Zócalo Public SquareRemedies – Zócalo Public Square http://www.zocalopublicsquare.org Ideas Journalism With a Head and a Heart Thu, 23 Nov 2017 01:59:12 +0000 en-US hourly 1 https://wordpress.org/?v=4.8 Should Jerry Brown Just Ignore His Cancer?http://www.zocalopublicsquare.org/2013/01/02/43668/ideas/nexus/ http://www.zocalopublicsquare.org/2013/01/02/43668/ideas/nexus/#comments Wed, 02 Jan 2013 08:01:32 +0000 by Shannon Brownlee http://www.zocalopublicsquare.org/?p=43668 As California’s oldest governor, Jerry Brown has gone out of his way to demonstrate his vigorous good health, jogging around the Capitol and even challenging reporters to pull-up contests—which he won. Now that he’s been diagnosed with prostate cancer and begun radiation therapy, some news outlets seem to be experiencing a bit of schadenfreude, gleefully calling the 74-year-old governor’s diagnosis a “blow to his healthy image.”

They missed the real story, which isn’t the governor’s prostate cancer but rather the fact that he has chosen to be treated at all. Given a choice between no treatment and radiation therapy, it’s a bit of a toss-up as to which is more likely to do him harm, and it’s entirely possible he didn’t really understand there was a choice.

That might seem like an outrageous claim, but here’s why it’s not. The governor’s office has released precious few details about his

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As California’s oldest governor, Jerry Brown has gone out of his way to demonstrate his vigorous good health, jogging around the Capitol and even challenging reporters to pull-up contests—which he won. Now that he’s been diagnosed with prostate cancer and begun radiation therapy, some news outlets seem to be experiencing a bit of schadenfreude, gleefully calling the 74-year-old governor’s diagnosis a “blow to his healthy image.”

They missed the real story, which isn’t the governor’s prostate cancer but rather the fact that he has chosen to be treated at all. Given a choice between no treatment and radiation therapy, it’s a bit of a toss-up as to which is more likely to do him harm, and it’s entirely possible he didn’t really understand there was a choice.

That might seem like an outrageous claim, but here’s why it’s not. The governor’s office has released precious few details about his diagnosis, but his doctor did say that the cancer was “early-stage” and “localized.” About half of prostate cancers that fall into that category—early-stage and localized—never would have caused symptoms in the patient’s lifetime, even if they were left untreated.

Only about 3 percent of deaths among men are due to prostate cancer—probably less than most people imagine. But a lot of men have prostate cancer and never know it. Autopsy studies of men who died of other causes have found that about 60 percent of men in their 70s have prostate cancer that was not diagnosed. For men in their 80s, that number goes up to 70 percent. In other words, more men die with prostate cancer than from it. That means there’s a good chance the governor has been overdiagnosed and is going through treatment for a cancer that would never have bothered him, or that could have been treated successfully at a later date if and when it started causing symptoms.

To make matters worse, Brown’s radiation treatment has a good shot at turning Governor Healthy into a patient who will suffer serious, life-altering side effects. The most common, long-lasting side effects of radiation therapy are bloody stools or rectal pain and other bowel problems; urinary obstruction, pain, or irritation, and other urinary difficulties; and erectile dysfunction. About half of men who undergo radiation therapy suffer one or more of these problems long-term. A few even die from their treatment.

This is the terrible conundrum that many men face when diagnosed with low-risk, localized prostate cancer. Should they be treated, and risk becoming candidates for Viagra and Depends? Or should they forego treatment and face the smaller risk that their cancer will go on to become aggressive and maybe even kill them?

Such personal decisions have implications far beyond the health of California’s governor. The state and private insurers could save a lot of money by refusing to pay for treatment for low-risk, localized prostate cancer, and the end result would be only a few additional deaths per year from prostate cancer, if any. Payers could save even more by refusing to cover the P.S.A. test, a blood test that is used to screen asymptomatic men for signs of early prostate cancer. Since it was first put into widespread use in the 1990s, the P.S.A. test has led more than a million men to be diagnosed and treated for a cancer that could have been ignored; many experts now believe it should not be used as a screening test.

Of course, no insurer would dare to make such a draconian move. There is another way to give men choices, reduce the number of men who are harmed by overdiagnosis and overtreatment, and save some money. It’s called “shared decision making.” In this process, doctors provide patients with digestible, balanced information about the potential benefits and harms not only of the P.S.A. test and prostate cancer treatment but also of a wide variety of elective procedures and tests. Then, the doctor and the informed patient decide together how to proceed.

That’s not what usually happens. In the case of the P.S.A. test, one-third of men who get one are never asked if they want it. Of men who are asked, two-thirds say their doctor failed to mention possible downsides that result from treatment that can follow screening.

When doctors share decisions with their patients, by first offering them accurate, balanced information, and then asking them about their values and preferences, patients often make very different choices. In the case of prostate cancer, many men choose to forego the P.S.A. test. Men who have been diagnosed with a localized cancer often choose not to be treated, but rather to watch and wait.

Let’s hope the governor is one of the lucky ones whose cure does not turn out to be worse than the disease. An even better outcome would be if he also realizes the need to get shared decision making into widespread practice.

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Cancer Doesn’t Have to Be This Deadly For African-Americanshttp://www.zocalopublicsquare.org/2012/12/06/cancer-doesnt-have-to-be-this-deadly-for-african-americans/ideas/nexus/ http://www.zocalopublicsquare.org/2012/12/06/cancer-doesnt-have-to-be-this-deadly-for-african-americans/ideas/nexus/#comments Thu, 06 Dec 2012 08:01:08 +0000 by Charles S. Modlin, Jr. http://www.zocalopublicsquare.org/?p=43139 Doctors and health experts have long known that members of minority groups in the United States tend to have poorer health outcomes than white Americans. I noticed it myself while in medical school. African-Americans suffered disproportionately from a variety of medical conditions, and they were dying younger because of it. Later, after completing my formal medical training and becoming familiar with more literature on the topic of differing health outcomes, I came to appreciate even more fully the devastating impact that health disparities have on minority populations, particularly on African-Americans with cancer. It became my mission to help bring minority survival rates up to the level of those of whites.

Here are the facts: African-Americans have not only higher rates of cancer than whites but also a greater likelihood, once diagnosed, of dying from the disease. For example, African-American men are 66 percent more likely than white men to develop

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Doctors and health experts have long known that members of minority groups in the United States tend to have poorer health outcomes than white Americans. I noticed it myself while in medical school. African-Americans suffered disproportionately from a variety of medical conditions, and they were dying younger because of it. Later, after completing my formal medical training and becoming familiar with more literature on the topic of differing health outcomes, I came to appreciate even more fully the devastating impact that health disparities have on minority populations, particularly on African-Americans with cancer. It became my mission to help bring minority survival rates up to the level of those of whites.

Here are the facts: African-Americans have not only higher rates of cancer than whites but also a greater likelihood, once diagnosed, of dying from the disease. For example, African-American men are 66 percent more likely than white men to develop prostate cancer and twice as likely to die from it.

Why the difference in outcomes? Many possible culprits have been cited. Some are environmental: African-Americans, on average, live in poorer neighborhoods and have less access to quality healthcare and preventive health screenings than do whites. Some possible culprits are genetic: certain diseases seem to be prevalent within certain racial populations for reasons not easily explained by non-genetic factors.

And many of the possible culprits are cultural: African-Americans are more likely to have diets high in fat, to engage less in physical activity, and to smoke and drink. Many African-Americans lack adequate health literacy and fail to recognize the importance of early screenings for cancer. Also, many are heirs to a historically rooted mistrust of health providers and health systems in general, a mistrust that is exacerbated by a lack of cultural competency among healthcare providers when it comes to communicating with patients.

