Posted on | June 11, 2013 | No Comments
This week the Obama administration gave the green light to unrestricted availability and sales of the morning-after contraceptive pill, Plan B. In the recent past U.S. District Judge Edward R. Korman had called the administration’s age restrictions “politically motivated” and “scientifically unjustified”. Without signaling a change in their opinion, the administration declined to continue its court case.(1) This is the latest brush up on a issue that is complex, contentious, but critical in the nation’s push to decrease the numbers of abortions. What is missing often in the heat of this debate is context and facts. Let’s have a look.
Support for birth control in America is close to universal, and now extends in emergencies, for up to 72 hours after unprotected pregnancy, to individuals in the US without parental permission and without a prescription.(2)
The use of Plan B and other forms of emergency contraception has steadily risen over the past six years. Approximately one-half of all US pregnancies are unintended (3,4). Plan B’s emergency contraceptive pill was first approved in 1998. Today four major brands are available over the counter for women aged 17 and over (5).
Usage reports recently released by the CDC contained a few surprises. But before we get to them, a few words on Plan B science.
Plan B is the distinctively neutral name applied to a product produced originally by Barr Laboratories as an emergency contraceptive. The product is the hormone Levonorgestrel. Its effect, when taken as a .75mg dose as soon as possible after unprotected intercourse, failed contraception or rape, and followed 12 hours later by a second dose, is to prevent implantation of a fertilized egg, thus avoiding unwanted pregnancies, and potentially decreasing the number of future abortions.(3)
Today, Plan B One-Step is available in a single dose form. Time is of the essence. If a woman initiates treatment within 24 hours of intercourse, the failure rate is .4 percent. But if it’s initiated between 48 and 72 hours after intercourse, the failure rate increases almost 7 times to 2.7 percent.(4)
Twenty-four hours was never much time to manage this process. The first step was knowing that Plan B existed. The second step was to obtain a prescription from a doctor. Next, you had to find a pharmacy that stocked Plan B (some didn’t and still don’t). And finally, you had to take the two pills as prescribed.
Since then, emergency contraceptives have been broadly publicized, gone over the counter and been made available without parental consent (where available) for those 17 and older. The safety track record has held up well. But controversy has always been a part of its history.
In 2003, the FDA leadership was challenged with the Plan B request to go OTC. It later rejected the recommendations of its own Advisory Committee and senior staff to approve this more accessible approach. As Dr. Susan Wood, former director of the FDA’s Office of Women’s Health, who resigned in protest, stated “…recommendations of an Advisory Committee that are strongly supported by the FDA’s review staff have rarely, if ever, been overturned at the highest level of the agency…”(4)
The action of the FDA’s Commissioner, who subsequently resigned, not to allow Plan B to be sold OTC, was viewed by some medical leaders to be at least in part the response to external pressure from social conservatives who believed that Plan B would increase teen promiscuity, teen pregnancy and sexually transmitted diseases. Yet, extensive scientific studies submitted with the original proposal to the FDA had already established this not to be the case. The rejection was clearly not the result of safety concerns. In December 2003, the FDA Advisory Committee of outside experts voted Plan B safe, 28 to 0. They also voted 23 to 4 to make the product available OTC.(4)
Ultimately OTC was approved for those 17 and older. The FDA subsequently moved to expand access to those under 17 in December 2011. However, the Secretary of Health and Human Services overruled the FDA decision.(6) Recently the American Academy of Pediatrics weighed in. They suggested that pediatricians “provide prescriptions/supply for teenagers to have on hand in case of future need (ie advanced provision). No pregnancy test is required before the use of levonorgestrel…Advanced provision increases the likelihood that teenagers will use emergency contraception when needed, reduces the time to use, and does not decrease condom or other contraceptive use.”(7)
Plan B One-Step earned Teva Pharmaceuticals over 90 million in 2011.(8) A recent CDC report of usage(9) contains a few surprises.
• In 2006–2010, among sexually experienced women aged 15–44, roughly one in nine (11% or 5.8 million) women had ever used emergency contraception, up from 4.2% in 2002.
