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WSJ: Women At Risk, Doctors Split On Procedure Linked To Rare Cancer

Here’s another excellent Wall Street Journal report on the controversial procedure known as “morcellation.”  Reporter Jennifer Levitz notes that even after the FDA issued a warning on the practice (which involves a “laparoscopic power morcellator” that allows for less invasive surgery to remove fibroids by slicing them up, but can also potentially spread a rare type of cancer through the body) doctors are split on how to proceed.

According to the report:

The FDA said women undergoing surgery for what look like benign fibroids actually have a 1 in 350 risk of hosting an undetected cancer called a uterine sarcoma. Morcellating these tumors can spread cancerous tissue internally and significantly worsen the odds of long-term survival, the agency said.

So what are women to do when the medical community itself is divided? From the WSJ:

(wikimedia commons)

(wikimedia commons)

A number of doctors believe the FDA overreached, and think the cancer risk is so small that gynecologists can go an entire career without seeing a case. Others call the advisory a necessary precaution.

Hospitals and private practices are taking an array of approaches. The University of Pittsburgh Medical Center system, which has more than 50 obstetrics and gynecology practices, opted to continue using the device.

The medical system changed its informed-consent forms to include wording on cancer risk and told doctors to discuss the risk with patients. But Allen Hogge, chairman of obstetrics, gynecology and reproductive sciences there, questioned the data behind the FDA’s estimate. The FDA began looking at the issue after media reports late last year about a prominent Boston doctor who discovered she had sarcoma after morcellation.

“I think this is mostly public relations and not science,” Dr. Hogge said. In response, the FDA said it conducted a rigorous analysis of published literature.

The common practice of morcellation, which is often used for hysterectomies, came under fire when Dr. Hooman Noorchashm, a cardiothoracic surgeon at Brigham and Women’s Hospital and his wife, Dr. Amy Reed, an anesthesiologist at Beth Israel Deaconess Medical Center launched a publicity campaign aimed at stopping the procedure, Continue reading

The Global View: Lessons For Mass. Health Care From Abroad

By Dr. Jonathan D. Quick
Guest contributor

A study released last week found that insurance is saving lives in Massachusetts. Expanded coverage will mean 3,000 fewer deaths over the next 10 years. We have state-of-the-art health facilities and are among the healthiest of Americans. Despite the fiasco of our failed enrollment website, the state maintains near-universal health coverage, and inspired the Affordable Care Act.

Our example is heartening not just for America, but for the many low- and middle-income countries around the world working toward universal health coverage. These countries aren’t just taking a page from our book, though — they have valuable lessons for us, too.

Dr. Jonathan Quick (Courtesy)

Dr. Jonathan Quick (Courtesy)

Here are four things Massachusetts could learn about health from developing countries:

1. Bring health care to the community level

Community health workers (CHWs) have been a staple of health systems in developing countries like Ethiopia for decades. Community members trained in basic prevention and treatment interventions, such as oral rehydration for childhood diarrhea and family planning education, are making a big difference. Although not as specialized as doctors or nurses, they work in places where those professionals either aren’t present or are overburdened. CHWs are not only cheaper to train and deploy, but they are also trusted neighbors, who don’t require the four-hour walk necessary to reach the nearest health facility.

CHWs are now catching on in Massachusetts and other places in the U.S. In NPR’s “A Doctor’s 9 Predictions About The ‘Obamacare Era,’” an American physician predicts “A new category of health worker will flourish: the community health worker.” Few Americans face long walks to health facilities, but many face other challenges, such as mental or physical disabilities, chronic pain, lack of transportation or difficulty navigating the health system. CHWs provide low-cost outreach that helps patients deal more effectively with these barriers.

2. Make it convenient

Another approach used in global health is accredited drug dispensing outlets. When people get sick in Tanzania, their first stop is a local drug shop. Although cheaper and more convenient than seeing a doctor, they often get the wrong drug, of poor quality, and at a high price. Through training and licensing, drug sellers are able to provide live-saving treatment for common problems like malaria and childhood diarrhea at reasonable prices. Not only has this model been successful in improving access to essential medicines, but drug sellers quickly proved they could do more to improve health: advise on HIV/AIDS prevention, check symptoms for tuberculosis, and dispense some forms of contraception.

Similarly, in the U.S. programs like CVS’s MinuteClinic and Walgreens’ Healthcare Clinic are broadening the role of pharmacy services from flu shots to screening, treatment, monitoring and other basic health services. Like the accredited drug dispensing outlets, these services are more affordable and more convenient. They are a shrewd business move by the pharmacies, but also a paradigm shift in how we provide health services.

