What about gluten?

What is gluten? It’s hard to read nutritional information online or packages in a food store without thinking that gluten is another word for “arsenic.” Avoiding gluten is the newest big food fad, with some claiming that such a diet can cure autism or allergies or asthma or any of a wide variety of conditions. Is gluten something you should avoid? What is it, what’s it used for, and what’s it doing to us?

Someone has probably written a book about the history of bread and its importance to human culture (if not, I’m on it). Long before Superman lunchboxes and Wonderbread, bread made out of crushed corn or plant roots made it possible for people to carry their nourishment with them for long trips. But these early breads were crumbly and fell apart easily and likely tasted like packing peanuts.

Once we evolved to Farmer-man, we figured out that cultivated grains, like wheat, were much better out of the oven. These grains contain the protein gluten, which is a long, tough molecule that gives modern bread dough its bounciness and elasticity. These loaves didn’t fall apart, and could be transported great distances. It’s not a stretch the say that gluten, like salt or cod or gummy bears, played a vital role in the very development of our culture.

These days gluten is used in many other foods as well. It’s useful as a protein supplement, and as an all-natural way to add sponginess to foods. Products like ketchup and ice cream are commonly thickened with gluten. Almost all imitation meats and cheeses prized by vegetarians are based on wheat gluten. And gluten is not just limited to food. Its a key ingredient in some of the new bio-plastic materials as an alternative to petrochemicals, and is commonly used in cosmetics such as lipstick to add firmness or body.

But for mysterious reasons, there’s been a growing trend in recent years to view gluten in a negative light. It is true that a small number of people are born with gluten sensitivities that reduce their ability to tolerate it to varying degrees. Perhaps the thought is that if some people can’t tolerate it, it therefore must be generally bad for everyone? As a result, some promoters of fad diets and various health schemes are now advocating gluten free diets, and shady characters and certain food manufacturers are cashing in.

Gluten free diets actually are necessary for some people, and advisable for others. These situations are quite rare, but they are real. The first is celiac disease (CD), or gluten-sensitive enteropathy. This is an autoimmune disease of the small intestine that occurs in people with a genetic predisposition. It’s not caused by gluten and you can’t develop it by eating gluten, but if you’re one of the unlucky few born with the gene, and you go on to develop CD, eating gluten will cause an adverse reaction. The immune system inside the bowel tissue reacts to the gluten proteins, causing inflammation of the bowel tissue, and this interferes with your body’s ability to absorb nutrients from food. There’s no cure for CD, and the only way to live with it is to adopt a gluten free diet for the rest of your life. Somewhere between 1 and 8 in 1,000 Americans have this, give or take (the exact frequency is not well known).

A wheat allergy is very different, and can be harder to track down since there are many different components of wheats and other grains that it’s possible to be allergic to. A wheat allergy is not a single condition; it is any of a great number of possible allergies. The symptoms are similar to what we expect from most allergies: hay fever type symptoms, hives, asthma, and swelling. More serious effects in the worst cases can include anaphylaxis, palpitations, swollen throat, diarrhea, and even arthritis. Unlike CD patients, sufferers of wheat allergies need not necessarily avoid all wheat products. The allergy is usually pretty specific and only some foods may need to be avoided. Standard allergy treatment with drugs such as antihistamines may prove effective enough to allow the patient to live with a normal diet. You need not eat wheat to have an allergic reaction; some may react by simply coming in contact with wheat. It’s very difficult to attach a number to how many people have some level of allergy to some type of wheat related protein, but it’s probably somewhere in the single digit percentage points.

There’s also a third type of gluten sensitivity, and that’s gluten sensitive idiopathic neuropathy. Idiopathic means the exact cause is not known, and a neuropathy is a disease of the nerves. Symptoms can include numbness or tingling in the extremities, or problems with muscular coordination often evidenced when walking, or even spasticity resembling epilepsy. Diagnosing this neuropathy is difficult. The blood test frequently produces false positives. And sometimes, sufferers may actually have a mild case of celiac disease instead. The number of people with a gluten sensitivity neuropathy is not well-known, but it’s very small.

That’s it for the poor souls that need to or may want to avoid gluten. But some people would have us believe that many more of us should avoid it. Of course, these people are generally the people who sell gluten-free products. For example, GlutenFree.com claims their products help people with autism or ADHD, which is completely untrue according to all the science we have. The autism claim in particular is broadly repeated across the autism activist community. The treatment of autism with a gluten free diet has been studied a number of times with varying results, but so far no well designed studies have shown any plausible benefit. A 2006 double blinded study published in the Journal of Autism and Developmental Disorders tested children with and without autism, on gluten-free and placebo controlled diets, and found no significant differences in any group.

In addition to those that seek profit from the fad, many well-intentioned naturopaths routinely list gluten as a potential cause of disease. This is a bizarre and unfortunate claim. Proteins are essential for nutrition, and there is certainly no evidence that disease has increased worldwide since wheat grain became a staple. Indeed, prior to this, life expectancy was probably something like 16.5 months, give or take. It’s true that bread itself is a rich source of carbohydrates, which are not essential and can be safely minimized in the diet, but this is true of gluten-free breads as well. By no logic should the strategy of avoiding carbohydrates be misconstrued as avoiding gluten.

