Demystifying Medicine One Month at a Time

Category: technology (page 2 of 11)

Timing is Everything

IUDs & Implant

Quick: Which US state has the highest rate of unintended pregnancy?

I’ll reveal below, but I learned the answer and several other surprising facts in an interview with Mark Edwards, the co-founder of Upstream USA, a non-profit training organization that provides technical assistance to health enterprises (medical practices, clinics, public health departments) in the use of long-acting, reversible contraceptives (known in the trade as LARC).

LARC consists of two options: IUDs (intrauterine devices) and implants — which are small, match-sized, plastic rods that deliver a slow, steady dose of hormone to prevent pregnancy. They are planted in the upper arm of women to provide another form of hassle-free contraception.

Both of these methods can be discontinued at any time, at which point fertility returns — faster, I’m told, than in the case of oral contraceptives.

Here’s a fact that surprised me about oral contraceptives (aka “The Pill”): Though when taken reliably their ‘success rate’ as a means of preventing unwanted pregnancy is considered to be 99%, over a 10 year use period, due to the challenging nature of remembering to take a daily pill, it’s likely that 61% of those taking the pill exclusively for birth control will become pregnant. Most definitely not the intended outcome. (Source: here.)

Big picture: every year in the US, there are about 6.6 million pregnancies. Of those, 3.4 million, or slightly more than half, are accidental: either altogether unwanted or ‘significantly mistimed’ — what we in the health care business describe as a pregnancy occurring 2 or more years before desired. The vast majority of these accidental pregnancies occur in women in their 20s (though teen pregnancy is a concern, only 20% of unplanned pregnancies are in teens, and the vast majority of those are in women 18-19 years old. In fact, the teen pregnancy rate has fallen significantly in the last 25 years).

That’s why, regardless of your politics, offering LARC to any woman of childbearing age is crucial. At the very first visit. As a primary care doc myself, I know that ‘family planning’ often falls down the list of concerns for patients that I see because there are so many other issues people wish to bring up in our short office visits. Thus, opportunities to provide women with LARC often fall through the cracks.

Upstream USA’s methodology includes technical assistance: training staff up to ask every woman that comes in a simple question: “Do you intend to get pregnant in the next year?”

If ‘yes,’ let’s get her into preconception care (folic acid, multivitamins, etc.). If ‘no,’ offer LARC right then and there. And the provider (doctor, nurse practitioner, or physician assistant) is trained up to put in an IUD or implant on the spot. No waiting until next time.

Why is this so important? Women with unplanned pregnancies are at greater risk for staying or falling into poverty. Their opportunity to advance in their education is diminished. Children should be brought into the world wanted — with parents that are prepared — with the maturity and resources to succeed.

It’s a fundamental choice for a woman to decide if and when she wants to have children. Of course, fewer unplanned pregnancies also means less need for abortion.

So what Upstream USA is offering is win-win-win. It’s bipartisan — a rare area that people on all sides of the political spectrum can agree upon. Upstream USA’s first big success was in none other than Texas. The organization also has partnerships in a number of other Red and Blue states.

The state with the highest rate of unplanned pregnancy? Surprisingly, Delaware. Upstream USA is there, too. And going big — across the whole state.

Theranos: In Need of a Little Sunlight

If you haven’t heard of Theranos (a made-up word coming from “therapy” + “diagnosis”), a startup company promising to disrupt the clinical laboratory industry, you might have seen news about it this week — the company has hit a wave of negative press inspired by a Wall St. Journal expose on its early failures.

elizabeth-holmes_416x416Theranos has a compelling backstory: Founder and CEO Elizabeth Holmes dropped out of Stanford at age 19, spent 10 years in obscurity developing a new technology for blood tests, then launched the company with a wave of publicity that would make Donald Trump and Steve Jobs envious: Business magazine cover stories, a New Yorker profile, a TEDMED talk. Along the way, she creates an advisory board with names like Kissinger, Frist, Shultz, Nunn, Perry, etc. — high-ranking former government officials. The company garners a valuation of $9 BILLION, making Holmes, at 31, on paper the youngest self-made female billionaire in the world (Mark Zuckerberg of Facebook is three months younger than Holmes).