3. Generate revenue while saving lives

Developing countries have also been figuring out how to make the most of limited resources. In Mexico, a tax on soda is providing new revenue for public health — with the added bonus of reducing consumption and improving health outcomes. Continue reading

Midnight Friends: How Wired Patients Are Transforming Chronic Illness

(mic_000/Flickr)

(mic_000/Flickr)

By Nell Lake
Guest contributor

Over the years, I’ve watched my cousin Deborah Haber struggle with several chronic, painful medical conditions, including fibromyalgia and a rare incurable disorder called Ehlers-Danlos Syndrome, a connective tissue disease that causes profuse sweating, a high heart rate and insomnia, among its many symptoms.

Largely housebound, and managing the life of her 11-year-old daughter, Deborah faces social isolation and persistent pain.

But along the way, my cousin has discovered a lifeline that’s lifted her outlook and improved her health. It combines the best qualities of a mother, best friend, therapist and trusted doctor to help her cope: it’s social media.

Deborah, 39, used to lie awake at night with “agonizing, shooting nerve pain,” feeling helpless and alone. She began going online, where she found others who were also awake and in pain; they became her midnight friends. “When you cannot sleep,” she says, “and you know your kid’s going to be up in a couple of hours, and you’re going to have to get her to school on time,” even if you’re exhausted — “knowing that you are not alone is a life-saver.”

With a rare and painful chronic condition, Deborah Haber found a lifeline: social media (Courtesy)

With a rare and painful chronic condition, Deborah Haber found a lifeline: social media (Courtesy)

Early on in her social media journey, Deborah mostly used Twitter. It was through people she met there that she learned about Ehlers-Danlos syndrome. She talked with her doctor, who did her own research and sent Haber to a specialist, who diagnosed the rare congenital disease. Deborah’s online activity, then, led directly to the diagnosis, which led to “far better care.”

Clearly, Deborah’s not alone: she’s part of a large and growing group of people with chronic illness in the U.S. who are using the Internet and other online technology to take charge of and improve their own health. This goes far beyond Googling your child’s weird rash: these millions of “empowered patients” are joining social-media communities, consulting online health databases, learning and sharing knowledge about drug side effects, crowdsourcing research studies, electronically monitoring their health and becoming health care activists who share what they’ve learned with their doctors.

Online patients with chronic illness use social media to improve both mental and physical health and to better connect with an understanding community, says Jennifer Covich Bordenick, chief executive officer of eHealth Initiative, which published a study earlier this year on patients’ social media patterns.

“It’s really incredible, if you look at what social media is allowing patients…to do right now,” she says. “It’s providing tremendous access to support, information, and it’s connecting people in a way that they haven’t been able to do before. … People with chronic illness are more motivated. … There’s an urgency there.” Continue reading

The Lowdown On ‘Low T’: Men’s Health Craze Booming Despite Risks

NPR reports that sales continue to soar for prescription testosterone to treat men plagued by low energy and a sluggish sex drive even while doctors fret over risks:

The number of testosterone prescriptions written in the U.S. more than tripled in the past decade. But researchers suspect that much of the testosterone dispensed at low-T clinics isn’t tracked, since it’s often bought with cash. This unfettered flow of testosterone — officially a controlled substance — has raised concerns among doctors who specialize in hormonal problems.

“In most doctors’ offices, you don’t see a big shingle over their door saying, ‘Get your testosterone here!’ ” says Dr. Edward Karpman, a board certified urologist and the medical director of the Men’s Health Center at El Camino Hospital in Los Gatos, Calif. Karpman says low-T clinics aren’t in the business of treating the complex medical problems that often masquerade as low energy and decreased sex drive. Those can include sleep apnea, depression and, perhaps most importantly, heart disease.

(Linden Tea/flickr)

(Linden Tea/flickr)

“Any man who presents, especially in his 40s and 50s, with new onset erectile dysfunction is at an increased risk for cardiovascular disease and even heart attack or myocardial infarction,” says Karpman.

Hormone treatment itself isn’t without risk: A recent study of more than 55,000 men found a doubling of heart-attack risk among older men who used testosterone. Younger men who had a history of heart disease had a higher incidence of nonfatal heart attacks. In addition, men who are on prolonged high-level testosterone replacement therapy can experience testicular shrinkage.