Given this fad, I have heard from many people that a gluten-free diet has helped them recover from various maladies. In my own observations, it is not uncommon for people to say they feel better since going gluten-free. Is this all placebo? And if it is, isn’t that okay? I mean, if someone is paying closer attention to their diet, and they feel better, is there reason to encourage such actions?

I think there is a good reason why the science and these perceptions are not contradictory. When you try to cut out gluten what are you cutting out? Let’s look at food that are high in gluten, foods like processed cheese, chocolate milk, ice cream, baked goods, cereals, pastas, breaded meats, lunch meats, gravy, jams, fruit-filled pastries, French fries, and flavored potato chips.

I propose that anyone that cuts the above foods from their diet will feel better! This is not because these foods contain gluten, even high levels of gluten. It is because these foods are also loaded with simple sugars and fats.

So think of gluten sensitivities in the same way you’d think of bee stings or peanut allergies: of great and very real concern to a small number of people, of some concern for a few more, and of no concern to most of us. Don’t let anyone tell you that gluten is harming you in some way that’s so far not supported by science. And yet, look at your diet with the vigilance of those that are aggressively cutting out gluten and find ways to balance your diet with complex carbs like fruits and veggies, healthy proteins, be they from animal, soy or even gluten sources, and fats. Eat food. Not processed imitations. Eat local whenever possible. But eat less overall. And you will indeed treat and prevent disease and just plain feel better!

The Scales of Karma

Since my announcement yesterday, I am so happy to hear all the positive “way to go!” comments. But one comment spoke to me by bringing up an important point, one that gave me great pause in making this decision.

Im sorry to say – this all would be very cool but ultimately it excludes poor people and there is nothing about that which addresses the health care crisis – as far as I can see you are just doing what they do on the TV show “Royal Pains” – being a concierge doctor and just because you’re doing it at home doesn’t make it folksy -perhaps you should consider barter and give less fortunate folks a chance to have a doctor’s care that doesn’t make them feel like a number – otherwise everyone is still a number – the number that you charge!

There is a large national Concierge Medicine company based in Florida that has recruited me for several years in a row. This company charges patients anywhere from $2000-5000/yr to sign up with their doctor. The doctors agree to limit their panel sizes to 200-300 patients, and they still charge insurance companies for services that are covered. Frequently the offices are in high rent districts in big cities and wealthy suburbs. To justify the prices, the physicians provide additional services, such as aesthetics or “executive” physicals, running every unneeded test available once a year. That, to me, is Concierge Medicine.

By comparison, Direct Primary Care practices are usually retainer-based only, or monthly retainer plus small per visit price. They’re often focused towards patients that are underinsured or uninsured, offering primary care at a much lower rate than insurance premiums. They typically focus more on wellness and prevention and don’t try to sweeten the pot by adding extra, unnecessary services.

Now, ultimately, Concierge. Boutique. Direct Primary Care. It’s all just semantics. Either way you look at it, I will no longer participate as an insurance provider and will be holding my knowledge and ability for ransom, asking people to pay for it at a time when every dollar counts. Call it what you want.

But. If I do this right, in addition to providing better care for those that sign up, I think I can save money overall, as I have no doubt that I will be able to keep people OUT of the ER and OUT of the hospital by being there when needed and by proactively managing chronic disease. I think I will be avoiding burnout that is causing a lot of my colleagues to just drop out of the profession all together, worsening the doctor shortage, which is so extreme here on the island. And, hopefully, such an arrangement will give me the time and ability to do exactly what you talk about , to work for barter and to work for free for those that need it. I have already been in contact with community health centers on the Cape to try and learn of ways to better meet needs here on the island.

The ethics of this are important to me. I feel like it came down to deciding between providing good, ethical care to a small number of patients who can pay for it or providing mediocre, inadequate care to a large number of people, rich and poor, and continue focusing more on the entities that control the money in healthcare (employers, hospital systems, health insurance companies, the government) than on patients. It’s estimated that for every scheduled visit, a primary care physician spends 7 minutes face-to-face with a patient and then, along with staff, spends 45 minutes on managing the patient’s payer needs, i.e., on getting paid. That, to me, is unethical.

Do Over. Part Two.

New practice. What should it look like?

A couple of weeks ago, I posted a “Shoot for the Moon” Facebook question asking my friends and contacts what they would like from their physician’s practice. I posted the not so surprising results here: Shoot for the Moon.

Dusting off the ashes of burnout, I decided that if I did return to practice, I would have to be true to myself and return to the roots of why I became a doctor in the first place—to interact with people in a meaningful way and try to be their guide in the pursuit of wellness. (I need to go back and check my Med School application to see if those were the exact words.) As such, I need to open a practice that is as much the opposite of my former one as possible.

It turns out that a lot of what people asked for in my Facebook poll are the kinds of things that should only facilitate such interaction. Things like online access to your medical records, same day appointments, decreased (even rare) waits in a waiting room (in fact, I’m not planning to have one), after hours and weekend access and appointments, and no robo-telephone answering service. These aren’t just patient-friendly enhancements designed to market a practice, these are the kinds of changes needed to help patients stay involved in their healthcare, to break down the current barriers to getting any healthcare at all (i.e., appointment availability), and to refocus towards wellness and prevention, instead of just “treat and street” medicine.

