The New York Times says “In Medicine, New Isn’t Always Improved.”

Who can argue with this?

“In Dining, New Restaurants Aren’t Always Better.”

Yes, that’s true, too.  But does it mean anything?

The article is about a type of hip that is apparently going to be the focus of a lawsuit.  The story goes that a lot of people wanted the new hip when it came out, because it was thought to be better than the older ones.  Unfortunately, the hip seems to have hurt some people, some of whom may have been better off getting the older one in the first place.

A doctor quoted in the article suggests it’s part of a uniquely American tic.  We want all of the latest and greatest things for ourselves, it seems.  This story is supposed to be a cautionary tale of what can go wrong when we do.

On the other hand, the latest and greatest things don’t appear out of nowhere.  In America, when people demand something, there will be someone who supplies it.

It’s true.  Doctors, researchers, the government, and, yes, for-profit companies, create things.  They invent diagnostic tests and treatments for disease that never existed before.  One reason why the U.S. has a trillion-dollar health care economy is because there are so many people creating so many new things that people can sanely talk about curing – or at least managing – all disease.  This is a good thing.

But all these breakthroughs are a two-edged sword.

The ability to create increasingly precise treatments means it’s more important than ever to diagnose patients correctly.  Published studies show that misdiagnosis rates are as high as 44 percent.  These studies show these errors happen because doctors are pressed for time, seeing 30 or 40 patients a day.  But whatever the cause, twenty-five percent of patients can’t possibly benefit from the latest medical advances – because they just don’t have the disease for which they are being treated.

Today we have the most medical knowledge, technology and treatments than at any time in history, and yet it’s harder than ever to get people the right care.  Policy-makers must fix an overburdened health care system in serious need of repair.  Let’s get back to basics.  Let’s put a premium on doctors’ judgment, not on how many patients they can see in a day.

There are plenty of “survivalists” out there who stock their basements with canned goods, getting ready for some unexpected (and unlikely) apocalypse.

Meanwhile there are things that are much more likely to happen to you, like getting sick, which many of us don’t prepare for at all.

So to help you get started, here are five important tips on how you can become a health care survivalist.

1.  Take care of your chronic conditions. Whether it’s high blood pressure, diabetes, high cholesterol, depression, asthma or any other kind of ailment, do what it takes to manage your own care.  Take your medications and follow your doctors’ instructions.  Why? Because if you don’t, your condition can get worse and lead to even more serious problems.  As much of a pain as it may (literally) be, there’s a reason the old saying “an ounce of prevention” still resonates today – because it’s true.

2.  Live a healthy lifestyle. Everyone gives you this advice, but with studies showing that 42% of Americans will be obese by 2050, it doesn’t seem to be getting through.  Denial can wonderfully appealing;  but when it comes to your health, it can also kill you.  Stop smoking, exercise, and eat right.  You may find that your employer has programs in place that will help you do all of those things, and many of them work.  Why not give one of them a try?  You can’t improve your life all at once, but you can start.  Your life will be happier if you keep yourself healthy.  So, rather than whistling past the graveyard, jog past it.

3. Make sure you are well-insured. You may not have the greatest insurance plan through your job, but there are things you can do to protect yourself on your own.  For example, most insurance doesn’t pay the full cost of long term care.  This is the kind of care you might need if you end up needing home nursing care or have to live in an assisted living facility.  That can be very costly.  You should buy long-term care insurance to cover these expenses and serve as a cornerstone of your health care survival plan.  Studies show that 60% of seniors will need long term care at some point in their lives – and Medicare doesn’t cover it.  Oh, and it’s not just a problem of the elderly.  About 40% of people getting long-term care are between 18 and 64.

There are other kinds of insurance you can buy, too, depending on the state in which you live.  These might be plans that supplement your health coverage, or cover other expenses of illness.  The best advice:  research your options, find an insurance broker you trust, and figure out a plan that helps protect you from the financial toll of illness.  Also keep in mind that your employer may offer, on a voluntary basis, a number of these kinds of programs at cheap prices – check them out and see if they make sense for you.

4.  Know your family history. It’s a little hard to believe in the 21st century, but it turns out that an old-fashioned knowledge of your family’s medical history can be some of your best protection.  It can help your doctor know whether you have a higher risk for certain illnesses.  And it can also help him or her know whether that symptom you’re complaining about is a sign of something other than what it seems to be.  A surprising study recently showed that a family history can be better than even genetic testing at predicting your likelihood of disease.   The Surgeon General has a neat tool that can help you get started. The more you know about your family’s medical past, the better off you and your doctors will be in your medical future.

