PBS Newshour feature on Medicaid Expansion (watch video)

Too Much Medical Care Can Be Unhealthy

This article appeared in the Roanoke Times, Huffington Post, and Fairfax County Times. 

Are we being harmed because we receive too much, instead of too little, medical care?

For many Americans, the answer is increasingly "yes."

Just last month, a new study showed a link between the iodine contrast that patients receive for routine medical scans and thyroid disease. Researchers found that people with thyroid disease were two to three times as likely to have received this agent than those who did not develop it. Only two years prior, another study in the same journal, Archives of Internal Medicine, estimated that radiation from medical scans was responsible for up to 30,000 new cases of cancer and 15,000 deaths every year.

Such scans and medical procedures are necessary and even life-saving for many of the patients who receive them. For many others, however, they are not. These patients end up undergoing medical interventions that do not benefit them yet still put them at risk for serious complications.

I have seen such complications as a physician. One of my patients suffered kidney failure and required lifelong dialysis because of medications that he had unnecessarily received years ago. Others incurred heart damage or infections from procedures that they did not need.

Unnecessary medical care is common in our country. It accounts for more than $200 billion in health care spending every year, according to the Institute of Medicine. Yet the uncertainties of modern medicine make it difficult for us to determine when an intervention is necessary and when it is not. That task is rightly left to the clinical judgment of individual physicians.

There are cases, however, where the medical literature renders a clear verdict. Certain interventions, such as antibiotics for viral respiratory infections, have been studied repeatedlyand found to be of no benefit to patients. Other examples include cardiac stents for cases of mild chest pain and certain procedures for back pain.

Yet, despite the evidence against their effectiveness, such interventions persist. For example, there were more than 100,000 recorded cases of vertebroplasty -- a back procedure that was recently shown to be of no benefit to patients -- performed in one year. In another example, a recent study documented up to 75,000 cases of patients receiving cardiac stents for inappropriate reasons. The complications from these two procedures, while rare, include blood clots, bleeding and even death.

These unnecessary medical interventions are largely a result of our distorted system of paying for medical care. Under the current "fee for service" model, insurers reimburse hospitals and doctors based on the volume of interventions they perform. It is easy to understand why this incentivizes more tests and procedures across the medical system without enough attention paid to whether patients end up benefiting.

Another culprit is a widespread assumption in medicine that "more is better." Both physicians and patients tend to overestimate the benefits of medical interventions, especially when advanced technologies are involved. This was documented in one recent study in which more than 80 percent of patients who were about to receive an invasive procedure did not understand its limitations, even though they had already consulted their doctors.

Paradoxically, the lack of access and fragmentation that plagues our current system exacerbates this problem. Patients who cannot see a primary care doctor often end up in emergency rooms where physicians who do not know their medical history are compelled to order more tests.

Fortunately, there are some signs of change. The Affordable Care Act will help by increasing access to care and encouraging more research into the effectiveness of certain interventions. It will also fund pilot projects to evaluate new ways of paying for health care instead of the traditional fee-for-service model. Physician organizations are speaking out as well. The National Physicians Alliance, for example, has embarked on a Good Stewardship Project to draw attention to medical interventions that do not benefit patients.

We must also strive toward a health care system that truly values informed consent. Patients need the resources to make informed choices. This includes sufficient time with their physicians to have all their questions answered as well as educational materials that clearly outline the risks and benefits of interventions. Research has shown that patients, when properly informed, opt againstmedical interventions that are unnecessary.

My advice to patients and families is to be more critical when offered a medical intervention, whether a diagnostic test, a medication or a procedure. Make sure to ask some basic questions up front: What is its anticipated benefit? Its limitations? What are the most common complications? The most dangerous? Are there any feasible alternatives? What are the consequences of forgoing this intervention?

Don't be rushed into a decision. Ask where you can find additional information.

And remember that more is not always better.

Health Reform Was Worth It

From the Huffington Post on Nov 3, 2010.

In the aftermath of the midterm elections, political commentators are saying that Democrats paid a heavy price for overreaching, particularly with healthcare. That is probably true. In our preoccupation with the political fallout, however, let us not lose sight of the real people who will benefit from the new health-reform law. As a physician, I am witness to the struggles of such people. David is one of them.

Several years ago, David went to an emergency room for a minor accident. His X-rays did not show any fractures, and he was cleared to go home. As he was leaving, a doctor informed him that he had high blood pressure. He told David not to worry. All he needed to do was make an appointment with a primary care doctor to get treatment.

David soon realized that there were no primary care doctors willing to see him without health insurance. Although his job as a taxi driver provided enough money to maintain a small apartment and pay the bills, it did not provide health insurance. So he had to forgo treatment as his high blood pressure silently damaged his kidneys.

