data base to find the most likely diagnosis. Then a treatment regime would be started based on statistical evidence about what gives the best outcome. The patient progress would be followed and logged into the global data base, and the diagnosis reevaluated and changed if necessary.
The "over-doing" aspect of this article has complete merit but I think the impetus for treatment often comes from patient expectation and less so physician desire. When a patient comes to urgent care with what physicians deem a "cold" and are hesitant to prescribe antibiotics, patients are upset. Patients expect treatment for their ailments. As an anesthesiologist I see the surgical side of this issue constantly. Patients and their families want "everything you can do" even when they are told about the chance of poor outcomes. Add in patient satisfaction driven care and how can you expect doctors not to comply with their patients' requests. Poor ratings can result in loss of potential patients. Lets return to a day when quality of care was measured by actual outcome, not perceived patient happiness.
1
Very simple explanation:
These superstar doctors are often travelling to this meeting or that convention. So if they are in town they will likely see the patient for 1 or 2 days before getting on a jet to Tokyo or Vienna. There is no continuity of care and someone else less familiar with the patient would assume follow up. I have been rheumatologist for 25 years and see this all the time. This happened to a family member : a young 12 year old niece developed a severe complication after her superstar cardiac surgeon ( at a very renowned tertiary care center) skipped town 1 day after open heart surgery. These wiz doctors thrive on being catered to by Big Pharma, they flash their sad disclosures on a screen for a split second before giving any talk and then go on with business as usual.
These superstar doctors are often travelling to this meeting or that convention. So if they are in town they will likely see the patient for 1 or 2 days before getting on a jet to Tokyo or Vienna. There is no continuity of care and someone else less familiar with the patient would assume follow up. I have been rheumatologist for 25 years and see this all the time. This happened to a family member : a young 12 year old niece developed a severe complication after her superstar cardiac surgeon ( at a very renowned tertiary care center) skipped town 1 day after open heart surgery. These wiz doctors thrive on being catered to by Big Pharma, they flash their sad disclosures on a screen for a split second before giving any talk and then go on with business as usual.
2
This is a good article with a surprising finding, but of course it doesn't apply to all the top cardiologists. I'm sure there are some of them who are both more knowledgeable than their peers and are more cautious about unnecessary interventions. My biggest personal health crisis was fairly advanced thyroid cancer, for which I initially underwent a major surgery (with many complications) and radioactive iodine treatment. The initial treatment was vital and successful, but there was still a little cancer remaining and my endocrinologist started talking about another surgery. Fortunately my mother found a more experienced endocrinologist at another teaching hospital (I was already treated at a teaching hospital initially) and he was much more cautious about interventions and recommended doing nothing and just doing regular diagnostic testing. (Most of the other best-reputed, most experienced endocrinologists we consulted said the same thing.) Now 9 years later, I still haven't needed surgery and my numbers have actually been going down on their own (my healthy lifestyle including lots of exercise and good nutrition probably helps). The point is, overzealousness about more interventions is not limited to the leaders in the field, and it's always a good idea to seek additional opinions from experienced doctors for major health decisions.
Having lost good friends to 'successful procedures' - I have learned to take the recommendations of my doctor friends with a grain of salt, and on occasion even a smear of butter.
Visiting a doctor's office, and arriving on time, only to be sat in a waiting area where patients are serenaded with a television set, children running amok, and patients visiting with their 'flu like symptoms' can raise the average patient's blood pressure by several points. But, don't worry. There's a lot of drugs for that. Now there's even a study that recommends your systolic pressure be brought to levels that can cause fainting. Hey, a broken hip from falling has nothing to do with bringing down that blood pressure.
Why are patients sounding cynical? ''Let's wait and see how this develops and if we need to take any direct measures,'' doesn't pay tuition bills or green fees like a stent. On the other hand, doctors tend to form their opinions from patients who run to see them, as opposed to those who wait and see how things develop after changing their diets, exercising, quitting smoking, and losing weight.
Visiting a doctor's office, and arriving on time, only to be sat in a waiting area where patients are serenaded with a television set, children running amok, and patients visiting with their 'flu like symptoms' can raise the average patient's blood pressure by several points. But, don't worry. There's a lot of drugs for that. Now there's even a study that recommends your systolic pressure be brought to levels that can cause fainting. Hey, a broken hip from falling has nothing to do with bringing down that blood pressure.
Why are patients sounding cynical? ''Let's wait and see how this develops and if we need to take any direct measures,'' doesn't pay tuition bills or green fees like a stent. On the other hand, doctors tend to form their opinions from patients who run to see them, as opposed to those who wait and see how things develop after changing their diets, exercising, quitting smoking, and losing weight.
"There are potential policy solutions. One would require that doctors provide patients with data about a procedure, including its rate of success, complications and the like, before every major intervention. A solution for overmedication, especially in older people, would be to require that doctors attempt to discontinue medications at least once a year."
Those are reasonable suggestions, but they should not be implemented as health care policy and laws! Health care is an art, and it cannot be improved by imposing top-down regulations that mandate aspects of care, In fact, when that has been tried, it can result in worse outcomes:
"The most important limitation of guidelines is that the recommendations may be wrong (or at least wrong for individual patients)... guideline developers may err in determining what is best for patients for three important reasons...
Firstly, scientific evidence about what to recommend is often lacking, misleading, or misinterpreted...
Secondly, recommendations are influenced by the opinions and clinical experience and composition of the guideline development group...
Thirdly, patients’ needs may not be the only priority in making recommendations. Practices... may be recommended to help control costs, serve societal needs, or protect special interests"
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1114973/
Government agencies should not make health care decisions. It is better to educate physicians and their patients and then let them decide.
Those are reasonable suggestions, but they should not be implemented as health care policy and laws! Health care is an art, and it cannot be improved by imposing top-down regulations that mandate aspects of care, In fact, when that has been tried, it can result in worse outcomes:
"The most important limitation of guidelines is that the recommendations may be wrong (or at least wrong for individual patients)... guideline developers may err in determining what is best for patients for three important reasons...
Firstly, scientific evidence about what to recommend is often lacking, misleading, or misinterpreted...
Secondly, recommendations are influenced by the opinions and clinical experience and composition of the guideline development group...
Thirdly, patients’ needs may not be the only priority in making recommendations. Practices... may be recommended to help control costs, serve societal needs, or protect special interests"
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1114973/
Government agencies should not make health care decisions. It is better to educate physicians and their patients and then let them decide.
1
Correlation is not causation.
Assuming Dr Emanuel correctly represented the study, its authors did a good job making sure their correlation was "real", not due to a statistical anomoly. But no matter how authentic the correlation, the hypothesis derived from it is only as strong as our understanding. And the idea that senior cardiologists increase mortality when they are are not away at conferences. sounds like a pretty flimsy hypothesis given the lifespan of older Americans compared to nations without access to the latest cardiology care. It's amusing, and confirms our intuitive feelings about modern medicine, but it's still pretty flimsy.
Assuming Dr Emanuel correctly represented the study, its authors did a good job making sure their correlation was "real", not due to a statistical anomoly. But no matter how authentic the correlation, the hypothesis derived from it is only as strong as our understanding. And the idea that senior cardiologists increase mortality when they are are not away at conferences. sounds like a pretty flimsy hypothesis given the lifespan of older Americans compared to nations without access to the latest cardiology care. It's amusing, and confirms our intuitive feelings about modern medicine, but it's still pretty flimsy.
Very good article. It's worth mentioning that doctors may order tests often enough under pressure from patients. I see this all the time in clients in the acute stage of back pain and/or sciatica, who say "I should get an MRI." An expensive test, and in the acute stage, usually not needed. I try to explain the MRI is for diagnosing refractory cases that may require surgery, and most episodes are self-limiting, not necessitating surgery. But there's some kind of magical thinking at work here, and often the information gets bounced off some kind of alternative belief system.
1
The truth is that the senior cardiologists are a figure! I have found that educating patients is what works! Simple explanations like why (ordering a test or medicine), what (is the likely hood of a desired outcome and undesired result?) with the caveat that There is no evidence that the evidence is infallible. Try it with an 85 years old bedridden gentleman short of breath with his wife by bedside clutching her hands around his wrist, asking you to do something! she wants him admitted rehabilitated so she can finally take him home. The just of it is applying mined data to a human interaction is like flying a plane on predetermined route regardless of the conditions. I really wished policy makers were more humans, interpret the facts with an app that is applicable to humans. Despite having the same diagnosis, no 2 patients are alike. There is evidence to the contrary that you are better off in teaching than teaching hospitals for certain conditions.
It is my practice to treat patients as though they are my family. We practice shared decision making.
It is my practice to treat patients as though they are my family. We practice shared decision making.
2
I'm sorry, but this seems like another of Dr. Emauel's attempts to raise controversy and attract readers by acting as if he has all the answers when all the article he cited did was raise a lot of questions.
The study only looked at mortality during the dates of meetings; it did not explain why the mortality was lower during those dates, which remains speculative.
As other commenters have noted, the Chief of a service is not usually the most adept clinician, as he/she may be too far removed from daily practice.
Anyway, how many of the front-line, not "senior," cardiologists went to those meetings? How many residents in training? We lack that information and much else that would help explain the observation. All we have is the observation, but Dr. Emanuel has accomplished his purpose - to re-enforce his reputation as someone who is plain-speaking when he actually tells only part of the story.
The study only looked at mortality during the dates of meetings; it did not explain why the mortality was lower during those dates, which remains speculative.
As other commenters have noted, the Chief of a service is not usually the most adept clinician, as he/she may be too far removed from daily practice.
Anyway, how many of the front-line, not "senior," cardiologists went to those meetings? How many residents in training? We lack that information and much else that would help explain the observation. All we have is the observation, but Dr. Emanuel has accomplished his purpose - to re-enforce his reputation as someone who is plain-speaking when he actually tells only part of the story.
2
The problem is if one asks the four questions one runs the risk that no doctor will treat you or if one is an established patient the doctor will fire you.
The physician's rational for this is that the patient takes too much time, the patient is asking intelligent questions, and there is a potential for a law suit.
Physicians understand that all interventions and treatments can cause a worsening of the patient's condition and more suffering. Most physicians are inured to this: it is for them a reality of the practice of modern medicine. Physicians are not apt to worry or feel bad about iatrogenic (doctor caused) problems.
Dr. Emanuel's advice is good. Patients should do this for self protection and doctors should welcome this approach. But the practicalities and realities of medicine today are such that doctors don't like this. And in an emergency where time is of the essence, most doctors won't participate in this kind of thinking.
For the average patient, especially, those with average or less than average financial means, limited words, compliance, and encounter speed appear to be the paramount concerns of physicians.
Doing what Dr. Emanuel suggests can cut both ways for the patient. It is now very hard for patients to do these things. And with medical records available to all and going everywhere, doctors may feel compelled to editorialize and, therefore, implicitly comment about a patient's suitability in order to be a "friend" to other physicians.
The physician's rational for this is that the patient takes too much time, the patient is asking intelligent questions, and there is a potential for a law suit.
Physicians understand that all interventions and treatments can cause a worsening of the patient's condition and more suffering. Most physicians are inured to this: it is for them a reality of the practice of modern medicine. Physicians are not apt to worry or feel bad about iatrogenic (doctor caused) problems.
Dr. Emanuel's advice is good. Patients should do this for self protection and doctors should welcome this approach. But the practicalities and realities of medicine today are such that doctors don't like this. And in an emergency where time is of the essence, most doctors won't participate in this kind of thinking.
For the average patient, especially, those with average or less than average financial means, limited words, compliance, and encounter speed appear to be the paramount concerns of physicians.
Doing what Dr. Emanuel suggests can cut both ways for the patient. It is now very hard for patients to do these things. And with medical records available to all and going everywhere, doctors may feel compelled to editorialize and, therefore, implicitly comment about a patient's suitability in order to be a "friend" to other physicians.
3
The heart is a complicated machine and medicine is complicated by all the electronic equipment and new medicines. It is quite an assumption to believe that the average person would be able to direct the activities of a physician who constantly encounters these problems and becomes aware of all new treatments. Cardiac issues are often emergencies so how the heck is the average person supposed to second guess the physicians? This is probably good advice when a person has the time to study and make decisions.
I am a physician in a tiny community hospital. After leaving a large teaching hospital, I am one of the few subspecialist consultants in my small community. Dr. Emmanuel's comments, I believe, are important. Thirty five years ago when I started practicing medicine there was less available to do. Most of our training was in hospitals and most invasive testing was done for emergencies to save lives at at time when we had no CT, no modern blood tests and unsophisticated ultrasound. Now we are in an era where we can pinpoint diagnosis with these noninvasive tools. Outpatient medicine has made inpatient care less frenetic, and "Code Blues" are run by teams of nurses.
Medicine is huge business today. Each procedure makes big money. When I was in training I did things as a resident at the bedside with no charge that now are done in the Operating room and cost thousands. Medications are very costly and everyone over sixty has 5 medications or more. the Pharmaceutical industry is huge. Everything in medicine makes big money except a 15 minute face to face with the patient. Money runs medicine.
So, when you enter the Medical Twilight Zone, value for service is not only, not the only factor, but it may not be the first factor in what is done to your body. Hence, the data Dr. Emmanuel has presented should raise many questions.
Medicine is huge business today. Each procedure makes big money. When I was in training I did things as a resident at the bedside with no charge that now are done in the Operating room and cost thousands. Medications are very costly and everyone over sixty has 5 medications or more. the Pharmaceutical industry is huge. Everything in medicine makes big money except a 15 minute face to face with the patient. Money runs medicine.
So, when you enter the Medical Twilight Zone, value for service is not only, not the only factor, but it may not be the first factor in what is done to your body. Hence, the data Dr. Emmanuel has presented should raise many questions.
80
My primary care doctor spends more time with his computer than with me. He states that he has to do this and now he hates being a doctor.
1
Absolutely correct. There ARE death panels, but they are in hospitals not the government. Human life and human beings mean NOTHING to these death panels, especially not senior human beings, who are viewed as a resource wasting nuisance.
Heartfelt thanks are in order for the refreshing honesty and sincerity of the doctor who wrote this article. Kudos...
I've written countless comments over the years aimed at getting people to question the wisdom of prophylactic medical testing, medications and surgical interventions. Whether the issue is high blood pressure, high cholesterol, low bone density, depression, coronary artery disease, prostate cancer, or sunscreen, people are all too often being too clever by half.
Money is the problem...
Get government and insurance companies and lawyers and big pharma adverts out of the medical business and get back to just patients and doctors.
Learn something about what constitutes a healthy lifestyle. Good health, hygiene and basic medical knowledge are essential; you do not need to go running to the doctor for every little thing...unless you just like to live dangerously.
I've written countless comments over the years aimed at getting people to question the wisdom of prophylactic medical testing, medications and surgical interventions. Whether the issue is high blood pressure, high cholesterol, low bone density, depression, coronary artery disease, prostate cancer, or sunscreen, people are all too often being too clever by half.
Money is the problem...
Get government and insurance companies and lawyers and big pharma adverts out of the medical business and get back to just patients and doctors.
Learn something about what constitutes a healthy lifestyle. Good health, hygiene and basic medical knowledge are essential; you do not need to go running to the doctor for every little thing...unless you just like to live dangerously.
12
Interesting. Of course, when someone is being rushed to the hospital there may not be the option to go to a teaching hospital. Then too, does "teaching hospital" include the many smaller hospitals which have a few residents or a few med students doing a rotation. In Chicago there are plainly big university medical centers. There are also smaller neighborhood hospitals which are part of one university 'system' or another. Are they as good as the main university hospital or more like the non-affiliated community hospital?
Your questions are great, but, again, when someone is ill and has little medical knowledge (many Americans know shockingly little about their bodies, much less medicine) is their time to ask those questions? Even if family asks, with a loved one laying critically ill in the ER or ICU, what family will have the assertiveness and resources (likely they'd have to pay for the move - ambulance, helicopter) to look for another hospital and get their loved one transferred. Often time is of the essence as well. Fear and uncertainty tend to reign in such circumstances, not clear eyed weighing of options.