• Most women who had ever used emergency contraception had done so once (59%) or twice (24%).
• Young adult women aged 20–24 were most likely to have ever used emergency contraception; about one in four had done so (23%).
• Almost 1 in 5 never-married women (19%), 1 in 7 cohabiting women (14%), and 1 in 20 currently or formerly married women (5.7%) had ever used emergency contraception.
• About one in two women reported using emergency contraception because of fear of method failure (45%), and about one in two reported use because they had unprotected sex (49%).
• Use of emergency contraception increased with educational attainment—12% of women with a bachelor’s degree or higher and 11% of women with some college education had ever used it. This compares with 7.1% of women who had a high school diploma or GED and 5.5% of women with less than a high school education.
• Non-Hispanic white and Hispanic women were more likely to have ever used emergency contraception (11%) compared with non-Hispanic black women (7.9%).
Next Steps? The FDA has asked the manufacturer of Plan B to submit an application to make the product available over the counter without restrictions. The agency says “Once FDA receives the supplemental application, the FDA intends to approve it promptly.”(1)
For Health Commentary, I’m Mike Magee
1. Dennis B, Kliff F. Obama administration drops fight to keep age restrictions on Plan B sales. Washington Post. June 11, 2013. http://www.washingtonpost.com/national/health-science/obama-administration-drops-fight-to-keep-age-restrictions-on-plan-b-sales/2013/06/10/a296406e-d22a-11e2-a73e-826d299ff459_story.html
2. Grossman CL. New Surveys: Catholics Want Birth Control Coverage. USA Today. February 7, 2012.http://content.usatoday.com/communities/Religion/post/2012/02/contraception-catholic-bishops-obama-hhs/1#.UR0OSjl7SxJ
3. Plan B Web site. “What is Plan B?” Available at: http://www.planbonestep.com/
4. Wood AJJ, Drazen JM, Greene MF. A Sad Day for Science at the FDA. NEJM. 2005;353:1197-1199.http://www.nejm.org/doi/full/10.1056/NEJMp058222
5. Wood SF. Women’s Health and the FDA. NEJM. 2005;353:1650-51.http://www.nejm.org/doi/full/10.1056/NEJMp058225
6. HHS Secretary Sebelius Overrules FDA On Plan B. December 7, 2011.http://feminist.org/news/newsbyte/uswirestory.asp?id=13368
7. American Academy of Pediatrics Policy Statement: Emergeny Contraception. November 26, 2012.http://pediatrics.aappublications.org/content/early/2012/11/21/peds.2012-2962.full.pdf+html
8. Selyukh A. Reuters. Plan B Profits. http://www.reuters.com/article/2011/12/07/us-teva-planb-fda-idUSTRE7B61V120111207
9. Daniels K, Jones J, Abma J. Use of Emergency Contraception Among Women Aged 15-44: United States, 2006-2010.http://www.cdc.gov/nchs/data/databriefs/db112.htm
Posted on | June 7, 2013 | No Comments
On January 1, 2014, as a result of implementation of the Affordable Care Act, the US will experience a major expansion of individuals covered by health insurance. The law includes three key pillars – insurers must provide coverage to all comers regardless of medical history; all citizens must pay in (either through purchase of insurance or penalty payments); and premiums for those with low income will be subsidized.(1)
From a human resource standpoint, the bottom line is that the already existing primary care deficits will be acutely exacerbated. It is this concern that drove the policy journal Health Affairs to update their White Paper on “Nurse Practitioners and Primary Care” several weeks ago, and to publish a study in partnership with the American Association of Medical Colleges (AAMC) on Americans’ support of nurse practitioners as primary care providers.(2,3)
First, some background. Currently 18 states allow nurse practitioners to treat patients without physician oversight. The federal government estimates that 55 million Americans in 5700 different locations currently suffer from limited access to primary care services. Fixing the problem will require 15,000 new practitioners if distributed properly. Attempts to address this need with primary care physicians have not been effective thus far. Training a physician, including schooling and residency requires 11 or 12 years compared to 6 years for a nurse practitioner or physician assistant.(2)