Five years passed. David began to tire easily. He could not make it across a parking lot without having to stop to catch his breath. A few months later, he would wake up from sleep gasping for air. His breathing was getting worse by the day. One night his sister finally brought him into the emergency room, where I first met him.

I could tell that years of high blood pressure had damaged David's kidneys beyond repair, causing fluid to accumulate inside his lungs and compromise his breathing. After a few days of treatment, David began to feel better. That is when I broke the news to him. To stay alive, he would need to go on dialysis.

David was stunned. "Doctor, will I be able to work?" was his first question. Then he asked me if he could ever visit his parents again. They lived abroad and were too frail to travel. That evening, it became clear that his life would never be the same.

David's life will have to revolve around dialysis. For three days every week, he will make his way to a dialysis center and wait for four hours as his blood is cycled through a large machine. Since missing a single session can be dangerous -- leading to sudden cardiac arrest, for example -- his ability to leave town will be curtailed. It is unlikely that he will ever see his parents again.

Working will also be difficult. In addition to the demands of thrice weekly dialysis, David will have to put up with the weakness, nausea, and cramping that accompanies his condition. There will be the fear of complications. His risk of having a heart attack, for example, has increased by ten fold because of kidney disease.

This could have been prevented. The emergency room doctor who saw him six years ago was right. All David needed was a primary care doctor to regularly check his blood pressure and write a prescription for pills that cost as little as a nickel a day. Yet, he was denied that access because his line of work did not come with health insurance.

Americans are understandably skeptical about the new health reform law. Some fear a larger government role in healthcare. Others wanted the law to go further and include a public insurance option. Many were disturbed by the politics that played out on their television screens, such as the raucous town halls and Senate backroom deals.

Yet, no one can deny that the new law will address a fundamental issue in healthcare -- the unacceptably high number of Americans, like David, who are uninsured.

Politically, it would have made sense for Democrats to put off health reform, at least until the economy had improved. Those without insurance, however, suffer the consequences of waiting. Had this law been enacted five years ago, David would have had a chance at saving his kidneys. Now, it is too late.

The new law will provide coverage for more than thirty million uninsured Americans. Those with insurance will have the peace of mind that they will be protected if they lose their job or fall ill. This matters for a mother unable to obtain a mammogram because she is uninsured or a diabetic who lost his insurance because he was laid off. With all the focus on the political fallout, now is a good time to remind ourselves that their stories matter. Because of them, health reform was worth it.

Haiti

Our first cases of cholera  in PortAuPrince. The tent only had room for eight patients so some were being turned away at the gate. I still remember a teenage boy who had carried a girl (his neighbor) after seeing her passed out. He pleaded for her to be let in despite being told that we were full. He didn't let up. The walk to the next treatment facility was too long and dangerous, he said. He was finally let in. We made room for the patient by removing another one who was not as sick. It soon became clear that he had saved her life. She would not have survived long enough to make it to the other place. I never had the channce to tell him that. Last I remember, he was giving me a thumbs up before dosing off for a few hours on the pavement. She ended up recovering. I didnt see him again. Even though I was in Haiti for a short time, I still remember the immense courage of people who had gone through so much ... the earthquake, then cholera. Inspiring.

Pakistanis need our solidarity

From the Huffington Post on Sept 21, 2010. 

Snow-capped peaks, shimmering lakes, and endless meadows – these are the memories from my last visit to Pakistan's northern areas fifteen years ago. The stories now emanating from Pakistan bear little resemblance to these memories. They are the stories of villages submerged underwater and schools washed away, of livestock destroyed and farmlands wiped out. “The world has never seen such a disaster,” UN Secretary General Ban Ki Moon said of the floods that have ravaged one-fifth of Pakistan. “It’s much beyond anybody’s imagination.”

Pakistan needs our help. Twenty million people are affected, a number that surpasses the number affected by the Haiti earthquake, Asian tsunami, and Kashmir earthquake combined. Ten people are homeless. Three million children are threatened by cholera. Seven thousand schools need to be rebuilt, five thousand miles of roads repaved, and an entire agricultural sector revived.

The national security argument for a robust American response to this crisis is compelling. Pakistan's help is vital for success in Afghanistan and in curbing nuclear proliferation.

This is about more than national security though. It is about how our country treats its allies. It is about the message of solidarity that we as Americans ought to convey to the Pakistani people. This message is that we value our relationship, and we want it to transcend the fight against extremists or nuclear proliferation. We want it to be based on mutual respect and trust. Only such a relationship can sustain cooperation on the difficult issues that our countries will inevitability continue to face.