As a practicing physician, I have often seen the cultural factors at work. I’ve treated many African-Americans with cancer, particularly prostate cancer, lung cancer, and colorectal cancer. In many cases, when I’ve informed these patients of their diagnosis, they have wrongly assumed that death was imminent. Many did not understand that there were treatment options for their cancers and that they might well be cured.

Even when informed of treatment options, some of my patients have refused them for invalid or superstitious reasons. Patients have refused surgical therapy out of a belief that if an incision is made and a cancer is exposed to the air, it will automatically spread throughout the body. (This particular misconception about surgical therapy for cancer is more prevalent than most people realize.) Clearly, then, doctors and other health professionals must work to educate people more about medicine and the importance of undergoing routine preventive health screenings for cancer.

Reducing disparities in cancer outcomes will be hard, in part because reductions require efforts that bump up against the very fear and ignorance contributing to the disparities. Take clinical research trials, one essential tool to gathering a complete understanding of the interplay of contributing factors in disparities. Many African-Americans, wary of past betrayals of trust such as the Tuskeegee experiments, are reluctant to participate in such trials, making it harder to discover and develop innovative ways in which to treat cancer in African-Americans.

Even without more clinical trials, we can do a lot to reduce the disparate incidence of cancer and higher mortality rates in African-Americans compared to white Americans. Much of it is just common sense. We should encourage African-Americans to take certain preventive measures against cancer: quitting smoking, cutting out high-fat meals, excersizing more. We should train new doctors to communicate effectively with people from a variety of cultures. We should improve the health literacy of African-Americans. We should have charitable assistance for African-Americans attempting to navigate the maze of the healthcare system, especially for those who are underinsured. And we should undertake collaborative research into the biological causes of cancer disparities in African-Americans, encouraging African-Americans to enroll in clinical research trials and other initiatives.

At the Cleveland Clinic, where I work, we have developed the Minority Men’s Health Center, which is a dedicated clinical research, educational outreach, and patient navigation access program to address health disparities among minority males. It is a start.

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Will High-Caliber Doctors Practice In Low-Appeal Places?http://www.zocalopublicsquare.org/2012/11/26/will-high-caliber-doctors-practice-in-low-appeal-places/ideas/nexus/ http://www.zocalopublicsquare.org/2012/11/26/will-high-caliber-doctors-practice-in-low-appeal-places/ideas/nexus/#respond Mon, 26 Nov 2012 08:02:30 +0000 by Rebecca Plevin http://www.zocalopublicsquare.org/?p=42722 It takes a special kind of doctor to practice in California’s San Joaquin Valley.

It’s one of the state’s sickest regions, with high rates of obesity and diabetes and an epidemic of asthma. It’s one of the poorest regions in California, which hardly makes it lucrative for new doctors looking to pay off student loans. And it has the worst air quality in the country.

Not surprisingly, the Valley has far fewer primary-care physicians and specialists than are recommended by nationally recognized benchmarks. Where the recommended number of primary-care physicians is 60 to 80 per 100,000 people, in the San Joaquin Valley that number is only 45 per 100,000, according to a 2010 California HealthCare Foundation report.

That’s why I listened with particular interest to an NPR report earlier this year about Benjamin Anderson, CEO of a health center in rural, southwest Kansas. Like the San Joaquin Valley, Anderson’s corner

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It takes a special kind of doctor to practice in California’s San Joaquin Valley.

It’s one of the state’s sickest regions, with high rates of obesity and diabetes and an epidemic of asthma. It’s one of the poorest regions in California, which hardly makes it lucrative for new doctors looking to pay off student loans. And it has the worst air quality in the country.

Not surprisingly, the Valley has far fewer primary-care physicians and specialists than are recommended by nationally recognized benchmarks. Where the recommended number of primary-care physicians is 60 to 80 per 100,000 people, in the San Joaquin Valley that number is only 45 per 100,000, according to a 2010 California HealthCare Foundation report.

That’s why I listened with particular interest to an NPR report earlier this year about Benjamin Anderson, CEO of a health center in rural, southwest Kansas. Like the San Joaquin Valley, Anderson’s corner of Kansas doesn’t naturally attract scores of physicians. It’s an agricultural community of about 900 people, located about an hour from the nearest Walmart, two hours from a Starbucks, and three hours from a big city, Wichita.

Yet Anderson has managed to turn around his organization, the Ashland Health Center, and improve service to his community. When Anderson joined Ashland almost four years ago, it was in a fragile position. Employee turnover was high, morale was low, and finances were upside down. Since then, Anderson has recruited one nurse practitioner, one physician assistant, and two doctors to join a solo mid-level provider.

I called Anderson to learn more about his approach. He told me there are four types of doctors that are willing to work in medically underserved communities: There’s the local person, who was born and raised in the area. There’s the foreign physician, who earns a work visa, stays for the required amount of time, and then transfers to a more desirable location, like San Francisco. There’s “the troublemaker,” a doctor with personality or quality issues who is tolerated in communities where the need for medical professionals is dire. And then there’s the mission-driven idealist.

It is doctors in this last category for whom Anderson searches. These are people who feel called to care for the underserved, both locally and abroad. To sweeten the deal, Anderson offers even more of the same: time off to practice in other parts of the world. All of his medical staffers get eight weeks of paid leave each year, and many have used it to provide healthcare and service in Africa, Asia, and Latin America. “We appealed to the physicians’ sense of mission,” Anderson explained. “If you’re willing to live and serve in a mud hut in the African bush, chances are you don’t need a Nordstrom or a Starbucks or a big airport nearby. You’re there to serve.”

I asked Anderson if he thought his approach would work in the San Joaquin Valley. “I think it works really in any underserved area, and the Valley is no exception,” Anderson said. “The same people that want to serve internationally in developing countries have a heart for people here.”

To be sure, the Valley already has several excellent, innovative programs at the high school, college, and medical school levels that are designed to train doctors to treat the region’s specific healthcare needs and diverse communities. This fall, Governor Jerry Brown signed AB 589, which creates a scholarship to help cover the cost of medical school tuition for doctors who commit to practicing for at least three years in one of the state’s more than 200 medically underserved areas. (The bill’s sponsor, Henry T. Perea, told me he hoped it would “spur more homegrown doctors to seek their medical training and then come back home.”)

But when it comes to retaining doctors in a place like the Central Valley, I agree with Anderson: The doctor who will stay has to be someone with a mission—someone who is driven by compassion and a desire to care for poor families, immigrants, and agricultural workers.

It’s someone like 20-year-old Stephanie Huerta, who grew up in Caruthers, a small, agricultural community in Fresno County. While a student at Caruthers High School, she participated in the UCSF Fresno Doctors Academy, a rigorous program intended to prepare Valley youth to become culturally and linguistically competent health professionals for the medically underserved region.

“It’s always been my dream and my passion to come back,” said Huerta, who today is a junior in college and on the pre-med track at UC Santa Cruz.

She knows doctors in the Bay Area are paid more, but she’s felt her home region’s need for doctors personally. She remembers long waits in the doctor’s office when she was pregnant with her daughter and an endless wait in a Valley emergency room when her fiancé broke his nose. “It’s not just about money,” she said. “It’s about caring for people.”

And it’s someone like medical student Agustín Morales, the Mexican-born son of immigrant strawberry pickers. In 2011, he joined the first cohort of the UC Merced San Joaquin Valley Program in Medical Education, a collaboration between the University of California, Merced, and the UC Davis School of Medicine. “I think that the level of quality and access [to healthcare] should be the same, whether you are the CEO of a company or you are a farm laborer, just like my mom or any of my relatives,” Morales told me last year. “We all deserve to be treated with dignity.”

Doctors and students like Huerta and Morales would probably be receptive to a San Joaquin version of the incentives Anderson is trying out in Kansas.