Your questions are great, but, again, when someone is ill and has little medical knowledge (many Americans know shockingly little about their bodies, much less medicine) is their time to ask those questions? Even if family asks, with a loved one laying critically ill in the ER or ICU, what family will have the assertiveness and resources (likely they'd have to pay for the move - ambulance, helicopter) to look for another hospital and get their loved one transferred. Often time is of the essence as well. Fear and uncertainty tend to reign in such circumstances, not clear eyed weighing of options.
6
"Little medical knowledge" is being very kind. Most patients do not even know what meds they take or what they are for. They are completely ignorant.
1
This was a surprise, and may reveal the bias of experts to use all the tools of their trade, w/o regard for unintended consequences. Or maybe it relates to a little too much reverence for the "best and brightest."
But the gist of this is in the 4 questions.
I started asking these in years past for my dogs, because some veterinarians recommended excessive, expensive tests, which were "fishing expeditions" -NOT to rule out a suspected condition that was affecting the animal's health, but in search of anything that might be "wrong." (leading to more tests and treatments).
Then I learned to ask questions on behalf of my parents - as well. Especially for the elderly, answers are not always simple when it comes to measuring the potential gains compared to the aggravation and risks. Some doctors get this and are willing to discuss pros and cons; others, too impatient with explanations and waiting.
What could be institutionalized in hospital settings is that, for patients without personal advocates, who may be unable to ask for themselves, someone on staff - a social worker, nurse or ombudsman, should be "deputized" to see that the questions are covered. (that person must be protected from protected from blowback; perhaps it could be a rotating position). Expanding the supply of geriatricians would also help avert damaging interventions.
So get yourself to a teaching hospital if at all possible, and ask questions before any Dr. starts piling on interventions.
But the gist of this is in the 4 questions.
I started asking these in years past for my dogs, because some veterinarians recommended excessive, expensive tests, which were "fishing expeditions" -NOT to rule out a suspected condition that was affecting the animal's health, but in search of anything that might be "wrong." (leading to more tests and treatments).
Then I learned to ask questions on behalf of my parents - as well. Especially for the elderly, answers are not always simple when it comes to measuring the potential gains compared to the aggravation and risks. Some doctors get this and are willing to discuss pros and cons; others, too impatient with explanations and waiting.
What could be institutionalized in hospital settings is that, for patients without personal advocates, who may be unable to ask for themselves, someone on staff - a social worker, nurse or ombudsman, should be "deputized" to see that the questions are covered. (that person must be protected from protected from blowback; perhaps it could be a rotating position). Expanding the supply of geriatricians would also help avert damaging interventions.
So get yourself to a teaching hospital if at all possible, and ask questions before any Dr. starts piling on interventions.
14
"Less is more" -- a new mantra of those interested in providing high quality medical care. Overdiagnosis and overtreatment cause unnecessary pain and suffering while also leading to higher health care costs (and potentially compromising the quality of health care receiving by marginalized and socioeconomically disadvantaged individuals). Kudos to this columnist and the NYT for exposing a problem that medical professionals have begun wrestling with only recently.
12
What an insane idea to have a patient being the one to determine what medical care they need, and should get. In medical emergencies, which a heart attack is, the idea you would be rational enough to systematically ask in depth questions about treatment options is delusional. So, before checking into the hospital to get your heart attack treated, call around and check to see if the experts are out of town. If you do research, you will find getting to the nearest hospital in the most timely fashion is the best option. Forget playing 20 questions with the doctor that show up.
7
In countries where there have been doctor strikes, the death rate also goes down. Doctors explain it by saying fewer risky procedures and surgeries are done, which would account for the difference. They refuse to believe that any treatment has a lot of risks. In the US, people over 55 take about 5 prescription drugs. If you listen to the ads on TV for many common drugs you can see why doctors are a danger to their patients. Of course fewer drugs reduce the number of serious side effects. People should question doctors more and not rush into any treatment unless it is absolutely necessary and even then it might not be. If you are not sick, keep away. If you are, question the doctor repeatedly when he suggests a treatment. Will it actually improve your health? If you don't want to go for a treatment, then don't go for the test, which may be an even greater danger.
13
S.L. Briarcliff Manor, NY: While it is always good to ask questions, often the questions are directed to you as an individual while the answers are of a statistical nature where the individual case cannot be addressed. Most patients are not qualified to truly assess risk - for example, you say, "People should question doctors more and not rush into any treatment unless it is absolutely necessary and even then it might not be." If a treatment is absolutely necessary (and how do you know this except for being told by a physician), how can you, as a patient, assess that it "might not be" absolutely necessary?
If you run enough correlation studies you are going to get some funny results. I'll bet if you plug in enough variables, the cafeteria serving salisbury steak could have a negative impact as well.
Senior cardiologists are more removed from clinical duties compared to their junior faculty members, their absence should have minimal impact either way. I doubt this study is anything more than statistical noise.
Senior cardiologists are more removed from clinical duties compared to their junior faculty members, their absence should have minimal impact either way. I doubt this study is anything more than statistical noise.
9
I believe this article is on the money. Personally, most of the health problems I have and have had in my 70 years were caused by the negligence and/or incompetence of the doctors of my home town of Beaufort, SC. Not that there are not some good ones there, but there are -- or were, at least -- a number of bad ones, too. And they can wreak havoc with your health.
2
Yeah, the first thing I'll do when I'm having a heart attack is start interviewing cardiologists! I should have plenty of time while the hospital is doing their standard wallet biopsy and I'm waiting on hold to find out whether the hospital and the prospective physicians are in-network.
But then again, do I really want to be treated by an "uncomfortable" physician?
But then again, do I really want to be treated by an "uncomfortable" physician?
13
Ah, a bit of realism, in stark contrast to Dr. Emanuel's alarmist preaching. Refreshing, to say the least.
Dr. Emanuel is more believable than Dr. Oz, but not by much.
Medical consumers don't ask for the cardiologist with the best judgment and the best outcome statistics. That's who I would want to do MY angioplasty- not necessarily the physician who had done the most (who might be too aggressive, or might need the fee for reasons best unsaid) or who had published the most (and not spent time in the cath lab, but at his desk)
In short, what might be the best tack to take would be to call the "best cardiologist" and ask HIM or HER who they would want to perform their angioplasty. In the meantime, I can't think of a more certain way to alienate and annoy the physician at your bedside than to brandish the NYTimes article by Dr. Emanuel and ask for the "best cardiologist" That won't stop some foolish folks from doing it, of course. In thirty years of emergency medicine practice (and we ER physicians see a LOT more people with chest pain than cardiologists do, believe me) I have seen all sorts of foolishness from patients determined to have the "best" specialist. Journal articles, pieces from the Web, phone numbers of their cousin who is a physician in Philadelphia- you name it.
The best general surgeon I've ever seen labors in obscurity at a community hospital in Maryland. Hardly anyone knows he exists, but if I needed my appendix out, I'd be glad to have him do it.
Dr. Emanuel is more believable than Dr. Oz, but not by much.
Medical consumers don't ask for the cardiologist with the best judgment and the best outcome statistics. That's who I would want to do MY angioplasty- not necessarily the physician who had done the most (who might be too aggressive, or might need the fee for reasons best unsaid) or who had published the most (and not spent time in the cath lab, but at his desk)
In short, what might be the best tack to take would be to call the "best cardiologist" and ask HIM or HER who they would want to perform their angioplasty. In the meantime, I can't think of a more certain way to alienate and annoy the physician at your bedside than to brandish the NYTimes article by Dr. Emanuel and ask for the "best cardiologist" That won't stop some foolish folks from doing it, of course. In thirty years of emergency medicine practice (and we ER physicians see a LOT more people with chest pain than cardiologists do, believe me) I have seen all sorts of foolishness from patients determined to have the "best" specialist. Journal articles, pieces from the Web, phone numbers of their cousin who is a physician in Philadelphia- you name it.
The best general surgeon I've ever seen labors in obscurity at a community hospital in Maryland. Hardly anyone knows he exists, but if I needed my appendix out, I'd be glad to have him do it.
2
Most of these senior doctors are men. important men with big egos. It is hard to back down from that perch. Younger doctors probably are more prone to seek second opinions.
7
Patients can have big egos too. I have a friend who is an exceptional plastic and reconstructive surgeon in a small Northeastern town. True story. A local college kid suffered a severe injury to an extremity which needed to be repaired immediately, or risk of amputation was high. This was explained to the patient's father, who wanted the patient seen by "the best" at the big city medical center 4 hours away. He insisted on having his child transferred, even though my friend assured him he could have easily saved the limb. Take a guess what happened? The father's ego cost his kid a limb.
I'm not sure what the issue is with these low performing cardiology chiefs, but in my experience as a doctor, the guy with all the accolades and titles is often not the go-to guy clinically. And sometimes "good enough" is all you need.
I'm not sure what the issue is with these low performing cardiology chiefs, but in my experience as a doctor, the guy with all the accolades and titles is often not the go-to guy clinically. And sometimes "good enough" is all you need.
From my experience at a training hospital, there tends to be a goal of doing less complicated admissions when the "senior attendings" are at a conference.
5
Interesting to see if it would be generalizable to other types of emergency care. Since it doesn't seem like that study wasn't guided by an actual research question, you have to wonder if it's just a fluke.
Patients complain bitterly about being made to take blood pressure meds; these kinds of columns don't help much
Patients complain bitterly about being made to take blood pressure meds; these kinds of columns don't help much
3
Or you could take the profit out of it. Hospital only get paid for treatments that improve their results. But hey what do I know. I live in Europe.
57
Defining quality care is harder than you think. Quality care from the patient's point of view is demonstrably bad for health outcomes. If we're going to use "health outcomes", what frame of time are we interested in? A week, month, year, decade, lifetime? Or do we just want to look at "episodes" of illness? And what exactly do we want to measure for an outcome? Subjective patient satisfaction or well being? Lab results? Physical exam measures? Tumor shrinkage? Functional restoration? Return to work? QALYs gained? Survival time?
One can have a completely different perspective on all of this whether one is the patient, doctor, hospital administrator, health insurance executive, member of congress, the President, or average citizen observer.
One can have a completely different perspective on all of this whether one is the patient, doctor, hospital administrator, health insurance executive, member of congress, the President, or average citizen observer.
Yes, with sensible single-payer systems. Here, we couldn't even achieve the public option. Stupidity and venality reign.
Except then you're encouraging doctors not to treat high risk patients. And it is not 100% known in every case what treatment improves results, medicine is a changing science.
Eat less, exercise more. There is a vanishingly small number of people that this is not the solution to their problems. Why are people overthinking this?
12
Bravo/Brava, J.
........ and I would add the famous ( or infamous ), "Just say No."
........ and I would add the famous ( or infamous ), "Just say No."
I have stopped reading conflicting opinions about Docters,Medicines, treatments etc.
We don't have much choice about anything.
At any given moment try to save yourself with available Doctors and Medicines and hope for the best
We don't have much choice about anything.
At any given moment try to save yourself with available Doctors and Medicines and hope for the best
7
The point that isn't mentioned: Doctors in hospitals make lots of money if they keep you alive, whether by procedures or surgeries or medication. (Or anywhere !) Hospitals are profit-achieving-corporations, first and foremost. My experiences with those 4 questions, & usually just asking one question that threatens or impedes their (unknown to patients) reciprocal payments, referral fees, or 'favors', results in a doctor that takes umbrage at you, the ignorant patient, daring to question or seek additional information that isn't snappily answered by his jargon. Off you go for a second opinion, time wasted, expense... if you've the luxury of time. The ability of us lay people, in the heat of the moment, to discern or "Google-best-doctor-for-me-in-this-situation" on your smartphone is too much to ask. You doctors have helped create this mess in America, as much as inept politicians eager to pass legislation suitable to their on-speed-dial-$upporting-con$tituent$.
19
With all due respect, RSH, most people are looking to stay alive. I do fully understand that there are times when these efforts are futile, and yes, expensive. You seem very unhappy with your experiences with physicians and I encourage you to look for good physicians. Remember, you always have the option to NOT go to the doctor.
I watched “high quality” medical professors put my 95 year old father through all kinds of medical procedures during the last year of his life, not to mention the drugs. He just got progressively weaker and his quality of life diminished. He was hospitalized less than a month before his death and the doctors wanted to send him to rehab. Thanks goodness we convinced my mom to send him home with hospice care. in the end we passed away peacefully with no pain in his own bed after a lot day of visits with people he loved.
43
Dr. Emanuel's assessment of the state of art of medicine is something to gnaw on. Not addressed, however, is the more basic question about the amount of unbiased reliable information possessed by the physician to answer the four questions that Dr. Emanuel would have the patient ask of the physician. It may actually not be very much if one accepts the judgment expressed in a recent "Open Letter to All US Presidential Candidates" published by the British Medical Journal. The letter asserts: (1) “No benefit can be derived from (clinical) trials which are either invisible or reported partially or selectively and (2) “Study results posted on clinicaltrials.gov are, by definition, incomplete and unverified. Even so, eight years after the introduction of federal law FDAAA 2007 a very small number of results of registered trials have been made available and updated.” http://www.bmj.com/content/348/bmj.g2263/rr
It is unsettling to realize how vulnerable physicians and their patients are to exaggerated and false claims of treatment effectiveness and safety because of lax government oversight. The patient can ask Dr. Emanuel’s four questions but can the answers that he or she receives be trusted?
It is unsettling to realize how vulnerable physicians and their patients are to exaggerated and false claims of treatment effectiveness and safety because of lax government oversight. The patient can ask Dr. Emanuel’s four questions but can the answers that he or she receives be trusted?
16
I have recently attempted to follow up on the results of several clinical trials that were ostensibly completed according to the clinicaltrials.gov site, and not found any published results. Like as not, the proposed intervention didn't work, and negative results were not published. This is obfuscatory and dishonest. Results are results.
The leader of a department is no more the best doctor than the Commander in Chief is the best fighter, no more than the coach of a sports team is the best player.
41
Did they consider that the top cardiologists may be attracting the sickest patients - so when some of them in the city are out of town, those patients (like the one quoted at the beginning of the article) go elsewhere?
19
During my 40+ years of practice, before I picked up my pen (or now keyboard) to order a test, I would check myself--could this change my management for this patient? This was an excellent brake on bad and expensive choices.
Sadly, explaining my reasoning to patients was a) difficult and b) often uncompensated. A patient's reflex to bad back pain is to request an MRI, not a bad idea if you have warning signs such as loss of bowel or bladder control or persistence over 6 weeks, but a very poor choice on day #3.
Finally, patients (and doctors) don't always think clearly in a crisis and always favor intervention, being often desperate as a drowning man clutching at a razor blade.
Sadly, explaining my reasoning to patients was a) difficult and b) often uncompensated. A patient's reflex to bad back pain is to request an MRI, not a bad idea if you have warning signs such as loss of bowel or bladder control or persistence over 6 weeks, but a very poor choice on day #3.
Finally, patients (and doctors) don't always think clearly in a crisis and always favor intervention, being often desperate as a drowning man clutching at a razor blade.
25
This story reminds me of an adage told to me during residency: "At a code, first take your own pulse." Doing nothing for a few moments depending on the situation often leads to a clearer diagnosis and treatment plan than immediate intervention! So much in medicine is wasteful, and extra interventions probably account for 25% or more of the overspending in American medicine. Of course, some of this is cover-your-butt testing for any malpractice lawyers lurking about, but most of it is because clinicians would rather cast a wide testing net than actually wait for the disease course to play out a bit. For instance, the best surgeons are the ones who don't automatically suggest surgery in the first 30 seconds of meeting the patient. Getting the "best" doctor is a joke on anyone in the lay community, as those physicians on "best" lists are usually dinosaurs, politically connected with referring doctors, or heavy advertisers in whichever publication is making the "best of" list. Glossy magazines in wealthy U.S. suburbs specialize in these dubious "best of" medical, dental, and law lists. A much better plan for finding a great physician is to query the nursing staff in any hospital or the residents in a large teaching hospital. Never ask for the chairman of any department, as they are probably the least involved in up to date clinical care.
