Tuesday, August 28, 2012

Advertising Credentials --But Not Results!

Here's an advertisement appearing in todays N.Y. Times Science Section (Aug 28, p. D2):

        Vascular and Endovascular Neurosurgery at NSPC
Featuring Renowned Experts

Dr. X

Dr. X is a Massachusetts General Hospital trained neurosurgeon who specializes in Cerebrovascular and Endovascular Neurosurgery.  He is one of about 100 neurosurgeons nationally trained in both endovascular and microneurosurgical techniques and the first endovascular neurosurgeon on Long Island. Dr. X treats aneurysms, AVMs, carotid stenosis, and strokes.  He has authored recent leading articles on cerebral aneurysms and stroke in The New England Journal of Medicine and Lancet Neurology.

Very impressive credentials indeed!

But what have we learned about Dr. X's results?  Nothing.   Before scheduling procedures with Dr. X, who, on paper, seems very accomplished, be sure to ask about his surgical volume and his results.  It's one thing to learn a technique, to research a technique, to author articles about a new technique - but quite another to actually be a truly proficient practitioner of the technique.

Monday, August 27, 2012

The Academy of Pediatrics "Re-evaluates" Circumcision

Systematic evaluation of English-language peer-reviewed literature from 1995 through 2010 indicates that preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure. Benefits include significant reductions in the risk of urinary tract infection in the first year of life and, subsequently, in the risk of heterosexual acquisition of HIV and the transmission of other sexually transmitted infections.

The procedure is well tolerated when performed by trained professionals under sterile conditions with appropriate pain management. Complications are infrequent; most are minor, and severe complications are rare. Male circumcision performed during the newborn period has considerably lower complication rates than when performed later in life.

Although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns. It is important that clinicians routinely inform parents of the health benefits and risks of male newborn circumcision in an unbiased and accurate manner.
Parents ultimately should decide whether circumcision is in the best interests of their male child.

Today's (August 27, 2012) New York Times includes the article "Benefits of Circumcision Are Said to Outweigh Risks" (Roni Caryn Rabin, page A3).  Above is the actual policy statement released by the American Academy of Pediatrics.

Let me begin with some "full disclosure."  I am Jewish, I am circumcised, my stepson and grandsons have undergone ritual circumcisions as have all male members of my family.  I, however, have had some ethical questions about this procedure - a procedure that is carried out on male infants only for ritual or "cosmetic" reasons.  I wonder how many of us who approve of ritual circumcisions would support the procedure if there were no religious issue.  How many physicians would consent to performing a circumcision if the reason were purely for "cosmetic" reasons?  How many of us would support infant circumcision under such circumstances?

If we support ritual circumcision for males, then it is incongruous not to support ritual female circumcision  Yet we regard this procedure as a form of genital mutilation.  Why?  Because it is generally carried out under non-sterile conditions in backward areas of developing societies, and performed without the girl's consent. Would we change our minds and support some innocuous form of female circumcision, carried out under sterile conditions, if such a procedure were implemented?

It is also extremely important that the Academy's statement be analyzed very carefully before using health as a "reason" or "excuse" for male circumcision.  Note the highlighted paragraph above.  Though the benefits outweigh the risks, they are "not great enough to recommend routine circumcision....."

Now let's discuss some statistics.  Let us assume that there are 500 infant males who are circumcised by the same person using the same technique; then compare them with 500 perfectly matched infant males who are not circumcised.  In the first group 1 boy develops a complication.  In the second group none develop complications, but 3 go on to eventually develop AIDS.  So, in fact, three times as many non-circumcised boys v. circumcised boys went on to have issues.  But.....we are still talking about an extremely low number of problems, whether circumcised or not circumcised.  Remember - of the first group of 500, 499 did well, and of the second 500, 497 did well!  In such a statistical situation, the health benefits are minimal.  And remember that AIDS is a preventable disease - and that  AIDS "prevented by male circumcision" is only the heterosexually transmitted (mostly African) form and not the homosexually (mostly American) transmitted form!

From an entirely "neutral" point of view - a person completely unaware of ritual tradition would most likely regard circumcision as a rather barbaric procedure - the painful removal of the male foreskin for no clear indication.  If a parent, for no reason other than "I want him/her to have it," insisted that a small permanent tattoo be inserted in the skin of her infant, I doubt that many of us would support her wish.

It is very important that those supporting ritual circumcision realize that the only clear reason is traditional.  One cannot rationalize one's choice by importing "health" in this decision process.  This argument (especially in a country like the United States) fails completely.

Monday, August 20, 2012

Nurse Practitioners as Diagnosticians

The New York Times Magazine of August 19, 2012 includes a problem in medial diagnosis - "The Telltale Heart".  The medical issue at hand concerned a 31-year-old woman with an interesting and esoteric diagnostic dilemma, which after appropriate evaluation turned out to be an unusual complication of Lyme Disease.  But that is not the only compelling fact here.  This case was first posted on August 9, 2012 an the first person to correctly identify the medical problem was a cardiologist from Vermont, who, according to the Times, "credited two nurse practitioners in his office with helping him solve the case."