Certainly, Anderson admits his approach to recruiting doctors is not traditional. “It really rides the edge of many people’s comfort level,” he told me. But it’s been successful. We need a fresh approach to recruiting and retaining health professionals, and Anderson’s tactic may be an effective way to attract young, passionate doctors to rural areas.

“From my experience, millennials are more driven toward issues of social justice than any generation in American history,” Anderson said. “If you can appeal to their sense of mission, you’ll attract them. No amount of money replaces that.”

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How About Ice Cream Without the Tonsillectomy?http://www.zocalopublicsquare.org/2012/10/17/how-about-ice-cream-without-the-tonsillectomy/ideas/nexus/ http://www.zocalopublicsquare.org/2012/10/17/how-about-ice-cream-without-the-tonsillectomy/ideas/nexus/#comments Wed, 17 Oct 2012 07:01:08 +0000 by Heather Boerner http://new.zocalopublicsquare.org/?p=39060 In 1981, I was 7, in love with Rick Springfield’s “Jessie’s Girl,” and so sick and sweaty and miserable that I woke myself from sleep in tears. When my mom asked me what was wrong, I told her my throat hurt—but “my other throat.” That was my best effort to describe the swollen, inflamed, and painful experience of having tonsillitis. After days of this, my mom had had enough. She bundled me up and drove me 45 minutes to the closest Kaiser clinic.

We reached Kaiser, I had my vitals tested, my temperature taken, and a throat depressor and pin light used to analyze my tonsils. My tonsils weren’t that bad, the doctor said. Take some antibiotics and go home and rest. But I was very disappointed. I wanted those tonsils out.

You could blame TV for this. By age 7, I’d absorbed the TV-rerun trope of the tonsillitis episode.

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In 1981, I was 7, in love with Rick Springfield’s “Jessie’s Girl,” and so sick and sweaty and miserable that I woke myself from sleep in tears. When my mom asked me what was wrong, I told her my throat hurt—but “my other throat.” That was my best effort to describe the swollen, inflamed, and painful experience of having tonsillitis. After days of this, my mom had had enough. She bundled me up and drove me 45 minutes to the closest Kaiser clinic.

We reached Kaiser, I had my vitals tested, my temperature taken, and a throat depressor and pin light used to analyze my tonsils. My tonsils weren’t that bad, the doctor said. Take some antibiotics and go home and rest. But I was very disappointed. I wanted those tonsils out.

You could blame TV for this. By age 7, I’d absorbed the TV-rerun trope of the tonsillitis episode. It always ended with Cindy Brady, Eddie Munster, or the Fonz in bed without tonsils and with a big bowl of ice cream. As far as I could tell, there was little risk and a big reward. My pain could be replaced by mint chocolate chip. But now the verdict from Kaiser was in—and it was depressingly ice-cream-free.

For years afterwards, every time I got a cold, my tonsils got inflamed, and I blamed Kaiser for being too cheap to yank them. I spent a few decades believing that I’d received subpar care. Actually, though, what we need is precisely more doctors like the ones who treated me at Kaiser.

If you want an example of avoidable, wasteful care, tonsillectomies are Exhibit A. Dr. David Goodman of the Dartmouth Atlas, which measures variability in care and healthcare costs, has gone so far as to call tonsillectomies “a silent epidemic of unnecessary care,” according to an article in The Washington Post.

Here’s what he’s talking about: Between 1996 and 2006, the number of tonsillectomies performed in this country spiked by 74 percent. About half a million children will have a tonsillectomy this year, making it the most common surgery performed on children requiring general anesthesia. It’s held that title for a century.

According to Goodman, few, if any, of the supposed benefits of the tonsillectomy are backed up by science. This is where The Brady Bunch collides with our heavy healthcare burden—and where we as consumers of healthcare have to make some decisions. Do we go with what’s always been done, to alleviate temporary pain? Or do we take a risk, wait and see, and avoid skyrocketing healthcare costs and unnecessary care?

Awareness of the arbitrariness of tonsillectomies goes back decades. In 1938, Sir Allison Glover, an English doctor researching the procedure and its use, found that the rate of tonsillectomies depended almost entirely on each doctor’s preference. In the 1960s and 1970s, Dr. Jack Wennberg, a pioneering health researcher, found the same thing: In one Vermont town, 70 percent of the children had their tonsils out. In the next town over, only about 20 percent of the kids did.

What gives? According to Dr. Wennberg, in a transcript from a 2008 interview with the Dartmouth Institute for Health Policy and Clinical Practice, the culprit was the doctor. A surgeon who’s a proponent of a certain kind of surgery can influence a family’s decision of what to do. And with a lack of double-blind randomized-controlled trials on tonsillectomies to back up or guide doctors on how to proceed, we’ve all continued to fly blind.

Now, for some kids, there does appear to be a marked and measurable improvement in quality of life after tonsillectomy. But for kids like me—kids with pain and trouble swallowing, but no recurrent infections and no trouble sleeping through the night—a tonsillectomy is going to cut the average number of sore throats from three per year to two. That’s right: For a cost of anywhere from $5,200 in 2007 to $6,082 per procedure in Iowa in 2011—somewhere between $2.6 billion and $3.04 billion a year—a tonsillectomy can save your child from having one sore throat, according to a 2009 review of the medical literature by the Cochrane Library.

And that’s not all of it: Tonsillectomy is a major surgery, requiring children to be put under general anesthesia. The American Academy of Otolaryngology found that about one in 16,000 people who have tonsillectomies die from complications.

“Simply counting spending, in the narrow financial sense, misses the real cost of giving patients care that they may not want,” says Amitabh Chandra, a healthcare economist at the Kennedy School of Government at Harvard University. “Tonsillectomies are a metaphor for a wide range of treatments, such as radical prostatectomies, where the side effects of incontinence and impotence likely swamp the dollar cost of the treatment.”

By the time I developed tonsillitis in the 1980s, tonsillectomy rates were at their lowest in history. But they’ve since rebounded. Goodman, of the Darthmouth Atlas, believes it’s provider bias that accounts for the surge in operations. Another factor is patients: They, or at least their parents, want the treatment. As Dr. Emily Boss, assistant professor of otolaryngology at Johns Hopkins University and a pediatric ear, nose, and throat surgeon, told me, “What we don’t capture [in the research] is what it’s like as a surgeon to sit across from a family with a child who has significant breathing problems and is tired all the time.”

Many of these families are made up of people like me (or a younger me)—people who equate more care with better care. I spent every winter for years cursing Kaiser, insisting that they’d done me a disservice in the name of cutting healthcare costs. Then, one winter a few years ago, I spoke to a nurse who suggested that it was the cold medicine I was taking that was causing the inflammation because it was drying out my throat too much.

I changed medicines and haven’t had a tonsil infection since.

So now I know that appropriate care, in my case, was less care. But for most of us it’s very hard to tell. “Healthcare is almost the only industry in the U.S. where people can’t tell great service from bad service,” said Gerald Kominski, professor of health policy and management at the UCLA Fielding School of Public Health. “If healthcare were cell phones, you’d have people out there with iPhones and people with those old phones the size of a brick. And people would be saying, ‘No no no. I like my brick. It works great. I need it.’”

Plus you can sell a lot to a kid if you offer ice cream.

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You Have the Right To Be Sick—But Not On My Patientshttp://www.zocalopublicsquare.org/2012/10/11/you-have-the-right-to-be-sick-but-not-on-my-patients/ideas/nexus/ http://www.zocalopublicsquare.org/2012/10/11/you-have-the-right-to-be-sick-but-not-on-my-patients/ideas/nexus/#respond Thu, 11 Oct 2012 07:04:12 +0000 zocalo http://new.zocalopublicsquare.org/?p=38837 Last week in my clinic, I saw a patient with AIDS. As part of this visit, my patient was examined by a medical assistant who had a cough and sniffles. This medical assistant declined an influenza vaccination this season, yet he still is allowed to work with patients. He was literally placing my patient’s life at risk.