137
Especially nurses who've been nursing in a particular ward for a long time. They really have clinical experience: they know the doctors that listen, that consider, that take time with patients. I learned a lot from nurses during my residency.
1
Thanks Dr. James for your brilliant opinion. Your comment, I feel is the highlight not only of the comment section but also it has uplifted the article value to a greater extent.
The advice to "query the nursing staff" is the best insight in this entire article.
The rest of the article is speculation.
Specifically, the insight gleaned from "BIG DATA" as framed in the headline ("Are good doctors bad for you?") is "click bait."
The rest of the article is speculation.
Specifically, the insight gleaned from "BIG DATA" as framed in the headline ("Are good doctors bad for you?") is "click bait."
It is posited that senior cardiologists may perform or recommend more procedures - it seems to me this hypothesis could be very easily tested and proven or disproved.
Overall, and also having a father who died at 43 from medical malpractice, resist medical intervention. Also, intrusive surgery at advanced ages is never a good idea. Remember Dick Clark who died after having two procedures in ONE week? My mother got a pacemaker implanted at 79 or 80, and have always questioned whether it necessary being she died within the year of the surgery.
3
This article fails to note how difficult it can be to get doctors to back off when they are intent on an intervention. My husband was hospitalized once with an infection. The hospitalist wanted to do a transesophageal echocardiogram (a TEE) to see if the infection was in the heart valves. If it had been, they would have proposed a valve replacement. For reasons related to another medical condition, my husband knew he would never consent to a valve replacement. For this reason, the TEE was not indicated. It was virtually impossible to get this across to the hospitalist. Every day he came into my husband's hospital room and announced that he was having a TEE today. "No, I'm not," my husband (who was at the brink of death) would reply. Finally I managed to dress this guy down with such vehemence that he stopped trying to force a TEE (in the process I scared him so badly that he never entered my husband's hospital room again). I have a Ph.D. and a great deal of knowledge about the medical system and about my husband's health. And I only just barely managed to avert that TEE. Anyone with less education and social capital would have caved to the monomania of that hospitalist, and the patient could only have been harmed (if a test is not indicated, the risks exceed the benefits, by definition).
49
There is no easy fix to this. Most studies are statistically based and usually done by epidemiologist PhD's and some MD's The typical MD is neither a scientist nor a statistician. If you are lucky the idea is to get a physician who is a flexible thinker and understand the limits of these studies. Many judgment calls are just that, judgment which require some flexible approach. Most patients do not want flexible thinkers as physicians. They want certainty4. Never in doubt is the hallmark for many people. Patients want someone to be sure. To many people that is good bedside manner. Patients love lots of procedures and lots of meds even if they kill them. Legally defensive medicine has not helped either,
3
But aren't colonoscopies vital in reducing colon cancer ? Not all medical procedures are about prolonging a very sick person for a short period of time, some procedures are preventive.
2
By the time we physicians achieve the status of being called "the best" we are usually in decline, getting old and burning out. Most of the truly best doctors are older than thirty-five and younger than fifty-five. Age may be a better gauge of ability than reputation.
6
Less medicine is the best medicine. My parents and grandparents both lived well into their high 90s. They stayed active, had a good diet and got plenty of rest. Most of all, they stayed busy. This is the way things were done in their day.
5
A dear friend and physician once told me that if he had to be operated on by the chief of vascular surgery at a prestigious NY hospital he would have preferred to have his brother do it. His brother was an accountant. It gets better: This chief of vascular surgery's son was in my friend's graduating class, and he makes his father look like a Nobel Prize winner. Scary!
2
Although a teaching hospital is a good choice, so is a private hospital with a good physician. Beyond the question about teaching hospital, the other three questions are appropriate.
In some cases, residents must check with attendings before addressing problems. This can slow down assessments and treatments at teaching centers. Also, in June, you are likely to meet a first or second year resident before the older residents, fellows, and attendings.
The physician who wrote this article is from a teaching hospital. I think that he should recuse himself from question 4.
In some cases, residents must check with attendings before addressing problems. This can slow down assessments and treatments at teaching centers. Also, in June, you are likely to meet a first or second year resident before the older residents, fellows, and attendings.
The physician who wrote this article is from a teaching hospital. I think that he should recuse himself from question 4.
2
I wonder if another factor could be that junior physicians wait for the senior cardiologist to weigh in, delaying treatment in an emergency situation.
4
I asked my mother's doctor why she, a woman in her late 80s with advanced dementia who never had a heart attack still needed to take statins, and maybe they have even increased her confusion, to which he replied "don't believe everything you read on the Internet".
When my mother became a resident of a nursing home, the geriatrician agreed - no statins for her. The same for some other medications she was taking - she takes them no longer. She hasn't improved, but it's done her no harm either. And, the taxpayers are saved some money (I'm in Israel, where socialized medicine covers the cost of most of these medications).
When my mother became a resident of a nursing home, the geriatrician agreed - no statins for her. The same for some other medications she was taking - she takes them no longer. She hasn't improved, but it's done her no harm either. And, the taxpayers are saved some money (I'm in Israel, where socialized medicine covers the cost of most of these medications).
58
So she hasn't improved without them, but now her risk of heart attack and stroke is higher based on peer-reviewed evidence.
And now you're posting a comment trumpeting how you've increasing the risk of your mother dying of heart attack and stroke because you don't like medicine and you apparently care more about tax payer money than your mother's health.
I'm confused?
And now you're posting a comment trumpeting how you've increasing the risk of your mother dying of heart attack and stroke because you don't like medicine and you apparently care more about tax payer money than your mother's health.
I'm confused?
1
Physician, heal thy self first. Hippocrates stated: “Let food be thy medicine and medicine be thy food” and so-called modern physicians should re-learn this lesson about diet and nutrition. Specifically, physicians need to work with patients and their nutritional choices first, rather than just pushing some pills.
Take statins. You go get checked and your cholesterol is 250, so the doc says here's some pills. Instead, in most cases, diet, nutrition, and exercise can bring these numbers down to below 120 (where, btw, there is statistically zero probability of a heart issue.)
Or say you have angina on exercise, these docs are likely to give you the 'works', including a stent (that btw closes up in 3 to 5 years anyway), instead of doing what's needed - a nutritional and exercise intervention.
Why have we created a system that rewards sickness rather than health? Heart attack, no problem, Medicare or other insurance will pay the 150k without questions asked, but say I need to spend an hour with a doc on nutrition, diet, and exercise - well, no way, pay for that yourself.
Yes, there are those cases where your EKG is throwing tombstones and you need an immediate intervention to save your life, and here your best bet is to go with an invasive procedure.
Take statins. You go get checked and your cholesterol is 250, so the doc says here's some pills. Instead, in most cases, diet, nutrition, and exercise can bring these numbers down to below 120 (where, btw, there is statistically zero probability of a heart issue.)
Or say you have angina on exercise, these docs are likely to give you the 'works', including a stent (that btw closes up in 3 to 5 years anyway), instead of doing what's needed - a nutritional and exercise intervention.
Why have we created a system that rewards sickness rather than health? Heart attack, no problem, Medicare or other insurance will pay the 150k without questions asked, but say I need to spend an hour with a doc on nutrition, diet, and exercise - well, no way, pay for that yourself.
Yes, there are those cases where your EKG is throwing tombstones and you need an immediate intervention to save your life, and here your best bet is to go with an invasive procedure.
9
Many inaccuracies here. Stents stay open about 94% of the time. Even the first generation bare metal stents reblocked about 20%.
You may not like statins but in 25 years of practicing cardiology I have never seen a cholesterol drop to 120 with diet and exercise alone. Even statins do not work that well in many patients. As for motivation, when they ask, I tell them about Dean Ornish. In the same period of time 2, number two, individuals followed his program.
You may not like statins but in 25 years of practicing cardiology I have never seen a cholesterol drop to 120 with diet and exercise alone. Even statins do not work that well in many patients. As for motivation, when they ask, I tell them about Dean Ornish. In the same period of time 2, number two, individuals followed his program.
1
Your mantra of healing all woes with diet and exercise is very quaint. First, a lot of medical problems don't go away with just diet and exercise. More realistically, have you been to Disney? Americans are fat, lazy, out of shape, sugar and fat fueled machines. Trying to get people to invest in their own health is a very uphill battle.
Counterintuitive, is an understatement! This is especially troubling because academic physicians are all board certified and thusly perform procedures routinely. You wonder if there were differences between Miami and New York City among the Chairman's hands at major teaching hospitals or was it more the seven or eight professors on staff compared to the fellows.
The patient has to remain alive long enough to get the second opinion.
Rolling in the door of the ED is no time to be fussy.
There are well established protocols which any and every physician follows to manage a heart attack or stroke in the initial minutes and hours.
Longer term manage allows room and time for debate.
But not when the patient is in crisis.
Rolling in the door of the ED is no time to be fussy.
There are well established protocols which any and every physician follows to manage a heart attack or stroke in the initial minutes and hours.
Longer term manage allows room and time for debate.
But not when the patient is in crisis.
4
And I may be out of town for a conference that actually helps patients when I return
I've been a caretaker for several family members with heart disease. I agree that it is not realistic for the patient or family to ask these questions at a critical time. If possible, it is best for the patient to express his or her wishes for major interventions in advance to a known family doctor or cardiologist. That was how my mother managed to avoid surgery despite several hospitalizations for heart problems in her 90s. She had a Do Not Resuscitate order in place and consistently refused surgery, eventually dying in a teaching hospital two weeks after a massive heart attack.
6
I always enjoy this good doctor's commentary. But as for asking the four questions, in most circumstances I would be out the door and down the road before waiting around for the answers. The mortality rate is 100%, no matter how good or bad your doctors are.
OMG, Dr. Emanuel nailed this one! I have a daughter who is in and out of the hospital regularly. She has had more problems when over-zealous doctors with seniority push their agendas on her.
Do you know that one time, a famous gastroenterologist insisted she had a stomach emptying disorder and put her on Reglan for years with terrible results when all along she had giardia lamblia?
This same doctor had her admitted to a psych ward for children because he thought her constant vomiting and not wanting to eat was an eating disorder. After 8 months in this place, they discovered the giardia!!
Needless to say, she and I have learned to question everything over the years and the outcomes of subsequent hospitalizations have improved. We still fight with arrogant docs who think the patient should be seen and not heard, but we stay firm.
Do you know that one time, a famous gastroenterologist insisted she had a stomach emptying disorder and put her on Reglan for years with terrible results when all along she had giardia lamblia?
This same doctor had her admitted to a psych ward for children because he thought her constant vomiting and not wanting to eat was an eating disorder. After 8 months in this place, they discovered the giardia!!
Needless to say, she and I have learned to question everything over the years and the outcomes of subsequent hospitalizations have improved. We still fight with arrogant docs who think the patient should be seen and not heard, but we stay firm.
31
These are people with acute conditions, right? Perhaps coming in through the ER? It may be that younger physicians are better trained in emergency medicine? Are there differences between people who come in via the emergency department and those with complex. but planned, surgeries?
2
Long before I retired (nephrology) I started to advise friends and family that they did not need a good doctor, but a doctor who had time for them. I also wonder when the senior cardiologists were in town who would be primarily responsible for the care of those patients with cardiac arrest or heart failure.
2
Please continue these provocative articles. There are more counter-intuitive things that need this kind of publicity. How much does all the pre-op screening we now do cost and how many perioperative complications does it prevent, for instance? How many abnormal mammograms are there for each person whose life is prolonged by the screening (it is in the thousands...).
4
Bravo to the scientists who thought to study this interesting question--and to the Times for publicizing the results. It's not entirely surprising, either; the airline industry learned that too much deference to senior pilots leads to accidents. Why not cardiologists?
Hopefully this realization will lead to better treatment.
Hopefully this realization will lead to better treatment.
7
Here in Oregon its well known that in smaller cities like Eugene, Corvallis, or Salem its better to get a second opinion or if say, the treatment or surgery you received failed, you go to Portland and find another well qualified doctor. Seems the specialists in one particular town cover for each other and don't contradict the past treatment regimen or surgery performed their fellow LOCAL colleagues. Out on the Oregon Coast, it's worse for the local residents of the various towns, they go to the valley for any major medical procedure or consultation. The "Creme de la Creme" of doctors are not on the coast, Portland's the place for them.
2
The Answer to the the Question "Are good Doctors Bad for your Health" is obviously NO. Good doctors are good for your health. However the premise of the question is that Senior Physicians (promoted) in Academic Hospitals are by definition Good Doctors. While they may be, they are more often excellent research scientists or perhaps astute administrators. If teaching hospitals wish to fix health care, both in terms of quality and cost, they will need to find ways to value and promote their clinical stars, the "Good Doctors" ,to the highest echelons of medicine, so their values and skills can be replicated in the students they teach.
2
Here in the Boston area, there are more doctors per square mile than in most cities of this size and yet I do ask questions of my cardiologist at Brigham and Women' hospital. She has is an MD with a PhD and seems very accessible and responds to my occasional emails. I've been on the NIH SPRINT blood pressure study for the past 2 years and may be over-medicated. My doctor is not comfortable with reducing my meds but I do monitor my BP with a reliable cuff. I'm tempted to titrate which of course is not advised but in the end I have to use my best judgment based on BP readings and side effects. The SPRINT seemed to conclude that while 120/80 is ideal to 140/90 some patients experience side effects by aggressive treatment and statistically, the mortality rate for those with the higher numbers may only be 3-4 years less. The conclusions are not completely clear as to long term benefits of those patients who are otherwise reasonably healthy.
2
Here in Canada doctors get paid less than in the US and they rush to see as many patients a day as possible. Drug reps seem to be their main source of information on new drugs so you are given a prescription to speed up the visit and most people want something other than a lecture "to do no harm"
I would bet the quality of life of most North Americans would improve with less pharmaceuticals.
I would bet the quality of life of most North Americans would improve with less pharmaceuticals.
3
A well-established doctor with a stellar reputation has less at stake with every new patient he treats and more at stake in his conference presentations. He may not give full attention and his best effort to each patient he treats.
3
One of the best things about the ACA is that it attempts to remedy this problem by paying for outcomes instead of procedures thereby reducing the incentive to do more than is called for. Even the most conscientious providers can fall prey to the allure of fee for service.
7
A couple more ideas: (1) Maybe the presence of the senior cardiologists stresses out the younger cardiologists, causing them to make more mistakes. (2) Perhaps the famous cardiologists are famous precisely because they work harder on self-promotion than on practice, meaning they are not such great surgeons after all.
10
As a retired surgeon, I continue to be rather puzzled that so many lay folks view cardiologists as "surgeons". Cardiologists are not surgeons.
Cardiology is one of about two-dozen sub-specialties that have existed for years within the very large field named "medicine." Each of those sub-specialty areas in medicine has its own practice scope, unique training requirements, and certification procedures overseen by the American Board of Internal Medicine. In the USA, for example, cardiologists are fully trained internists who have completed several additional years of formal fellowship training to qualify for admission to the cardiology certifying examination.
Completely separate from all sub-specialties of medicine, surgery also represents a huge branch of healthcare. There are numerous sub-specialty areas within surgery, each of which has particularized residency training and fellowship requirements; practice scope; and rigorous Board-certification procedures administered by entities like the American Board of Surgery, the American Board of Thoracic Surgery, the American Board of Pediatric Surgery, etc.
Cardiology is one of about two-dozen sub-specialties that have existed for years within the very large field named "medicine." Each of those sub-specialty areas in medicine has its own practice scope, unique training requirements, and certification procedures overseen by the American Board of Internal Medicine. In the USA, for example, cardiologists are fully trained internists who have completed several additional years of formal fellowship training to qualify for admission to the cardiology certifying examination.
Completely separate from all sub-specialties of medicine, surgery also represents a huge branch of healthcare. There are numerous sub-specialty areas within surgery, each of which has particularized residency training and fellowship requirements; practice scope; and rigorous Board-certification procedures administered by entities like the American Board of Surgery, the American Board of Thoracic Surgery, the American Board of Pediatric Surgery, etc.