The premise is this: Holmes hated giving blood for routine medical tests. Her phobia was so great she thought there had to be a better way to do it: Microfluidics. Using a finger stick to collect of drop of blood instead of the more traditional practice of puncturing a vein near your elbow, Theranos promises the ability to run dozens of medical tests from that single drop — instead of the numerous traditional blood vials. Moreover, Theranos promises to perform the tests at a fraction of the cost of industry leaders LabCorp and Quest.

Disruptive technology indeed.

The problem is that Theranos is highly secretive about its methods, choosing to go the press to announce its new technologies and partnerships, never proving its mettle in a peer-reviewed scientific publication. Medical and scientific skepticism therefore abounds.

In appearances, like one moderated by an acquaintance, Holmes seems more like the charismatic mouthpiece for some sinister group than a true wunderkind.

Last week the WSJ reported extensively on the fact that Theranos is outsourcing its blood tests to third parties, not running the tests themselves. Moreover, the microfluidic (finger stick) assays work on only five of the company’s menu of dozens of tests — the rest of the time their test centers obtain blood via traditional veinipuncture.

What’s going on here?

Rather than come out and discuss the company’s problems and plans to address them, the company has simply issued denials and obfuscations, hiding behind attorneys rather than letting its CEO speak.

Schadenfreude is the word for it — now it seems every business publication is piling on after the WSJ story. Nobody likes an upstart that promises to trample the established way of doing business, then fails to measure up — especially when dis-inviting scrutiny at every turn.

This is shaping up to be a story of colossal underperformance for such high promise — if not outright fraud in the hype and publicity departments.

Why Many Docs Are Griping of Late

dosequisicd10October 1st marked a national transition to a new classification scheme for diagnostic codes in medical care and treatment. These codes are used to translate a diagnosis like strep throat into an alphanumeric code that can be used for

  1. research purposes, and of course
  2. billing (the most important aspect!).

When you visit a health care professional, the diagnosis is translated by a biller (now most often done by computer software) into one of these specific codes, which is then submitted to the insurance company for payment. You receive an explanation of benefits (“EOB”) with this information on it (which the insurance company is sure to remind you is “not a bill”), which is usually indecipherable.

The new scheme (ICD-10) has almost 70,000 diagnostic codes, many of which are of a level of specificity that seems absurd. The old scheme, ICD-9, had only about 13,000 codes.

Not only are there more codes, but they come with a wholly different alphanumeric system attached to them. Luckily, the software lets us ‘translate’ the old codes into the new ones, but often, there isn’t adequate specificity in the old codes to be valid with the new ones. This is where the headaches result.

If you follow health media, you’ll see some funny articles about the tranisition. NPR ran a cute story headlined “Struck by a Macaw? Now There’s a Code for That.” The Wall St. Journal‘s explainer was headlined, “70,000 ways to Classify Ailments.” Among my favorites: V91.07 — Burn due to water skis on fire. Or W56.11 — Bitten by a sea lion.

It gets weirder than that. There are codes for ‘injuries from falling space debris.’ Doesn’t seem all that likely, but you never know.

Are we in a Medical Economic Bubble? [UPDATED]

In the roaring 1990s I completed both four years of medical school and three years of residency. Day after day I read accounts of my contemporaries starting or joining Internet startups to great fanfare and loads of stock options.

Dot-com-bubbleThere were many times I thought to myself, “Why should I continue on this slog?” I fantasized about pitching my idea for an Internet company that would wow investors by providing not only crackers, but slices of cheese varietals on those crackers for people logging into the website and entering a credit card number.

Stock options!

Glowing media coverage!

Super Bowl commercials!

In a scene reminiscent of the those go-go 90’s, Chrissy Farr of KQED (public) radio in San Francisco reports that Stanford and University of California-San Francisco medical students are abandoning the traditional practice of medicine to join Internet companies in the hopes of creating the killer health care app.

Here’s the data:

Bay Area-based medical students from Stanford and UCSF have among the very lowest rates of pursuing residency programs after graduation compared to the rest of the country. Stanford ranked 117th among 123 U.S. medical schools with just 65 percent of students going on to residencies in 2011, according to Doximity, a physician-network that generates data for the U.S. News Best Hospitals rankings. UCSF is 98th on the list, with 79 percent of its graduating students going on to residency.

Pretty easy to pooh-pooh this — these med school graduates, for all their smarts, haven’t had enough training (actually being in the hot seat) to know what practicing medicine in the current climate is like.