As a doctor of internal medicine, I would like nothing better than to tell this medical assistant to get a flu shot or stay away, but I have no such authority. Nor does my healthcare organization, which employs this medical assistant. Healthcare workers are protected by union contracts, and unless the state of California overrides a given provision, the contract determines what employers can demand. As things stand, if you want a healthy nurse, you have to keep your fingers crossed.

To understand this absurd situation, it’s necessary to understand something about the

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Last week in my clinic, I saw a patient with AIDS. As part of this visit, my patient was examined by a medical assistant who had a cough and sniffles. This medical assistant declined an influenza vaccination this season, yet he still is allowed to work with patients. He was literally placing my patient’s life at risk.

As a doctor of internal medicine, I would like nothing better than to tell this medical assistant to get a flu shot or stay away, but I have no such authority. Nor does my healthcare organization, which employs this medical assistant. Healthcare workers are protected by union contracts, and unless the state of California overrides a given provision, the contract determines what employers can demand. As things stand, if you want a healthy nurse, you have to keep your fingers crossed.

To understand this absurd situation, it’s necessary to understand something about the public policy involved. For years, the official recommendation from the Centers for Disease Control has been that at least 90 percent of healthcare workers get flu vaccinations. Ninety percent is the magic threshold for what’s called “herd immunity.” If you have a herd of 100 animals and 90 of them are immune to a contagious disease, then that disease will be unable to establish a stronghold within the herd.

In other words, if 90 percent of healthcare workers were to get inoculated—leaving room for up to 10 percent of their colleagues to refuse based on known allergies or a past adverse reaction—then our hospitals and doctor’s offices would be safe. Currently, however, only 64 percent of healthcare workers in California get the influenza vaccine. Even a devastating and well-publicized H1N1 pandemic in 2009 didn’t prompt the implementation of all possible precautions.

For that reason, last February, California state legislators wrote up a bill to do something about it. The bill, Senate Bill 1318, would require healthcare facilities to meet a 90-percent flu vaccination rate among their workers by 2015. Of course, in order to meet a requirement like that, employers must be able to force—or at least strongly incentivize—their employees to get the vaccine. To that end, the original version of SB 1318 contained a mandate that all unvaccinated healthcare workers wear a mask for the duration of the influenza season, from October through April, while in patient care areas. That way, no healthcare worker would be forced to get the vaccine, but the price to pay would be the inconvenience of wearing a mask.

Along the way, however, legislators experienced a last-minute loss of nerve, so they removed the mask provision, fearing it to be a landmine of personal rights violations. Instead came a general requirement that all healthcare facilities meet the 90-percent worker vaccination mark by 2015. As for how facilities would enforce that measure absent any teeth, that question was left unresolved.

In any case, SB 1318 made it to the desk of Governor Jerry Brown, getting California a little closer to doing away with a needless health hazard. But Brown vetoed it on September 30 of this year. The California Nurses Association, a powerful labor union, had objected to the measure, alleging it was “divisive and could lead to future discrimination issues in the workplace.” (The alternative of letting unvaccinated employees wear a mask seven months out of the year had been struck down by the union months earlier.)

For now, the only hope for doing something about the problem can be found at the local level. In California’s public health system, the public health departments of individual counties are governed by physician “health officers,” the local equivalent of the surgeon general. These doctors have oversight of all communicable disease control within their jurisdiction, and they technically have the power to quarantine a city and even to throw infectious citizens in jail. Of course, no one is expecting them to do anything like that. But odds are good that more and more physician health officers will institute their own influenza mask mandate—or find some other way to motivate workers to get the shot.

As Dr. Bob Hartmann, health officer of Amador County, recently told me, “If the legislature is going to continue to wimp out, we as health officers need to mandate.” Hartmann ordered masks for unvaccinated workers in October 2011, and Amador County has already seen its hospital vaccination rate soar to 89 percent. “Hospital CEOs were begging me to do it,” Hartmann said. “It made their job easier when I gave the order, so they didn’t have to. And really, it’s my responsibility as the Health Officer of this county to step up to the plate.”

Is such use of power unprecedented or, as some healthcare workers allege, unconstitutional? Actually, no. For years most hospitals in the United States have required employees to receive vaccinations against measles, mumps, rubella, and Hepatitis B as a condition of employment. Adding influenza shots to that mix hardly seems dramatic, especially considering that more people die from influenza each year than of all those other diseases combined.

To be sure, measures like the mask mandate have prompted skeptics to object on scientific grounds. They point to a study by the CDC in 2008 that concluded that viruses such as influenza can survive for hours on surfaces, that they can be spread by surface-to-hand or hand-to-hand contact, and that masking creates a false sense of protection for employees and patients. But the study did not show that masks make things worse—and, more important, if the effect of a mask mandate is that more healthcare workers get vaccinated, then the mandate surely serves its purpose.

Of course, all of these fights revolve around a more fundamental—and age-old—debate over where to draw the line between protecting the rights of the public and the rights of the individual. Should our government have the power to mandate a vaccine? Or do individual rights take precedent? But that debate seems awfully arcane when a potentially infected healthcare worker is coughing on my AIDS patient. They have a right to work in a different profession if they like, but no healthcare worker has a right to infect—and possibly kill—my patients.

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When We Die, Who Is Kind?http://www.zocalopublicsquare.org/2012/10/03/when-we-die-who-is-kind/ideas/nexus/ http://www.zocalopublicsquare.org/2012/10/03/when-we-die-who-is-kind/ideas/nexus/#respond Wed, 03 Oct 2012 07:01:17 +0000 by Toni Miles http://new.zocalopublicsquare.org/?p=38656 I am writing this piece as a middle-aged woman who recently lost her younger brother. We were “Catholic twins,” born 18 months apart in Kansas City. As kids, we fought. In high school, we played duets at weddings—my brother on violin, me on viola, the two of us strolling about the room. As teenagers, we made plans to leave home together.

I studied medicine at Howard University, and he got an MBA from General Motors Institute. My career moved me around the country. He settled in Detroit, then Oakland. Throughout it all, we stayed in touch. As technology evolved, so did our communications: telephone, mobile phone, email, Facebook. I knew that he was gay long before he admitted it to our parents. I came to know and appreciate his boyfriends, the last of whom he married.

My brother’s widow is a good man. He did not deserve to experience the

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I am writing this piece as a middle-aged woman who recently lost her younger brother. We were “Catholic twins,” born 18 months apart in Kansas City. As kids, we fought. In high school, we played duets at weddings—my brother on violin, me on viola, the two of us strolling about the room. As teenagers, we made plans to leave home together.

I studied medicine at Howard University, and he got an MBA from General Motors Institute. My career moved me around the country. He settled in Detroit, then Oakland. Throughout it all, we stayed in touch. As technology evolved, so did our communications: telephone, mobile phone, email, Facebook. I knew that he was gay long before he admitted it to our parents. I came to know and appreciate his boyfriends, the last of whom he married.

My brother’s widow is a good man. He did not deserve to experience the events surrounding my brother’s last moments. They took place on July 25. My brother, age 56, was having breakfast. During the meal, he told his husband that he did not feel well and left the table to return to his bed. Thirty minutes later, my brother’s husband walked in to find my brother dead. Hysterical, the husband dialed 911. A series of professionals arrive on the scene—the ambulance workers (couldn’t save him), the police (couldn’t help him), and finally the coroner. After determining there was no evidence of foul play, the coroner left. My brother’s husband was now alone in the home with his dead partner. All the professionals had abandoned him.