In the Facebook thread I am referring to, after about 180 messages of people talking about how to re-engineer the typical current doctor’s office experience, including non-sense requests like “home-cooked meals,” a colleague and friend of mine chimed in.  Janet Chaffee, a wonderful, experienced island nurse wisely replied:  “You are going to need one heck of a staff. Coming from 30 + years in an office, it would be wonderful to do all these things, but is it impossible? I think yes. Doctors are people with lives. No one can expect 24/7 and be upset if they don’t get it. Evening hours? Weekends?? Deliver babies. When do you sleep or see your family. Sorry, I’m coming from the other end.”

She’s right, of course. But…

I am going to work out of the cottage on our property and open up initially with a skeleton crew–me. I’ll be answering the phones, seeing the patients, and shoveling the steps if it snows again.

I am going to offer online access to medical records, same day appointments, online self-scheduling of appointments.

My patients will have my cell phone number and email and will be encouraged to use them when needed.

I will be available for appointments outside of the usual 9am-4pm timeframe, most days of the week.

I will offer housecalls as well as online visits for when you just need a simple follow up visit and don’t need to miss a day’s work.

How?

I am hoping to provide this better, more personalized care and improved customer service by seeing a lot less patients (the roster will be limited to 500 patients total, a number that might fluctuate depending only on how easily I can meet these promises) and by ignoring health insurance companies–the myriad of their regulations and the frustrations of their denials and the armies of personnel needed to interact with them!

I am opening a Direct Primary Care practice. It’s a new model, gradually catching hold around the country. The idea is that a practice stops billing health insurance companies and instead bills patients directly for the enhanced care, often using a monthly retainer and/or nominal visit fees to cover all services.

“Ahhhhhhh. The Catch.”

I’m sorry. I’m sorry the system is so broken as to make me buck it like this. I’m sorry that you have health insurance that purports to cover services like mine; maybe you even purchased it yourself at great costs (as opposed to having it provided for you by your employer). So Sorry.

Ask yourself this:  how well does my insurance cover the primary care services I need? Most plans have a $15-25 copay. Often there is a $2,000 deductible that is out of pocket. Most plans have a $150-250 ER copay, and making multiple trips to the NCH ER every year is almost a given these days, given our extreme shortage of doctors and appointment slots. It is not uncommon for a family of four to spend $1,000 on ER copays and another $250 for office copays. So what if you could redirect that money in a way that allows you to mostly avoid ER visits, to see the same physician every time you need to see one and who answers your phone calls at night when you just want to know it’s okay to not go to the ER, and gives you the convenience of making an appointment that best fits your schedule?

I have not completely settled on the price yet for this service. Most DPC practices charge anywhere between $60-120 a month for such services. And, if there is enough interest, and the practice matures (allowing me to bring more services in-house, e.g., nutritional counseling, on-site lab tests, a health coach), I can see a price point that falls somewhere on the lower side of that range. (I am going to focus harder on controlling overhead than raising revenue.)

As way of introduction, however, especially as I work the kinks out, I am going to charge less. I am considering $50/mos with a family cap of $125/mos. This will include everything. I will not ask for a co-pay or per-visit fees. If you need an ECG or a strep test, it will not cost extra.

I should point out that this plan is in no way a replacement for health insurance. Your health insurance will still work, and be needed, for example, if you need a $6,000 knee MRI at NCH, or a $300 Lyme test, or a $15,000 Medflight transport, or $55,000 worth of treatment for a cat bite. But, given my non-participation, it is unlikely that health insurance will cover my monthly fee.

So, there you have it.

What’s next? I have to renovate our cottage, turn the turn ground floor bedrooms into consultation rooms. I have to buy some equipment. I need to get a license to work out the building. I have some important decisions to make when it comes to Medicare and how to handle people who have managed care plans.

In the next week or two, I am going to redesign this website and blog and flesh out the details of how it will all work. I’m sure there will be many questions, so I’ll need an FAQ section. There will be a sign-up if interested page.

Still a lot to think about. But I think I can start seeing people within 4-6 weeks though!

Please feel free to comment below or email me at info@ackdoc.com if you have questions or comments. Be nice.

Do Over. Part one.

I am opening a new medical practice. Soon. This is the first in a series of posts in which I will explain the whys and hows and what-fors of this new practice. Bear with me, I’m still working on the business plan, but I have decided that the best way to handle it all is by being honest and transparent about the whole process. I’m looking to do something new.

In the summer of 2001 I moved here with Amy, James (who was 3) and Jack (only 2 mos old) for what has been an amazing island journey. No one is going to write a book about it or make it a movie; I’m not Robinson Crusoe. But Defoe’s novel is in some ways an interesting metaphor for living as a physician on Nantucket. Crusoe could barely make out a distant continent on the horizon and, but for Medflight and technology, we’re similarly isolated. And, unlike when we first arrived, there are now cannibals to worry about, for certain. Medicine has changed a lot since 2001. Romneycare. Obamacare. Health maintenance organizations. Pay-for-performance. ACOs, PCMHs, and Meaningful use certification. E&M coding. DRGs. HIPAA.