One solution is to allow nurse practitioners and physicians assistants to practice independent of physician oversight. As such, they would be able to establish their own care centers and offices, and would inject a level of competition into the health care system that could increase access, improve service and lower cost. The American Medical Association has steadfastly opposed such actions. As Health Affairs states, the organization “…asserts that encouraging patients to see nurse practitioners rather than primary care physicians may put patients at risk, although the evidence does not support these claims.”(2)
In fact, the Institute of Medicine, after a thorough review of 26 studies published since 2000, found no difference in care outcomes between the two groups, and recommended that state legislatures reform scope-of-practice laws.(4)
But would Americans be willing to see nurse practitioners and physicians assistants? The AAMC/Health Affairs survey says yes. Specifically, the study revealed that while approximately one half of those surveyed preferred to see a physician for care, when presented the choice of waiting 3 days to see a doctor compared to one day for a nurse practitioner, the majority chose the earlier nurse practitioner visit.(3)
As important, medical leaders are beginning to signal openness to new solutions. In the words of Darrell G. Kirch, MD, President and CEO of the AAMC, “As this nation faces a critical doctor shortage—90,000 by the year 2020—we must find ways to be certain patients have access to the care they need…This study shows that Americans are open to that possibility. There is no single solution to this problem. We need to focus on building our capacity to train physicians, while also embracing the roles in which other professionals can serve.”(5)
Health Affairs is even more explicit. Here is what they have to say about the value of allowing nurse practitioners to expand their scope of practice: “ … patients seeing nurse practitioners were also found to have higher levels of satisfaction with their care. Studies found that nurse practitioners do better than physicians on measures related to patient follow up; time spent in consultations; and provision of screening, assessment, and counseling services. The patient-centered nature of nurse practitioner training, which often includes care coordination and sensitivity to the impact on health of social and cultural factors, such as environment and family situation, makes nurse practitioners particularly well prepared for and interested in providing primary care.”(2)
Finally, on the issue of cost, in the 18 states where nurse practitioners are allowed to functiuon independently, they are reimbured at 85% of the physician rates under Medicare law. As for Medicaid, more than half the states pay nurse practioners less than physicians for the same services.(2)
As we approach the January 1, 2014 turning point, with a defined need, and a well documented and well supported cost-effective solution at hand, it makes good sense for the 32 states restricting nurse practitioner and physician assistant scope of practice to rethink their positions. As of one year ago, the National Conference of State Legislatures reported that there were 245 bills under consideration related to scope of practice, with 50 involving nurses.(2)
The movement toward “Medical Home” and “Accountable Care Organizations” fueled by the Affordable Care Act is driving us all toward team-based, personalized and preventive care models. To do so without fully mobilizing the human resources available to us makes little sense any longer.
For Health Commentary. I’m Mike Magee.
1. Accountable Care Act. http://www.healthcare.gov/law/timeline/full.html
2. Nurse Practitioners and Primary Care: Federal and state laws and other policies limit how these health professionals can help meet the growing need for primary care. May 15, 2013. Health Affairs. http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_92.pdf
3. Dill MJ et al. Survey shows consumers open to a greater role of physicians assistants and nurse practitioners. Health Affairs. June, 2013. vol. 32 no. 6, 1135-1142.
4. IOM Study. The Future of Nursing: Leading Change, Advancing Health. October,
5. AAMC Press Release. June 3, 1013. Report Shows Patients Would Consider a Greater Role for Physician Assistants and Nurse Practitioners for Timely Access to Care.
Posted on | May 30, 2013 | No Comments
We are a globe trotting, increasingly mobile human population. And when we are traveling any sort of distance, especially if it involves crossing oceans, most of us travel by commercial airlines. In fact there were 2.75 billion passenger flights booked last year. That translates into nearly 10 billion passenger hours in the air. With those kind of numbers, it is reasonable to ask “What happens if I get sick up there?”