Earlier this year, WBUR’s Tom Ashbrook highlighted the risks of prescription testosterone and explored the meteoric rise of the ‘Low T’ diagnosis. Continue reading

My Mother’s Surgery And One Doctor’s Substance Abuse

By Karen Shiffman
Guest contributor

USA Today reports more than 100,000 doctors, nurses, technicians and other health professionals struggle with abuse or addiction. This wasn’t news to my family.

Some 20 years ago, my mother was mauled by a dog. She was on vacation in Florida and went over to a friend’s house for dinner. To understand what happened next, you need to know a few crucial facts about her: She is afraid of dogs and barely five feet tall. When her friend opened the front door, her daughter’s dog — an Akita- tore out of the house and lunged . My mother turned away quickly. The dog lunged again. Because of her short stature, his teeth sunk into her calf. He all but ripped it off.

(Alex E. Proimos/flickr)

(Alex E. Proimos/flickr)

Blood everywhere. Screams. Tears. Ambulance. Thirty-nine stitches at the ER. She would need a skin graft.

And then there was the drama with the friend. Turns out, this wasn’t the first time the dog had bitten someone. Still, the family didn’t want the dog put down. Eventually, he was. My mother and her friend of 30 years never spoke again.

Back home in Boston, my mother was referred to a plastic surgeon at what is now Beth Israel Deaconess Medical Center. He was kind and I agreed with my mother that he should do the surgery.

The operation went well. I went with her to the post-surgery checkup. We both thanked the surgeon for doing such a great job and for taking such good care of my mother.

So, imagine my shock, in 2008, to read in The Boston Globe that my mother’s surgeon was fired for being impaired in the OR. And that he had been struggling with substance abuse for the past six years. Continue reading

Second Opinion: Doc Says Blue Cross Opioid Policy Is Flawed

Amidst concerns over a massive national increase in the use and abuse of prescription painkillers, health insurer Blue Cross Blue Shield of Massachusetts instituted a new policy to reduce pain medication addiction and misuse.

This week The Boston Globe reports that as a result of the new policy, Blue Cross has cut prescriptions of narcotic painkillers by an estimated 6.6 million pills in 18 months.

But Daniel P. Alford, MD, an associate professor of Medicine and director of the Safe and Competent Opioid Prescribing Education (SCOPE of Pain) Program at Boston University School of Medicine and Boston Medical Center, calls the policy “flawed and irresponsible.” Here’s Alford’s response:

By Dr. Daniel P. Alford
Guest Contributor

The Blue Cross Blue Shield of Massachusetts opioid management program was implemented to provide members with “appropriate pain care” and reduce the risk of opioid addiction and diversion.

In a recent Boston Globe report they claim “very significant success” with this program after 18 months because they have cut opioid prescriptions by 6.6 million pills.

Dr. Dan Alford

Dr. Dan Alford

Is this really a measure of success and if so, for whom? It likely saves Blue Cross money but has it successfully achieved their program’s stated goals? Does decreased opioid prescribing mean more appropriate pain care? Does decreased opioid prescribing reduce the risk of addiction or diversion, or does it decrease access to a specific pain medication (opioids) for treating legitimate chronic pain? Is the observed decrease in opioid prescribing evidence that opioids have been overprescribed, as Blue Cross claims, or is it proof that instituting a barrier to opioid prescribing (prior authorization) will decrease prescribing even for legitimate need? Are patients with chronic pain really benefiting from this program? I doubt it.

Adding yet more paperwork for physicians will not improve pain care, decrease addiction or the numbers of accidental overdoses from prescription opioids. Those physicians who are unwilling (or ambivalent) to prescribe opioids even when indicated will use the prior authorization requirement as an excuse to continue not prescribing. Those who are overly liberal in prescribing will figure out the most efficient way to satisfy the insurance requirements for approvals. Physicians who responsibly prescribe opioids – that is, prescribing them only when the benefits outweigh any risks — will be saddled with more administrative burdens to justify their well thought-out treatment decisions.

Some physicians may ultimately decide that prescribing opioids isn’t worth the trouble despite known benefits for some patients. Continue reading

Circumcision Boost: Study Cites Benefits, Notes Foreskin-Related Health Problems

New findings may offer a boost to proponents of newborn male circumcision: Researchers in the U.S. and Australia report that the health benefits of undergoing the procedure “exceed the risks by over 100 to 1,” and note that “over their lifetime, half of uncircumcised males will contract an adverse medical condition caused by their foreskin.”