I started my practice with Sally as my assistant and Annie as receptionist. I had a delivery the weekend before I opened and had 25 patients on my first day. The practice had been Dr. LaRochelle’s, and the hospital had maintained it after his departure with locum tenens physicians (including Dr. Hartmann filling in at times). Back then, I outsourced the process of billing and managed the practice myself. Since then, the practice of medicine has evolved (in futility) in the name of cost control and improved care, and it is more and more difficult to get paid.

Electronic medical records have been installed in the majority of practices. These record systems were conceived to make it easier for physicians to get paid, to meet the difficult requirements for documentation required to justify the levels of complexity tied to reimbursement levels set by Medicare and health insurance company contracts. These inefficient systems, with clicks and checks and bullet points, have made it more difficult for a physician to see as many people per day, even as the pressure to do so is increasing. They make it easy to cut and paste records from visit to visit, patient to patient, which results in errors. (I used to chuckle when I received a consult note from a specialist about Mr. Jones that included, in the examination section, details about his breast and pelvic examination; now I just want to cry.) It’s not a surprise then that recent studies show that these systems are not saving money, as hoped for by policy makers, nor are they improving care, though everyone assumes that if records are digitized and easily communicated amongst healthcare providers, and hospitals, and pharmacies, and consumers, we should be able to provide much better and safer care. But this standard of interoperability has proven to be the Holy Grail so far and, instead, we have a splintered industry of hundreds of software providers, none of who have products that easily communicate with others (nor are they motivated to do this in as much as it is perceived is prohibitively expensive and/or as a threat to market share).

Since that time, healthcare reform has attempted to control and reform the costs and practices of health insurance companies (e.g., mandating certain coverages), to curb the need to use Emergency Rooms for primary or even urgent care, and to stop self-referrals to expensive specialists and use primary care providers as gatekeepers instead. A higher and higher percentage of health insurance products available are Managed Care policies, instead of the traditional fee-for-service policies.

This seems like a smart change. In an attempt to control costs and improve care, Managed Care tries to standardize the delivery of healthcare and ration resources. Consumers are not able to see a dermatologist about a simple Poison Ivy rash without being sent there by the PCP on record who, presumably, will see the patient instead—at a cost of $80 instead of $300—and prescribe the simple, needed treatment. PCPs won’t be able to prescribe the latest and greatest antihypertensive, available in the sample closet thanks to the nice drug rep that bought dinner last night, when hydrochlorothiazide at $4/month will work just as well, without getting the insurer’s permission first and needing to justify the increased expense. A well-meaning back specialist will not be able to order an MRI for uncomplicated low back pain just because a patient is insisting on it, without having the PCP call and ask for pre-authorization.

It is easy to see how these kinds of changes are good and necessary, if we are to control the way healthcare costs are threatening to bankrupt our country. But, to health insurance companies, concerned primarily with profit and dividends and astronomical CEO salaries, Managed Care is a means to cause confusion and preserve margins. If you require pre-authorizations and prior approvals, and you change the rules frequently, more things will get retroactively labeled as uncovered, resulting in consumers having to pay or healthcare entities having to eat the bad debt.

The detriment of all of these changes which are on the surface well-meaning but ultimately meant to save recently-created administrator, legislator or bureaucrat jobs and increase insurance company profit margins, was so apparent in my little practice. I started with Sallie and Annie and me. But I finished with Dr. Koehm as a partner, and the two of us being responsible for (and needing) a Nurse Practitioner, Sally in the front primarily on the phone with insurers getting tests and medications approved, 1.5 receptionists and a computer answering the phone, a full-time manager, two RNs, a medical assistant helping out in the back, a part-time translator, and a large billing staff in Boston that withdrew 11-15% of collections right off the top. (I gave this as a range because I cannot remember the exact number. I think it was 11% of collections and a 3-4% “management fee,” but I could be off by a point or two.) And, in the few months leading up to my departure I saw, on average, the same number of people per day. 25.

It does not take a Harvard MBA to see the problem.

The salary I paid myself in 2001 was $150,000. My salary last year as an MGH employee was $161,000, though my charge, for example, for 9 months of obstetrical care and delivery changed from $2,400 to over $6,000, and my charge for a medium complex office visit changed from ~$60 to ~$180. Over the 11 years, employee salaries increased in a manner more consistent with everyone else’s. In fact, in the new MGH practice, the employees were now mostly in a union, with contracted pay increases and a very generous benefits package. (This is a good thing, in my opinion, but it further explains the recent, difficult evolution of small medical practices.)

So, if my salary was relatively static, but the overhead increased as described above, and the number of appointment slots stayed the same, what had to give to keep the doors open? I’ll tell you what: my efficiency, my compassion, my abilities, and my sanity. That’s what.

And that is why I need a new practice and why it has taken me awhile to plan it. I have to make sure I don’t open the same can of worms.

I need a new can of worms.