Did the researchers have a way of assuring that the sickest cardiac patients weren't being sent elsewhere when it became known that the top cardiologists were away? One common determining factor of comparative success rate is who gets the sickest patients. I could easily imagine situations where sick people, would, like your friends, be demanding that they only see the top docs, even if it means going to a different city.
1
For sure places like NYC need to read this. When I practiced there I was asked for referrals to the best all the time. Now that I am at an FQHC in rural Maine my perspective is a bit different. Here so many LACK so much. Yes many are on inappropriate medications but many lack necessary care.
What I am tired of is insurance companies questioning my decisions - particularly someone with no degree. It delays necessary care.
I am tired of the cost shifting to patients. They cannot afford life saving treatments.
I am tired of the greed - of insurers and pharmaceutical companies. Please help us solve that.
What I am tired of is insurance companies questioning my decisions - particularly someone with no degree. It delays necessary care.
I am tired of the cost shifting to patients. They cannot afford life saving treatments.
I am tired of the greed - of insurers and pharmaceutical companies. Please help us solve that.
154
The outcome described here is news only to the people embedded in the pharmaceutical & surgery culture. The over-the-top practice of "heroic" procedures and godawful pharma products when they aren't called for is one of the primary reasons so many people seek out "alternative" practitioners - reformed M.D.s, N.D.s, Oriental medicine practitioners, etc. - and one of the primary reasons for the high cost of medicine in this country versus others in the industrialized world.
11
"One possible explanation is that while senior cardiologists are great researchers, the junior physicians — recently out of training — may actually be more adept clinically."
Totally agree. More recent graduates tend to have more fire in them and better training, and be more careful and less complacent. I saw a resident at the University of Washington and he was incredibly thorough and caring. Way more than all the jaded or cursory physicians I've seen who work in family practices. Teaching hospitals are a very good thing.
Totally agree. More recent graduates tend to have more fire in them and better training, and be more careful and less complacent. I saw a resident at the University of Washington and he was incredibly thorough and caring. Way more than all the jaded or cursory physicians I've seen who work in family practices. Teaching hospitals are a very good thing.
48
Nothing strange about this result in a country where doctors primarily view patients as "billing opportunities." It would also be interesting to see how much of the increased mortality was due to adverse effects from unnecessary tests and procedures. The only thing worse than not enough health care is too much health care.
1
"It is not clear why having senior cardiologists around actually seems to increase mortality for patients with life-threatening heart problems."
Allow me to offer an alternative explanation based on ancient Jewish wisdom:
The ancient teaching of the Jewish Mishna/Talmud states "The best of doctors will go to hell." (Tractate Kidushin 82a)
The commentaries explain:
"'The best of doctors' means he who considers himself the best of doctors, that there is none comparable to him. He relies only on his own expertise because of his haughtiness. Sometimes he misdiagnosis the illness and because of this he sometimes kills his patients. Instead he should consult with his colleagues in matters of life and death." (Commentary of R' Samuel Eidlis 82a)
That insight was realized 2000+ years. Perhaps things haven't changed much.
Allow me to offer an alternative explanation based on ancient Jewish wisdom:
The ancient teaching of the Jewish Mishna/Talmud states "The best of doctors will go to hell." (Tractate Kidushin 82a)
The commentaries explain:
"'The best of doctors' means he who considers himself the best of doctors, that there is none comparable to him. He relies only on his own expertise because of his haughtiness. Sometimes he misdiagnosis the illness and because of this he sometimes kills his patients. Instead he should consult with his colleagues in matters of life and death." (Commentary of R' Samuel Eidlis 82a)
That insight was realized 2000+ years. Perhaps things haven't changed much.
3
My father Eugene Kirsten, MD published a double blind study in the 1970's that concluded that in a Bronx assisted care facility among patients who had no clear indication for their digoxin, (many had no obvious reason that they were on dig) digoxin could be stopped with no negative effects. Actually the same can be said in my opinion with many psychotropics especially among elderly patients. Patients are someone like boats which need a good scraping dry dock. Meds often need to be shed.
2
Here's one recent example on the over-medications part of this article. The elderly are often kept on high blood pressure medication for decades. One of them had repeated incidents involving momentary loss of consciousness, leading to many visits to the ER, with ultimate release because nothing was wrong. Finally a smart internist who specializes in the elderly just stopped the high blood pressure medication. Problem solved. No such incidents for the last 6 months.
3
No surprise to those of us working full-time clinical practice. I smile at my friends who want the chair of orthopedics at the ivy tower to do their hip replacement - that guy pushes paper across a desk half the time while his partners who operate full time become and remain much more skilled at clinical practice than he. Same for the world famous researcher/clinician - she spends all her time researching and writing grants. My advice to friends: steer clear of the department chairs and researchers, and see someone who practices clinical medicine full time.
1
My father was a physician, a pediatrician and a damn good one. His frequent advice on selecting a doctor was that you didn't want the top pf the class. They were too arrogant, too self-confident, and too unwilling to listen the the input of others. Certain they couldn't possibly make a mistake. They were the best! Nor did you want the bottom of the class, for obvious reasons. Rather, he always recommended someone board certified, but not viewed as the best of the best. You wanted a good physician, but one not so full of him or herself that they thought themselves incapable of making a mistake. They were always aware of that fact, not deterred by it, and willing to listen to the equally capable people that surround every good physician to contribute to the best care of the patient. I've followed that advice throughout my life, and have been well served by it.
4
Setting aside the obvious biases of the author, an advocate of Obamacare and the fact that this is a single study, let's discuss his questions. I had a cardiac arrest in my 20s; now decades beyond later I have been prodded and poked for yrs by cardiologists, and overmedicared. You can ask the questions; the problem is that physicians are not trained to answer them. Effectiveness of treatment? Big pharma begins dating in medical school and it continues throught a doc's career. Questions about effectiveness are likely to provoke a preprinted answer from big pharma. So why not have independent NIH funded research on effectivenessof treatment, which, by the way, is a MARKET oriented reform. Treatment alternatives..a personal story. I wanted to get off beta blockers, an astute physician told me that no doc would ever risk..I was living on the drug...depressed, lethargic, but living. I hated it. Through diet and exercise, I got off every heart drug I was on. Which brings us to the fact that over half of all chronic conditions are results of lifestyle choices...obesity, smoking, stroke, heart disease, diabetes...and too many of us prefer an "easy pill" to avoid the hard work of being health conscious. Do docs receive any training on diet and exercise? No, nor does big pharma push it..no profit in it. Stints by bypasses v drugs? Studies show follow up lifestyle changes after a cardiac event improve outcomes, but smokers smoke and gluttons eat as before. And we pay.
Unfortunately the results are not tied to a rationale. Its one thing to find a startling non-intuitive result, but its a lot more meaningful if you can determine why those results happened. In this case I would like to know why care deteriorated when the most senior specialist is gone. This clearly needs more investigation. In the meantime, do these result also happen at the non-teaching hospitals? Even if overall outcomes are better at teaching hospitals, it is still important if the effect happens only at teaching hospitals or at most or all hospitals. I suspect they only happen at these "great" teaching hospitals.
Science is the art of careful observation. Interpretation of the observations is speculation, best done with friends, over a few beers. Dr. Emanuel seems to like to run with the data on a national stage. Scientific studies should provoke thought and questions, not pronouncements and recrimination.
Let's face it, star docs are often prima donnas in a hurry, not used to being questioned or questioning themselves. My husband nearly died after one such pneumothoracic surgeon inserted a tube for collapsed lung, but forgot to check blood ox levels. I convinced a nurse to do it without waiting for orders, after husband turned a deep shade of purple. She slapped on an oxygen mask pronto and he pinked up. Dr. Big shot never reappeared but sent his underlings, thank god. They were much more on the ball. The same is true in many fields. Find a rising professional trying to prove himself.
1
Dr. Emmanuel makes an enormous assumption that the reason for the variation in cardiac outcomes in this study is due to a predominance of senior Academic Cardiologists attending national meetings. When I go to these meetings I see large numbers of bright young Cardiologists there. I can think of many reasons why a variation can occur. To suggest that more experienced academic docs are more likely to perform risky, unnecessary procedures makes little sense (their incomes are often less dependent on volume than other Cardiologists). Indeed, if this is a general principle, why wouldn't it be true for other specialties?
Overuse of procedures like cardiac caths and stents are a real problem among some practitioners. To hang this on our most experienced and best informed academic Cardiologists isn't fair and wasn't proven in the JAMA-IM study.
Overuse of procedures like cardiac caths and stents are a real problem among some practitioners. To hang this on our most experienced and best informed academic Cardiologists isn't fair and wasn't proven in the JAMA-IM study.
Was the study adjusted for the fact that those cardiologists thought of as "best" are likely to be asked to take on the most challenging cases? Those cases with the highest risk of s negative outcome? I also assume they are often involved with more experimental treatments and are the first to be asked to perform newly inttoduced procedures. And if patient outcomes are really that bad, why are they considered to be the "best"? What exactly is the criteria for that mantra, if not success? How did they get that reputation?
2
This is not surprising to me whatsoever. Being a geriatrician, I can say that I've discontinued more medications than I've prescribed over the course of my career. Many geriatricians approach their patients this way, and have been shown to have good outcomes at lower cost to the system. The problem? There are fewer than 7,000 of us and the number is going down every year. It is time to stop trying to legislate how physicians practice and to educate both existing and future physicians in the proper care of older adults with chronic conditions. We don't need more workarounds. Perhaps Dr. Emanuel should read my chapter on this issue (Geriatric and Primary Care Workforce Development, Healthcare Changes and the Affordable Care Act, 99-115, Ed. Powers, James S., http://dx.doi.org/10.1007/978-3-319-09510-3_6, Sprin- ger International Publishing). I've tried sharing this information with my legislators for years, but to no avail. It's time to start focusing on the fact that we subsidize graduate medical education (GME) from the Medicare Trust Fund and use it to train physicians how NOT TO CARE for older adults. This data is not surprising!
25
It has always been my experience that the best doctors for me were the young doctors, up and coming, ambitious and with a hunger for success (which hopefully included dealing with my ailments).
The top might be good for consultation, but they are extremely busy, travel non-stop and it can take a long time to get an appointment. They tend to have ego issues. There is also a tendency, as time goes by, for them to get a little lazy and sloppy, even if not intentionally, after all doctors are human also and subject to stresses of body and psyche. The years take their toll. I do not want to be the patient when the top doctor begins to realize that he or she is starting to slip, even if just a little bit.
The top might be good for consultation, but they are extremely busy, travel non-stop and it can take a long time to get an appointment. They tend to have ego issues. There is also a tendency, as time goes by, for them to get a little lazy and sloppy, even if not intentionally, after all doctors are human also and subject to stresses of body and psyche. The years take their toll. I do not want to be the patient when the top doctor begins to realize that he or she is starting to slip, even if just a little bit.
3
The NYT article is short on data (I have not read the original JAMA paper - that seems like a necessity, given the lack of information here). For example - is it only the senior cardiologists who go to the annual meetings (unlikely), or also their attendings, fellows, and residents? If a whole section of the "cardiology team" is away at the meeting(s), and outcomes in the hospital improve at that time, what is the conclusion? Is the improved patient outcome due to the absence of a direct "negative influence" of the senior cardiologist (or others in the cardiology team), or is it indirect - for example, do the remaining (i.e., not away at the meeting) attendings, follows, residents-- and, heck -- nurses, med students, PAs, etc., simply perform better when the senior cardiologist (or others) are away; and if so, why -- are they less intimidated; more versatile in their approach; more careful; have less cases to handle??
We need those data to begin to understand the casue and effect here. If those data are in the JAMA article, they could have been usefully summarized here; if not, their absence should have been identified.
We need those data to begin to understand the casue and effect here. If those data are in the JAMA article, they could have been usefully summarized here; if not, their absence should have been identified.
4
As a physician who has trained at a number of esteemed institutions, national meetings do not mean the senior doctors are gone. There is typically one on service, and only one, at any point in the year, even during meetings. So this data really is fairly useless. In addition. The concept that a teaching hospital is better is also laughable.sometimes, we get one chance set of data and use this to weave an intriguing set of absurd conclusions. dr. Emanuel should know better and simply as for this to be replicated a few more times.
4
The information about over-medication presented in this article is extremely important as well, and directly related to the excessive medical intervention issue. I wonder how many Americans die annually from medication interactions resulting from over-medication. Or who simply waste away from brutal side effects. Who profits from Americans using more prescription meds? It's disgusting.
3
The senior specialist is usually not the one doing the daily patient rounds. He may be the Chief of Service, but that title is usually given to one who is doing more administrative work for the department rather than see the day to day patients. It doesn't mean he doesn't know anything about his field, but hands-on experience is the only sure way to keep your mind sharp in the clinical setting (especially in an emergent setting). Those who are away on meetings and such are usually there to look at pending pharmaceutical or interventional opportunities and are less versed about the more mundane patient care
3
The right-to-be-let-alone to live the kind of life we want, presumably guaranteed to each of us under the Constitution, is being violated everywhere, and not just in medicine. Who was it anyway that gave President Obama the authority to require people to
carry health insurance, or pay a fine in lieu of it?
I am in the stage of my life where my expectations of doctors are very modest. I am not looking for radical cures or even substantial improvements in the maladies that afflict me. I appreciate the fact that my doctors are trying to help me, but I want that help to be of the kind that interferes the very least with the daily business of my life. I view every additional pill I am asked to take as a likely hindrance to that. I want no doctor helping me to run marathons, walk them or watch other people walk them. The fact that I have never run or walked a single marathon in my life is an important reason why I am still here.
carry health insurance, or pay a fine in lieu of it?
I am in the stage of my life where my expectations of doctors are very modest. I am not looking for radical cures or even substantial improvements in the maladies that afflict me. I appreciate the fact that my doctors are trying to help me, but I want that help to be of the kind that interferes the very least with the daily business of my life. I view every additional pill I am asked to take as a likely hindrance to that. I want no doctor helping me to run marathons, walk them or watch other people walk them. The fact that I have never run or walked a single marathon in my life is an important reason why I am still here.
1
As a practicing radiologist, I could not agree more with the premise of this piece. Unnecessary imaging is rampant with many exams having no impact on patient care regardless of the result. Many blame liability concerns but I am becoming more and more convinced that the true reasons are impotence and expediency. There are so many medical complaints with no real remedy and imaging seems to make the doctors and patients believe something is being done. The result is radiation exposure and many inconsequential findings requiring more testing to evaluate.
46
It is not the imagings, it's the subsequent interventions.
great piece!
Not exactly the same point, but along the lines of how patients may not know what is best for them and hence the disconnect between "patient satisfaction" (wanting the chief of cardiology, not the fellow) and "quality of care" (getting someone who does a lot of clinical care): many patients demand antibiotic drops for pink eye even though many cases are viral. They get mad when they don't get a script.
An angry, uneducable pt who thinks he is being denied antibiotics will mark down a doctor on "patient satisfaction" surveys, but actually
the doctor is providing high quality of care. A good doctor will consider the cost of the medicine, the likelihood it will not work, the risk of increasing antibiotic resistance if too many scripts are written for conditions they were not meant for.
But Medicare and insurance companies will soon be tying doctors' payments to "patient satisfaction" surveys!!
Not exactly the same point, but along the lines of how patients may not know what is best for them and hence the disconnect between "patient satisfaction" (wanting the chief of cardiology, not the fellow) and "quality of care" (getting someone who does a lot of clinical care): many patients demand antibiotic drops for pink eye even though many cases are viral. They get mad when they don't get a script.
An angry, uneducable pt who thinks he is being denied antibiotics will mark down a doctor on "patient satisfaction" surveys, but actually
the doctor is providing high quality of care. A good doctor will consider the cost of the medicine, the likelihood it will not work, the risk of increasing antibiotic resistance if too many scripts are written for conditions they were not meant for.
But Medicare and insurance companies will soon be tying doctors' payments to "patient satisfaction" surveys!!
