Common knowledge asserts that physicians often do not let patients tell their story prior to interruption. Many physicians apparently feel that patients will just talk forever, and that they (the physician) will not have time to ask their important questions. This research shows that we can let patients have their say. Length of patient's monologue, rate of completion, and relation to other components of the clinical encounter: observational intervention study in primary care

Just go read the article - it is short and makes an important point.

For those who have access to Circulation - this perspective on the effectiveness article that I cited last week hits the mark - We Must Use the Knowledge That We Have to Treat Patients With Acute Coronary Syndromes I will quote a couple of relevant paragraphs.

Audit is an important component of quality improvement, but little is known about the effectiveness of quality improvement and audit programs. A recent pilot initiative by the Guidelines Applied in Practice (GAP) Committee of the American College of Cardiology,14 conducted in 10 acute-care hospitals in Michigan, tested strategies such as dissemination of guidelines, grand round presentations, and use of physician and nurse opinion leaders. Reassessment 3 to 11 months later showed that the usage of aspirin increased from 84% to 92% (P=0.002) in patients with acute MI, and the proportion of patients receiving counseling for smoking cessation increased from 53% to 65% (P=0.02) at discharge. The usage of ß-blockers and ACE inhibitors in "ideal" patients also increased (from 89% to 93% and from 80% to 86%, respectively), but these increases were not significant.

Some recent registries have documented relatively high usage rates of therapies. In the Global Registry of Acute Coronary Events (GRACE),15 92% of patients with ACS were prescribed aspirin at discharge, 77% were prescribed ß-blockers, 56% were prescribed ACE inhibitors, and 47% were prescribed statins. It should be noted, however, that the GRACE investigators were aware that their practice was being audited, and findings from previous audits were reported back to the investigators and compared with findings from other local and international centers.

National data sets from the United States1 show that aspirin usage in patients with coronary disease increased from 18% in 1990 to 38% in 2001, while ß-blocker usage increased from 19% to 40%, and ACE inhibitor use in patients with congestive heart failure increased from 24% to 39%. However, although the usage of these therapies has increased, it remains suboptimal, and the rate of increase in usage has slowed.1 At 1.4 years after an acute coronary event in the European Action on Secondary and Primary Prevention Through Intervention to Reduce Events (EUROASPIRE) study, 21% of patients smoked, 31% were obese, 58% had total cholesterol levels of 192 mg/dL (4.9 mmol/L), and >70% of diabetics had inadequate glucose control (fasting blood sugar 126 mg/dL [7.0 mmol/L]).16 Furthermore, too many patients were not taking aspirin (14%) or ß-blockers (37%).

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Surprisingly little is known as to why doctors do not prescribe evidence-based therapies, but it has been shown that the factors most likely to encourage usage are dissemination of strong evidence, supportive opinion leaders, and integration of clinical practice within an organization that is committed to evidence-based practice.

Institution of the knowledge we already have could reduce mortality after an ACS by perhaps 80%. It is not sufficient to simply add 1 therapy at a time in patients at high risk of future ischemic events. Instead, whenever clinically possible, patients should be started simultaneously on as many as 4 evidence-based therapies while they are still in hospital, combined with nonpharmacological approaches to risk prevention such as smoking cessation, achievement of ideal weight, and graded exercise programs. There should also be insistence on long-term patient and physician commitment to these programs, with periodic testing of biomarkers and reassessment of the target variables for which the various therapies have been prescribed, in association with regular clinical examinations, stress testing, and selected imaging assessments.

Our research group spends much energy trying to understand the best ways to help physicians do this. While it does seem simple to non-phyisician observers, the problem really has great complexity. We can easily write about acute coronary syndrome care, but physicians care for patients with many problems. How can we help physicians keep up with knowledge and practice changes for all the problems that their patients have?

This commentary reemphasizes what our research group knows. Knowledge and efficacy studies are not enough. We must continue to study the problem of translating our knowledge into better practice.

Bush and Kerry, healthcare foes (warning - this link will give you the latest Kondracke column - thus if you are reading this in the future, you will have to search back through his columns to find this particular column).