QA on Vaccines

From my Facebook Messages:

Dr Hinson,

Feel free to not answer this question since this is your personal facebook, but I thought I’d give it a try.

I’ve only immunized one of my children, and have remained undecided for the others because of the controversy of vaccines’ effectiveness/dangers. In my limited experience with you as a Dr, you seemed to be in the middle of the road between conventional medicine and natural alternatives, so I’m interested in your opinion. Which vaccines, if any, do you think are necessary?

Thanks in advance. I hope things are going well for you with your plans of a new practice!

JS

PS. We just moved, and the few Drs in our area so far seem to be seriously conventional only, ie: antibiotics absolutely necessary for ear infections, the nurse looked at me like I had 3 heads because I didn’t want the flu shot (after I told her I’d already had the flu this year), and I just found out my Dr will no longer see me for prenatal care because I’d like a home birth with a midwife. All that to say, we miss you guys! You guys rocked.

I think there is little reason to worry about any of the vaccines that are out there. Are they risk-free? No. There are always risks (mostly in the form of allergic reactions). But the risks are so low as to be less than the chance of getting sick from the diseases they protect you from. (Unfortunately, this is more and more the case thanks to the unwarranted controversies out there that have affected vaccine rates.) For example, the polio shot. Polio pretty much no longer exists here in the US. So, you could ask, why bother with the shot? Well, it is almost as unheard of to have a reaction to it. And, there is certainly the possibility that a kid might grow up to be the wonderful person that decides to join the Peace Corp and go work in sub-Saharan Africa where the disease persists. And then that apple-of-any-mother’s eye might bring it back and reintroduce it here. So, as unlikely as that might seem, it is more likely than a problem from the shot.

Now, the polio shot also demonstrates another important facet of the immunization debate–public vs personal benefit. If a child born today is not vaccinated at all, the truth is, there is not a huge risk these days. However, I can only say that because of the vaccination program. If every child in your child’s daycare or school is vaccinated, and your child never leaves the island, the risk would be very low, and one could argue against the need to vaccinate. BUT, what if everyone came to that same conclusion? There is a concept known as herd immunity. As long as a certain percentage of the population is vaccinated, then, we don’t have as much to worry about as a public health issue, and this huge public health advantage is easily overlooked these days, as we have gotten so use to low-to-zero rates of some of the diseases involved.

That said, to answer you question, what vaccines are most important to personal health these days? That is, if not vaccinated, which diseases are most likely to greatly affect a kid, i.e., hospitalize them, or even lead to something worse?

I would rank them like this (and this is just opinion, unencumbered by science, stats or the CDC):

1. flu
2. HIB*
3. Pneumococcal*
4. Rotavirus
5. Pertussis
6. Measles
7. Mumps
8. Tetanus
9. …the rest.

Flu? Seriously? Yep. If you simply look at stats, that is the infection most likely to cause death! HIB and pneumococcal are starred because this list is age dependent. If you are asking about a 6 or 8 year old, these are less important because these are common bacteria. They’re everywhere. They cause the vast majority of ear infections, sinus infections, pneumonias, and even meningitis cases in kids under 5. And, as such, they are very pertinent vaccines to be given to an under-2. But, by the time you’re 5 or 6, your immune system has seen the germs so much as to have created its own native immunity. Another way of looking at this is, you are much, much more likely to hospitalize a 1.5 yr old with pneumonia than we are a 10 year old with it.

So, there. Probably more than you wanted to hear. But the vaccine program is extremely important to our society. We are a generation or two removed from when everyone knew someone paralyzed from polio, or made infertile by mumps or born with horrible birth defects due to rubella. We are removed enough that all of that is easily forgotten.

GH

Not too much info. I soak this stuff up. Thanks so much for taking the time. You’ve possibly convinced me…and if that’s the case, my sister who is a nurse thanks you!

JS

I’m going to give you one more bit of info (that you did not ask for). Toxins. Heavy metals. Mercury. Etc. Do you realize you would have to get 75 flu shots at once to get the amount of mercury (in a different, less-toxic form, no less) to equal the amount you would get from eating a serving of swordfish? (And, to make it more local, just 4 tiny bay scallops have the amount of mercury that you see in one flu shot.)

Like everything else that is manufactured–plastics, apple skin wax, shampoo–vaccines have “industrial” ingredients. But so does the real world. You cannot avoid this stuff; it’s in the air we breathe, the water we drink, even on the shelf at Annye’s. It’s a testimony to our bodies’ ability to handle all of this stuff that we’re not all sick all the time. And yet, as our environment has become more and more saturated with stuff like this, our life expectancy has continued to climb.

Now, does that mean you should bathe a kid in pesticide and feed them nothing but processed foods, heated in plastic? No. Of course not. But, when there is measurable benefit to something, e.g., vaccines, it means there’s no reason to be overly afraid of it.

Okay. I’m done. Stepping down from the pulpit to go turn this in to a blog post. Hmmm. Certainly went on long enough about it…

GH

Haha, you should. Just copy and paste. I didn’t realize that about the mercury until I was sitting in your office last year and saw the chart comparison. I was really surprised!