The review, published online in the Mayo Clinic Proceedings, bolsters the position of mainstream physician groups, such as the American Academy of Pediatrics, which supports insurance coverage of the practice and full access for families who choose circumcision for their infants. But the new report is unlikely to silence critics of the practice, who have called it “insane” and a “disservice to American parents and children.”

Here’s some context, from the study, which shows a slight increase in circumcision among older men, but a decline among newborns:

Preparing for a circumcision

Preparing for a circumcision (Cheskel Dovid/Wikimedia Commons)

“The latest data on male circumcision in the United States show a 2.5% overall increase in prevalence in males aged 14 to 59 years between 2000 and 2010. In contrast, there has been a downward trend in neonatal circumcisions, with the present analyses finding that the true extent of this decline is 6 percentage points.”

And here’s more from the news release:

Whereas circumcision rates have risen in white men to 91%, in black men to 76%, and in Hispanic men to 44%, the study authors found an alarming decrease in infants. To get the true figures they had to correct hospital discharge data for underreporting. This showed that circumcision had declined from a high of 83% in the 1960s to 77% today.

There seemed to be two major reasons for the fall.

One is a result of demographic changes, with the rise in the Hispanic population. Hispanic families tend to be less familiar with the custom, making them less likely to circumcise their baby boys.

The other is the current absence of Medicaid coverage for the poor in 18 US states. In those states circumcision is 24% lower. Continue reading

Flipping Health Care: From ‘What’s The Matter’ To ‘What Matters To You?’

Patient-centered care is all the rage, but what does that actually mean in the medical trenches?

It means “flipping” the entire notion of health care around, says Maureen Bisognano, President and CEO of the Institute for Healthcare Improvement (IHI), speaking today at the nonprofit group’s annual national forum in Orlando, Fl.

Instead of traditional medical care, which focuses on a patient’s disease or illness by asking the question “What’s the matter?” Bisognano says providers should focus on the person and his or hers individual needs and lead with the much more intimate: “What Matters To You?”

An example: A standard mode of assessing whether a patient’s diabetes is under control is through traditional numeric measures, like blood pressure, cholesterol levels and blood sugar. But isn’t it more meaningful, Bisognano suggests, to measure in more human terms, like how many leg amputations and heart attacks were avoided by controlling diabetes, or how many fewer trips to the ER were needed? And of course, what was the dollar savings?

It’s worth listening to Bisognano’s far-reaching talk here, which touches on what health means to a 96-year-old (living pain-free and being productive) and highlights “centering pregnancy” — group prenatal and maternity care visits in which women and teams of providers support each other.

Bisognano also features a young Millennial named Trevor, a self-described “diabetes evangelist” who explains why he’s glad he has Type 1 diabetes (it’s so much easier to be healthy when you’re forced to focus on the nutritional content of food); and what true health means to him (answer: it’s all about staying high-energy in the erratic world of college student life).

Delicate Doctoring Moments: A Medical Error By Another Physician

(Alex E. Proimos/flickr)

(Alex E. Proimos/flickr)

What if you’re a doctor, and you discover one of your patients is the victim of another doctor’s mistake, say, a serious misdiagnosis or administration of the wrong drug?

What do you do?

It’s a delicate type of problem that’s rarely discussed, even while the whole question of how to better handle medical errors is gaining new attention and focus in hospitals and medical centers around the nation. (Many institutions are embracing a new “full disclosure” philosophy with more open communication, honesty and maybe even an apology when a medical error occurs, but these policies often take years to truly take hold.)

Dr. Jo Shapiro, chief of the Division of Otolaryngology and director of the Center for Professionalism and Peer Support at Brigham and Women’s Hospital, co-wrote an article in this week’s New England Journal of Medicine exploring the topic of how clinicians should talk to patients about a medical error caused by a colleague. In the piece, she touches on the institutional, cultural and emotional barriers to such open communication, and the challenges when one doctor feels, “This is not MY error.”

It’s important to think about this problem now, Dr. Shapiro writes, because medical care these days is often delivered by a team of clinicians across “multiple care settings.” She writes that much of the medical literature assumes that “the physician providing the disclosure also committed the error,” but that may not necessarily be the case. Here’s the hypothetical example at the top of Dr. Shapiro’s piece:

You are a young neurologist practicing in a small hospital. You admit a 55-year-old woman with hypertension and type 2 diabetes mellitus who had an embolic stroke at home. On reviewing the patient’s medical record, you notice that she appears to have been in atrial fibrillation during two electrocardiographic (ECG) tests during visits to the office of her primary care physician (PCP) for palpitations. Her PCP, an internist who provides many of your referrals, read both ECGs as normal and attributed her palpitations to “probable mitral-valve prolapse and anxiety.” The patient is currently in normal sinus rhythm. You show the internist the ECGs and express concern that they
indicate atrial fibrillation. He politely disagrees and says you are confused by noise from his old ECG machine. However, when you ask two cardiologists to look at the ECGs, both immediately say “A-fib.” The internist requests that you transfer the patient to his service.