I am also writing this piece as someone who has spent the past 25 years thinking about aging, particularly among minority populations. I live in the world of public health research and move in research circles. I hear many public-policy discussions that focus on advance care planning, with phrases like “making your wishes known” and “patient choice” and “do not resuscitate” dominating the conversation. What I don’t hear enough is the simple word “compassion.”

In my professional life, my colleagues and I have a thousand variables in our statistical models to explain deaths that happen too soon. Compassion is generally viewed as beside the point—a view that isn’t a problem in the world of statistics. But the cold language of public health research—with terms like “explanatory risk factors”—has also crept into our day-to-day discourse. Engage in high-risk behaviors—smoking, heavy drinking, eating junk food—and the numbers show you’ll die sooner. You should have known better.

The distress of sickness or bereavement is not diminished by a recitation of bad habits. Anyone living in the space of grief and loss needs the kindness of others. Neuroscientists have begun to assess the physiology of emotions by examining the brain in different states. In an MRI of the brain, a blue color indicates serenity. When someone is in deep meditation, whole regions of the brain turn a deep blue. Can we not conduct analogous research into the effects of compassion on a grieving brain?

In my professional life, my colleagues and I also see numbers relating to geography and end-of-life care. Live in certain parts of the country and you’re much more likely to die in a hospital than at home. Where you live affects how you die; but how does it affect compassion? Do resources missing from the community where my brother lived determine how my brother’s husband was treated? I think so. If you live in the wrong place, if you die under certain circumstances, then neither you nor those who mourn your death can expect too much sympathy. My brother’s house was in a poor and crime-plagued neighborhood in Oakland. There was no compassion.

Using research, I can confidently say that many Americans, black Americans especially, refuse to engage in end-of-life planning or discuss treatment limits. Some researchers link such refusal to some specific historical grievance, such as the Tuskegee syphilis study conducted between 1932 and 1972. But there’s not much evidence for the link. I see something simpler. In kitchen-table conversations with my female physician friends, we share stories about our experiences with patients at the end of life. Abandonment is a central theme: the experience of having had a professional make a fateful pronouncement and then walk away, without compassion. Maybe some of us request fruitless treatment and intrusion because it’s the closest we can get to human sympathy—because the alternative, being alone and uncared for, frightens us even more.

For better or worse, I have never had a family member die after a prolonged decline. There was never any fighting over whether a machine should be disconnected. There was no selection from a menu of treatment options. During a 30-year period, I’ve had 10 relatives die from a variety of causes. Some of the deaths were “natural,” while others were the result of violent crime. But in all cases, death came suddenly. No wonder that the idea of “advance care planning” has felt remote and the idea of abandonment has felt acute.

Compassion shouldn’t be confined to the patient, either. The loved ones we leave behind when we die, people like my brother’s husband, deserve a more compassionate system. I was moved when, a short time after my brother died, I got a call from his physician. She expressed her sympathy and her puzzlement. His death came as a surprise, she told me. She had seen him a few weeks before and found nothing remarkable. This didn’t give me answers, but it gave me a lot of comfort. After the nonviolent deaths of family members, I’d encountered indifference. After the violent deaths, I’d encountered silence. This physician cared, and I was grateful.

Fortunately, I am part of a large, noisy family. Like most American families, we live scattered across the country. But in times of bereavement, we gather. Most of us have private sources of comfort and support, and no healthcare system can ever supplant that. But neither should any healthcare system leave a grieving widow alone with the body of a spouse and no one to call for help.

Before my brother died, I happened to be studying the health effects of bereavement. I call it The Mortality Project. Other researchers and I are developing ways to measure the injury associated with loss. Time does not heal all wounds. We are finding evidence that, when an adult loses a parent, there is a 10 to 20 percent increased risk for illness during the next 10 years. Grief can cause body changes that are indistinguishable from diabetes. Seeing a loved one die in the ICU and hospital is strongly associated with prolonged grief and post-traumatic stress disorder. We know that parents whose children die before them live in a perpetual state of mourning. Loss is an understudied and under-recognized public health threat, and a cruel system makes it even worse.

Should patients have more control over their final days? Yes. Does where you live determine how likely you are to have intrusive end-of-life care? Yes. We should try to have everyone live in a “patient-centered” neighborhood. But it’s also time to have everyone live in a compassionate neighborhood.

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What the Heck Are Medicare Vouchers?http://www.zocalopublicsquare.org/2012/09/25/what-the-heck-are-medicare-vouchers/ideas/nexus/ http://www.zocalopublicsquare.org/2012/09/25/what-the-heck-are-medicare-vouchers/ideas/nexus/#respond Wed, 26 Sep 2012 06:40:33 +0000 by Ted Marmor http://zocalopublicsquare.org/thepublicsquare/?p=35585 Enacted in 1965 and implemented in 1966, Medicare, which largely covers the healthcare costs for America’s seniors, has become one of the federal government’s most beloved programs. It’s also one of the most expensive. In 2011, outlays came to $486 billion, about 14 percent of federal expenditures.

Everyone knows Medicare needs to be set on a sustainable course, but partisan exchanges about how to achieve that have become increasingly sharp. This election season, Republicans have accused President Obama of cutting Medicare, while Democrats have accused Republicans of intending to end Medicare altogether. The rhetoric heated up further when Republican presidential aspirant Mitt Romney chose Congressman Paul Ryan as his running mate. Ryan is known to favor Medicare “vouchers,” with which he contends seniors could shop around for private insurance, as a remedy for Medicare’s presumed unaffordability. Democratic figures charged that vouchers would “end Medicare as we know it,” and New

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Enacted in 1965 and implemented in 1966, Medicare, which largely covers the healthcare costs for America’s seniors, has become one of the federal government’s most beloved programs. It’s also one of the most expensive. In 2011, outlays came to $486 billion, about 14 percent of federal expenditures.

Everyone knows Medicare needs to be set on a sustainable course, but partisan exchanges about how to achieve that have become increasingly sharp. This election season, Republicans have accused President Obama of cutting Medicare, while Democrats have accused Republicans of intending to end Medicare altogether. The rhetoric heated up further when Republican presidential aspirant Mitt Romney chose Congressman Paul Ryan as his running mate. Ryan is known to favor Medicare “vouchers,” with which he contends seniors could shop around for private insurance, as a remedy for Medicare’s presumed unaffordability. Democratic figures charged that vouchers would “end Medicare as we know it,” and New York Times columnist Paul Krugman has dubbed Ryan’s ideas “Vouchercare.” So what’s the truth of the matter? Is Medicare really unsustainably expensive—and are vouchers a viable means of addressing its fiscal challenges?

Before diving into the fray, let’s first briefly lay out how Medicare works. Medicare has four “parts”: A, B, C, and D. Part A provides hospital insurance, using social insurance methods to finance the program—i.e. taxes on wages and salaries. Part B provides physician insurance, drawing on federal taxes and premiums paid by seniors, the disabled, and those requiring kidney dialysis. Part C, introduced in 1997, allows Medicare beneficiaries to receive their benefits through private insurance plans. Under Part C, beneficiaries can enroll in “Advantage” programs, which initially were set up for group practices that combined the financing and delivery of care in one organization. Part D, enacted in 2003, covers the costs of some prescription drugs.

Since 1966, Medicare has expanded in enrollment, complexity, and costs. Medicare’s overall outlays will only increase, but for two quite different reasons. The first is demographics. The proportion of the US population over 65 is expected to rise by 50 percent between 2010 and 2030, and the proportion of those under 65 will necessarily shrink. An even higher percentage of Americans will therefore shift from private insurance to Medicare, which prompts dark warnings from those who oppose any growth of government. For defenders of Medicare, the fact that the country will have more seniors to cover simply requires increases in Medicare’s revenues and expenditures balanced by lower expenditures elsewhere for healthcare coverage.