I suppose I tend to look at the flip side. I think of all the pesticides, processed foods, prescription drugs, and look at all the food allergies, autoimmune disease, chronic conditions that seem to be absolutely everywhere. Yes we live longer but at what quality? Is it just the drugs that keep our bodies ticking but really we are unhealthier than ever?

JS

Again, without researching the science to back this up (if there is any), I would say that we are more used to good health, so simpler things like food intolerances or arthralgias are now more likely to be complaints. If, say fifty years ago, you could barely walk due to polio or were 40 years old and going blind from uncontrolled diabetes, you probably were not going to complain much about your “rheumatism.”

That said, there is still every reason for vigilance. Just because meds might be able to extend your life, doesn’t mean it should be one of misery. I do not believe meds are as good at extending one’s life as getting out of the chair, moving, and eating less food, but better foods (that are less processed and more local).

This is where modern life and its techno advances are a blessing and a curse. There are more and more options for recreation and exercise; but it is a lot easier to never get out of a chair these days. Given transportation systems and advanced agri techniques, it easier to eat better (we certainly have less to fear for from famine); but at the same time, the same technologies have made it much easier to eat poorly too.

The older I get, I think these two things are more important than anything you can buy on a shelf (e.g, supplements, vitamins, natural meds, cleanses, etc.) or anything ordered on a prescription pad!

GH

Interesting point at the beginning…hadn’t thought if that. Love this convo.

JS

The Doctor Is Not In…

Mmmm. Infographics.

Click to make this bigger.

A New Therapy That is Difficile to Swallow

Imagine the following. A tube is placed down a nostril, snaked into and through your stomach, right to the start of your intestines. Then someone else’s stool is pumped in to the tube and down your throat.

And if you’re suffering from a “C-diff” infection, trust me, the day has come when you’ll be begging for it. You can ask someone who has experienced it, or just ask an experienced nurse, about what it is like to suffer through the severe diarrhea that comes from an infection by the bacteria Clostridium difficile. It is severe, non-stop, and often life-threatening. It generally only happens when the gut has been robbed of its normal flora, the bacteria that is supposed to be there to compete with bad guys like C-diff (and a good reason to run whenever you hear anyone talk about a “colon cleanse,” a clean colon is an unhealthy colon!).

A C-diff infection is notoriously hard to treat, sometimes requiring months of a potentially toxic IV antibiotic (Vancomycin). But a new study seems to verify an old treatment. We can treat the infection by doing a fecal transplant, essentially replacing the normal flora that should be there. I have to say, when I first read about this treatment, my immediate response was “No Shit!” It makes sense though.

Donor stool  is screened for parasites and other serious infections, diluted and strained, and is then introduced in to the patient. (Now, to be fair, in Europe studies have been performed with the nasogastric tube as described above, but in the US, studies have been done via colonscopy.) The study linked to above was stopped early because it was so successful as to mean it would be unethical to continue the control arm. The treatment was 94% effective. Of 16 transplant patients, 13 were cured on their first infusion, and two more on a repeat round. In the two drug arms, the rates were 31 percent in the vancomycin-only group (4 of 13) and 23 percent (3 of 13) in the group receiving vancomycin plus lavage. That’s amazing.

In science, everything always needs to be repeated, and every endorsement is always hedged — but really, this was a rousing success. As an accompanying editorial says:

The study is an important confirmation of the efficacy of (fecal microbiota transplantation) for recurrent C. difficile infection… The results … represent a clear precedent in which planned therapeutic manipulation of the human intestinal microbiota can lead to demonstrable, clinically important benefits, thereby bringing FMT to the mainstream of modern, evidence-based medical practice. (It) will encourage and facilitate the design of similar trials of intestinal microbiota therapy for other indications, such as inflammatory bowel disease, irritable bowel syndrome, prevention of colorectal carcinoma, and metabolic disorders, to name just a few.

Given the Yuck factor, once we can meet the demand for the procedure as is, the next goal will be to create a synthetic stool, grow in cultures the bacteria needed and suspend them in some sort of benign slushy. NPR’s Shots health blog has a great interview with the Canadian team who came up with the synthetic substitute, amusingly dubbed “RePOOPulate.”

Kodak, Instagram and Healthcare

Dr. Rob Lamberts is a new friend of mine. (I’ve never actually met him, but with Facebook and Twitter and the like, you no longer to know someone to know someone, right?)

He is a Med-Peds physician in Augusta, GA, who is also rebounding from burn out (my diagnosis, not his).

Looking through his blog, I found an entry from last fall that, I think, speaks a lot of truth about the impending implosion of our health care system. At a time when costs are escalating, and quality is falling, and more and more people are going to make use of the health care system given the well-meaning, but ultimately misguided policies of the Affordable Care Act (I’ll go in to that more at a later date), something has to change. This industry has to evolve, or it risks becoming the Kodak of the first part of this century.

He writes:

Kodak was, at one point, the consummate American success story, dominating its market like few others. In 1976, it had a 90% market share of film, as well as 80% of cameras sold in the US.  Kodak Park, the property at the center of manufacturing once employed 29,000 employees, with its own fire company, rail system, water treatment plant, and continuously staffed medical facility.