Well, first of all, your chances of having any sort of emergency are statistically slim. A recent retrospective study of 5 major airlines flying domestic and international routes found that there were 16 medical emergencies for every 1 million passengers. Looking at it another way, there was a medical emergency once in every 602 flights in this study. What were the presenting symptoms of these high flying patients? Fainting or feeling faint occurred in 37%, breathing difficulties in 12%, nausea or vomiting 10%, cardiac symptoms 8%, and seizures 6%.(1)
What is the process that guides medical treatment in the air? Here are the five steps along the way.
1. Initial response: All major airlines require the flight crew be trained in basic medical emergencies. Most of those presenting have mild problems managed by the flight attendants without additional help.
2. Volunteer assistance requested: If the attendant believes the condition to be serious, an announcement is made requesting volunteer assistance from doctors or nurses onboard. The Aviation Medical Assistance Act passed in 1998 includes a Good Samaritan provision, protecting passengers who offer medical assistance from liability, except in cases of gross negligence or willful misconduct.(2) In this study, assistance was provided by physicians (48%), nurses (20%), EMS providers (4.4%), or other health care professionals (3.7%).(1)
3. Equipment support: All airlines maintain a medical kit with equipment and drugs to address basic emergencies. Some airlines maintain an enhanced medical kit which allows more serious interventions or procedures in the air. The contents of these kits are as follows:
Basic Medical Kit:
1-inch Alcohol sponges
IV administration set
Manual resuscitation device with 3 masks
Basic instructions on use of the kit
non-narcotic Antihistamine, 50 mg
injectable Antihistamine tablets, 25 mg
Aspirin tablets, 325 mg
Atropine, 0.5 mg
5 cc Bronchodilator, inhaled
Dextrose, 50% / 50 cc
injectable Epinephrine 1:1000, 1 cc
injectable Epinephrine 1:10,000, 2 ml
injectable Lidocaine, 5 ml, 20 mg/ml
injectable Nitroglycerine tablets
Saline solution, 500 cc
Enhanced Medical Kit: (all of the above plus…)
Emergency tracheal catheter
4. Medical Support On The Ground: Many airlines now maintain coverage with expert clinicians on the ground who are contacted in a true medical emergency, and who can help guide and support volunteer health professionals in the air. Some airlines require contact to be made in every case where the medical kit is opened.
5. Diversion of Flight: Under certain circumstances, flight captains can divert the aircraft to protect the life of the passenger. In this study, it occurred in roughly 7% of cases.(1) This low percentage reflects both the non-critical nature of many of the emergencies, and the fact that in many international flights there in no convenient alternate landing location available.
So how did the patients in this study fare? Of the 11,920 in-flight medical emergencies in this study, there were 36 deaths (.3%). 30 of these occurred in-flight. In one third of the total cases, the problem was mild and resolved sufficiently so that patients requested no additional care on landing. Roughly 2/3’s of the patients were met by EMS personnel on landing. 37% of these were taken to the hospital for further testing and evaluation, and 9% admitted for care. The major reasons for admission were stroke, cardiac symptoms and obstetrical or gynecologic emergencies.(1)
In general, obstetrical symptoms in-flight were rare, and supported recommendations that air travel is safe up to the 36th week of gestation.(3) Diversion of aircraft occurred in only three cases of women in labor beyond 24 weeks.
In this study, the overall death rate for airborne medical emergencies was .3%. Most were the result of cardiac arrest and accompanying arrhythmias. In the 920 cardiac cases that did not involve an arrest, there were no deaths. Most were treated with oxygen, aspirin, and nitroglycerin.(1) An Automated External Defibrillator (AED) device was commonly used to assess heart rhythm and for defibrillation when indicated. With cardiac arrest in the air, survival rates can be as low as 16%, but are substantially higher with ventricular fibrillation (up to 55%).