5.  Ask Questions. No matter how well you prepare and try to protect yourself, at some point you may still end up seriously ill.  Hopefully, if you’ve taken good care of yourself and have all of your information in order, you’ve put yourself in the best position to make it through.  But there’s still so much more you can and should do.  The world is full of well-intentioned, highly skilled, and hard working doctors.  The trouble is, they work in a system that makes it very difficult for them to do their jobs.  So, ask questions, and use every resource available to you to make sure you’re getting the right medical care.

What’s the highest peak in North America, Mt. McKinley or Denali?  This is a great question the web can answer for you.

“What is that lump on my neck?”  This is another great question – but not one you should rely on the web to solve.

Best Doctors recently conducted a Twitter-based poll to find out what channels of information people use to get health care advice.  It turns out, 54% of respondents use the web as their primary source of information.

Is this kind of do-it-yourself medicine a good idea?

I’m a firm believer that you should do everything you can to make sure you’re getting the right care when you’re sick.  But, before you start your do-it-yourself journey, here are five things to keep in mind.

First, to get the right answer, you need to ask  the right questions.  If you decide that that lump on your neck is a sign of lymphoma, you’re going to get very worried and start researching everything you can on lymphoma.  You may see your doctor and when he tells you it’s actually a benign cyst, you’re going to have a hard time believing him.  Now, your skepticism is a good thing, but before you start driving yourself crazy with serious conclusions, make sure you have your facts straight.

Second, consider the source.  Is what you’re reading written or sponsored by a company with its own agenda?  If there are links to other information, who wrote that information?  Is the article you’re reading quoting an unknown medical journal article about a study on four people?  As in every age, there are snake oil salesmen, and the internet has many of them plying their trade.  Don’t assume that just because it’s on the internet it’s true.

Third, no health information on the web is going to be about you. Sure, you can find lots of detailed, highly educational information, but whatever you’re reading doesn’t take into account your specific circumstances, your medical history, your family’s medical history.  Sometimes these can be the most important factors of all.  Use what you read to help you learn more about your condition, but remember: the most important information of all is about you.

Fourth, make sure what you’ve got fresh information.  Medical science is constantly advancing, and so information that is even a year old may be terribly out of date.  Check to see when what you were reading was published.  If it’s old, see if you can find a more recent version of it, or fresher references to the same subject.

Fifth, be careful of the tricks your mind can play on you.  It is a known phenomenon that you are likely to be influenced in diagnosing yourself by your knowledge of the experience of someone you know, or something you are afraid of.  For example, if you know someone who died of a heart attack, you are  more likely to notice chest pain and think maybe you’re having a heart attack, too.  (Shark attacks are an interesting example of this – from 1670 until 2009 there were a total of only 41 reported deaths from shark attacks in the United States- yet sharks may be the most feared creature in America.)  Don’t fall prey to your own mind.

So, yes, use the web, but be smart about it.  And don’t stop with what you read.  Be proactive and tap into whatever other resources are available to you.  Make sure you get the right care.

As for the highest peak in North America? It’s Mt. McKinley, also known as Denali.

If a web site touted misleading health care information, you’d hope the government would do something about it.  But what do you do when the government is the one feeding the public bad information?

Last week, the Obama administration launched the new Healthcare.gov.

It’s mostly an on-line insurance shopping site.  It is very much a federal government version of sites like eHealthInsurance.com or Massachsetts’ HealthConnector site, which have been around for years.  So when HHS Secretary Kathleen Sebelius, in announcing the new site, claims it gives consumers “unprecedented transparency” into the health care marketplace, you should wonder what she means.

But that’s not the big problem with this site.

Right there in the middle of the top of the page is a big tab that says “Compare Care Quality.”  If you click on it, you are taken to an “interactive web tool” that claims to show you “44 quality measures” about hospitals.  The site says it will help you compare the quality of care hospitals provide.

I decided to look at hospitals in the area where I live, Boston, Massachusetts.  It gives you a list of hospitals in your area, and gives you options to compare hospitals based on medical conditions and surgical procedures.

I decided to compare the Brigham and Women’s Hospital in Boston with the Hallmark Health System in Melrose.  If you don’t know these two facilities, the Brigham is a Harvard teaching hospital, justifiably world-renowned in many areas of care.   The Hallmark Health System is a network of community hospitals, which I suspect most people even in the Boston area aren’t familiar with.

I decided to run my search based on the idea that I was trying to help someone with breast cancer.

The first problem I ran into is this: they don’t have any data on breast cancer.  Actually, they don’t have data for cancer at all.  The only things they can tell you about are chest pain, heart attack, heart failure, chronic lung disease, pneumonia and diabetes in adults.