Fast-forward to 2012, and the picture changes dramatically.  In a single year, Kodak declared chapter 11 bankruptcy, received a warning from the New York Stock Exchange that its stock was below $1/share for long enough that it was at risk of being delisted, announced it is no longer making digital cameras so as to focus on its core business: printing, and then a few weeks ago announced it was no longer making inkjet printers.  The job force in Rochester alone has gone down by nearly 90%, to an estimated 7200 employees.

Adding pain for former Kodak fans was the announcement in April of this year that Facebook was buying the photo sharing company Instagram (which employed 13 people at the time) for an estimated $1 Billion.

I remember reading that at the time of their bankruptcy hearings, a judge placed a value of $525 million on the assets (primarily patents) of the company. And here the app, whose sole purpose is to take a photo that pales in comparison with the quality of a photo taken on kodak film, then to apply a filter to it, making it look like a photo taken on old, outdated film, was purchased for almost twice that amount!

…the success of Instagram at the expense of the wonderful folks up in Rochester happened because Kodak had too much at stake to embrace a disruptive technology that spelled doom to its business model.  Even if Kodak had embraced digital technology, wouldn’t they have still had to lay off tens of thousands of people in the process?  Wouldn’t they have had to stop making film, printing paper, and doing all of those tasks on which they had built a 90% market share?  The Kodak of my childhood, the one that paid for my college education, gave a canvas for Hollywood’s imagination, and inspired Paul Simon to write one of my favorite songs, that Kodak had to disappear because something better came along.

It used to be that photography was a mysterious process to most consumers.  They bought film from Kodak without understanding how it worked.  Kodak succeeded by making the process easy enough for the average person to do.  People used the camera without knowing how their pictures would turn out, sent the film off to get it magically transformed into photographs that they could show others.  Ironically, the company that literally made black boxes made billions by keeping the process a black box for most people.  Then came digital photography, cameras on phones, and eventually social media.  Now there was no need for film, no need for cameras, no place to send the photos to get developed, and even no need to be on the same continent to share pictures with people.  Technology eviscerated Kodak’s business model by removing the black box.  It wasn’t just digital cameras that doomed Kodak, making it easy to carry cameras everywhere and to share with people instantly was also needed…

Dr. Rob proceeds to apply this lesson to the idea of health care reform:

Health care has previously been a black box to most consumers – a mysterious process by which the high priests (doctors) would perform healing through the use of their special knowledge and the wondrous healing of medications.  But unlike Kodak, health care was able to keep raising prices instead of becoming more efficient.  Now the health care industry has an economy larger than nearly all countries on this planet.  The number of people employed by this economy is staggering, and the number of businesses built off of this model of inefficiency is huge.  Imagine the damage an “Instagram of health care” could cause.

That is why I no longer feel that the solution to our problem will come from within the system: the system itself must be eviscerated for it to survive, and most systems (like Kodak) don’t see evisceration as a good business strategy.  Legislators may pretend to pursue meaningful reform, but far too many of their constituents stand to lose their jobs if they succeeded, and far too much of their campaign funds come from companies built on the old economy of waste.  Having hospitals oversee ACO’s [Accountable Care Organizations] is like putting Kodak executives in charge of laws concerning digital image sharing.

So what would the “Instagram of health care” look like?  I think it would:

  1. Rely on technology to simplify things greatly.
  2. Use social technology to cut out black boxes.
  3. Put the control of care in the hands of the people who use it.

In a tiny, little way, this is what my informal Facebook Focus Group experiment is pointing me towards. Why not try to step out of the system (before it is eviscerated anyway) and at least try to do things  in a new way.

(photo:  Kodak No. 2A Brownie (Model C) by flickr user John Kratz)

The Doctor will E you now…

In my Facebook Focus Group experiment, one of the leading concerns was decreasing wait times in the office. Many people expressed dissatisfaction with taking an hour off from work, waiting an hour in the waiting room, and 30 minutes in the exam room (missing more work than planned), and then spending only 7 minutes in front of the physician for a simple problem. And who can blame them?

Another (single) response suggested e-visits. What’s an e-visit, you say? An e-visit is an encounter with a doctor or a nurse that doesn’t involve a trip to the office. It might be by phone or by teleconference. Sometimes it involves a pre-visit questionnaire. You don’t hear a lot about e-visits because, like so many things we do, it all depends on what the insurance companies think about it. If the health insurance companies in an an area pay for e-visits (and they do in some places, typically at discounted rates), then patients usually are excited to take advantage of them. Typically for simple problems or follow up for ongoing management of stable, uncomplicated chronic disease states.

Assuming reimbursement is not an issue, are they okay? Can a doctor do as good a job without seeing a patient face-to-face? A new study was just published that looked at simple problems like UTI’s and sinus infections found e-visits to be more cost effective and similarly effective. The one difference they found was that those receiving care in an e-visit were more likely to receive antibiotics then those seen in person. But there was no ultimate difference in outcomes.

My opinion is that, when your doctor knows you well, a lot of what typically happens in the office could safely happen over the phone (or via teleconference), and certainly be more convenient for the patient, compared to taking time off work and suffering long waits in the office. I’m interested to know how you feel…

Shoot for the Moon. And Bacon.