In my Blog entitled "Medical Care - Payment and Practice (May 30, 2011) I opined as follows:

License nurse practitioners and other similarly trained medical personnel (e.g. physician-assistants) to practice medicine - independently and without supervision by a physician.
There are 158,348 licensed nurse-practitioners in the United States (American College of Nurse Practitioners, 2008). Just imagine the increase in the availability of medical practitioners if even 50% of them would open family practices, supplementing the present number of family practitioners (95,075 in 2009, according to the American Association of Family Practitioners). Nurse practitioners (see Blog July 16, 2008) are perfectly capable of handling the vast majority of medical issues (I would guesstimate some 95%) for which patients visit physicians.

And so we have further evidence of the knowledge and diagnostic capability of non-physician medical personnel.

Wednesday, August 15, 2012

Applying "The Cheesecake Factory" to Medical Care

The colloquy as to how to resolve issues regarding medical care in the United States continues.   A recent article by the talented writer Dr. Atul Gawande in the most recent issue of The New Yorker tries to draw a comparison between how well the Cheesecake Factory manages its bottom line with how poorly medical care is managed in comparison.  He is absolutely right!  But why is he right?

Doctors, for better or for worse, are not like the franchise-holders of the Cheesecake Factory.  They are not required to follow a particular "reproducible, appealing, and affordable" recipe.  Not only are we not required to,  we also have no commitment, financially or otherwise, to do so.  But, in certain respects, maybe we should.

All reputable specialty organizations (e.g. American College of Cardiology, American Society of Gastroenterology, American Cancer Society) issue guidelines based on a thorough analysis of data from multiple studies pertaining to the clinical problem at hand. These studies are all listed for the practitioner to review should he so wish.  Guidelines are then published for the management of issues such as, i.e. when to prescribe cholesterol-lowering drugs, when to order mammograms, who should get a stress test, etc.  These publications further provide the practicing physician with an evaluation of the "level of certainty" for each of the proposed recommended guidelines, based on these extensive reviews.

Of course no physician is required to follow these recommendations.  But maybe he should.  We physicians, like everyone else, are prisoners of our experience.  We anecdotally remember our successes and failures and often, inappropriately, rely on this thoroughly unscientific data.  I, for example, clearly remember recommending open-heart surgery for a patient who did not survive the procedure, and allowing future diagnostic decisions to be influenced by this exceedingly rare outcome.

I strongly believe that these guidelines should be followed - they are shown to be "reproducible, appealing, and affordable recipes (as per the Cheesecake Factory.)"  Medicare, and insurance companies are using, and will (and should) continue to use these expert guidelines in decisions regarding coverage.  Physicians recommending steps and procedures outside the published guidelines will have to persuade the payers to cover them, and will be asked to provide thorough data to support their views.

If a physician recommends a procedure or diagnostic test not considered indicated by published guidelines, he should, of course be permitted to do so.  But an insurance carrier or Medicare (in other words, we the public) should not be obligated to cover the cost.  The patient, should he wish to proceed, must also assume full financial responsibility.   (Perhaps there could be a separate insurance market for such instances!)

Following guidelines a la Cheesecake Factory can make sense and can help bring down the upward- spiraling medical expenditures.

Wednesday, August 1, 2012

The Truth Shall Make You Lose Elections

"You know, it's hard to know just how well it will turn out. There are a few things that were disconcerting, the stories about the private security firm not having enough people, supposed strike of the immigration and customs officials, that obviously is not something which is encouraging. Because there are three parts that makes Games successful.  Number one, of course, are the athletes. That's what overwhelmingly the Games are about. Number two are the volunteers. And they'll have great volunteers here. But number three are the people of the country. Do they come together and celebrate the Olympic moment? And that's something which we only find out once the Games actually begin.”
 "And as I come here and I look out over this city and consider the accomplishments of the people of this nation, I recognize the power of at least culture and a few other things."

So said Mitt Romney on his visits to London and Jerusalem.  Boy, did he make headlines.  But the statements made front page news not because what he said was essentially correct, but because it was essentially politically incorrect.

Both statements, if not completely factual, are, at least, replete with reality.  Lets get real - the Brits were worried about strikes of customs officials and there were stories about insufficient security possibilities.  Threatened labor issues  deliberately timed to the Olympic Games are hardly a manifestation of "people coming together.....to celebrate the Olympic moment."   By the way, have you noted the empty seats that now have to be re-sold to be filled.

There certainly is a cultural difference between Arab states (including the Palestinian Authority) and Israel.  Is there really a dispute here?  If economic success is the issue under discussion, Israel wins in "straight sets. "  A culture  dedicated to freedom, cultural exchange, governmental openness and debate, and success in research and development for its population and the world is one that will (and has) resulted in economic success.  Can one really say that the economic "culture" of Arab states is dedicated to  similar outcomes?  Has any Arab state reached the economic success and international reputation in science and industry that Israel has?  

Yes, Gov. Romney seems to know how to be direct.  He has to learn to be more indirect - in other words, more politically correct."  That's the way to win elections!