The second reason Medicare’s outlays can be expected to increase is that per-capita costs of medical care in the United States have vastly outpaced inflation. The U.S. spent 7 percent of national income on medical care in 1970; today it spends roughly 18 percent of a much larger national income. Overall medical care inflation, reflected in increasing per person costs, is an indisputable national problem, crowding out all other spending, public or private.

This is where Paul Ryan and vouchers come in. Vouchers are fixed sums of money that can be spent only for a specified, limited purpose. Ryan’s idea is to give Medicare beneficiaries vouchers with which to buy health insurance on the private market. Instead of serving as a direct insurance provider, the federal government would provide each Medicare beneficiary with some fixed dollar amount—say, $10,000 a year—that he or she could use to shop around for different health plans.

Supporters of this idea see several advantages to it. The first is that the federal government would have a limited annual budget instead of an open-ended commitment to pay for as much care as its beneficiaries receive. Medicare’s budget would become a matter of much simpler arithmetic: the average voucher amount, set by Congress, times the number of beneficiaries. The second benefit, supporters say, is that vouchers would help contain medical inflation, because the government wouldn’t write blank checks to healthcare providers but instead allocate fixed sums that would cover health-insurance premiums paid to private insurers. The resulting competition among insurers would not only restrain healthcare inflation but also, thanks to lower federal outlays, help to reduce the federal deficit.

To see how Ryan’s plan might look in an ideal world, imagine Fred, age 70, who has $10,000 with which to purchase health insurance. He can choose a plan from Aetna or Kaiser or Cigna, each plan with different benefits and limits. His choices would, in short, be much like those most people under 65 have today. While healthcare costs would be substantially covered, there would be no blank check. All of Medicare’s beneficiaries—people like Fred—would be active consumers, using their vouchers to select the firms that respond to their demands. Because insurance firms would compete for customers on price and quality, the rate of medical inflation would go down.

But that’s in an ideal world. For all the superficial attractiveness of medical vouchers, they come with many problems. For one thing, Fred might be in poor health. Maybe he has diabetes and prostate cancer, and he needs extensive medical attention. No insurance firm in the free market would want to cover Fred, when it could instead take on Bill, age 66, fit and healthy and still playing tennis. To prevent such discrimination, insurers would have to be subject to regulations that would set minimum standards for care and ban discrimination against unhealthy customers. Or else Medicare would have to adjust the voucher sum to the risks of different patients, a task that would be hugely costly and administratively complex. Another problem is that if medical inflation were to increase faster than the value of the voucher in the years to come, Joe’s voucher would buy less and less health coverage and his out-of-pocket costs would increase.

If vouchers would provide enough money to purchase basic Medicare coverage for everyone, there would be nothing objectionable to them in principle. Indeed, beneficiaries enrolled in Medicare Part C, the Medicare Advantage program, already enjoy an analogous arrangement, with Medicare sending payment directly to the beneficiary’s insurance provider. But the history of Part C doesn’t offer much encouragement when it comes to cost savings. Average expenses for those in the Medicare Advantage program have been 10 to 15 percent higher than those for comparable seniors in traditional Medicare. Competition for customers seems to have inflated rather than reduced costs.

Supporters of vouchers also point out that some European countries employ a voucher system, notably Holland (since 2006) and Switzerland (since 1996). Both countries introduced universal health insurance mandates under the banner of “managed competition,” and Dutch and Swiss citizens could use the equivalent of a voucher to select insurance plans. However, while the control of medical inflation was the announced goal, the experiment did not work out that way. Medical inflation increased in both countries.

In sum, the voucher system, as closer examination reveals, would not control medical inflation, simplify administrative complexity, or secure uninterrupted and stable economic protection. That raises the question of why it has become so central to reform efforts by Paul Ryan and his allies. I suspect that the dispute is fundamentally philosophical rather than actuarial. If your view of the proper role of government is far more limited than that of Roosevelt’s New Deal, Truman’s Fair Deal, or Johnson’s Great Society, then you look wherever possible to cede leadership to the marketplace. In short, we are back to the struggles that divided Franklin Roosevelt from Herbert Hoover; Harry Truman from Thomas Dewey; Lyndon Johnson from Barry Goldwater.

A telling example of the divide emerged last spring with a proposal by Senators Tom Coburn (R-OK) and Joe Lieberman (I-CT) to raise the age of Medicare eligibility from 65 to 67. As the Kaiser Foundation pointed out, that would trim expected annual federal expenses by $7 billion per year, but it would also increase total actual annual outlays for those over 65 by $10 billion dollars. In short, the “reform” just shifts costs to the elderly and their private insurance and does nothing to stem medical inflation.

A more defensible proposal for reforming Medicare would begin by reasserting its fundamental social insurance aims: protecting elderly Americans and their families from the costs of medical care, financing healthcare from reliable sources, and providing a common benefit that treats seniors with similar ailments similarly. The pressure of an increased number of senior citizens means that more of our collective funding must be spent on their coverage, but this need not be a crisis. Between 1980 and 2000, the countries of northern Europe—Norway, Sweden, Germany—experienced an increase in their elderly populations comparable to what the United States will face between 2010 and 2030. None of these nations had to transform their national health systems to cope with the demographic changes. What all of them did have to do was hold their medical care systems to a budget, with annual negotiations to adjust agreements and keep healthcare affordable. That’s simple to say and hard to do. But the sooner we start doing it, the better.

Ted Marmor is professor emeritus of politics and public policy at Yale. His most recent book, with Rudolf Klein, is Politics, Health and Health Care.

*Photo courtesy of Gage Skidmore.

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Doctors Really Do Die Differentlyhttp://www.zocalopublicsquare.org/2012/07/23/doctors-really-do-die-differently/ideas/nexus/ http://www.zocalopublicsquare.org/2012/07/23/doctors-really-do-die-differently/ideas/nexus/#comments Tue, 24 Jul 2012 03:27:13 +0000 by Ken Murray http://zocalopublicsquare.org/thepublicsquare/?p=34185 In late 2011, I wrote an essay for Zócalo called “How Doctors Die.” Drawing on my observations and experiences as a doctor, I reported that doctors tend to seek less end-of-life care than ordinary patients do. They know when further treatment is likely to be futile and when life would cease to be worth living. The point I wanted to make was that all of us should have the choice to die that way if we wish–at home, with family, without dramatic hospital interventions, without pain.

The response to this simple idea was overwhelming. I read thousands of comments people posted online regarding the end-of-life care of loved ones. They told of near-dead relatives being assaulted with toxic drugs and painful procedures for no good reason. I am haunted by one description of a patient who could neither talk nor move, begging with her eyes for it all to stop.

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In late 2011, I wrote an essay for Zócalo called “How Doctors Die.” Drawing on my observations and experiences as a doctor, I reported that doctors tend to seek less end-of-life care than ordinary patients do. They know when further treatment is likely to be futile and when life would cease to be worth living. The point I wanted to make was that all of us should have the choice to die that way if we wish–at home, with family, without dramatic hospital interventions, without pain.

The response to this simple idea was overwhelming. I read thousands of comments people posted online regarding the end-of-life care of loved ones. They told of near-dead relatives being assaulted with toxic drugs and painful procedures for no good reason. I am haunted by one description of a patient who could neither talk nor move, begging with her eyes for it all to stop. Thankfully, such stories are slowly becoming less common, and, with an advance directive or POLST, you have considerably better chances of having a peaceful death, if that is what you want.

While the article rarely provoked hostility, it did, among some readers, prompt skepticism. I’d written the article in a personal, anecdotal style, so I rarely made use of numbers, studies, or charts. For example, Ezra Klein, writing in The Washington Post, wanted to see more evidence for my assertions. “Does anyone know of data on end-of-life spending for doctors?” he asked. “Or even on the percentage of medical professionals who have signed living wills?”