I asked Dr. Shapiro a few questions — about the particular case she describes and the issue in general. Here, lightly edited and via email, are her responses.

In the hypothetical case of the neurologist in your piece, how does he or she speak up about the error, and also overcome the deep instinct to protect a colleague?

There is of course a strong pull toward loyalty that can lead one to not speak up.  We all have the sense that we are human and can make errors and we want to be treated respectfully by our colleagues.  But currently we understand that this loyalty should not stand in the way of transparency and compassion towards our patients.

So, should the first step be for the doctor who learns about the error to confront the mistake-making doctor? And if you do this, might you alienate this doctor forever?

Yes. Ideally one would contact the physician who had been previously caring for the patient so you could discuss your perspective and concerns with him/her.  Often, that physician might have a perfectly reasonable explanation regarding the care.  If not, it is still important to have the conversation so that two things can happen:  the MD learns from the error and the MD has the opportunity to discuss this with the patient and to apologize.

Have you experienced this personally?

Yes.  I have been a practicing surgeon for more than 25 years and on rare occasion, I have seen a patient where I felt the prior care had not been optimal.

Why might this situation (one doctor learning of another’s mistake) arise more in the current health care climate?

I think this issue arises more now only from an awareness point of view.  That is, the phenomenon of seeing that another clinician may have inadvertently made an error is not a new phenomenon.  What has changed is the understanding that patients have a right to know what has happened to them, and we as a medical community need to discuss and give feedback to our colleagues so that we can all learn from any mistakes and prevent them from happening in the future.

There’s a good deal of talk about more disclosure, honesty and apologies when it comes to medical errors, but are things truly changing? And which institutions are doing the best job ?

Yes, the culture is changing. Continue reading

Why I Left Medicine: A Burnt-Out Doctor’s Decision To Quit

By Diane Shannon
Guest Contributor

When I introduce myself as a physician who left clinical practice, non-physicians ask me why I left. They’re generally intrigued that someone who sacrificed many years and many dollars for medical training would then change her mind. But physicians, almost universally, never ask me why I left. Instead, they ask me how. They call and email me with logistical questions, wanting to learn the secret of how I managed the transition out of clinical medicine (read “escape”).

Earlier this month I attended a conference on physician well-being at the Massachusetts Medical Society where I heard an alarming statistic: the suicide rate among women physicians is more than two times that of women in the general population.

Diane Shannon, plagued by constant worry about patients, and fear of medical errors, gave up her career as a physician. (Courtesy)

Dr. Diane Shannon — plagued by constant worry about her patients and fear of medical errors — walked away from a career as a physician. (Courtesy)

It may be dramatic and self-serving to frame my career change as a way to avoid suicide, but I can attest that medicine was not conducive to my health. As an internist, working in adult outpatient clinics around Boston, I had trouble leaving my work at work. I’d go for a run and spend the entire 30 minutes wondering if I’d ordered the right diagnostic test. I suffered from chronic early morning wakening, even on my weekends off. I startled easily. I found it impossible to relax. I worried constantly that I’d make a mistake, like ordering the wrong dosage of a medication, or that a system flaw, like an abnormal lab report getting overlooked, would harm a patient. I no longer remembered the joy I’d felt when I first began medical school, and I couldn’t imagine surviving life as a doctor.

I no longer believe it was weakness or selfishness that led me to abandon clinical practice. I believe it was self-preservation. I knew I didn’t have the stamina and single-mindedness to try to provide high-quality, compassionate care within the existing environment. Perhaps, due to temperament or timing, I was less immune than others to the stresses of practicing medicine in a health care system that often seemed blind to humanness, both mine and my patients’.

That’s not to say that I don’t miss practicing medicine. I do. I miss engaging in meaningful interactions and being of service, reassuring an elderly woman that we could make her emphysema easier to endure, bearing witness to a cancer patient’s grace in the face of death, supporting a college student facing an unexpected pregnancy. I miss spending my days in deeply meaningful work. Continue reading