Our response has been far from robust, however. Americans have given $25 million in private donations to Pakistan compared to the $900 million that we gave for the Haiti earthquake. The Red Cross has received $10,000 for Pakistan compared to $32 million it received for Haiti. The media coverage for Pakistan has been one tenth of what Haiti received. While our government has done better with a $200 million commitment, it is only a fraction of the estimated $7 billion that Pakistan needs to rebuild.

This tepid response is sending the wrong message. It confirms the widely held notion among Pakistanis that our relationship with them is merely transactional – that our commitment is limited to paying for their cooperation in fighting extremists. This perception is supported by the patterns of US aid to Pakistan. Billions of dollars were given in the 1980s to help Pakistani-backed militants fight the Soviets in Afghanistan. Once the Soviets were ousted, however, virtually all of the aid dried up. Since 2001, the same pattern has been repeated with billions in military aid to fight Al-Qaeda. This aid has had little effect on the lives of ordinary Pakistanis.

What Pakistanis have felt, however, is the fallout from our war on terror. The same people who suffer from Taliban bombings in their marketplaces have had to flee their homes when the Pakistani military retaliates. The US-backed military operation in the Swat valley, for example, forced two million Pakistanis to flee their homes, the largest such migration in recent history.

These same people are now facing another tragedy, one that dwarfs others in recent memory. This is our opportunity to show that we actually care about them. To succeed, however, we must act decisively.

First, we should all donate now to any of the organizations working on the ground. A ten dollar contribution can also be made to the UN operation by texting “SWAT” to 50555 and the State Department relief fund by texting “FLOOD” to 27722 from our cellphones.

Second, we must urge those with influence to step up. Now is the time for the celebrities and media personalities that have been conspicuously silent to speak up. Now is the time for our corporations to match employee donations. Now is the time for our politicians to press for a larger relief operation.

Finally, we can build bridges at home by reaching out to Pakistanis in our own communities, whether a taxi driver, physician, or co-worker. We should ask how the floods have affected their families and if we can help.

Last month, Secretary of State Clinton said, “I want the people of Pakistan to know that the United States will stand with you during this crisis. We will be with you as rivers rise and fall. We will be with you as you replant your fields and repair your roads. We will be with you as you meet the long-term challenges to build a stronger nation and a better future.”

My hope is that the stories that Pakistanis tell one day will actually resemble the words of our Secretary of State. Only then will we have finally achieved the relationship with Pakistan that both of our countries need.

Only then will the towering peaks and shimmering lakes of my childhood memories regain their true place in our world – not as venues of strife but as monuments to human resilience and solidarity.

Fog

HIV in America: Why you should get tested

From the Huffington Post on June 28, 2010.

Yesterday was National HIV Testing Day, a reminder for all of us to get tested for HIV. Among the one million Americans living with HIV, twenty percent do not know they are infected. This is despite Centers for Disease Control guidelines that recommend testing for all Americans between the ages of thirteen and sixty-four.

The consequences of not knowing one's HIV status can be devastating. I saw this firsthand a few months ago as a doctor on call at my local hospital.

Michelle was an Asian woman in her forties who had been hospitalized overnight. It was thought that she had a mild pneumonia. I took over her care the next morning and set off to check in on her before meeting my team for morning rounds.

Upon entering her room, I noticed that she was was thin-appearing and sleeping comfortably. I approached her gurney. Suddenly, the alarms went off. Her oxygen level was dropping dangerously low. This was unusual for a mild pneumonia. Could she have asthma or a clot in her lung instead? A list of alternative diagnoses ran through my head as I dialed up her oxygen.

Her nurse rushed into the room. "Someone from the lab is on the phone," she said. "Michelle's HIV test just came back positive."

She had PCP pneumonia, a rare fungal infection of the lungs that is seen when HIV cripples the immune system. If not recognized and treated promptly, it can be fatal.

Michelle's case reminded me that our country has not yet overcome AIDS. In fact, the rates of HIV infection in some American populations actually rival those in sub-Saharan Africa, the center of the global epidemic.

In Washington D.C., for example, one in thirty individuals is infected, a higher rate than in Ethiopia or Rwanda. New York City has the most infections in the country, with alarmingly high rates among specific populations: one in forty African Americans, one in eight injection drug users, and one in ten men who have sex with men. Increasingly, heterosexual women, not traditionally considered 'high risk,' are being diagnosed with HIV.

Despite such startling numbers, HIV is not part of our national consciousness as it was even a decade ago. In a 2004 debate, former Vice President Dick Cheney was criticized for not knowing that HIV is the largest killer of young African American women. Five years later, a Kaiser Family Foundation poll confirmed that fewer Americans thought that HIV was a serious problem domestically. Not infrequently, patients admit to me that they engage in risky sexual behavior without fear of contracting the virus. Many have not been tested.