This essay is an attempt to address such questions. Perhaps it should be viewed as a set of endnotes to “How Doctors Die.” For every assertion of mine that was based on observation, I’ve looked for relevant scholarly evidence that might support or refute it. Here is what I found:

First, and most important, is the question of whether doctors, for the most part, die differently. One of the clearest indicators we have is a survey from Johns Hopkins University. It’s called the Johns Hopkins Precursors Study, and it’s based on the medical histories and decisions of students from the School of Medicine classes of 1948 through 1964 who volunteered to be part of the survey. According to the study, 65 percent of the doctors (or former medical students) had created an advance directive, i.e. a set of legal documents spelling out in advance what sort of end-of-life care they would like. Only about 20 percent of the public does this. When asked whether they would want cardiopulmonary resuscitation, or CPR, if they were in a chronic coma, about 90 percent of the Johns Hopkins doctors said no. Only about 25 percent of the public gives the same answer.

I also asserted in “How Doctors Die” that CPR is rarely as effective as people seem to think. What people have seen on television is at odds with happens in real life. A 1996 study published in The New England Journal of Medicine found that CPR as portrayed on television was successful in 75 percent of 60 cases and that 65 percent of the patients went home. In contrast, in a 2010 study of more than 95,000 cases of CPR in Japan, health professor Hideo Yasunaga and fellow researchers found that only 8 percent of patients survived for more than one month. Of these, only about 3 percent could lead a mostly normal life. A little more than 3 percent were in a vegetative state, and about 2 percent were alive but had a “poor” outcome.

My sense that there’s a yearning among ordinary patients to have more peaceful deaths has been echoed in the research of University of Wisconsin-Madison nursing professor Karen Kehl. In an article called “Moving Toward Peace: An Analysis of the Concept of a Good Death,” Kehl analyzed a collection of relevant articles and, based on their contents, ranked the attributes of an ideal death as follows: being in control, being comfortable, having a sense of closure, having one’s values affirmed, trusting in care providers, and recognizing impending death. Hospitals cannot help with most of these things. Unfortunately, most patients do not see their wishes fulfilled. A 1998 study published in the Journal of the American Geriatrics Society looked at Medicare patients and found that, while most said they preferred to die at home, most died in hospitals.

I discussed the tense, and often tragic, circumstances that surround many of the treatment decisions made in hospitals. Often, I noted, family members or medical staff effectively override the wishes of a dying patient. The studies I’ve found on this suggest that family plays a particularly big role in taking things in an unintended direction, especially when there’s nothing in writing. A 2003 study published in the Journal of Clinical Oncology found that most patients and families agree in theory that patients should make their own end-of-life decisions, but in practice about half of families override the stated preferences of patients. They have disagreements about the use of life-sustaining measures, and they lack written documents to resolve the matter. In contrast, a 2010 study in The New England Journal of Medicine found that people with advance directives usually receive the care they’ve chosen.

Every doctor has heard stories about people who have had miraculous recoveries, despite a doctor’s prediction. (Such stories are one reason doctors hate to make predictions.) But the sort of cases I’ve written about are those where all treatment has failed and the patient faces death soon. When applied to a patient in the last stages of a terminal decline, CPR is particularly ineffective. A 2010 study published in the journal Supportive Care In Cancer looked at terminal patients who wanted no CPR but got it anyway. Of the 69 patients studied, eight regained a pulse, but, 48 hours later, all were dead. Well-meaning CPR advocates talk in terms of “survival,” but all the term means is that the heart again beats on its own. In the above example, survival was 11 percent, but “survival” as often understood by the public–regaining a reasonable quality of life–was zero.

We don’t like to think about death. But that avoidance is one reason so many Americans fail to arrange an advance directive, even when they are severely ill. When patients of mine would come to my office accompanied by a family member, I often asked the patient how he or she wanted to die. I didn’t do it because the patient was on the brink of death, or even sick. I did it because I wanted the patient to think about the question and also to make sure that a loved one got to hear the answer. Unwanted futile measures, prolonged deaths, and hospital deaths remain commonplace in America and many other places. But they don’t have to be. It just requires our doctors and, no less, the rest of us to come to terms with the inevitable.

Ken Murray, MD, is Clinical Assistant Professor of Family Medicine at USC. He appeared in a Zócalo event, “How Doctors Die,” on July 30.

*Photo courtesy of Ephemeral Scraps.

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Why Does the Doc Keep Calling?http://www.zocalopublicsquare.org/2012/06/19/why-does-the-doc-keep-calling/ideas/nexus/ http://www.zocalopublicsquare.org/2012/06/19/why-does-the-doc-keep-calling/ideas/nexus/#respond Wed, 20 Jun 2012 06:01:08 +0000 by Heather Boerner http://zocalopublicsquare.org/thepublicsquare/?p=33361 You’ve got diabetes. Maybe also a little asthma. You’ve got a few extra pounds you know you should lose. You gave up smoking. You’re of a certain age. That is, you’re over 65.

And maybe, in the last few months, you’ve started getting calls from your doctor’s office, following up on your last appointment, making sure you’re taking your medication, checking on your mood.

Welcome to the world of ACOs (short for accountable care organizations), the latest attempt to save our healthcare system and our economy. How you respond to these calls–whether you end up spending less money on care, whether you avoid extra trips to the hospital, whether your chronic health conditions stabilize and improve–may determine whether ACOs become part of a bona fide solution–or whether they’re just another also-ran in the scrap heap of healthcare reform ideas.

“Our healthcare system is sort of like a big rig going

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You’ve got diabetes. Maybe also a little asthma. You’ve got a few extra pounds you know you should lose. You gave up smoking. You’re of a certain age. That is, you’re over 65.

And maybe, in the last few months, you’ve started getting calls from your doctor’s office, following up on your last appointment, making sure you’re taking your medication, checking on your mood.

Welcome to the world of ACOs (short for accountable care organizations), the latest attempt to save our healthcare system and our economy. How you respond to these calls–whether you end up spending less money on care, whether you avoid extra trips to the hospital, whether your chronic health conditions stabilize and improve–may determine whether ACOs become part of a bona fide solution–or whether they’re just another also-ran in the scrap heap of healthcare reform ideas.

“Our healthcare system is sort of like a big rig going downhill with failing brakes,” says Gerald Kominski, director of the UCLA Center for Health Policy Research. In the ’80s and ’90s, everyone from the Center for Medicare and Medicaid Services (CMS) to healthcare economists to academics thought managed care was going to be the brake on the system. “We wore out the last pair of brakes” with HMOs. “And we don’t know if this new braking system is going to be more effective or not.”

The new braking system, the ACO, was created in 2011 by CMS. An ACO is a formal network of independent doctors, specialists, and hospitals who agree to care for a group of patients for a lump sum.

This is a major departure from how traditional Medicare works. Today, non-ACO doctors are paid on a fee-for-service model that rewards more tests, more screenings, more surgeries, and more treatment, all without proof that they are improving the lives or prognoses of their patients.

“Doctors who do interventions make more money, and doctors who talk to patients get far less money,” Dr. Otis Brawley, chief scientific officer of the American Cancer Society, told a group of healthcare journalists in April. His book, How We Do Harm, delineates the blame, which he spreads out among everyone in the healthcare system, including patients who insist on getting every treatment or test regardless of whether it’s appropriate. “The incentive is for doctors to get patients in and out and not talk to them.” The result: healthcare spending accounts for nearly 18 percent of the U.S. gross domestic product–nearly $8,000 per patient, the most per capita in the world.

The question is whether ACOs can change all that.