If you or a loved one suffers from cancer, heart disease, diabetes or another dread disease — or you fear you might contract one — you have a hard choice when you vote for president this year.

President Bush is cutting the budget for medical research that might find a cure for your disease. At the same time, the Democratic frontrunner, Sen. John Kerry, D-Mass., wants to strangle the revenues of the pharmaceutical companies who'd develop a medicine to treat you.

Between the two of them, they're a deadly duo. And Sen. John Edwards, D-N.C., would be little better. He's joining in his party's jihad against drug companies.

The remainder of the article argues that Bush is worse because of the proposed NIH budgets.

Disclaimer: I receive NIH funding and AHRQ funding.

Wow, this is a really tough issue. I am reminded of the famous George Bernard Shaw quote (often attributed to Winston Churchill) - "We've already established what you are, ma'am. Now we're just haggling over the price.". We know that we cannot increase the NIH budget by 100%. Our challenge is to understand how much we should increase that budget.

Supporting the NIH is akin to motherhood and apple pie. One can always stand on the high moral ground when criticizing the President's NIH proposal. The question becomes not the NIH budget per se, but the NIH budget in the greater context of the overall budget.

I would love to see NIH increases and AHRQ increases. Our research group would have better funding odds. Our fellows would more likely have successful research careers. And even more important, our contributions (and the contributions of similar groups around the country) would improve our overall health status.

Read the article and perhaps you can decide (just on this issue) whose approach would benefit the common good. I fear that I cannot tell.

I often rant that each party has good and bad proposals related to health care. This article reinforces my beliefs.

2 Cancer Drugs, No Comparative Data - this title is misleading, because the drugs are really anemia drugs, used both with cancer patients and with Chronic Kidney Disease patients.

Medicare officials sought the study, hoping to see if Aranesp, a drug made by Amgen that costs about $1,300 a vial, is superior to Johnson & Johnson's Procrit, an earlier version of the drug that costs $470 a vial. The federal Medicare program spends more than $1 billion a year on the two drugs, which stimulate the bone marrow to produce red blood cells in patients who have become anemic during treatment for kidney disease or cancer.

We (physicians) have no way to choose between two similar drugs (and these drugs are just variants of each other) unless we have head-to-head comparisons. I have repeatedly ranted on this subject. For physicians to control pharmaceutical costs, we must do the right studies. The study which CMS wants is the right study. Congress should not prevent important medical research.

I hope that we can overcome the pharmaceutical industries meddling so that we can do good comparative studies. Interestingly, the health insurance industry wants these studies. Thus, the Republicans have two major support groups at odds over this provision.

I hope that Congress revisits this issue. Perhaps this article and more like it will help everyone understand the importance of doing this type of research.

Senate Democrats Block Caps for Malpractice

For the second time in less than a year, Senate Democrats on Tuesday blocked a White House-backed effort to impose strict caps on jury awards in medical malpractice cases. But Republicans vowed to bring the issue up again later in the year.

The backers of the measure, which would curb jury awards in medical liability cases against obstetricians and gynecologists, fell 12 votes short of the 60 necessary to have the bill considered by the Senate. The final vote, 48 to 45, fell mostly along party lines; the outcome was a foregone conclusion.

"We're going to keep going until we succeed," said Senator Elizabeth Dole, Republican of North Carolina, at a news conference before the vote. Senator Bill Frist of Tennessee, the majority leader, said after the vote, "I want to keep the issue out there, because I think patients are being hurt."

You know how I feel about this issue. While caps will not solve the malpractice issue, they would help keep obstetricians practicing.

I found this link on theheart.org (which is heavily underwritten by pharmaceutical companies) - The Dawn of McScience. Just one quote to give you the sense of this long polemic.

Even scientific journals, supposedly the neutral arbiters of quality by virtue of their much-vaunted process of critical peer review, are owned by publishers and scientific societies that derive and demand huge earnings from advertising by drug companies and from the sale of commercially valuable content. The pressure on editors to adopt positions that favor these industries is yet another example of the bias that has infiltrated academic exchange. As editor of The Lancet I have attended medical conferences at which I have been urged to publish more favorable views of the pharmaceutical industry. For Krimsky, "the idea that public risk (that is, publicly supported research) should be turned into private wealth is a perversion of the capitalist ethic." The Pope would probably agree.

