Category: Physicians

I guess we’ll have to think of another reason to oppose single payer

published date
January 8th, 2007 by

If there’s one thing everyone hates about single payer health systems it’s waiting lists for treatment. The trade-off is that costs are lower in single payer systems and everyone has access to care.

We can rationalize the situation in the US by saying we’ve decided not to make the trade-off. We’ve decided as a country that we don’t wan to “ration” health care or artificially limit its supply. Assuming you have access to the system you should be able to get as much care as needed to make you better.
But maybe there isn’t a trade-off. The US spends more on health care per capita and as a percent of GDP than anywhere else in the world. Massachusetts is the highest spender in the US. And Boston is the capital of the state and of its health care system.

Yet according to a new study reported in the Boston Globe (Dangerous delays to see skin doctors; Hub patients wait longest, study says), patients in Boston wait an average of 10.5 weeks to see a dermatologist for a “changing mole” –perhaps the closest thing in dermatology to an emergency. At the Brigham and Women’s Hospital, patients wait 3.5 months on average for a routine visit!

No one can really figure out what’s going on, especially when Boston has so many dermatologists.

  • Some physicians say the data must be wrong
  • Others cite the expansion of cosmetic services
  • Others blame it on the high percentage of researchers

In any case, no one’s accountable. (By the way this is not the first time physician access in Boston has been shown to be wanting.)
Just for kicks, I had a look at the UK’s National Health Service website, which has detailed, up-to-date information on waiting times by specialty. I looked at the “Provider Based Hospital Waiting Times for 1st Outpatient Appointments: England,” and checked the “Effective length of wait from receipt of GP written referral request to first Outpatient attendance (weeks). I’m not expert in reading these tables –so maybe I’m reading something wrong– but according to my calculations:

  • 37% of patients were seen in under 4 weeks
  • 63% in under 8 weeks
  • 98% in under 13 weeks

These numbers aren’t directly comparable with the Boston statistics. Still, it shows something terribly wrong with health care in my fair town.

Who’s afraid of the big bad debate?

published date
January 8th, 2007 by

The American Society of Hypertension (ASH) has taken a lot of heat from those (including the journal Hypertension) who think it is too cozy with the pharmaceutical industry. Responding to the pressure, ASH scheduled a panel discussion on “Conflicts of Interest” for its upcoming conference. However, the society then canceled the session –calling it one-sided– and this was reported in the Boston Globe (Medical group puts stop to talks on drug-firm ties). Once news of the cancellation got out it caused more controversy; now ASH is reversing course again.

This time, according to the Globe (In shift, medical society to hold panel), ASH plans to invite advocates of pharmaceutical company involvement in addition to industry critics. That has the critics (including Harvard Medical School professor Jerry Avorn and former New England Journal of Medicine editors Marcia Angell and Jerome Kassirer) up in arms.

“It seems to be standing the whole thing on its head,” said Angell. She said the original intent of the panel had been to provide a counterweight to the drug industry’s sponsorship of scientific papers and physicians at the annual meeting.

“This seems like a very different panel than the one originally proposed,” Avorn said. “Those two individuals [the industry advocates] will be expressing views that are quite different from those that were originally envisioned.”

I don’t know why Angell and Avorn are complaining. Angell’s opposition, in particular, seems silly. Does it really make sense to balance one biased part of the conference with another biased part? I say get all sides in a room and argue it out in a lively debate. Certainly the drug companies deserve a chance to put forth their arguments. If the room is full of people with the same views no one will learn much.

It would also be useful to have some participants who aren’t physicians. A patient advocate or economist, for example. One reason physicians and pharmaceutical companies have become so intertwined is that physicians don’t understand economics very well.

Henry Ford regulates pharma reps

published date
December 19th, 2006 by

The Henry Ford Health System is banning free lunches and gifts by pharmaceutical and medical equipment sales reps, starting January 1, according to the Detroit Free Press. Representatives will also have to schedule appointments with physicians and pay a $100 certification fee to Henry Ford before being allowed to do so.

“The evidence shows that when physicians are exposed to pharmaceutical representatives, their decisions are different,” Dr. A. Mark Fendrick, a U-M drug price specialist, told the Detroit Free Press. “It is very unusual to find generic drugs in a physician’s sample closet.”

The program is portrayed as a way to keep industry in line, but I look at it as part of the maturation of the relationship between pharma and docs. Sales reps buy lunch and provide gifts because doctors want that to happen; many expect it as a kind of entitlement. It’s just as well to have that practice end. I’d suggest Henry Ford use that $100/rep tax to fund an education program for physicians to help them get the most out of their interaction with drug reps. Maybe an online course to explain industry economics and help doctors ask the right questions.

There are at least a couple of companies I can think of that could benefit from Henry Ford’s decision:

  • PreferredTime, which schedules rep appointments with physicians
  • Medvantx, which makes machines that provide generic samples in doctors’ offices

Putting the Informed into Informed Consent

published date
December 8th, 2006 by

Putting the Informed into Informed Consent

Physicians and clinical trial coordinators often view “informed consent” as just a form that needs to be filled out or a procedure that needs to be undertaken. A common consequence is that those who have consented have not necessarily been well informed. Informed consent should really be treated as an ongoing process, with a chance for patients to absorb and discuss information over time.

A new study of informed consent for clinical trials conducted in the ICU comes to the not very surprising finding that most patients who consented to participation in a trial don’t really know what’s going on. I would have been shocked if the data showed anything else.

A more useful study, in my view, would examine how many patients undergoing elective procedures or enrolling in clinical trials outside of the hospital understand what is happening.

In case having prostate cancer wasn’t bad enough

published date
December 1st, 2006 by

In case having prostate cancer wasn’t bad enough

If you’re unlucky enough to get prostate cancer, you’d at least expect your doctor to help arrange the best possible treatment plan for you. However, some urologists may be a little more interested in boosting reimbursement for themselves than in making life easier and better for their patients. They’re using I.M.R.T., a radiation therapy that can result in payments of up to $47,000, which is far higher than for other methods. According to the New York Times:

Helping drive the trend is a Texas company, Urorad Healthcare, which sells complete packages of I.M.R.T. technology and services, and hopes to persuade even more urologists to buy them.
“Join the Urorad team and let us show your group how Urorad clients double their practice’s revenue,” the company says in a marketing pitch to doctors on its Web site.
Urologists who have purchased the new multiple beam systems say they are embracing a superior way to treat prostate cancer. But because there is little research directly comparing I.M.R.T. with the other treatments, there is little consensus among urologists about which approach is best…

Compared with seed implants, for example, I.M.R.T. involves a large time commitment, requiring patients to visit a radiation center 45 times over the course of nine weeks.

One thing that particularly concerns me is those patients who will be pushed into IMRT when they might be better off with no treatment at all.