So what can each of us do, since we are unlikely to stop flying any time soon. For passengers, come on the plane full hydrated, stay hydrated during the flight, and get up and move around intermittently to aid circulation. Be certain to bring your medications with you, and a list of serious medical conditions you might have. For potential health professional volunteers, be aware that you might be called upon for help in the air. Reread the list of materials listed above, and consider how you might be asked to utilize these with the assistance of a skilled emergency physician providing support on the ground.
For Health Commentary, I’m Mike Magee.
1. Peterson DC et al. Outcomes of Medical Emergencies on Commercial Airline Flights. NEJM. May 30, 2013. 368:2075-83. http://www.nejm.org/doi/full/10.1056/NEJMoa1212052#
2. Aviation Medical Assistance Act of 1998, Pub. L. 105-170, 112 Stat. 47 (1998).
Posted on | May 24, 2013 | No Comments
In 2003, I was moderating a Q&A session with Craig Venter, the American biologist and entrepreneur of DNA mapping fame. On behalf of the audience, I asked him what percentage of the knowledge required to optimally care for human beings did we currently possess. His unhesitant response? “Less than one percent.” Over the years I’ve wondered a bit whether that was an exaggeration. But this week I became a true believer.
My full conversion came at the hands of Michael Pollan’s New York Times Magazine article titled “Some of My Best Friends Are Bacteria”.(1) I’ve been a fan of Pollan – the citizen scientist, food expert and brilliant investigative environmental and ecological journalist – for a number of years. But now Pollan has decided to not leave food on the table, but instead follow it directly into the human gut. And what he reveals, on behalf of leading edge gastrointestinal researchers is nothing short of revolutionary and mind-altering for medical science.
What’s the big picture? Well to start with, you may think of “you” as you, but “you” are largely “them”. On the average, you carry about 2 pounds of microbes, largely in your intestinal tract. That includes some 100 trillion organisms, with hundreds of varieties, including non-invasive freeloaders, mutually beneficial symbiotics, and occasional harmful pathogens. Only 10% of the genomic material in your body is your own. The other 90% is possessed by these organisms, now termed your “second genome”, or your “microbiota” or “microbiome”.(1, 2)
In 2010, professors at the Center for Ecology and Evolutionary Biology at the University of Oregon published a landmark review article titled, “From Structure to Function: The Ecology of Host-Associated Microbial Communities”. The authors created quite a stir when they said we humans needed to think of ourselves not as individuals but as communities, or in their words, “a collective property of the human-associated microbiota”. (3)
Going one step further, and reflecting on the fact that the average human gastrointestinal tract manages the passage of 50 tons of food in a lifetime, the authors suggested that much of that food goes to feeding the microbiome, a teeming collective life form essential to our survival, and integrated into all of our major homeostatic mechanisms. Further they suggested that feeding the microbiome the wrong types of food led to adjustments in the varied colonies of organisms, which in turn resulted in altered gut permeability and inflammatory reactions, and possibly common pathways to chronic diseases including diabetes, auto-immune diseases, cardiovascular disease, and cancer.(1,3)
It seems that intestinal epithelial cells are an internal type of skin that plays by very different rules. Where most cells receive nourishment through molecules distributed by our extensive vascular system, our colonic epithelial cells feed on short-chain fatty acids derived from intestinal bacteria driven fermentation of plant fiber in the large intestine.(2)
So we’re harboring a hidden world down there, a world that must be fed and treated properly if we are to thrive. But the story does not end there. It seems that evolutionary wise, we’ve outsourced a wide range of functions to this “second genome”, experts believe, because they are capable of managing normal and abnormal physiology better and quicker than our primary genome.(1,2,3)
Understanding the complexities of this huge and hidden wilderness is in its infancy. But what scientists have uncovered in just the last year or two, through the use of new gene sequencing technology to map the microbiome, is pretty startling including:
1. Our microbiome manufactures a variety of substances including the neurotransmitter serotonin, enzymes, vitamins, amino acid and short-chain fatty acids, and signaling molecules that help modulate our immune and the metabolic systems.(2,3)