How about a search on surgical procedures?  Nothing again.  My only option is a “general” search.

Ok, well, I guess it’s a work in progress.  So how do the two hospitals stack up?

They give you a few ways to compare, but the one that I think most pertinent is “outcome of care.”   If you click on that you see that “outcomes” are based purely on how many people died who had a heart attack, heart failure, or pneumonia.  So much for my “general” search (and my cancer patient).

So how do they stack up?  You can’t tell the difference.  Both hospitals are “no better than the national average” in two categories, and “better than the national average” in one.

You get more detailed information – but it only makes things worse.

For example, in death rates for heart attack, the Brigham and the Hallmark hospitals are both “no better than the national average.”  Is that good?  It turns out that that “above average” hospitals are as rare as four leaf clovers – out of 4,569 hospitals in their data set, only 95 are better than average (2%). Only forty-five (1%) are worse than average.  Two-thousand seven hundred and forty four (60%) were “no better than the national average.”

The other 1,685?  They don’t have enough data to figure that out.  The smart money says they’re all “average,” too.

Maybe if I just compare them to other Massachusetts hospitals I will get a clearer picture.  Nope.  Out of 65 hospitals measured in Massachusetts, only nine were better than the national average (14%).  Fifty-one were average (78%), and zero – zero - were worse than average (5 didn’t have enough data).

I know health care in Massachusetts is good -but not a single hospital is below average?

It is deeply misleading to consumers to suggest they inform their health care decisions in any way shape or form by this kind of data.  It’s not that the data is incomplete – it is – it’s that even within the data you can’t tell the difference between a major teaching hospital and a local community hospital.

I’d love to know if the people presenting this as a useful tool for consumers think it really is.  It leaves you knowing less about the differences among hospitals than before you use it.  That’s shameful because the site encourages people facing medical situations to use it for that purpose.  The only thing it is going to do for sure is heighten patients’ anxiety, and make their decision-making more difficult.

What do you think?

That’s the headline in today’s Boston Herald. It tells the story of young Michael Sanders, who was born in 2007. Michael went home from the hospital but after a few weeks in which he didn’t seem right, his mom, Denise took him to the doctor.  As the Herald reports:

A seemingly routine doctor’s visit brought devastating news: the baby had a fatal, congenital heart defect and just a few weeks to live.

“They said he would never, ever have a normal functioning heart,” his mother recalled, “and they said nothing could be done to fix it.”

The parents, Chris and Denise, got a second opinion from another doctor that supported the original finding. They didn’t have much choice. They brought hospice workers into their home, and started to make arrangements for Michael’s funeral.

At work, Denise had Best Doctors as an employee benefit. She decided to call and see if there was any hope, or if she really had to face the reality of her awful situation. “I was a little afraid to call at first,” she said, “but then I thought, at least it will confirm what I already know.”

After gathering and reviewing Michael’s records, Best Doctors consulted with Dr. Pedro del Nido, chief of cardiac surgery at Boston Children’s Hospital. Dr. del Nido told them very unexpected news – Michael had been misdiagnosed. In fact, he told them, he could fix Michael’s defect and allow him to live a completely normal life. In May 2008, he had the surgery, which went extremely well.

Today, Chris and Denise brought Michael, now almost 3, to visit us at Best Doctors, along with Michael’s big sister Katie. Michael is a very outgoing and playful 2 year-old. He attends pre-school at his family church, where I’m told Michael was greeted as a hero on his first day of school. The community had rallied around young Michael after he was born and during his surgery and recovery, and so his arrival at pre-school was a milestone in the lives of so many people.

Chris and Denise both told me they don’t know why our paths crossed, Best Doctors and the Sanders family. We are honored that they did. And we are grateful that they came to see us today to share their story, and to give us a chance to meet them and their wonderful son. I know I am also thankful for the many people at Best Doctors that helped Michael through his journey, especially Helen Thomas, one of our member advocates.

It is a freezing cold day today in Boston, but not in the offices of Best Doctors.

Michael, earlier this year in Boston

UPDATE: The local Fox affiliate in Boston is covering this story tonight at 6. And the local NBC affiliate will have it on this evening as well. Video to follow.

UPDATE 2: A complete round-up of media coverage is here.

At the Wall Street Journal’s Health Blog, Jacob Goldstein writes that programs that pay more for better quality care are a “tricky proposition:”

Even if you can figure out what to measure, and how to account for differences between patient populations, you still need to have a decent sample size; anybody can have a bad (or good) day, so you need to measure a large enough number of events to minimize the role of random variation.