Under the ACO model, healthcare providers will be expected to meet both quality and cost targets. They have incentive to do so. If they meet the quality targets, they are eligible for a share of any savings they achieve. The theory is that, in order to provide better care for less, these doctors will shift how they practice, working together with hospitals and patients. Doctors will emphasize preventative care. They will follow up more frequently with patients with more than one chronic condition to make sure patients adhere to their treatments, thereby reducing complications and the need for additional services. They will use electronic medical records to better coordinate between offices and save money. The list goes on.

It’s not yet clear how much healthcare consumers–which is to say, just about everybody–will see and feel this. A lot of things are being shuffled behind the scenes to try to provide higher quality care while curbing the stratospheric growth of healthcare spending in the U.S.

So far, at least 1.1 million of the 45 million Americans covered by Medicare are getting care through ACOs, mostly in areas selected for pilots of the new approach. For most of these patients, the shift to ACOs is invisible. If their current doctor joins one, they’re part of one. Since ACOs don’t penalize patients for going outside the ACO network for care, they may never be aware. If the concept works there–that is, if patients and their providers meet various measures of cost and quality–it’s likely to spread to the rest of us in coming years.

This sort of approach isn’t entirely new. It resembles how Kaiser Permanente is organized, says Mark Pauly, Ph.D., a healthcare management professor at the University of Pennsylvania. Kaiser is a closed system of doctors and insurers who work together to manage your care, prevent some screenings and tests, and do procedures when medical literature indicate they will help.

But Pauly is quick to add that doctors often don’t know what tests are necessary in particular cases. In ACOs, “[CMS] will try to get doctors to provide care based on evidence that it is effective,” he says. “But nothing will be perfect and in many cases the evidence doesn’t exist yet.”

Will ACOs work? The approach makes intuitive sense, and some early results are promising. The Michigan Pioneer ACO was able to reduce hospitalizations and their associated costs and medical complications. An ACO-like demonstration called the Physician Group Practice Demonstration showed that all systems improved quality and many achieved savings; the doctors got bonuses as a result.

But there are already doomsayers. Regina E. Herzlinger, a professor of business administration at Harvard Business School, recently declared in the trade journal Managed Care that “ACOs will implode just as … HMOs did in the 1990s,” when HMOs denied care not because it was medically unnecessary but because they didn’t want to cut into their profit margins.

The problem, she and others argue, is implementation. Herzlinger suspects that inefficient electronic medical records, the lack of team culture in healthcare, and the vagaries of setting up state insurance exchanges will frustrate attempts to control costs and boost quality. As Dr. Elliott Fisher of Dartmouth College, who coined the term ACO and helped create the model, only halfway joked recently, “They’re the perfect solution. If only we can get them right.”

Getting them right means there’s a lot of pressure both on patients and on the healthcare industry to stop doing unnecessary tests. Getting it right will mean that healthcare providers will have to get on board with the concept. There are as many as 160 ACOs in the U.S. already, but every month a new article comes out with doctors and medical associations claiming that the model has already failed, that’s it’s unrealistic and too confining to attract enough specialists to reach a critical mass. Getting it right will require that ACOs don’t consolidate to the point of becoming monopolies–and that they won’t use their ability to coordinate care with all their providers to fix prices and actually drive up the cost of healthcare.

Providers will have to resist the urge to give less care for less money. Since providers will get a lump sum per patient, they could try to push off their rolls patients whose complicated cases don’t get better with the innovations offered under ACOs.

And of course, the success of ACOs will depend on us–people who may not know they’re even in an ACO. For this to have a chance of working, we will have to stay in the ACO network, follow doctor advice, stop asking for antibiotics for viral infections, and resist the urge to demand the newest, unproven treatment just reported in the newspaper.

“What we’re talking about is collaborative care–doctors collaborating with one another and patients collaborating with doctors,” says Pauly. “I’m not sure Americans are ready for collaborative care.”

Heather Boerner is a healthcare writer based in San Francisco. Find her at www.heatherboerner.com.

*Photo courtesy of Brewcaster.

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This Is How I Wish To Diehttp://www.zocalopublicsquare.org/2012/06/05/this-is-how-i-wish-to-die/ideas/nexus/ http://www.zocalopublicsquare.org/2012/06/05/this-is-how-i-wish-to-die/ideas/nexus/#respond Wed, 06 Jun 2012 07:00:54 +0000 by Janet Hayes http://zocalopublicsquare.org/thepublicsquare/?p=32881 Dr. Ken Murray’s article about how doctors die generated a lot of comments about the bureaucratic side of end-of-life preparation. Curious to know about a form called the POLST, or Physician Orders for Life-Sustaining Treatment, we contacted a Californian who’s filled one out to explain what was involved. Her account follows.

About a month ago, the last time I had a visit from my home health care nurse, she suggested I fill out a document called the POLST, or Physician Orders for Life-Sustaining Treatment. She gave me the papers to take to my doctor for my next checkup. The document looked familiar. I’ve had surgery several times in the past five years, and I feel as though I’ve filled it out every time I’ve been to the hospital. But POLST is not a standard directive. It’s signed by your doctor, and it’s always in your records, no matter where you’re

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Dr. Ken Murray’s article about how doctors die generated a lot of comments about the bureaucratic side of end-of-life preparation. Curious to know about a form called the POLST, or Physician Orders for Life-Sustaining Treatment, we contacted a Californian who’s filled one out to explain what was involved. Her account follows.

About a month ago, the last time I had a visit from my home health care nurse, she suggested I fill out a document called the POLST, or Physician Orders for Life-Sustaining Treatment. She gave me the papers to take to my doctor for my next checkup. The document looked familiar. I’ve had surgery several times in the past five years, and I feel as though I’ve filled it out every time I’ve been to the hospital. But POLST is not a standard directive. It’s signed by your doctor, and it’s always in your records, no matter where you’re getting treatment.

I know what overtreatment looks like. My husband died of emphysema 25 years ago. He couldn’t breathe or eat anything on his own, and he was hooked up to the machines for several weeks. It was terrible for me and my family to see him like that, and eventually we got him off the machines.

About six months ago, I got surgery for rectal cancer. Afterwards, I was put on chemo for a few months, as a precaution. Soon the doctors took me off because they said chemo isn’t good for patients over 80 years old. I’m 88. I don’t want to be put on feeding tubes or respirators or anything else to prolong life.

Of course, if you have a really bad bout of pneumonia when you’re my age, sometimes life support machines can get used for a day or two and help pull you through. My doctor told me this as he helped me to fill out the POLST. People as old as I am can sometimes recover–maybe not completely, but at least enough to get around again and see their family. But for me it’s not worth suffering greatly for a small possibility of living a little longer. My POLST form now reflects these personal preferences.

I wouldn’t even have done the chemotherapy at all if I had known better–if I had spoken with my own doctor more when I got the cancer. I later learned he thought it was too drastic for me. But when I was diagnosed I didn’t know anybody else to talk to, so I wound up following the course laid out by the oncologist and the surgeon. It wasn’t that people didn’t give me information, but I was just in such a state after the surgery that I couldn’t absorb it all.

Now, things are clearer to me. The chemo would slightly reduce the risk of cancer returning, but considering how sick it was starting to make me feel it just wasn’t worth it for a person my age. I’m just happy that the surgeons removed everything during surgery and that I’m cancer-free right now. They said I probably have a few good years left in me. That’s not so bad for an 88-year-old woman.

I’m not so afraid of death, but like most people I’d prefer to die in my sleep. What I fear most is having a lot of pain or being put through suffering for only a small chance of recovery. My hope is that having filled out a POLST that reflects my wishes on how to be treated will let me live out the rest of my life as I want–and, one day, die as I want, too.

As told to Antal Neville.

*Photo courtesy of Guillaume Brialon.

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