1
As a practicing internist I see overtreatment and testing all of the time. I also see subtle symptoms and test abnormalities ignored when early intervention would have made a difference. I agree that people who are on many medications almost always get better when their med list is reduced.
But none of that wisdom translates to measuring "metrics" which is what medical care is all about now.
Sorry but most of the time patients want to trust their doctors, not question their decisions and recommendations.
But none of that wisdom translates to measuring "metrics" which is what medical care is all about now.
Sorry but most of the time patients want to trust their doctors, not question their decisions and recommendations.
2
Actually most of us doctors know that we perform too much care and wish we could get away with performing less than we actually do. The medico-legal environment we operate in, the compensation structure, as well as the recent trend of having patients regularly review doctor's care strongly encourages performing more and more expensive care. Doctors are rational people that respond to incentives - align the incentives properly and you will notice an improvement in quality and efficiency of care.
Having practiced at several teaching hospitals, I can attest to the fact that it is common for the most senior attending physicians to have their residents or fellows (young doctors in training) examine the patient, while they step in at the end for a very brief consultation--so that they can bill the patient. The less senior physicians, on the other hand, tend to do the exam themselves--which probably results in better diagnosis and care than that provided by a physician in training. And no reason to believe this holds true just for cardiology; similar studies of other medical specialties might well yield similar findings.
2
It is common practice for some doctors to make a visit, write a note and send a bill. They have to get their beak wet.
It is also common practice for some doctors to place the patient first and go the distance.
It is also common practice for some doctors to place the patient first and go the distance.
Every second study coming out these days seems to be finding that extensive medical intervention and over-treatment is a health risk. In a for-profit medical system there are financial incentives to overtreat patients and it now seems they can be worse off as a result. A single payer system with limited resources and no incentive to intervene unnecessarily may result in better outcomes for patients. People often in Canada often complain if they can't get all kinds of state-of-the-art tests and procedures but now it seems they probably fare better than Americans in the long run.
1
"...having senior cardiologists around actually seems to increase mortality." Does it? The author (and I presume the study) only mention 30-day mortality. Maybe chief cardiologists are more willing to chance risky interventions, e.g. an intervention that has a 10% chance of immediate death vs. 90% chance of significant and long-term improved quality of life, as opposed to no intervention and the patient dying of heart failure in a year or two.
Also, "one solution would be to provide patients with data before a major procedure?" You're going to attempt to explain the risk/benefit of multiple treatment options to someone who is in cardiac arrest?
Also, "one solution would be to provide patients with data before a major procedure?" You're going to attempt to explain the risk/benefit of multiple treatment options to someone who is in cardiac arrest?
1
The four good questions are actually terrible. Another thing...when great cardiologists do all of this vaunted 'research,' what exactly do they do? Attend conferences on golf courses? There isn't much new in cardiology. Here are the big decisions for heart attacks: to stent or not to stent, eluted sent or not; by-pass surgery or atherectomy; assess need blood pressure and cholesterol meds; assess for vascular issues.
To be sure, there are several valvular concerns and matters of cause for heart failure. But, in most cases the heart issues are clear, the choices are clear.
The paths are very well worn. None of us is as "unique" as we may think we are. Great cardiologists who attend a lot of conferences claiming research are bored part-timers on the floor and practitioners on the golf course.
I want full-time on the job.
To be sure, there are several valvular concerns and matters of cause for heart failure. But, in most cases the heart issues are clear, the choices are clear.
The paths are very well worn. None of us is as "unique" as we may think we are. Great cardiologists who attend a lot of conferences claiming research are bored part-timers on the floor and practitioners on the golf course.
I want full-time on the job.
In that context, one should not forget about patient expectations. Many patients and/or their families emphasize that "something needs to be done", be it diagnostic, therapeutic or both - otherwise, the visit is considered futile and the doctor unhelpful. But there are many complaints (and even some conditions) where doing nothing, or, as physicians sometimes say, following an expectant course, is better than initiating very low yield imaging studies or some medication that, in the best case, has some mild benefit (often a placebo effect) and no harm but, in the more likely case, will provide net harm as suggested by the study from Israel that Dr. Emanuel mentioned. Instead of saying: something needs to be done, one should rather ask: how likely is the test, intervention or medication going to help me and what are potential downsides?
In medicine as well as many other things (defense and intelligence spending, extreme exercise, eating), more is not always better. In this country we've been exposed to so many more drugs and interventions than other advanced countries. Proponents rightly point out that life expectancy keeps going up. Yet we still lag far behind most of Europe and Japan. This is a difficult train to stop- ~18% of GDP now is spent on health care. But clearly to keep from bankrupting ourselves we need to get smarter about the care we provide to focus on value.
The dangers of excessive interventions, testing, and procedures is one of the most overlooked risks of our medical system. We are very bad at assessing the risk/reward ration of any procedure. This doesn't only apply to this example of acute cardiac events. We are able to detect various conditions earlier and earlier. Our traditional "take no prisoners" approach coupled with the legal liability considerations trigger an avalanche of tests, surgeries, rehabilitations, and drugs. Yet as the population ages, it is only natural that things more various potential threats will be detected, do we have to fight all of them, right away. We already know that aggressive treatment of prostate cancer in men is way overdone. Yet we continue to fight diseases to a bitter end. Sometimes it's the patient's end. There is a good russian-jewish joke that goes like this :
Doctor - Did the patient break sweat before his passing?
Nurse: yes, Doctor
Doctor: Well that's certainly a good sign...
Doctor - Did the patient break sweat before his passing?
Nurse: yes, Doctor
Doctor: Well that's certainly a good sign...
Senior docs seem to perform well as mentors, researchers and subspecialty consultants, but sometimes not as well in emergency situations. I recently watched an old BBC medical drama "cardiac arrest" that I thought illustrated that dynamic fairly well, if not a bit overdone. Cardiac emergencies are typically pretty straightforward to treat in that most interventions are well-documented and widely used. What is important is rapid recognition of the problem and rapid response. My guess is that older docs don't react as quickly, perhaps as a matter of age, and while residents and fellows may have recently taken or recertified in advanced life support and other CME, this may not always be true with older practitioners
1
Not really surprising. Reputations among physicians, especially at academic centers, are built on research and publications. Even physicians in other specialties really have no idea if a surgeon or other interventionalist is good. They will patients based on availability, affability, and ability, in that order. They will continue referrals based on whether referred patients liked the specialist. Hard date is needed to determine who really does their job well.
As an all-too senior physician, I am not in the least surprised by any of this. This is a robust finding, and it supports what many of us have suspected for a long time. Michael's comment about the effect of senior docs on the teamwork of an existing team is well taken. So is Zeke's suggestion that senior docs may overtreat, especially in teaching hospitals. At the same time, the information that people will do better in teaching hospitals is also important: the choice that many make for local/familiar/luxurious may not always be wise.
That kind of irrational response and the general disbelief of this study by so many underlie Mark Thomason's suggestion that medical professionals assume responsibility for these decisions. Unfortunately, these decisions very often are in fact made by bean-counters. And we as Amurricans value (the illusion of) free choice and self-determination over our real well being. We want what we think is the best, which is usually identified by price and quantity. When someone as rational and well-informed as Zeke Emanuel speaks up, that person is seen as an enemy of "freedumb."
That kind of irrational response and the general disbelief of this study by so many underlie Mark Thomason's suggestion that medical professionals assume responsibility for these decisions. Unfortunately, these decisions very often are in fact made by bean-counters. And we as Amurricans value (the illusion of) free choice and self-determination over our real well being. We want what we think is the best, which is usually identified by price and quantity. When someone as rational and well-informed as Zeke Emanuel speaks up, that person is seen as an enemy of "freedumb."
1
The "best" physicians may be the best informed, aware of the latest findings, the most intelligent and sophisticated. Nothing wrong with that, but with the aim of offering "the best", some telling, perhaps mundane matters can be overlooked or set aside. One example of which I have direct knowledge: a newborn cried, and cried, day and night, for some three months. The parents took her to the best, the most famous pediatrician of an advanced country (not the USA), who did many things and diagnosed more. He did not weigh the baby before and after her mother breast-fed her. The entire problem was that the mother didn't produce enough milk. The baby was hungry!
Of course you would not put a matter of life and death to someone with an acute infarct, but properly informing those who can make decisions probably results in better medical practice.
Of course you would not put a matter of life and death to someone with an acute infarct, but properly informing those who can make decisions probably results in better medical practice.
1
A little more data would make the narrative more convincing. Were there actually fewer cardiac procedures performed during the conferences? Was it in fact the senior cardiologists who were away (tangential question: why are the junior physicians not going to conferences?). Were fewer cardiac patients admitted to the teaching hospitals during conferences? One can go on and on. It takes a lot of work to find causal connections within correlation data! But then again, why dig for data to spoil a good story?
1
An event like cardiac arrest and being rushed to the hospital is one type of medical crisis. But there are others like getting an ominous diagnosis. Consider the man who is diagnosed with high grade prostate cancer and has to decide among five or eight treatment options, each with benefits and serious risks and each with major uncertainties as to outcomes including quality of life. Add to that the awareness that some specialists have much more experience and successful outcomes than others (thus making them among "the best"). Worse, each specialist recommends the procedure they were trained to do.
In this scenario does the title of Dr. Emanuel's article still make sense? I see the point about too much care being bad for your health but conflating that idea with really good doctors seems like an oxymoron.
In this scenario does the title of Dr. Emanuel's article still make sense? I see the point about too much care being bad for your health but conflating that idea with really good doctors seems like an oxymoron.
Dr. Emanuel was careful to specify cardiac doctors.
There is a crucial question that Dr. Emanuel does not advise posing: "Are you going to actual perform the surgery or will it be performed by residents, who are not yet board certified, and if yes, will you actually be present during the whole procedure?"
It is not unusual for a post-surgery report by a top-notch surgeon to contain the following phrase: "I was present during the critical part of the surgery."
To put it differently, perhaps the less than stellar outcomes of surgeries by good doctors, as Dr. Emanuel characterizes them, as the result of the actual work being performed by not yet qualified physicians with the good doctors not being present or fully participating, even though, of course, they billed for the procedure.
It is not unusual for a post-surgery report by a top-notch surgeon to contain the following phrase: "I was present during the critical part of the surgery."
To put it differently, perhaps the less than stellar outcomes of surgeries by good doctors, as Dr. Emanuel characterizes them, as the result of the actual work being performed by not yet qualified physicians with the good doctors not being present or fully participating, even though, of course, they billed for the procedure.
3
It seems perfectly reasonable for doctors to be able to give their patients information about rates of success and complication rates. Unfortunately, we don't know that information for sure, since clinical questions that have been investigated by more than one study, tend to have a range of answers to the question. Certainly it doesn't seem reasonable to expect an individual physician to have curated the vast medical literature on his or her own.
This sort of research observing an apparently paradoxical association may not reveal that more treatment is lethal. Many MDs avoid conventions- especially clinicians with dedication to their patients in private practice. While fee for service may create incentives for excess interventions, it also makes an MD feel greater responsibility for patients who are known over a long time.
Maybe the better research question would be to observe errors and mortality when acutely I'll people are treated by MDs who do not know them.
Maybe the better research question would be to observe errors and mortality when acutely I'll people are treated by MDs who do not know them.
2
EFFECTIVE CARE Since June, there have been multiple health problems of a family member, involving broken bones, surgeries, rehabilitation programs, treatment for a hospital acquired infection, stress, depression, and physical therapy. The healing has been slow, accompanied by appointments with many specialists and subspecialists. We needed to change to medical providers affiliated with the hospital that provided inpatient treatment. It is an ongoing ordeal, traipsing from one appointment to another. But the doctors are very judicious about treatment. The primary internal medicine group are focused on establishing trust with new patients and communicating effectively. So we've felt safer and better cared for medically than at any previous time. Not because the doctors are intervening more, but because they're engaging us in building working relationships built on trust. It's very comforting to know that your doctors really value the professional relationship and have healing wishes toward patients. Prescribing a medication may take care of the physical problem; but building trust supports patients emotionally. The value of building trust and sharing healing wishes cannot be overstated.
1
I have refused medical tests and interventions and should have done so more often. I have a deformity from a surgery done by a "top" doctor. My surgery was medically necessary, but two minutes before I went into the operating room she told me she was going to do an additional procedure for cosmetic reasons. I made the mistake of assuming this was normal. In fact it was malpractice, but because it didn't start to look bad until I went back to my normal weight (not overweight) it was too late to sue. Apparently she was bored by doing the same surgeries over and over, and wanted to be creative, like Dr. Frankenstein.
1
My sister is lying gravely ill in a large urban hospital - not a teaching hospital - after 5 and half weeks of treatment. She is elderly, but had no serious underlying physical conditions when she collapsed and was admitted. The most probable diagnosis of the cause of her loss of consciousness is a pulmonary embolism. By the time the embolism could be visualized it was small, following several days' treatment with blood thinners. Following her admission to the ICU, she developed pneumonia, ICU delirium, low grade infections and finally, a major infection that now threatens her life. During her hospital stay she was intubated and extubated repeatedly, had a tracheostomy, and has been bedridden in intensive care for over five weeks. An individual who was functional six weeks ago is now at risk of dying, largely as a result of medical care.
This is an exceptionally egregious example of something which happens every day in our hospitals as a result of over treatment.
This is an exceptionally egregious example of something which happens every day in our hospitals as a result of over treatment.
115
Unfortunately yours is an example of lay people not being able to understand modern medicine.
Your sister must have had a serious underlying physical condition or she would not have had a pulmonary embolism. These come overwhelmingly from deep vein thromboses in the legs, which are commonly linked to immobility,
If a pulmonary embolism causes loss of consciousness (read: loss of adequate perfusion to the brain) it is most likely a life-threatening event. She probably would have died right there without doctors.
But they saved her and later she developed pneumonia. This is a very common complication of sick patients in the ICU, and particularly elderly patients with pulmonary emboli. It sounds like they miraculously saved her again though; in the past she would have again died right there.
She is not dying as a result of medical care. She is only alive because of heroic medical care.
Your sister must have had a serious underlying physical condition or she would not have had a pulmonary embolism. These come overwhelmingly from deep vein thromboses in the legs, which are commonly linked to immobility,
If a pulmonary embolism causes loss of consciousness (read: loss of adequate perfusion to the brain) it is most likely a life-threatening event. She probably would have died right there without doctors.
But they saved her and later she developed pneumonia. This is a very common complication of sick patients in the ICU, and particularly elderly patients with pulmonary emboli. It sounds like they miraculously saved her again though; in the past she would have again died right there.
She is not dying as a result of medical care. She is only alive because of heroic medical care.
2
...and Medicare will pay for each test, treatment, consult, etc thereby improving the revenue of the hospital, the doctors and the pharmaceutical companies. Our system rewards doing something. After 35 years in medicine, I have seen very little meaningful reforms and mostly see the perpetuation of the medical-pharmaceutical-hospital complex.
Kate - there is a lot here to suggest that your sister was not as healthy to begin with as you suggest. The health of elderly persons, unfortunately, is often more precariously balanced than outwardly appears and it doesn't take much to upset the apple cart.
1
The viewpoint expressed here infers that one usually seeks out care at the "best" university hospital. Many specialists, who were all trained at the major institutions, are now providing excellent quality care in the community settings and at lower costs and better outcomes. Sometimes the suggestion of additional testing, etc is the fear of being sued for malpractice or patient demands. Practicing medicine is part science, and part art with interpretation by a well-trained and knowledgable physician of all data points including the actual physical exam. Every bit of data is not essential for providing appropriate care. Patients need to understand that humans are not machines and results are dependent upon many variables. Improved quality of life should be the best outcome.
23
Good article. As with so much in medicine, the logical response isn't always the best. Senior physicians at teaching hospitals tend to be academics more than clinicians, authors and investigators but often not those with the most patients.
Give me a busy, non senior doctor for just about anything,. I want the physician who may not do the most exceptions to the rule but does the most routine surgeries over and over and over.