Maybe that’s the point. They are not encumbered by notions of things being “the way they are.”

I envy their opportunity — proximity is important, even in a digital economy. But if their companies don’t pan out, I do wonder if they’ll be able to “get back into” medicine. Residency is the orthodox pathway, and if a young physician leaves the straight and narrow path, medicine is a challenging profession to re-enter.

I also wonder what’s going on at those other schools near the bottom of that list — i.e. why so many graduates aren’t choosing residencies. Is it for the same reasons or due to another cause?

CORRECTION: From Public Information at UCSF, in response to this and other stories about this phenomenon: The main reason that the ‘match rates’ for these schools is reported so low is that many students are not going directly into the match, instead taking ‘gap years’ to pursue research or other degrees, e.g. Masters’ in Public Health. Per an information officer, “Between 2011 and 2015, 816 medical students graduated from [UCSF]. Among them, 803 matched into residencies (98.4 percent match rate). An additional six students matched after taking a gap year, bringing the match rate for the period to 99.1 percent.”

An Amazing Story of Patient Engagement

Patient engagement is the term used to describe people that are motivated about their health and taking action accordingly. Engaged patients naturally like to interact with their health professional not just at the doctor’s office but in-between — with email, two-way data [the doctor sends the patient results; the patient sends the doctor stats like blood pressures, blood sugar, etc. for real time input], follow-up on lab tests — and anything else you might imagine that bears on health.

No one epitomizes the engaged patient more than Dave deBronkart, who is known across the world as “e-Patient Dave.”

Dave was diagnosed with Stage IV (i.e. metastatic) kidney cancer in 2007. He was already engaged in his own care, and with miraculous help from Boston’s Beth Israel Deaconess Medical Center – and an online community his doctor recommended – was able to survive his cancer. Now he is a sought-after keynote speaker and evangelist for patients becoming engaged in their own care. He collaborates with the medical community to make doctors and nurses see the value of engaging with patients in new ways.

After all, although today’s laws don’t say so, patient data logically belongs to you, the patient. It’s a simple idea that’s somehow revolutionary in the big business world of industrialized medicine, where a generation ago everyone thought nobody but a doctor had any use for such data. Dave speaks and writes about his experiences and champions other patients and doctors who work together in new collaborative ways.

I read his blog; I’d encourage you to read it also. Dave is enthusiastic about tech, which you may or may not like. But what struck me about the story below, edited for brevity, was how Dave’s wife Ginny handled her own bilateral (both right and left) knee arthritis in seeking a surgeon and bilateral knee replacements. It’s a great story. And as Dave points out, results will vary. But Ginny’s story is worth sharing.

What stands out to me is the level of engagement of her surgeon, Dr. Howard Luks (a doctor well known in social media circles), and the amount of homework Ginny did in selecting him and getting ready for her surgery to achieve the best possible outcome. The surgical innovation is kind of neat, too.

This post originally appeared on Dave’s blog, and is used with his permission.

The best of medicine: my wife gets the new “muscle sparing” knee replacement

By e-Patient Dave

Ginny at Half Moon restaurantOn Friday I posted this picture of my wife Ginny.

As you read this, bear in mind, your mileage may vary – everyone’s different, this wouldn’t be appropriate for everyone, and Ginny herself played a big part in it.

The astounding story:

In this photo we were out to dinner, nine days after Ginny had both knees replaced. She walked into the restaurant using only canes – no walker, no wheelchair. The surgeon is Howard Luks, the social media orthopedist (@HJLuks), whom I met on Twitter in 2009, and the surgical approach he used is called muscle-sparing (or “quad-sparing”) minimally invasive surgery, part of a larger package of methods he uses, described below. Bottom line:

  • None of her muscles were cut
  • She had no transfusions
  • She has not needed to have any of her dressings changed
  • She left the hospital on day 3, was discharged from rehab 8 days after surgery, and today on day 12 we’re returning to New Hampshire, to continue outpatient physical therapy from home.

Of course she’s still on pain meds, tapering down, and her endurance is of course limited. But she is basically functional and able to live on her own if she needed to, or rehab wouldn’t have discharged her.