Certainly this quote does not do justice to this long piece. If the subject interests you, I recommend reading and considering the problem of the pharmaceutical industry its influence on academe.

I have a hobby - I listen to books and courses as I drive. Currently I am listening to a college course on existentialism - No Excuses: Existentialism and the Meaning of Life . Several comments follow from this.

First, if you are interested in lifelong learning about various topics, you should explore the Teaching Company. Second, as I listen to this course, I am finding much in existentialism that reflects my own personal philosophy.

This interesting web page - Existentialism: A Primer - has this interesting quote as the author discusses existentialism.

Despite encompassing a staggering range of philosophical, religious, and political ideologies, the underlying concepts of existentialism are simple:

• Mankind has free will.
• Life is a series of choices, creating stress.
• Few decisions are without any negative consequences.
• Some things are irrational or absurd, without explanation.
• If one makes a decision, he or she must follow through.

Existentialism, broadly defined, is a set of philosophical systems concerned with free will, choice, and personal responsibility. Because we make choices based on our experiences, beliefs, and biases, those choices are unique to us — and made without an objective form of truth. There are no “universal” guidelines for most decisions, existentialists believe. Instead, even trusting science is often a “leap of faith.”

While this philosophy (at least this abridgement) does not describe the philosophical underpinnings of this blog completely, it does come close. I particular respond to the free will, choice and personal responsibility concept. Since I will be listening to these tapes for the next few weeks, you may see several more rants on existentialism. I believe that philosophy has great relevance to medicine and the politics of health care. Having strong philosophic underpinnings allows one to develop a more consistent decision making process. As I learn more about existentialism, I will try to share my thoughts on this subject.

On a light note, you might find this excerpt from one of Woody Allen's early movies thought provoking (or even funny) - Existentialism

WOODY ALLEN: That's quite a lovely Jackson Pollock, isn't it?

GIRL IN MUSEUM: Yes it is.

WOODY ALLEN: What does it say to you?

GIRL IN MUSEUM: It restates the negativeness of the universe, the hideous lonely emptiness of existence, nothingness, the predicament of man forced to live in a barren, godless eternity, like a tiny flame flickering in an immense void, with nothing but waste, horror, and degradation, forming a useless bleak straightjacket in a black absurd cosmos.

WOODY ALLEN: What are you doing Saturday night?

GIRL IN MUSEUM: Committing suicide.

WOODY ALLEN: What about Friday night?

GIRL IN MUSEUM: [leaves silently]

"Play It Again, Sam", Paramount Pictures, 1972

For long time readers, this essay reflects issues that we have discussed several times. For new readers, read this NY Times piece, and then read my former rant on this topic.

When Your Doctor Goes to the Beach, You May Get Burned

Gifts

I will reiterate my position on pharmaceutical gifts. I accept anything that costs less than $10, e.g., lunch at noon conference, a pen (although I generally discard it after clinic), a pad of paper. I go to NO pharmaceutical company sponsored events - talks, golfing, consultations. I did some of these activities many years ago - then as I learned about influence, I understood that I was not immune from drug company manipulations. Thus, I had to distance myself.

From the NY Times piece:

Relatively few researchers have investigated the question of exactly what that something big is. Among other considerations, it is one of the few research topics in medicine that will not attract drug company financing.

A handful of studies have looked at the common practice of giving doctors free drug samples and have shown that it unquestionably induces them to prescribe drugs they would otherwise avoid. The other gifts also appear to bring a nice return. In one clever 1992 study published in the journal Chest, Cleveland researchers surreptitiously tracked doctors' use of two drugs before and after all-expense paid educational jaunts to sunny resorts. They found that drug prescriptions more than tripled, an effect that persisted for more than a year, while the use of equivalent drugs remained stable.