As for the 4 questions, Dr. Emmanuel, I agree that forcing doctors to tell me what difference an intervention will make, what the side effects are likely to be, what improvements I can expect in quality of life, and where will the surgery be performed can to a long way to guiding my decision.
Isn't that what "accountable" care means today? The right for a truly informed patient to weigh his or her own tolerance for risk in light of informed answers to those 4 essential questions?
Give me a busy, non senior doctor for just about anything,. I want the physician who may not do the most exceptions to the rule but does the most routine surgeries over and over and over.
As for the 4 questions, Dr. Emmanuel, I agree that forcing doctors to tell me what difference an intervention will make, what the side effects are likely to be, what improvements I can expect in quality of life, and where will the surgery be performed can to a long way to guiding my decision.
Isn't that what "accountable" care means today? The right for a truly informed patient to weigh his or her own tolerance for risk in light of informed answers to those 4 essential questions?
3
Okay, so "senior" doesn't equal "best." A senior cardiologist is probably good at sucking up to management, in other words, a politician, so that's obvious.
Next, Dr. E.E. says "A solution for overmedication, especially in older people, would be to require that doctors attempt to discontinue medications at least once a year."
Actually, a solution for overmedication would require first, that physicians consult a verifiable medical record for the patient to ascertain possible drug interactions and of course pre-existing conditions before prescribing; that would require a national health system of some kind. Second, the solution for overmedication would abolish direct-to-the-public advertising of all prescription drugs, and probably most OTC medications as well. Not to mention prosecuting companies that extend, and docs who accept, kickbacks for prescribing certain medications:
http://healthimpactnews.com/2014/doctors-earn-3-5-billion-in-kickbacks-f...
Our costs go up and up, and Americans get sicker and sicker. Average life expectancy is declining, along with quality of life for the vast majority of the population. Yeah, the best advice is: exercise, eat decent food, don't smoke, stay out of hospitals and be a stranger to your doctor.
Next, Dr. E.E. says "A solution for overmedication, especially in older people, would be to require that doctors attempt to discontinue medications at least once a year."
Actually, a solution for overmedication would require first, that physicians consult a verifiable medical record for the patient to ascertain possible drug interactions and of course pre-existing conditions before prescribing; that would require a national health system of some kind. Second, the solution for overmedication would abolish direct-to-the-public advertising of all prescription drugs, and probably most OTC medications as well. Not to mention prosecuting companies that extend, and docs who accept, kickbacks for prescribing certain medications:
http://healthimpactnews.com/2014/doctors-earn-3-5-billion-in-kickbacks-f...
Our costs go up and up, and Americans get sicker and sicker. Average life expectancy is declining, along with quality of life for the vast majority of the population. Yeah, the best advice is: exercise, eat decent food, don't smoke, stay out of hospitals and be a stranger to your doctor.
Having practiced at a number of teaching hospitals throughout my career, I can attest to the very common practice of senior physicians having their trainees (residents or fellows) examine the patient, and then stepping in for a very brief consultation at the end -- so that they can "legally" bill the patient for their service. This likely results in less adequate care than that provided by a less senior but fully trained physician who is more likely to see the patient him/herself. My guess is that this is not limited to just cardiology and that were similar studies done for other specialties the results would be similar. Solution? For serious conditions, always ask to see the supervising doc. The squeaky wheel gets the grease.
2
Life-preserving 'luck' when senior cardiologist-absent status is confirmed, when accessing health care for acute cardiac conditions may be more accurate that we think, and not only in jest. This may be akin to patient's and/or family request to do our best, and more, for a particular case, which seems to weer us from our automatic and usually accurate assessment and treatment...to searching for new, more aggressive, and possibly unproved methods to beat our 'average' ...and lose the benefit of years of experience where action does free us from disaster. The only situation to top this absurdity would be to assume that a first- year resident, on July 1st, is ready to do unsupervised work. The adage "first, do no harm", is easier said than done, by a mile, or two. Best results are achieved when a chief resident is involved, with the most up-to-date information, and the ability to perform well, guided by any capable on-call staff physician. Incidentally, senior physicians, cardiologists in this case, pursuing other interests to benefit humanity, will be gladly excused from garden-variety cases of the day.
Like most discussions relating to "evidence based medicine," this article confuses the overall post facto results from care and the real-time individual cases. Intervention is binary--it happens or it does not. A doctor cannot choose, a 50% or 75% intervention. The "four simple questions" all relate to knowledge about groups of patients. When a doctor proposes to intervene, she or he has no idea what difference it will make in that individual case--only what difference it could make. For that patient, it will either help, or not, a lot, or a little. The physician cannot know "how much improvement" the intervention will make--just how much it could make. The intervention may improve matters a great deal, a little, not at all, or cause harm. In a group of a hundred, or thousand patients, trends appear. Each individual is not a trend--and only one outcome can occur. Side effects may be "likely" (or not) in a hundred patients--but the patient in front of the doctor will either have troubling side effects, or not--not some percentage of a side effect. And even if the hospital is a community hospital, does every patient there do worse than at a teaching hospital? Of course not. And the doctor has to make each decision knowing it will either be right for that particular patient, or not. It will not be 66% right and 34% wrong, for example.
What medicine needs is evidence based medicine for the particular, precise, suffering person in front of each doctor. And we are not there yet.
What medicine needs is evidence based medicine for the particular, precise, suffering person in front of each doctor. And we are not there yet.
1
As an academic physician, I am quite surprised that this was discussed as if an observational study like this could establish cause. The literature is replete with association studies that lead to incorrect conclusions because of unrecognized residual confounding. This is an interesting observation, but to discuss it without even alluding to the weakness of the study approach can give individuals the impression that association indicates cause. Yes, the authors tried some things to rule out some causes of confounding, but the lesson of medical research during the past quarter of a century is that such attempts are often inadequate, and that the sources of confounding are often hard to see. Even things like propensity scores are often inadequate. The observation may be real, but some recognition that this would hardly be considered as level A evidence should at least have been included.
3
This appears to be great research, and it is consistent with decades of research on organizational behavior and management of complex technology.
Those recognized for their research, analytical, and "political" skill of getting published, are not necessarily the ones you want leading in an emergency situation.
Simply put, the "smartest people in the room" often think too much when the hurricane hits.
This also has serious implications for "evidence based" medicine, as it is currently conceived.
Current forms of "evidence" management, especially as envisioned in the ACA, would have complex medical record systems capture millions of rushed notes, jotted by doctors trying to get from one of their 20-30 patients per day to the next, sent to research specialists who live and work far from the action.
From this, suspect, data, the analytic specialists are expected to issue process instructions, back down the chain of command to all practitioners on the front lines.
And, waiting in the wings, are malpractice attorneys, who exploit ambiguities for personal gain.
This article should be the stimulus for a new discipline of "case management under conditions of urgency and uncertainty"
Medicine used to be called an "art" for a reason. It is also a "craft".
Those are important concepts for a "science" that is so good, it proves that yesterday's hypotheses were 50% to 70% "wrong".
Those recognized for their research, analytical, and "political" skill of getting published, are not necessarily the ones you want leading in an emergency situation.
Simply put, the "smartest people in the room" often think too much when the hurricane hits.
This also has serious implications for "evidence based" medicine, as it is currently conceived.
Current forms of "evidence" management, especially as envisioned in the ACA, would have complex medical record systems capture millions of rushed notes, jotted by doctors trying to get from one of their 20-30 patients per day to the next, sent to research specialists who live and work far from the action.
From this, suspect, data, the analytic specialists are expected to issue process instructions, back down the chain of command to all practitioners on the front lines.
And, waiting in the wings, are malpractice attorneys, who exploit ambiguities for personal gain.
This article should be the stimulus for a new discipline of "case management under conditions of urgency and uncertainty"
Medicine used to be called an "art" for a reason. It is also a "craft".
Those are important concepts for a "science" that is so good, it proves that yesterday's hypotheses were 50% to 70% "wrong".
My father was a surgeon from circa 1960 to 1985. All of his friends and associates were doctors, mostly surgeons, and they had an uncanny tendency, when confronted with medical problems, to think that extirpating the thing was the best possible solution. Imagine that.
He and his friends (yes, it was predominantly a male enclave then), argued that no one was better able to regulate their world other than themselves, and to suggest otherwise was blasphemy. (Worse still: socialist medicine was right around the political bend. Yikes! I found the very sound of that scary as a ten-year-old at those cocktail parties.)
Yet in the 1970s and the 1980s and the 1990s -- I lost interest after that -- there was clear evidence that much unnecessary surgery was going on in nearly even aspect of health care.
Gosh, if my father were alive today I guess he would advise me that socialized medicine, not too much unnecessary surgery, was the problem with medicine.
Were he alive today, I would make a very serious attempt to sell him the Brooklyn Bridge.
He and his friends (yes, it was predominantly a male enclave then), argued that no one was better able to regulate their world other than themselves, and to suggest otherwise was blasphemy. (Worse still: socialist medicine was right around the political bend. Yikes! I found the very sound of that scary as a ten-year-old at those cocktail parties.)
Yet in the 1970s and the 1980s and the 1990s -- I lost interest after that -- there was clear evidence that much unnecessary surgery was going on in nearly even aspect of health care.
Gosh, if my father were alive today I guess he would advise me that socialized medicine, not too much unnecessary surgery, was the problem with medicine.
Were he alive today, I would make a very serious attempt to sell him the Brooklyn Bridge.
3
It all depends upon the doctors whether they have sufficient knowledge, expertise and experience to deal with an ailment given the condition of the patient. Next comes the ethics whether the doctor is following the professional ethics or whether he or she is in collusion with the unethical practice of the hospital and insurance concerned. Not necessarily every senior doctor is good and every junior doctor is bad. It all depends upon the dedication of the doctor and ethics.
I cite the case of my mother here. She is 83 years old, diabetic and has high B.P for the past many decades. Few months back she was staying with one of my sisters in a town called Khammam in my state of Telangana. During that time she felt severe pain in her head as if the nerves were squeezing her. My sister took her to a qualified M.D. Her C.T scan, blood tests and X-ray were taken. C.T scan and blood tests were found normal. The doctor noticed something abnormal in her X-ray and concluded that she has water in the heart, God only knows how he came to that conclusion. Further he prescribed a number of unnecessary extra neorological, heart and diabetic medicines. My mother's health deteriorated further.
We brought her to Hyderabad as soon as my sister informed me. We took her to a well known cardiologist in a reputed hospital here. After the diagnosis and certain needed tests, the cardiologist asked her to continue only her regular diabetic and B.P medicine, that's all since then she is doing well.
I cite the case of my mother here. She is 83 years old, diabetic and has high B.P for the past many decades. Few months back she was staying with one of my sisters in a town called Khammam in my state of Telangana. During that time she felt severe pain in her head as if the nerves were squeezing her. My sister took her to a qualified M.D. Her C.T scan, blood tests and X-ray were taken. C.T scan and blood tests were found normal. The doctor noticed something abnormal in her X-ray and concluded that she has water in the heart, God only knows how he came to that conclusion. Further he prescribed a number of unnecessary extra neorological, heart and diabetic medicines. My mother's health deteriorated further.
We brought her to Hyderabad as soon as my sister informed me. We took her to a well known cardiologist in a reputed hospital here. After the diagnosis and certain needed tests, the cardiologist asked her to continue only her regular diabetic and B.P medicine, that's all since then she is doing well.
Only 4 comments so far? Hmm. Zeke, maybe this article which has a catchy title but really went in the direction of the issue of over treatment should have been named differently. As a primary care internist, who sees daily the over treatment and over medication prescribing by cardiologist and many of my other specialist colleagues, its an excellent topic. Much is based on the very significant treatment bias that doctors accrue during training and is enhanced by economic advantage. Especially in any competitive, urban medical market. More treatment has the effect of saying to patients -better treatment. Patients are unable to choose less and understand the limitations of the "data". Near end of life treatment by oncologists to try to "help" in any way is highly suspect and in many cases futile and causes more suffering without any significant increase in length or quality of remaining life. Yet, all oncologists fall back on that one case that did well and beat the odds. The other large factor in treatment is the "just in case" rational so that everything possible is done in all cases.
IMO, doctors need ongoing joint help in actually helping patients in real life situations. How this can be done is still very difficult to construct and off topic here.
IMO, doctors need ongoing joint help in actually helping patients in real life situations. How this can be done is still very difficult to construct and off topic here.
1
The finding that having senior doctors around leads to more procedures and more deaths is not really surprising in America.
That is because we do not have Evidence Based Medicine. I have been involved as a statistician in medical research a the University of California San Francisco since 1980, and the problem was highlighted to me by a PhD student. She was a leading nurse with 25 years experience.
One third of medical procedures in the US are useless and another third are actually harmful, she told me. This was based on a lot of personal observation and a variety of academic studies.
That is why American health care costs twice as much as health care in other countries, and why the outcomes are worse. Other countries make an effort to find out which procedures are effective (Evidence Based) but the US does not. Medicare and other funders here pay for 'usual and customary' care.
To see the story in detail read Confidence Men, about Obama's first years in office. The author is an award winning former Wall St Journal reporter.
To see what we should do about several things, go to YouTube and watch Comedy Party Platform (2 min 9 sec). Then send a buck to Bernie Sanders and invite me to speak to your group. Thanks.
That is because we do not have Evidence Based Medicine. I have been involved as a statistician in medical research a the University of California San Francisco since 1980, and the problem was highlighted to me by a PhD student. She was a leading nurse with 25 years experience.
One third of medical procedures in the US are useless and another third are actually harmful, she told me. This was based on a lot of personal observation and a variety of academic studies.
That is why American health care costs twice as much as health care in other countries, and why the outcomes are worse. Other countries make an effort to find out which procedures are effective (Evidence Based) but the US does not. Medicare and other funders here pay for 'usual and customary' care.
To see the story in detail read Confidence Men, about Obama's first years in office. The author is an award winning former Wall St Journal reporter.
To see what we should do about several things, go to YouTube and watch Comedy Party Platform (2 min 9 sec). Then send a buck to Bernie Sanders and invite me to speak to your group. Thanks.
1
I trained at an excellent university hospital for advanced heart failure cardiology. I learned from cardiologists at the pinnacle of the field. They are both excellent teachers and clinicians. If I was in cardiogenic shock from a heart attack or any other cause, I would want them at my bedside, not at a conference. I trust their clinical judgment and their compassion implicitly. That being said, I know there are some cardiologists who are great teachers and researchers contributing to our field of knowledge who are required to work in the hospitals only periodically to maintain their credentials and job titles, who I would not want taking care of my family. Not all senior teaching cardiologists are bad clinicians, but a large enough number are to make a study turn out results like this one. I wish this author had quoted the absolute and relative risks of mortality from the association. Was it large and truly meaningful, or just big enough to be noticeable?
1
I side with the too-much-intervention theory, particularly the implanting of stents. My late mother had one of those put in -- unnecessarily, according g to later protocols -- and it degraded her quality of life considerably. Because of the blood thinner she had to take (until the end of her life) she was constantly covered in bruises. She weakened rapidly, and her mobility declined. She simply fizzled after that procedure.
I wonder how much ego (cardiologists are known for having enormous egos and poor bedside manner) and greed (overtreatment often means expensive surgeries) affect the death rate. I'm thinking of all those young, optimistic residents, not yet cynical, cold, or burned out. I'd rather be cared for by someone who still has a light in their eyes than by any of the older, "big name" cardiologists I have encountered.
I wonder how much ego (cardiologists are known for having enormous egos and poor bedside manner) and greed (overtreatment often means expensive surgeries) affect the death rate. I'm thinking of all those young, optimistic residents, not yet cynical, cold, or burned out. I'd rather be cared for by someone who still has a light in their eyes than by any of the older, "big name" cardiologists I have encountered.
When suffering with severe leg pain on walking, due to lumbar spine problems - not insufficient blood flow (confirmed twice by tests that measure blood flow to the legs), a physician friend suggested he take my magnetic resonance scan of my spine to a colleague for an opinion. The presence of calcification of my aorta was noted and the suggestion was that I (it) needed treatment.