(Of course I have Ginny’s permission to talk about all this. Also, I’m an e-tool geek and she’s not, so I’m the one using the tools discussed here.) She was discharged from rehab after demonstrating (among other things) that she can safely walk up and down a full flight of stairs … six days after the surgery. She can get herself into and out of bed, into and out of our Prius, etc. She’s not speedy at any of it but she’s functioning reliably.

Again, everyone, please read this: your mileage may vary – everyone’s different, this wouldn’t be appropriate for everyone, and Ginny herself played a big part in it.

The part Ginny played, as an activated, engaged patient

In my speeches I talk a lot about “patient engagement” – the patient as an active partner in health and care – but usually I’m asking healthcare to listen to and welcome patient voices. The flip side is equally important: the patient stepping up and doing as much of the work as they can.

In joint replacements this is essential, because nobody but you (the patient) can do the physical work required to recover after the surgery, and it can be hard.

Howard Luks with headset

Howard (he insists on being called Howard) says that in his experience the biggest reason knee replacements fail is if the patient simply isn’t willing to do his or her part of the work. It hurts – he says “You know why mob guys hit you in the knees? Because knee injuries really hurt!

Ginny was willing to do the work:

  • An essential part was “prehab” (a play on “rehab”) – two weeks of physical therapy before surgery, to get in practice for what the muscles would need to do after.
  • She also lost 20 pounds in the months leading up to the surgery, so her replaced knees would have less weight to lift and carry.

Another aspect is her choice of a surgeon who happened to be three hours from home. Ginny’s a retired veterinarian who’s done thousands of surgeries herself, and was on the New England Board of Veterinary Medical Examiners, where she was exposed over the years to many many doctors of varying degrees of excellence, so she has strong opinions about wanting someone good and decades of intuition about who that is. A few years ago she met Howard when we happened to be driving through his area, and when she decided surgery time had come, there was no question: “I want Howard to do it.”

Yes, my wife is an empowered, engaged, informed, activated patient. Imagine. (Unlike me, though, she doesn’t talk about it – she just does it.)

All of that happened before we learned about the new muscle-sparing approach. That turned out to be quite an unexpected bonus – we were prepared for the normal recovery that our friends and family had endured.

What it’s like to work with an “e-patient surgeon”

Howard Luks truly believes in making medicine more efficient. Like many docs I know, he’s suffering some from the changes in health policy and the sometimes obscene reimbursement rates he’s offered. (Know how much he gets paid by Medicaid for doing a knee replacement? $330!  Can you believe that??)  Installing their EMR and complying with Meaningful Use has cost his practice a big hit in productivity so far (appointment volume, and therefore income). But he sees the future and is pushing through into it, using whatever tools he can.

Cloud software tools

  • He’s a big fan of Twistle, a secure (HIPAA-compliant) messaging system.
    • This is a huge help if your doctor’s office(s) doesn’t / don’t have good, modern secure messaging; among other things, Twistle can include messages from multiple docs even if they work in different places. (It can integrate with EMR platforms, but most docs don’t consider that a necessity; Howard does, and he’s planning on doing it: “With machine learning and smart forms the platform can intelligently perform many useful functions.”)
    • BUT, and it’s a big but, just remember that without such integration, Twistle messages aren’t visible in each doc’s “real” system where they work. (I’m starting to think “Who cares??” for most messages, but for seriously important information I’d want to be very careful about where the information lives.)
  • He’s happy to communicate by any medium – email or anything. My feeling is that anything we need to look up later needs to be in the secure message system, and of course anything confidential needs to be there. But for casual questions, he’ll use anything. (Just remember, if you don’t use an “official” communication tool with your providers, don’t expect a response in any particular timeframe. Providers have a life.)

Pre-visit communication

You could say Howard is nuts, because he’s so committed to sharing empowering information with everyone who needs it; he also knows how to do SEO [search-engine optimization] so his content can get found: his site gets 9,000 new visitors per day(!!!) and up to 20,000 pageviews/day from around the world. Let’s just say the vast majority of them are not his paying patients. 🙂

Here’s an example of his approach: In my book Let Patients Help I said e-patients should ask “What’s your infection rate?”  Howard not only welcomed the question (“average is 0.8%; mine is 0.6%”), he described the protocol he uses to minimize it. I asked “Is that on your website?? I didn’t notice it” and he said “It probably should be,” and now it is.