But 65% of primary-care docs work in practices that are too small to draw meaningful conclusions about the quality of care they provide (at least if you rely on Medicare data), according to a study published this week in JAMA.

Fair enough.  But it begs the question:  why would we need to pay doctors more for delivering quality service (whatever that term might mean)?

The hidden assumption in these kinds of programs is that quality problems in health care are caused by bad financial incentives. Since doctors are paid the same regardless of the quality of their work, they don’t care enough about whether they do a good job or not.  Pay them extra if they do well, and you’ll see improvements as they try to earn that extra pay.

It might be true if the practice of medicine were like an assembly line.  In that kind of work, the goal is to deliver large numbers of standardized products through a series of repetitive, simple tasks.  People are good at this kind of work, and can be incentivized to deliver different kinds of outcomes, depending on how you pay them.  Want more cars?  Pay extra for hitting some production target.   Want higher quality manufacturing?  Pay extra for lower levels of defects.  Robots do this kind of work even better, and you don’t even need to pay them anything at all.

But doctors aren’t robots, and this isn’t what medicine is all about.  Of course, this hasn’t stopped the exact opposite from becoming the conventional wisdom about health care.

Costs are too high?  Increase throughput and reduce unit costs.  Or, in English, make the doctor see more patients and pay him less for each one he sees.  Still too high?  Get nurses to do some of the work so throughput can be increased even more.  Oh, and let’s cut the pay, too.  Meanwhile, let’s buy some new computer systems that will make work more efficient.  Computer systems always do that.  Let’s also come up with some quality measures, like maybe, 1,500 or so, and pay doctors a little extra if they meet some of them.

If it weren’t for all the politics surrounding health care, I think many people would find it amusing that anyone thought this was a very good idea.  But it’s the state of the art in reform.  And it’s characterized by a fixation on metrics that too often misses the bigger, more important, picture.

So what’s wrong?  In health care, we do not have a consensus on what “quality” means.  Some say quality should be measured based on outcomes, but even the very best doctor can’t ensure a good outcome.  Sometimes the news is bad, and the outcome will be what it will be.

Instead, why aren’t we measuring quality based on what people really want from their doctors – the right diagnosis and treatment?  As a patient, I would gladly pay more to go to a doctor who I knew was better at this than her colleagues.

As I’ve noted many times before, the fundamental mistake is prioritizing money over medicine.   By focusing on ever more clever ways to design economic incentives, our system undervalues the very things that make it possible for doctors to deliver the right diagnosis and treatment. Things like time with the patient, thinking about his or her problems, consulting with colleagues, and coming up with sound advice.

If we want to remake our health care system, we need to start with the idea that the right diagnosis and treatment is the fundamental goal.  Everything else we create should be based on whether it helps serve this goal, above all others.

Dr. Toni Brayer asks – is it dangerous for doctors to say “sorry?”

In the past, physicians were advised to never admit to a problem or to apologize for clinical errors with the thought that it would lead to more lawsuits. Saying “I’m sorry” might be taken by a lawyer as an admission of guilt and malpractice. Attorneys advised, “Say nothing” but that left patients with unanswered questions and often the feeling that the doctor just didn’t care.

She points out that some 35 states have passed laws that prevent a doctor’s apology from being used against him or her in proving a malpractice claim.

I understand why these kinds of laws may be needed.  If you say you’re sorry for something, you are implicitly taking some degree of responsibility for whatever has happened.  Plaintiff’s lawyers will use a doctor’s apology to the maximum extent possible to show the doctor knew what they did was wrong.

“Sorry” is, as wise people have observed, the hardest word in the English language.  But why is this?

I think people like to think of themselves not as infallible in their actions but as infallible in their intentions. By this I mean, whatever I do, it will be with the right intentions.  Even if something goes wrong, it will not be so much my fault so much as a bad twist of fate.  Apologizing is, in this sense, a very un-natural thing to do.  You haven’t done anything wrong.

But think of it from the perspective of the person who has been harmed by your actions.  If you’ve hurt me in some way, I may conclude that the reason it happened wasn’t dumb luck but rather that you were careless, or at the least not concerned enough with my well-being.  Your failure to apologize will look to me like my conclusions are right.  You can’t even say you’re sorry?  You must not care much about me at all.

It’s enough to make someone very angry.  And it’s awfully easy for an angry person to find a lawyer who will listen to them.  At that point, it’s too late for sorry.