It is all quite deplorable, my friend says. He used to add routinely that none of this data was applicable to him, but a recent series of events may have changed his mind.

For those who want to understand why drug company gifts work please read Cialdini's work starting with this web site devoted to the psychology of influence - Influence at Work. If you are intrigued I highly recommend his book - Influence: The Science of Persuasion.

Many critics assert that we (the medical profession) should work harder on quality. This concept now carries great political weight. Here is what several critics say - The quality challenge: How best to raise the bar for medical care

Dr. Schoenbaum suggested establishing a new federal agency with the sole purpose of overseeing health care quality improvement. The same recommendation was made by a presidential advisory commission in 1988, but neither the Clinton nor Bush administrations have pursued it. That commission also recommended the creation of the National Quality Forum to promote the use of standardized quality measures and public reporting of results. The forum began collecting and endorsing those measures in 2000, but it relies on health care practitioners to voluntarily adopt their use.

NQF President and CEO Kenneth Kizer, MD, said there needs to be at least a point of focus within the federal government to help coordinate efforts. "If we're going to see the improvements in patient safety and health care quality overall that have been so well defined by the Institute of Medicine in recent years, then the U.S. government has to play a central and an active role in that regard," Dr. Kizer said.

The NQF could expand its role, if asked by the federal government, to include such activities as endorsing national quality improvement priorities, establishing a national medical error reporting system, and creating a uniform medical licensure process, he said.

But practicing physicians point out that measuring quality is much more complex than just examining a scorecard -

Doctors also remain skeptical about whether measures provide an accurate picture of their quality of care. Although large group practices might have the patient volume to accurately measure quality, small or solo practices often don't see enough patients for a meaningful assessment.

"The scale of a physician's office, combined with the variety of patients and procedures that are performed, make it virtually impossible to measure quality accurately and fairly in a physician office," said Robert Reischauer, PhD, president of the Urban Institute, a Washington, D.C., think tank, and a member of the Medicare Payment Advisory Commission.

But that doesn't mean Medicare and other public programs can't begin to experiment with quality incentives for physicians, Dr. Reischauer said.

"I don't think we have to wait in the sense that we can apply qualitative measures and reward those with high quality," he said. "And those who choose to organize their practices as solo practitioners will just be out of that income stream."

Measuring quality in physician offices remains beyond the government's reach for now, said Tom Scully, former administrator for the Centers for Medicare & Medicaid Services.

"It's just too complicated. You've got how many hundreds of thousands of physicians, and appropriately measuring them is years off," he said. "My view is they all work in institutions, and what you're really trying to do is not necessarily rate the individual physicians, you're trying to drive change. If you can rate the institutions, it drives that."

So we have tension. Should we measure and score quality? Should we ignore this movement because we believe it too philosophically difficulty to find good measures of quality?

I sit on the side of starting to measure quality - as long as the quality measures predict outcomes. One would have a difficult time arguing that the quality measures used in this study (that I ranted about last week) were unimportant - Proper care of Acute Coronary Syndrome - effectiveness data.

With this (and other studies) as landmarks, I believe that we can develop measurable quality indicators which lead to observably better outcomes. As long as we stick to that standard, then I favor the quality movement.

This article does not explicitly address medical issues. However, I believe it does a nice job emphasizing the costs of any benefit. One can take these principles and apply them to malpractice suits, drug benefits, marijuana laws, and many other issues that we address regularly. Goodies cost us

There are no two ways about it: There are benefits from all the costly federal, state and local regulations imposed on American businesses. But we must also acknowledge our federal, state and local regulatory agencies have no jurisdiction in India, China, Southeast Asia and Latin America. That means for many products and services, people who are far less productive than we, in a physical sense, can beat us in the global marketplace.

We all can agree there's no benefit that's worth any cost. If that weren't true, we'd do nearly anything that has a benefit, and that would include mandating a 5-mile-per-hour speed limit. Why? The benefits would be enormous in terms of the tens of thousands of highway fatalities and injuries avoided. We don't have a 5-mile-per-hour speed limit because we have decided its benefit is not worth the enormous cost.

No free lunch. Someone has to pay.