I posted the following status update on Facebook today and had an overwhelming 180-plus responses, and dozens of “likes” endorsing individual answers. It was amazing. Although not very scientific, the exercise turned out to be a good marketing survey!

Facebook Focus Group time–Other than a doctor that knows what he or she is doing, what do you want in a doctor’s office? Shoot for the moon. Do you want free lollipops? Evening hours? Humans answering the phones? Reply with one or three things you think you would want from your doctor?

(Please comment here whether or not you have been a patient of mine in the past, or whether you want to be in the future. This is for anyone who has ever been a patient. Forget what is conventionally available. Ask for anything you want!)

My purpose is obvious. I am hoping to start a new practice on Nantucket, and need to decide on what I want that practice to look like. What better way to plan it than to ask the people it might matter to the most?

In asking everyone to “shoot for the moon,” I wanted honest opinions about how an office should run, about what would make a new practice stand out, and be the best one out there.

Here are the results. I grouped the responses into categories and summed their mentions and “likes.” In order:

40       Online access to medical records
35       Decreased wait times
31       Dual waiting rooms—sick and well
31       Undivided attention/good listening
27       Evening hours
27       Weekend hours
25       Attention to diet/nutrition/exercise, overall wellness
24       Email access
21       Help to avoid unnecessary ER visits
18       Questions to prompt for reasons for visit (during visit or before)
18       Courtesy call if running late
18       Courtesy from receptionist
18       Avoid triage or gatekeeper role of receptionist
17       Alternative/integrative treatment options
16       Online self-scheduling tool
15       Waiting room comfort (seating, temperature, good magazines, privacy)
15       Decreased wait for appointments
12       No automated answering machines
10       Bacon
10       Followup with test results
9          Comfortable exam room environment (seating, lighting, good magazines)
9          Seeing doctor, not NP or PA
8          Walk-in slots
8          Enhanced check-in technologies
8          Respect my opinions on illness
7          Donuts
7          Alerts/reminders from doctor
6          Telephone access for after-hours emergencies
5          Coffee
4          Teleconference (Skypelike) or other alternative visit options
4          Nutella
4          Wifi
3          No lollipops
2          Lollipops
2          Home-cooked meals
1          Same day appointments
1          Cookies
1          Snacks
1          Drinks
1          “Fancy” chocolates
1          Massages

Pretty interesting results, don’t you think? First of all, it would seem that it is more important for me to provide complimentary bacon to my patients than a comfortable exam room environment or walk-in slots for appointments. Why didn’t I think of that? Bacon is always the key to excellent customer service!

You can tell the thread had a little humor in it, and that is always a good thing. But, ignoring the requests for Nutella and home-cooked meals, I was happy to see that online access to medical records was the most “liked” topic. This shouldn’t be a surprise. Today’s patients, raised on WebMD and the University of Google want to be involved in their care, or at least feel well-informed about their visits.

In October, a study was published in the Annals of Internal Medicine that looked at the interaction between clinician and patients (as well as the satisfaction each party feels and its affect on healthcare) when visit notes were made available after every doctor’s visit. It was summarized as follows in an article on the study in Forbes magazine:

“Patients accessed visit notes frequently, a large majority reported clinically relevant benefits and minimal concerns, and virtually all (99%) patients wanted the practice to continue.  With doctors experiencing no more than a modest effect on their work lives, open notes seem worthy of widespread adoption.”

So now, in my own little study, my Facebook friends have put online access to medical records as their number one request in an “ideal medical practice.” In the study, this meant actually delivering copies of the notes. But there are different ways to interpret this informal request from Facebook, especially since I did not specify what this would entail. Other than in the study environment described above, not many electronic medical records are programmed to share visit notes online, as this is something that, prior to this study, is so foreign to ambulatory medicine that it has likely never been requested of the health IT companies. Today, online access to medical records is more likely to be represented in a patient portal, written by the software companies, to which a patient can securely log in and see some portion of their records. This should, in the least, include appointment requests, problem lists, allergies, medicine list, visit summaries, lab results, and secure messaging.

“Decreased wait times” is not a surprise at number two, given our severe doctor shortage and the pressures from our third-party payer system that makes a doctor see more and more patients each day to maintain a steady income. If I were to recreate the practice that I left, the mill that grinded me up and spit me out in a bag of grits, I would have the same situation all over again. In opening a new practice, I will need to find a way to limit the overall patient load to better match the advanced level of service I am talking about trying to provide, which includes minimal wait times. I think at least part of the solution, in addition to limiting patient load, is found farther down the list. If I try to mostly stick to same day scheduling, allowing patients to schedule their own appointments online, and offer alternative visit options like Skype or telephone visits, then I should be able to limit the time spent waiting for me to see you.

Coincidentally, this will also help me take care of the issue that surprised me by coming in third, having a dual waiting room, separating the sick from the well. Going forward, I do not want a practice with more than one person waiting!

So what is next? I need to take this list, as grandiose as it may seem, and see if I can come up with a practice model that can make it happen. I am going to try!

© 2009 ackdoc - Greg Hinson, MD 508/325-9981 info@ackdoc.com Purchasing help RSS feed