My pain has been resolved following back surgery and I can now walk nine miles uphill without pain and no doubt I still have the calcification in my aorta.
As a physician myself, I would strongly advise that physicians treat patients (people) and not tests and encourage people to seek medical help only when they are having problems and forgo the so called annual health examination and the routine tests that accompany them. (other than in the very few conditions where there is incontrovertible evidence that treating abnormal tests improves outcomes.)
My pain has been resolved following back surgery and I can now walk nine miles uphill without pain and no doubt I still have the calcification in my aorta.
As a physician myself, I would strongly advise that physicians treat patients (people) and not tests and encourage people to seek medical help only when they are having problems and forgo the so called annual health examination and the routine tests that accompany them. (other than in the very few conditions where there is incontrovertible evidence that treating abnormal tests improves outcomes.)
2
Two years ago, if I had foregone my annual physical, then I would not have been diagnosed with multiple myeloma. I had no symptoms. I am now in remission and have had few symtoms of the disease. Treatments have been hard but without the annual phsyical, where would I be?
1
Not surprising. Agressive doctoring is common and costly. We live in a culture that places too little emphasis on prevention and personal responsibility, and too much on the ability of modern medicine to cure almost anything. Indeed the average patient equates a doctor's decision to do nothing with ineptness if not malpractice. Whether consciously or not, doctors do what they were trained to do - intervene. The 'first do no harm' creed went out the window decades ago.
Perhaps I can illustrate the breadth of the problem with a small story. Having recently attended a party where virtually everyone in attendance took turns comparing the doctors they were seeing, the tests they were undergoing, and the drugs they were on - it came to my turn. I admitted I hadn't seen a doctor recently, wasn't scheduled for any tests, and wasn't on any drugs. There was momentary silence, followed by a look of disbelief, then disapproval and finally a comment from another sixty-something to the effect I could well 'have something' but not know it.
What I didn't tell them (because I feared even more disapproval) was that I hadn't seen a doctor in 20 years, that I exercised regularly, that I was careful what I ate and drank, and that I had cultivated a number of techniques to keep stress at bay. When I look at the healthy centenarians in places like Okinawa, I realize that this is really the way life should be. For some people, illness is inevitable but it shouldn't be the expectation.
Perhaps I can illustrate the breadth of the problem with a small story. Having recently attended a party where virtually everyone in attendance took turns comparing the doctors they were seeing, the tests they were undergoing, and the drugs they were on - it came to my turn. I admitted I hadn't seen a doctor recently, wasn't scheduled for any tests, and wasn't on any drugs. There was momentary silence, followed by a look of disbelief, then disapproval and finally a comment from another sixty-something to the effect I could well 'have something' but not know it.
What I didn't tell them (because I feared even more disapproval) was that I hadn't seen a doctor in 20 years, that I exercised regularly, that I was careful what I ate and drank, and that I had cultivated a number of techniques to keep stress at bay. When I look at the healthy centenarians in places like Okinawa, I realize that this is really the way life should be. For some people, illness is inevitable but it shouldn't be the expectation.
3
Speaking as a medical specialist (not a cardiologist), this is not so surprising to me. Especially in the non-surgical specialties, the "top" practitioners in their fields have for the most part made their names in research, not clinical care. One gets good at treating acute disease by treating lots of acute disease, not by writing grants, supervising post-docs in the lab or running international, multicenter therapeutic trials, but for better or for worse, those are the sorts of professional activities that earn a doctor department chairs and the presidencies of professional associations.
That said, I'm skeptical about attempts to quantify physicians' performance and make such data available to patients. In surgery, where the interventions are more standardized and the outcomes easier to measure than in internal medicine, efforts at quantification of performance have created perverse incentives, encouraging surgeons to cherry-pick the lowest risk cases, making good surgeons who remain unafraid to tackle high-risk operations look worse than they are and in some cases making it hard for patients with a requirement for a high-risk operation to find a surgeon willing to provide the care they need.
That said, I'm skeptical about attempts to quantify physicians' performance and make such data available to patients. In surgery, where the interventions are more standardized and the outcomes easier to measure than in internal medicine, efforts at quantification of performance have created perverse incentives, encouraging surgeons to cherry-pick the lowest risk cases, making good surgeons who remain unafraid to tackle high-risk operations look worse than they are and in some cases making it hard for patients with a requirement for a high-risk operation to find a surgeon willing to provide the care they need.
2
There is no question that informed consent is essential. We should remember that every treatment decision represents a partnership where both the care-provider and the patient assume risk regardless of how informed either party is. I do wonder, however, if the explanation for increased mortality when the senior cardiologist is away relates to the observation that fewer interventions are performed while they are gone. Could it be that an inevitable death is only postponed while the most skilled person is absent? I would ask: When the senior cardiologist stays home during major national meetings do his patients die more often? Also, the observation that the absent senior orthopedists don't represent as much of a threat as absent senior cardiologist could relate to what statisticians call effect-size. That is, death from ones heart attack is more likely then death from ones broken leg whether the senior guy is there or not.
I applaud Dr. Emmanuel for highlighting this interesting study, given the counterintuitive results. I do however worry about the suggested responses to these findings. Firstly, while it will be fantastic to require physicians to provide detailed evidence-based safety and efficacy data on every intervention, such data do not always exist, and could inadvertently stifle the development of new treatment interventions. Secondly, while placing the burden on patients and families to scrutinize each treatment option would help them make better informed choices and should be standard, second-guessing expert advise is not without peril, if it results in a bad outcome, often resulting in a feeling of guilt: "if only we had listened to the doctor's advice".
I believe that the value of studies such as these is to give us cause for pause, to methodically and scientifically try to figure out the paradoxical results. The study did not answer this question, and we must avoid speculating about the reason for the results, and especially making prescriptions based on these speculations, however reasonable they may seem.
I believe that the value of studies such as these is to give us cause for pause, to methodically and scientifically try to figure out the paradoxical results. The study did not answer this question, and we must avoid speculating about the reason for the results, and especially making prescriptions based on these speculations, however reasonable they may seem.
1
Medical interventions require a patient to sign an informed consent form. A patient is not ready to sign if the doctor does not voluntarily explain the pros and cons -- including specific serious negative side effects. Let's not overlook the fsct that the doctor has a conflict of interest and may not be terribly motivated to say much about downsides and possible negative outcomes. So it's not only impractical and unethical to conduct medical business by putting the burden on the vulnerable patient to extract the information from the doctor that the patient has a right and a need to know. Not getting that information promotes the doctor's financial and other interests at the expense of protecting the patient's safety and peace of mind. The MD doesn't make money if the patient doesn't buy their services.
If possible, consult a primary care MD to help sort things out when a specialist is not informative enough.
If possible, consult a primary care MD to help sort things out when a specialist is not informative enough.
I agree that less is often more, in medicine and life. However, with respect to mortality rates and community hospitals there are several confounding factors. As a rural medical practitioner for more tha 30 years, I can tell you that patients often arrive dying from the nursing homes, sent to improve death statistics for those institutions. Sometimes, of course, this is at the behest of the distraught families not ready to let go. In addition, we will hospitalize terminally ill patients who have a DNR request, whereas without that designation such patients would be transferred to a regional hospital. When a patient in cardiac arrest or having an acute coronary syndrome arrives, we rapidly stabilize them and transfer, often by air to a site where interventionalists are available. Also, when one suffers a cardiac arrest 30 minutes from the hospital it is often neither possible nor appropriate to resuscitate them.
2
It's a sad comment on our medical system when patients are told to ask, "Will that procedure/treatment/medicine actually help?"
It seems obvious that doctors should weigh those questions, and make their judgment, before making recommendations. After all, wouldn't we assume that their knowledge and experience is actually useful, and helps them to provide better care? But the sad fact is that far too often, as described here, the burden falls on sick, uninformed patients, to have the knowledge and presence of mind to probe the doctor's recommendations, for a course that will actually help.
This is a great failing of our medical system. We need education and training to emphasize that the goal of medicine is not the niftiest science or the most complicated techniques, or the most sophisticated technology. We need to take corporations out of health care, so that the goal actually is not to make the most money possible. The goal should be improving patients' lives. This should be the definition and true practice of "health care." We have drifted way too far from that.
It seems obvious that doctors should weigh those questions, and make their judgment, before making recommendations. After all, wouldn't we assume that their knowledge and experience is actually useful, and helps them to provide better care? But the sad fact is that far too often, as described here, the burden falls on sick, uninformed patients, to have the knowledge and presence of mind to probe the doctor's recommendations, for a course that will actually help.
This is a great failing of our medical system. We need education and training to emphasize that the goal of medicine is not the niftiest science or the most complicated techniques, or the most sophisticated technology. We need to take corporations out of health care, so that the goal actually is not to make the most money possible. The goal should be improving patients' lives. This should be the definition and true practice of "health care." We have drifted way too far from that.
96
"It seems obvious that doctors should weigh those questions, and make their judgment, before making recommendations."
I would agree with your statement - if the physician has first explored with the patient what their goals of care are. You and the patient may differ on what is considered a benefit or a harm. My 90 year old mother-in-law who has lived a healthy life with a good diet and exercise refused all preventive screenings and medical tests much to the chagrin of her physicians. She is the extreme yet highlights the point that each patient has their own values about what is beneficial treatment.
I would agree with your statement - if the physician has first explored with the patient what their goals of care are. You and the patient may differ on what is considered a benefit or a harm. My 90 year old mother-in-law who has lived a healthy life with a good diet and exercise refused all preventive screenings and medical tests much to the chagrin of her physicians. She is the extreme yet highlights the point that each patient has their own values about what is beneficial treatment.
@F. T.
"We need education and training to emphasize that the goal of medicine is not the niftiest science or the most complicated techniques, or the most sophisticated technology."
And there is where I point out the Zeke Emmanuel is a full professor and dean of one of the most prominent medical schools in the US (Penn). If these goals were easy to do, why isn't Zeke doing it at Penn?
The answer is that it is not as "cut and dried" as people think. It is sad that Zeke criticizes the medical profession instead of working with the educators at Penn to solve these problems.
"We need education and training to emphasize that the goal of medicine is not the niftiest science or the most complicated techniques, or the most sophisticated technology."
And there is where I point out the Zeke Emmanuel is a full professor and dean of one of the most prominent medical schools in the US (Penn). If these goals were easy to do, why isn't Zeke doing it at Penn?
The answer is that it is not as "cut and dried" as people think. It is sad that Zeke criticizes the medical profession instead of working with the educators at Penn to solve these problems.
An anecdote:
I was living in London when a friend of my girl friend showed up one Sunday night with a high fever. We rushed him to the local hospital. The ER was dark and dinghy and empty. There was a widow with a woman behind it. We were sent to an examining room and in a minute a doctor showed up. He treated my friend and handed us two prescriptions. He said the pharmacy was around the corner.
I handed the pharmacist the scripts and in five minutes had the drugs, I then asked, "Where do we pay?"
"Pay?" she said, "There's no money in this hospital."
"You don't understand, " I said. "We are not British citizens. We are just guests."
"No, YOU do do not understand, This is England. This is a hospital.. We treat sick people. We treat all sick people, Brits, Frenchmen, Chinese, even Americans. And that's all we do. We just treat sick people."
I was living in London when a friend of my girl friend showed up one Sunday night with a high fever. We rushed him to the local hospital. The ER was dark and dinghy and empty. There was a widow with a woman behind it. We were sent to an examining room and in a minute a doctor showed up. He treated my friend and handed us two prescriptions. He said the pharmacy was around the corner.
I handed the pharmacist the scripts and in five minutes had the drugs, I then asked, "Where do we pay?"
"Pay?" she said, "There's no money in this hospital."
"You don't understand, " I said. "We are not British citizens. We are just guests."
"No, YOU do do not understand, This is England. This is a hospital.. We treat sick people. We treat all sick people, Brits, Frenchmen, Chinese, even Americans. And that's all we do. We just treat sick people."
2
There may be another factor operating here. When friends and family ask for the "best" doctor for a problem, I am happy to provide names but I always warn about VIP syndrome.....something happens when a patient is labeled a VIP. When the "hot shots" --- the departmental chairman for example are requested, it is not uncommon for the request to be a special one. We do our best when we do our jobs in the predictable, routine way that has been shown to be safe and effective. When a patient becomes a VIP, they get sometimes more treatment and sometimes less (skipping a routine test to minimize discomfort e.g. when in fact it is needed.) Finally and this may be a bit shocking but sometimes the "hot shots" are removed from direct patient care and decision making as their research and national administrative demands increase. Nothing beats a careful, experienced bedside clinician with good judgment and sometimes it may be the mid level clinician who fits the bill.
35
I am a mid level clinician and I appreciate your observation that the person who takes the most care in treatment who gets it right, not necessarily the person with the most advanced degree. I find things all the time missed by my physician colleagues in the community. The woman in her 70s running a fever who received an extensive workup when all you had to do is look in her throat to see she had strep. Expensive tests ordered for low back pain with the problem is piriformis syndrome, easily elicited with the right maneuver. I find my physician colleagues often don't have the time with patients to pinpoint the problem and treat it correctly. Because they make so much more money than midlevel clinicians, and are expected to see that many more patients to pay their own salaries, they can't take time to get it right. What you get with the MD is a contest to see who can get it right, or the closest to right, under a time limit. Each patient exam is like a timed exam, and midlevels have twice as much time as physicians. Young, relatively inexperienced physicians are at the greatest disadvantage. An experienced midlevel dreads having a physician fresh out of residency on site when a physician consult is needed.
Not good for patients, and not good for physicians.
Not good for patients, and not good for physicians.
Just as the cobbler’s kids has no shoes, many times the doctor’s family gets the WORST care. Over or under done.
I had a friend in pre-med back in the late 1960s. She was a beautiful girl in nursing school. Her dad was the top orthopedic surgeon at Shriner’s. He had invented most of the procedures done throughout the entire USA in ortho. Her uncle was the top chest surgeon in the state.
She began having headaches so severe, she lay for days in a dark room not moving. She “looked” good otherwise. A psychiatrist came to the home--under “stress” given anti-depressants and a sleeping pill. She worsened.
Finally I went to her dad--I was a pathetic pre-med student AND a girl! This was before MRIs or CT scans. I said “Can’t it be organic? Maybe she should see a neurologist?”
There is strife between specialties. MDs feel they know it all...don’t need someone else--especially for a family member..”What if it makes us look bad?”
The neurologist ordered plain skull x-rays and Jennie started seizing on the x-ray table. Jennie had two large brain abscesses. After 2 years of multiple surgeries, intrathecal antibiotics (antibiotics administered through a spinal tap), loss of her long blonde hair, Jennie got back about 75% function.
Everything or nothing. Medicine is more of an art form than science. Today more medical schools are accepting French lit and dance/music as college degrees. Students of liberal arts have a better holistic understanding of humans. I’m glad!
I had a friend in pre-med back in the late 1960s. She was a beautiful girl in nursing school. Her dad was the top orthopedic surgeon at Shriner’s. He had invented most of the procedures done throughout the entire USA in ortho. Her uncle was the top chest surgeon in the state.
She began having headaches so severe, she lay for days in a dark room not moving. She “looked” good otherwise. A psychiatrist came to the home--under “stress” given anti-depressants and a sleeping pill. She worsened.
Finally I went to her dad--I was a pathetic pre-med student AND a girl! This was before MRIs or CT scans. I said “Can’t it be organic? Maybe she should see a neurologist?”
There is strife between specialties. MDs feel they know it all...don’t need someone else--especially for a family member..”What if it makes us look bad?”
The neurologist ordered plain skull x-rays and Jennie started seizing on the x-ray table. Jennie had two large brain abscesses. After 2 years of multiple surgeries, intrathecal antibiotics (antibiotics administered through a spinal tap), loss of her long blonde hair, Jennie got back about 75% function.
Everything or nothing. Medicine is more of an art form than science. Today more medical schools are accepting French lit and dance/music as college degrees. Students of liberal arts have a better holistic understanding of humans. I’m glad!