2. While involving itself in fundamental physiologic feedback cycles, the microbiome is also managing the speed, motility and efficiency of the movement of food through the human gut, and at the same time keeping a close eye on its own needs for food. Each organism has somewhat different needs. So the food we chose helps tip our microbiota in the direction of those microbes who like the diet we’ve selected for them.(1,2,3)
3. It turns out that scientists have been doggedly pursuing fecal samples in young and old here, there, and everywhere. Initially, newborns guts are sterile. Most of the bacteria are inherited from the mother when babies pass through the microbial rich birth canal. Babies born by C-section, lack this natural insemination. Their microbial guts early on resemble mostly the microbe colonies of mother and father’s skin. Babies who are breast fed have a different microbiome than those who are not. By age three, children have a nearly adult microbiome.(1,2)
4. Individuals in less developed nations have a more diverse micobiome which may in part be the reason they exhibit less inflammatory and chronic diseases than those in the developed world. At the same time, this diversity results in higher rates of morbidity and mortality from infectious pathogens.(2,3)
5. Our overuse of antibiotics clearly represents an assault on our microbiomes, and is life altering for the many microbial species we support as part of the “second genome’. But in addition, it likely has significant implications for basic physiologic mechanisms. For example, livestock producers have for many years used feed laced with low dose antibiotics because it is known to speed up growth of animals. Where it used to take 6 years to bring a cow to market, it now takes 18 months.(4,5) Might childhood obesity be similarly favored considering that the average American child ingests 10 to 20 courses of antibiotics before age 18?(1)
6. Where our personal genome is relatively rigid, fixed, and slow to adapt, our “second genome” is far more malleable and open to manipulation.(2,3) For example, individuals critically ill with Clostridia difficile have been successfully treated with fecal transplants donated from normal individuals.(6) If the microbiome can be positively impacted by treatment from below, could the same be true from above? Scientists involved in the field agree the answer is yes. Expect the rapid emergence of “therapeutic foods”.(1) But be aware of a high rate of fraud until regulations catch up. For example, one study of 14 probiotic products revealed that only one of them contained the microbes promised on the label.(7)
7. The American highly processed, additive rich, fast food diet favors upper GI quick feeding at the expense of lower GI slow fermentation. The resultant microbiome may be leading to gut epithelial permeability, inflammatory responses and numerous chronic disease entities.(1,2,3)
Clearly this is just the beginning. But it does point the way toward some actions now, according to the experts. These include:
1. A more cautious approach to the use of antibiotics.
2. A more relaxed sanitary regimen. Super sterile environments result in less microbiome diversity. Greater diversity overall is beneficial.
3. Elimination or serious reduction in processed food that discourages fermentation in the colon. To feed bugs well think Al dente pasta, steel-cut oats, raw or lightly cooked vegetables, home preparation, slow food and slow digestion. As Pollan says, “This is at once a very old and a very new way of thinking about food: it suggests that all calories are not created equal and that the structure of a food and how it is prepared may matter as much as its nutrient composition… With our diet of swiftly absorbed sugars and fats, we’re eating for one and depriving the trillion of the food they like best: complex carbohydrates and fermentable plant fibers.”(1)
For Health Commentary, I‘m Mike Magee
1. Pollan M. “Some of my best friends are bacteria”. NYT Magazine. May 19,2013. http://www.nytimes.com/2013/05/19/magazine/say-hello-to-the-100-trillion-bacteria-that-make-up-your-microbiome.html?pagewanted=all&_r=0
2. Lozupone CA et al. Diversity, stability and resilience of the human gut microbiota. Nature.489:7415, Sept. 13, 2012. http://www.nature.com/nature/journal/v489/n7415/full/nature11550.html
3. Robinson CJ, et al. From Structure to Function: The Ecology of Host-Associated Microbial Communities. Microbiology and Molecular Biology Reviews. 74(3):453-476. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2937523/
4. Gaskins HR et al. Antibioptics as growth promotants: Mode of action. Animal Biotechnology. 13:1,2002. http://www.tandfonline.com/doi/abs/10.1081/ABIO-120005768#.UZ-TEjl7SHU
5. Pollan M. The Omnivore’s Dilemma. The Penquin Press. 2006. http://www.amazon.com/The-Omnivores-Dilemma-Natural-History/dp/1594132054