Saying you’re sorry is so hard because it takes so much humility.  We have to be willing to accept that not only are we imperfect in our actions, but we can also be imperfect in our intentions.  Or at least that others may believe we are imperfect in our intentions.  You have to be able to admit that, yes, it’s true, I wasn’t as attentive as I could have been.  Or you know, you’re right, I can see why you would think I was being careless, I’m sorry for what I did.

So long as your apology is genuine, timely, and based on a true understanding of the problem you have caused, you will defuse the problem.  But your work isn’t done.  Apologizing doesn’t fix everything, it just gives you the opportunity to repair your relationship.  So, saying sorry is not a cure for problems of medical malpractice, but it might prevent more cases than you think.

Still, there is something very wrong with the notion that we need to pass laws to make it so that an apology isn’t a legally dangerous thing to do.  We should not look upon a doctor’s apology as something to be used against him, but rather as a sign of his humility and his caring for his fellow man.

If he has committed malpractice, there will be plenty of facts that can demonstrate it.  Whether he acted as a good and caring person in dealing with the aftermath of a bad event ought not be one of them.

I’ve blogged for a long time (like here, here and here) about how the conventional approach to health care systematically devalues the thinking, processing and deciding aspects of medical decision-making.  Among the symptoms of this problem is the limited amount of time doctors are expected to spend with their patients.  For example, the latest government data show that the average doctor visit features face time with the doctor of less than 15 minutes.

Now, a new study is out.  Some of those talking about it are saying the time problem is being solved.

Really?

According to the study, between 1997 and 2005, the average length of a doctor visit increased significantly.  Well, statistically significantly.  It went from 18 minutes to 20 minutes 48 seconds.

Does it mean anything?  A study by ABC News earlier this year found that the number one complaint patients have about their doctors is the amount of time they get to spend with them.  Patients don’t seem to be noticing much of a difference.

Still, the whole thing misses the point.  You don’t go to your doctor to spend time with him or her.  You go to the doctor to find answers to your medical problems.  You go to your doctor because you want him to listen to you, answer your questions, and give you confidence about the next steps in your care.   Having limited time with your doctor doesn’t help, but pushing the median to 22 minutes or 24 minutes or whatever isn’t the answer.

The answer lies in fundamentally rethinking our approach to health care.  We need to move away from the fixation on units of health care and towards a focus on the needs of the patient.  We need to have a profound respect for the doctor-patient relationship, for the time doctors are able to spend thinking about their patients.  We need a system that puts these fundamentally qualitative measures of care at the center, and not the assembly-line metrics that have for too long moved health care away from serving the needs of patients and their doctors.

So, I guess it’s a good thing that patients have an extra three minutes of time.  But health care shouldn’t be about reducing the rush your doctor is in to an acceptable level.  It’s about things that are more fundamental, and more important, to patients and their doctors.

In today’s Booster Shots, Shari Rowan says sometimes patients “shouldn’t hold on to hope.”

She describes research that suggests that patients that have a realistic view of their medical situation do better than those who don’t.  One of the authors of the study said that hope “is an important part of happiness. But there’s a dark side to hope.”

I think she’s talking about just another form of denial.   These are patients – and, often their families – who suffer not only from a disease, but also of the psychology of how they deal with it.  As I wrote at the time:

I remember my father, who is an internist, telling me stories [of] . . .people with obvious, visible effects of a disease, but who weren’t getting any care.  It wasn’t that they had no one paying attention to them – often they had family and friends almost begging them to go and get help.  They just refused to go.

It is a reaction that I think is common to anyone who has suffered from a serious illness.  You don’t want the bad thing to be happening, it’s much easier to deny its existence.  The thinking is: I don’t want to be sick.  If I need medical treatment, then that means I’m sick.  So I will not seek medical treatment.

It’s much worse if the family of the patient is in on it, too, enabling the denial.  And I’m sure it’s devastating to those family members who want to see their loved one get help, but can’t get them to listen.

Misplaced hope is really the same.  Of course, realizing this is not the hard part.  Figuring out when your hope is misplaced is the hard part.  Is it really true that the condition is irreversible?  Sometimes it’s easy to say “yes,” or “no,” but very often the answer is “we don’t know.”

What then?

The struggle – the journey – for a patient or the family of a sick patient is trying to figure this out.  Are you doing more harm than good by fighting to get a better outcome, when you’d be better off just accepting reality?  Or are you doing yourself or your loved one a disservice by giving up when there are things you could do to make their situation better?  And as a family member of a patient, is it all really dependent on you?

— Whatcha got ain’t nothin new. This country’s hard on people, you can’t stop what’s coming, it ain’t all waiting on you. That’s vanity.