Physicians bear responsibility for this trend as well. Despite universal screening guidelines, only seventeen percent of respondents in the Kaiser poll said that their doctor offered them an HIV test.

Thus, it is not surprising that a full one-third of Americans with HIV are diagnosed late in their disease. These are people that miss out on life-saving treatments and are likely to infect their partners without even knowing it.

Michelle was one of these people. By the time she was diagnosed, her immune system was irreversibly damaged. She was battling a life-threatening PCP infection. Fortunately, with intravenous antibiotics and steroids to reduce the swelling in her lungs, she eventually overcame the pneumonia. However, she had to endure a fifty-day long hospitalization in which she was nearly put on a breathing machine. All this could have been prevented had she been tested even once during the previous five years.

It is time that we all acknowledged the reality of HIV in our country. It is time for a renewed commitment to bring our domestic epidemic under control. We need a commitment from elected officials to increase funding for HIV programs, especially ones that expand testing. We need a commitment from doctors to offer testing to their patients. Most of all, we need a commitment from every American to understand their own risk of infection and get tested.

All of us have a role in overcoming HIV in America.

Identifying information has been changed to protect patient confidentiality. This piece was written as part of the Partnership for Physician Advocacy Skills program at UCSF.

Yosemite

Healthcare reform: Giving up now is not an option

From a speech given at a health reform rally on February 19, 2010.

This week, President Obama will meet with Congressional leaders to take up the topic of healthcare reform once again. As a physician who works on the front lines, my message for them is simple: giving up now is not an option.

I am fortunate to work with dedicated doctors and nurses, and in them I see the strength of our health care system. Yet, like so many of my colleagues, I also see what is wrong with our healthcare system.

I see the patient with asthma, merely in his twenties, who runs out of inhalers and suddenly can't breath. I see him connected to a breathing machines in our intensive care unit.

I see the small business worker who could never afford insurance, now requiring dialysis because high blood pressure damaged his kidneys beyond repair.

The single mother of two who showed up for her mammograms every year. Then she lost her job and with it her insurance. I see her, three years later, to confirm that indeed that lump on her breast is cancer.

I see this and so much more. And like other physicians, I know that healthcare reform cannot be pushed back any more.

For those of us who support reform, the last few weeks have been difficult. We are so close to passing a bill that, while imperfect, is still a significant step in the right direction. After the election in Massachusetts, however, the media thinks that we cannot pass health reform. Some in Congress are afraid. There is talk of giving up.

This talk reminds me of a conversation I had with another physician a few months back. He was taking call, working all day and then admitting new patients to the hospital that same night. He was on his feet, taking care of patients, responding to pages, talking to families, checking labs, writing notes. Finally at 2:30 in the morning, twenty hours into his shift, there was a lull, a chance for a quick nap. He made his way to the call room in the basement of our hospital. Just as his head touched the pillow, his pager went off again. There was another patient waiting to be admitted.

I asked him, "What keeps you going? You have a wife and kids at home. You could be spending time with them or getting a full night's sleep in your own bed." He looked at me and asked? "You think we have it tough? Our patients are the ones who are going through real struggles. They have to cope with illness and the thought of burdening their loved ones. Yet, they don't give up. So who am I to give up on them?"

It is tempting, when things get difficult, for us to give up. It is tempting, when the political winds change course, for members Congress to give up on those who need healthcare, to move on to something easier.

For us who work in healthcare, we know that giving up won't cure our patients' asthma. It won't make cancer go away. Giving up won't relieve the pain of a lady with a fracture or that of a family that just lost a loved one.

The mother undergoing chemotherapy for breast cancer while also holding down a job is not giving up.

The wife who prays at the bedside of her husband injured in an accident is not giving up.

The alcoholic with cirrhosis, having resisted a drink for four years and now patiently waiting for a liver transplant, is not giving up.

The nurse who eases the pain of a patient with a stroke, the physical therapist who gets him to walk again, the doctor who works to prevent another one -- they are not giving up.

Our patients do not give up. Because of them, we cannot give up. Neither should our elected officials, until every American has access to the affordable and quality healthcare that is their right.

Marin headlands

Fixing healthcare: Primary care is job No. 1

"The Senate and House are inching closer to extending health insurance to millions of Americans. Access to insurance, however, does not necessarily mean access to healthcare. What is also needed is a sufficient supply of primary-care doctors. As an internal-medicine physician who works in multiple clinical settings, I repeatedly witness the consequences of patients not having that access."

Read more in the Los Angeles Times.

Perspective

Perspective

California Academy of Sciences