The evaluation appointment

  • Prior to our first appointment I emailed him Ginny’s radiology images, so we didn’t need to take more images. (Howard gladly welcomed them, saving us time and saving everyone money.)
    • Thanks to Beth Israel Deaconess, where our primary care is, for giving us a free CD of the images (at time of service) and for giving us free online access to the radiologist’s report!
  • Howard Luks wall monitorHoward’s practice has flat-screen displays on the wall of each exam room (right), so we can look at images together and we can watch what he’s doing in the EMR, while he does it.
  • He gave us a clipboard with a pad labeled “What We Discussed,” to take notes on.

Between visits, when questions come up

In my first book Laugh, Sing, and Eat Like a Pig (my cancer journal) I noted that my world-class oncologist Dr. David McDermott welcomes dialog, including in email: once when I apologized for what turned out to be a dumb question he replied “I am happy to field your questions.”

Howard is exactly the same. Ginny is less verbose (ahem), so with her permission I messaged Howard (sometimes several times a day), and every time he responded within a couple of hours. In short, he recognizes that when patient and family have questions, it’s a sign of engagement. Plus, he says, he understands “most people are too afraid to ask questions… so I offer platforms to communicate which are less imposing than sitting on a cold bench in my office with the clock ticking :-).”

There’s more to the package than this quad-sparing surgery

Personally, my mind is blown by this new surgical approach, but Howard quickly points out that Ginny’s extraordinary outcome is a result of a program that has many parts:

  • Infection control (before, during and after surgery) (see his protocol, above)
  • TXA (tranexamic acid) – The Mayo Clinic cites TXA’s use in emergency medicine (e.g. EMTs using it to stop blood loss in injuries), but Howard noted that cardiovascular surgeons have used it for decades, and now he is, in orthopedics. Result: “less blood loss, fewer transfusions, less blood received which leads to fewer infections.”
    • TXA is also why she didn’t bleed enough to ever need her dressings changed, he says.
  • An engaged patient who understands their role (their responsibility for doing the work)
    • Includes doing the “prehab” as well as the rehab.
  • A doc who understands the patient’s expectations. He will ask a patient what outcome they’re after, and won’t always recommend surgery, even if from the first description of symptoms that seems obvious.
  • The surgical method (quad-sparing)
    • Note: He says patients who get the usual surgical method do catch up eventually; the benefit is in faster recovery time. “People gain back their strength faster with a muscle sparing approach. Thus they can sustain a faster rehab.”
    • Well, heck: I don’t know much about orthopedics, but I know people who’ve been out of week 12 weeks after having a single knee replacement, so being released from rehab in 8 days, functional, sure sounds like something worth knowing about as an option.
  • Multi-modal pain management. Ginny received regional anesthesia during the surgery, and Howard injects the inside of the knee with a cocktail of meds to take advantage of pre-emptive analgesia.  She’s now on four pain meds for different pain pathways.
    • “Pain management is incredibly important in these cases,” he says, “because it affects how able the patient is to do the work and regain strength. But too often people overlook that not all pain is the same – you can’t treat it all with opiates.”
    • Not to mention the horrid constipation that morphine, dilaudid etc can cause, sometimes bringing weeks of real suffering.

“All of that,” he says, “comes together to result in a better experience, fewer surprises and fewer complications.”

Astounding indeed. Every patient should know this option.

As I said: an astounding story, right?

Of course there are no guarantees, and problems do happen, and no two cases are identical … but wouldn’t you want to know about a new option that might have you functioning again five or six times sooner than the usual treatment, with a lot less pain?

I’m going to be blunt here about something I think is important: it’s not uncommon for a newer option like this to not be widely known, and thus not offered to patients. (Last month I spoke at a conference where someone mentioned this type of knee replacement, and said that it’s only used 18% of the time.)

I applaud the surgeons, like Howard, who have taken the steps to learn this surgical method (including the comprehensive package he uses). Honestly, it’s deeply moving to see my wife doing so well – she’s  not out of the woods yet, but doing so well – and I want to help spread the word, so docs who offer this method can be rewarded by eager patients – and perhaps so surgeons who don’t know it yet will be inspired to learn.

Postscript: Seventeen days after her bilateral muscle sparing knee replacements, Ginny played a round of miniature golf with Dave, using no assistive device beyond the requisite putter.

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