1
Zeke:
Two points:
1) Steven Dubner published a podcast on this phenomena months ago
2) Please look at regulators the same way...the stronger the intervention, the greater the harm. For example, the ACA!
Thanks,
Two points:
1) Steven Dubner published a podcast on this phenomena months ago
2) Please look at regulators the same way...the stronger the intervention, the greater the harm. For example, the ACA!
Thanks,
2
An insurance plan is neither a diagnosis nor a treatment. The ACA is not regulatory. It is medical insurance. Do you have such insurance? Why not say "Give up my UHC. It is a regulatory plan I can voluntarily live without. Come to think of it, so are my home and auto insurance."
Mixing in political hatred with policy debate shows your thoughtlessness about both.
Mixing in political hatred with policy debate shows your thoughtlessness about both.
The ACA was designed to be the least disruptive to the current system it could be. Maybe that is the problem.
1
It's true. More is not always good. There are countless interventions, medical tests, scans done which in no way contributes to an improved treatment and outcome. Not to mention the enormous cost for providing needless care. The four questions are the right questions a patient and her family have to ask for getting optimal care. But why are physicians so uncomfortable and reticent? The answer is simple. It is a fear of a malpractice lawsuit for under-treatment. Every physician knows that if he does not give in to the satisfaction of patients, then you have a hostile patient and a hostile patient is more likely to sue. This is one of the basics in Risk Management. Unless there is a cap on malpractice claims, these excesses are going to continue. Patients have to be educated enough, to be convinced that more is not only useless but also may not be good. Meanwhile, Physicians will keep prescribing antibiotics for viral fevers against all their misgivings.
8
I know physicians believe this, but the data show this is simply not true. Some states have caps; some do not. There is no statistical difference between the state that do and the states that do not in terms of cost or frequency of tests and treatments. Furthermore there is little or no change in these statistics when the caps were first put in place.
Just to restrict to the CBO, on page 150 ff of http://www.cbo.gov/ftpdocs/99xx/doc9924/12-18-KeyIssues.pdf, and http://www.cbo.gov/ftpdocs/71xx/doc7174/04-28-MedicalMalpractice.pdf, the CBO found no significant saving in those states such as Texas that have instituted "tort reform. In addition there was no reduction in the frequency of tests and treatments. Their costs and frequencies were also similar to those in states with tort reform. In a recent letter to Senator Hatch, the CBO said that an ideal system of torts would not save more than 0.5%, 60% (0.3%) of which would be in reduction of overutilization, i.e. "defensive medicine." They admit that this figure may be too high as examples have shown that in some cases, "tort reform" has increased some aspects of overutilization, and they ignored that in their computation. This amounts to about $32 a year on the average policy.
Just to restrict to the CBO, on page 150 ff of http://www.cbo.gov/ftpdocs/99xx/doc9924/12-18-KeyIssues.pdf, and http://www.cbo.gov/ftpdocs/71xx/doc7174/04-28-MedicalMalpractice.pdf, the CBO found no significant saving in those states such as Texas that have instituted "tort reform. In addition there was no reduction in the frequency of tests and treatments. Their costs and frequencies were also similar to those in states with tort reform. In a recent letter to Senator Hatch, the CBO said that an ideal system of torts would not save more than 0.5%, 60% (0.3%) of which would be in reduction of overutilization, i.e. "defensive medicine." They admit that this figure may be too high as examples have shown that in some cases, "tort reform" has increased some aspects of overutilization, and they ignored that in their computation. This amounts to about $32 a year on the average policy.
2
Actually no. Most health care systems use arbitration. When you sign that contract one of the paragraphs that no one reads is that you cannot sue! Kaiser has had this policy for 40 years. (Read the book “Sick” by Johnathan Cohn.)
No, today’s biggest problem is that health care is run by business majors. As a doctor you get evaluated by patients...and you BETTER get that 5 star rating or you get called in. “The patient had a headache. Why didn’t you order an MRI?” Or this patient “felt he needed antibiotics” why didn’t he get them?”
Uhhh because they didn’t NEED them? In a business model the bottom line is ALWAYS money. Keep the patients coming back. Don’t let them go to a competitor! So now we need to make each patient HAPPY! That sounds unempathetic...it’s not. 60% of non-medical people think that antibiotics helps a cold or bronchitis. No. And this is why we are developing so much antibiotic resistance. And NO. Not every patient who wants oxycodone is going to GET a narcotic. Yes for acute pain we will give a limited prescription. But for chronic pain? Let’s figure out another way of dealing with pain--physical therapy, pain management clinics, etc.
We live in a country where patients want to get well immediately. We want a “magic bullet” not a script for 6 weeks of physical therapy, a prescribed diet, told to cut down on fats, eat vegetables, and lean fish and poultry.
Medicine has become a business of “Keep the customer satisfied!”
No, today’s biggest problem is that health care is run by business majors. As a doctor you get evaluated by patients...and you BETTER get that 5 star rating or you get called in. “The patient had a headache. Why didn’t you order an MRI?” Or this patient “felt he needed antibiotics” why didn’t he get them?”
Uhhh because they didn’t NEED them? In a business model the bottom line is ALWAYS money. Keep the patients coming back. Don’t let them go to a competitor! So now we need to make each patient HAPPY! That sounds unempathetic...it’s not. 60% of non-medical people think that antibiotics helps a cold or bronchitis. No. And this is why we are developing so much antibiotic resistance. And NO. Not every patient who wants oxycodone is going to GET a narcotic. Yes for acute pain we will give a limited prescription. But for chronic pain? Let’s figure out another way of dealing with pain--physical therapy, pain management clinics, etc.
We live in a country where patients want to get well immediately. We want a “magic bullet” not a script for 6 weeks of physical therapy, a prescribed diet, told to cut down on fats, eat vegetables, and lean fish and poultry.
Medicine has become a business of “Keep the customer satisfied!”
1
Link to the study please.
2
So maybe the millions of dollars top cardiologists earn are not justified?
10
Intervention bias is seen commonly in the modern world. Our default mode is always to do something and feel in control. Interestingly I read that uncertainty leads to the ordering of excessive diagnostic tests and the overtreatment of patients. However it would seem that anxiety would be highest in neophyte clinicians rather than the experienced.
1
Right. A beginning cardiologist in my local hospital recommended immediate open heart surgery after looking at my echo cardiogram. When I went to a senior cardiologist at a major teaching hospital in Boston, he said that since I had no symptoms, he would wait and see for a while although I probably would need surgery in the long run. When I asked him about the previous recommendation, he said, "Well, it is always easier to suggest an operation."
I wish "Zeke" had provided us more information about the Affordable Care Act. He seems to be proving inadvertently that the best and the brightest aren't necessarily so smart.
27
People, when recognized (by others or by themselves) as best, brightest, or smart, sometimes begin to think that every thought that passes across their minds is brilliant, a conjecture that is itself worthy of critical review, along with the rest of these "brilliant" thoughts.
Thoughts themselves aren't intrinsically intelligent anyway. That one might think that they are may be a consequence of our language and the way we use it. Thoughts and ideas exist and operate in in contexts, and contexts keep changing. The idea that "more" is or leads to "better" may be seen as a case of such language-driven mental shorthand.
Thoughts themselves aren't intrinsically intelligent anyway. That one might think that they are may be a consequence of our language and the way we use it. Thoughts and ideas exist and operate in in contexts, and contexts keep changing. The idea that "more" is or leads to "better" may be seen as a case of such language-driven mental shorthand.
You have to wonder what his thoughts are on the current medical attitude that essentially All people should take a statin since it is such an amazing wonder drug (known side effects such as "inexplicable" muscle pain and weakness for the rest of one's life notwithstanding, and unknown side effects and manifestations...well, if unknown they don't exist, right?).
As time goes on I move further and further away from western medicine because it is bogged down with bad research and conflict of interest (profit), viz. it has become a business like any other business.
As time goes on I move further and further away from western medicine because it is bogged down with bad research and conflict of interest (profit), viz. it has become a business like any other business.
1
This article has nothing to do with medical insurance.
"There are potential policy solutions. One would require that doctors provide patients with data"
It is absurd to put these judgment calls on individual sick patients, at their weakest and most vulnerable moment, when they are least lucid.
This is something for medical professionals. This is their job. Don't shift it off on someone else, least of all someone so out of it their heart recently stopped. And not either onto their terrified and exhausted close family sitting for long hours in the waiting room.
And not insurance companies either. They don't have the expertise. Their adjusters in some cases are straight from cash register jobs at Target or WalMart, learning on the job. I took testimony from one such adjuster, on why she denied care. That is not the way to fix this.
Doctors are making mistakes? Doctors ought to fix that. Rested, expert doctors with time to think, maybe at one of their conventions, ought to re-evaluate their interventions. don't put it on someone else.
It is absurd to put these judgment calls on individual sick patients, at their weakest and most vulnerable moment, when they are least lucid.
This is something for medical professionals. This is their job. Don't shift it off on someone else, least of all someone so out of it their heart recently stopped. And not either onto their terrified and exhausted close family sitting for long hours in the waiting room.
And not insurance companies either. They don't have the expertise. Their adjusters in some cases are straight from cash register jobs at Target or WalMart, learning on the job. I took testimony from one such adjuster, on why she denied care. That is not the way to fix this.
Doctors are making mistakes? Doctors ought to fix that. Rested, expert doctors with time to think, maybe at one of their conventions, ought to re-evaluate their interventions. don't put it on someone else.
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Perhaps you have never been in such a situation? One is required to sign consent forms; one must make such decisions at these very moments of stress and need.
And at these times (been there, more than once), I always ask for the information Dr. Emanuel suggests should be supplied: the exact purpose of the procedure, rates of success, of complications, and of subsequent and long term treatments and consequences. I have asked these questions in the middle of a heart attack; fear of death did not render me irrational (on the contrary, I find that one can think very clearly at these times). When possible I research the information independently, having in the past been sometimes misled by some medical professionals.
But I certainly agree that insurance companies should not have any input at all in these decisions, other than providing information.
And at these times (been there, more than once), I always ask for the information Dr. Emanuel suggests should be supplied: the exact purpose of the procedure, rates of success, of complications, and of subsequent and long term treatments and consequences. I have asked these questions in the middle of a heart attack; fear of death did not render me irrational (on the contrary, I find that one can think very clearly at these times). When possible I research the information independently, having in the past been sometimes misled by some medical professionals.
But I certainly agree that insurance companies should not have any input at all in these decisions, other than providing information.
1
In the 1950's doctors typically treated their patients with a paternalistic philosophy, meaning they acted in the patient's best interest without including the patient in the decision making process. That methodology has been soundly rejected by our society, instead we have chosen a collaborative model that requires the physician to quickly educate the patient about complex issues and data that takes years to master under calmer circumstances. As a result we crave certainty; exactly how much heart disease do I have so I can decide what to do next? This drives more procedures and tests. If you want less procedures then society will have to rely more on the experienced judgement of physicians and less on the hurry-up education of appropriately scared patients to make clinical decisions. And that means limiting our current medical malpractice system which punishes paternalism.
I wish you would have supplied the reference to the study you cite Mr Emmanuel, but since you note that more tests and procedures lead to worse outcomes the next logical question to solve this puzzle is to ask; if we don't aim to gather every bit of information with invasive tests, does the experienced judgement of a good physician provide better outcomes?
I wish you would have supplied the reference to the study you cite Mr Emmanuel, but since you note that more tests and procedures lead to worse outcomes the next logical question to solve this puzzle is to ask; if we don't aim to gather every bit of information with invasive tests, does the experienced judgement of a good physician provide better outcomes?
No, like most things in life you need to take responsibility for your own medical treatment and not put all decisions in the hands of doctors. Doctors make decisions based on their own experience and community and often don't look at the larger picture, or may not even be aware of alternative treatments. I recently was diagnosed with a disease requiring surgery, and all of the local options were a several hour long operation. Instead i searched and found an alternative approach that was being done 3000 miles away with less risk in under 30 minutes. The lesson learned is the best person to look out for your own health is yourself in consultation with experts.
A dear friend in Italy helped to put this into perspective for me. She said that with her, growing up decades ago, that she looked toward certain figures like her doctor, her local priest and attorney as someone in whom you had the utmost trust, an unchallenged authority. These attitudes were passed largely unchanged to her from her mother and father.
For many of us growing up in the U.S., we had a similar experience. As a young boy, I felt a certain kind of awe when the doctor came to our house one evening to see my mother when she was not doing well. For years, I felt an apprehension about questioning anything my doctor suggested, even if I felt uneasy about it or had questions.
I have discovered through some difficult experiences which affected my health negatively, from the insistence of a physician, that doctors are like the rest of us, human beings, fallible, sometimes irritable and intimidating, sometimes kind and thoughtful, sometimes deeply insensitive. Each doctor is, after all, an amalgam of his own nature, his upbringing, his beliefs, his experiences and his training.
It is up to us as people to ask questions of our doctors when feeling uneasy or unsure, and if the response received does not feel right, to take time to consider, to not be rushed into taking any medicine or having any procedure we do not understand. Often a ‘second opinion’ brings much needed light and reassurance. And always paying attention to our own inner voice within.
For many of us growing up in the U.S., we had a similar experience. As a young boy, I felt a certain kind of awe when the doctor came to our house one evening to see my mother when she was not doing well. For years, I felt an apprehension about questioning anything my doctor suggested, even if I felt uneasy about it or had questions.
I have discovered through some difficult experiences which affected my health negatively, from the insistence of a physician, that doctors are like the rest of us, human beings, fallible, sometimes irritable and intimidating, sometimes kind and thoughtful, sometimes deeply insensitive. Each doctor is, after all, an amalgam of his own nature, his upbringing, his beliefs, his experiences and his training.
It is up to us as people to ask questions of our doctors when feeling uneasy or unsure, and if the response received does not feel right, to take time to consider, to not be rushed into taking any medicine or having any procedure we do not understand. Often a ‘second opinion’ brings much needed light and reassurance. And always paying attention to our own inner voice within.
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The reason Dr. Emmanuel recommends teaching hospitals is because there are more eyes--looking out for your care and just as importantly, more eyes of doctors and nurses looking over the processes and procedures of OTHER doctors and nurses, a situation that usually produces a higher QUALITY of care.
Bad doctors often lurk in environments where there is the least amount of peer review.
Bad doctors often lurk in environments where there is the least amount of peer review.
1
For decades, every intern knows that the last person you want to see during a cardiac resuscitation is the Chief of Cardiology!
Emergency responses require good teamwork, which requires that team members practice together often and provide feedback to each other during the emergency procedures. That may be less likely to happen when the most senior person is there.
Emergency responses require good teamwork, which requires that team members practice together often and provide feedback to each other during the emergency procedures. That may be less likely to happen when the most senior person is there.
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The study is probably right, but there is always a worry about "sample selection bias"; for example, if patients with poor prognoses, on hearing that the expert was out of town, opted for another, more convenient hospital. Maybe this effect was controlled for or is not a significant factor.
+1 Michael
Since I was a pre-teen the biggest problem was for older family members and friends to have what some call "executive physicals". Then I found top surgurical nurses or other respected support staff to recommend hospitals and doctors with best and busy surgical teams and ICUs.
Doctors Without Borders and Royal Flying Doctors do a most worthwhile job in delivering medical services to those in remote country towns, in the bush besides in Third World countries.
Since I was a pre-teen the biggest problem was for older family members and friends to have what some call "executive physicals". Then I found top surgurical nurses or other respected support staff to recommend hospitals and doctors with best and busy surgical teams and ICUs.
Doctors Without Borders and Royal Flying Doctors do a most worthwhile job in delivering medical services to those in remote country towns, in the bush besides in Third World countries.
2
Never ever be treated by the chief of anything, he or she didn't become chief because they were a great clinician. they became chiefs because of their research curriculum vitae. If they were interested in taking care of patients they wouldn't be chief administrators. What do I know? Only the perspective of someone who had operated at a major teaching institution for 26 years.
3
Does anyone know the name of them? I am really interested.