6. Kelly CP, LaMont JT. Clostridia difficil – More Difficult Than Ever. NEJM. 2008;359:1932-40. http://elearning6.ttuhsc.edu/som/internalmedicine/general/education/must_reads/documents/clostridium_difficile_nejm_oct2008.pdf
7. Marcobal A, Underwood MA, Mills DA. Rapid determination of the bacterial composition of commercial probiotic products by terminal restriction fragment length polymorphism analysis. J. Pediatric Gastrointestinal Nutrition. May, 2008. http://www.ncbi.nlm.nih.gov/pubmed/18493222
Posted on | May 21, 2013 | No Comments
“There were 2.8 million RNs (including advanced practice RNs) and 690,000 LPNs working in the field of nursing or seeking nursing employment in 2008 to 2010. About 445,000 RNs (16 percent) and 166,000 LPNs (24 percent) lived in rural areas. The per capita distribution of RNs varied substantially across states.
The nursing workforce grew substantially in the past decade, with RNs growing by more than 500,000 (24 percent) and LPNs by more than 90,000 (16 percent).
Growth in the nursing workforce outpaced growth in the U.S. population. The number of RNs per 100,000 population (per capita) increased by nearly 14 percent, and the number of LPNs per capita increased by about 6 percent.” Continue….
Posted on | May 15, 2013 | No Comments
This week, the Washington Post published a lengthy piece focused on Medicare Part D, its history, and how it might be improved.(1) The suggestions – ranging from mining data to requiring diagnostic codes on prescriptions – zeroed in on “better prescribing”. What they missed completely was a simpler strategy with arguably greater benefit to health consumers – “less prescribing”.
Let’s step back for a moment and review the last 30 years of the health consumer movement. Gaining steam in and around 1983 as part of the civil rights movement, we have seen health consumers move from emancipation to educational empowerment to responsible direct engagement in their own health decision making. During that same period, the patient-physician relationship has shed much of its paternalism and moved toward partnership models marked by mutual decision making. Finally provision of care is increasingly delivered by a team, rather than by an individual. The teams are more diverse, multi-skilled and both technologically enabled and more mobile.(2)
All that said, further progress will be tied to adjusting biases of both providers and consumers to align with what appears to be an emerging age of “health enlightenment”. The sparks of this movement are largely being driven by two bands of women. The first are young mothers and mothers-to-be who are information and resource focused, and who rely on the Internet and social networking to advise, plan and execute healthy environments that maximize the human potential of their now and future families. The second band are a group of women, age 40 to 70, who are managing frail and disabled parents and grandparents while remaining engaged with children and grandchildren. These family caregivers seek a simpler, more efficient, more effective home-centered delivery system.(3)
In many ways these two bands leading the ‘health enlightenment” movement are mining the same simple fundamental truth – “less is more”. Less drugs, less fake food, less eating out, less stress, less sleep deprivation, less office visits, less hospitalization. They see low hanging fruit all around them. But how best might they execute this current revolution?
Here are three steps that would go a long way toward resetting a century of health provider driven bias that limits quality of life in a modern society.
1. Be Biased Against Medications. Ever since doctors returned from WWII flush with the joy of access to the “wonder drug”, Penicillin, our physicians have embraced the prescription pad as their best friend. Pharmaceutical reps happily fed the frenzy, and patients embraced what they saw as “easy fixes”. The reality is that many of these drugs are based on an incomplete understanding of human basic science, over-marketing of benefit and under-marketing of risk, and complex inter-drug interactions that create as many problems as they solve. The two critical questions consumers need to ask are, “Do I really need to take this drug?” and “How can I adjust my daily life to avoid having to take this drug?” The two critical questions the health professionals need to ask (think statins or anti-hypertensives) are “Has the ratcheting down of protocol driven ‘normal ranges’ been effected by expert witness/pharmaceutical conflict of interest?” and “Is the basic science underpinning for this drug I’m about to prescribe as well understood as the powers that be portray?” or stated in another way, “Have I properly weighted the downside of putting everyone with a diastolic blood pressure of 90, or a total cholesterol of 220, on a lifelong drug regimen?”
2. Be Biased Toward Self-Management. With the support of Obamacare, we are seeing major expansion of insurance coverage and conversion to electronic medical records. These changes will hopefully improve continuity of care and elements of health planning. Some consumers have interpreted this to mean that, if they can only find the right doctor and health system, the doctor will “keep track of keeping them well”. But health consumers need to understand that no health professional is as motivated, focused and undistracted when it comes to the health planning for them and their families as they are. They need to maintain a file of their own medical records and results. As important, they need to plan forward and organize a system that will reliably flag them when certain preventive milestones like mammograms, colonoscopy, annual flu shots, childhood immunizations and more are due.
3. Be Biased Toward Learning. Deeply embedded in the psyche of America’s patients is the belief that medicine is too complicated for them to understand and is better left to doctors and nurses to learn and communicate to us. Nothing could be farther from the truth. The basics – including normal and abnormal function of organs, basic disease entities, basic approaches to safety and prevention, and basic techniques to promote family wellness are well within the reach of everyday people. We have come to understand that poor financial knowledge places individuals and families at risk. Well the same is certainly true for medical science knowledge. Now this knowledge is at our fingertips, and it is only going to get better. And in certain areas, such as home-based nutrition, stress reduction, and life balance, the consumer is often far ahead of the health professional.
In the modern patient-physician relationship, we will rely on the health professional team to analyze data, coach, and advise on our performance against customized, well thought-out, personalized health plans. That trusted team will also be called on to ease access to specilized care, complex diagnostics and hospitals if and when these are required. As important, in an era of “health enlightenment”, we seek out their knowledge, judgement, and counsel, and in return we adjust our behaviors to reinforce the health professionals success and well-being. To do all this, we must bring knowledge and good will to the table, and must be well informed, prepared, alert, engaged and enlightened.
Foe Health Commentary, I’m Mike Magee.
1. Weber T, Orenstein C, LaFleur J. Strengthening Medicare’s Drug Benefit: 8 Recommendations. ProPublica published in Washington Post. May 11, 2013.http://www.washingtonpost.com/national/health-science/strengthening-medicares-drug-benefit-8-recommendations/2013/05/11/6998fdd6-b8f5-11e2-aa9e-a02b765ff0ea_story.html
2.Magee M. “Connecting Healthy Homes To A Preventive Healthcare System: Leveraging Technology.: The Populist Transformation of American Health Care”,Harvard Health Policy Review, Volume 8:7, Fall,2007. http://hhpronline.org/publication/previous-issues/fall-2007-part-1/
3. Magee M. “The Patient – Provider Relationship” in Connecting With The New Healthcare Consumer, McGraw Hill, 1999. http://www.amazon.com/Connecting-New-Healthcare-Consumer-Defining/dp/0071346724
Posted on | May 13, 2013 | No Comments
IHI ANNOUNCEMENT: “Quality pioneer W. Edwards Deming once remarked, ‘If I could reduce my message…to just a few words, I’d say it all has to do with reducing variation.’ If reducing variation is the path to improved quality, then identifying and understanding variation are surely the first steps. ‘Counties of Interest: Achieving Better- or Worse-Than-Expected Health Outcomes‘ —- a recently posted IHI 90-Day R&D Project Summary Report —- is the type of analysis that can help. This project identifies US counties with health outcomes significantly better or worse than expected based on their socioeconomic status and looks at what is behind the results through both a statistical analysis and a qualitative investigation. For those interested in learning more about geographical variation in health outcomes, be sure to check out the updated data from County Health Rankings —- a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute.”keep looking »