practicing medicine


Majority Of Young People With Depression Don’t Get Treatment, Report Finds

A new national snapshot of the state of mental health across America is, frankly, a little discouraging, especially when it comes to young people.

One startling finding from the annual report produced by the nonprofit Mental Health America: “[S]ixty-four percent of youth with depression do not receive any treatment.”

In addition, the report found:

Even among those with severe depression, 63 percent do not receive any outpatient services. Only 22 percent of youth with severe depression receive any kind of consistent outpatient treatment (7-25+ visits in a year).

I asked one of our frequent contributors, child psychiatrist Dr. Eugene Beresin, executive director of the Massachusetts General Hospital Clay Center for Young Healthy Minds and professor of psychiatry at Harvard Medical School, for his thoughts on the report.

Here, lightly edited, is his response:

First, I am not surprised. There are a number of issues not emphasized by this summary:

1. There is a huge shortage of child and adolescent psychiatrists in the U.S. Currently there are about about 7,000.

So while many parents seek help, the access to care is severely limited. Primary care pediatricians are inadequately trained in psychiatry and this has been addressed by the American Academy of Pediatrics. Their graduate training requires only two months in developmental behavioral pediatrics and few have any significant training in psychiatry. They are desperate to make referrals and often are at a loss to find qualified clinicians. Some states such as Massachusetts and New York have statewide efforts to assist them through consultation and education in psychiatry, but this only scratches the surface. Continue reading

Shameful Operating Room Moments: Medical Journal On Calling Out ‘Dirtball’ Doctors

(Just Us 3/Flickr)

An essay published in the Annals of Internal Medicine begs the question: How many of us are being mocked and crudely disrespected while we’re at our most vulnerable? (Just Us 3/Flickr)

Imagine this scene:

A female patient under general anesthesia is being prepped for a vaginal hysterectomy. As the attending doctor washes and scrubs her labia and inner thighs, he turns to a medical student and says: “I bet she’s enjoying this.” Then he winks and laughs.

No, this account doesn’t come from a racy British tabloid. It was published this week in a reputable medical journal, Annals of Internal Medicine.

The account, written by an anonymous doctor and titled “Our Family Secrets,” also describes an incident involving an obstetric patient, Mrs. Lopez, who experienced hemorrhaging and other complications after childbirth. To stop the bleeding and ultimately save the patient, her doctor performs what is called an “internal bimanual uterine massage,” which means he must get his entire hand inside her vagina. From the piece:

“…something happened that I’ll never forget. Dr. Canby raises his right hand into the air. He starts to sing ‘La Cucaracha.’ He sings, ‘La Cucaracha, la cucaracha, dada, dada, dada-daaa.’ It looks like he is dancing with her. He stomps his feet, twists his body, and waves his right arm above his head. All the while, he holds her, his whole hand still inside her vagina. He starts laughing. He keeps dancing. And then he looks at me. I begin to sway to his beat. My feet shuffle. I hum and laugh along with him. Moments later, the anesthesiologist yells, ‘Knock it off, assholes!’ And we stop.”

Stomach Churning

Dr. Christine Laine, editor in chief of Annals of Internal Medicine, said this is the first time in her tenure that such a profanity has been printed in the journal. But, she said in an interview, it seemed appropriate in this case. When she first read the essay she says it made her “stomach churn,” and it made her angry.

“Angry for the patients … angry for the younger physicians who encountered this behavior, angry at myself and others who have witnessed colleagues being disrespectful to patients but were too timid to speak out,” Laine said.

In an accompanying editorial condemning the behavior described in the essay, Laine and her colleagues wrote: “The first incident reeked of misogyny and disrespect — the second reeked of all that plus heavy overtones of sexual assault and racism.”

So how did this series of unfortunate medical events unfold?

Here’s the backstory: The anonymous author of the essay (the journal decided to keep the doctor’s identity a secret) was leading a course on medical humanities for senior medical students. The topic was “the virtue of forgiveness.” At one point the doctor put a question to the class: “Do any of you have someone to forgive from your clinical experiences? Did anything ever happen that you need to forgive or perhaps still can’t forgive?” Continue reading

Where Does Life Begin, And Other Tough Abortion Questions For Doctors In Training

Our recent post on how residents training to be OB-GYNs think about providing abortions (or not providing them) went viral earlier this month and triggered a broader conversation among readers. The topic was also featured on Radio Boston and WBUR’s All Things Considered.

I asked Janet Singer, a nurse midwife on the faculty of Brown University’s obstetrics-gynecology residency program, and the person who organized the initial discussion among the residents, to follow up. She, in turn, ​asked Jennifer Villavicencio, a third-year resident​, to lead a discussion digging even more deeply into the topic.

Two of the residents ​in the discussion ​perform abortions, two have chosen not to do so. ​But they are colleagues and friends who have found a way to talk about this divisive issue in a respectful and productive way. ​Here, edited, is ​a transcript of ​their discussion, which gets to the heart of a particularly fraught question: When does life truly begin? ​Three of the residents have asked that their names not be included, for fear of hostility or violence aimed at abortion providers.

Jennifer Villavicencio (Resident 3): Let’s talk about a woman who comes in, has broken her water and is about 20 to 21 weeks pregnant and after counseling from both her obstetricians and the neonatologist [a special pediatrician who takes care of very sick newborns] has opted for an abortion. Let’s talk about how we each approach these patients.

Resident 2: As a non-abortion provider I will start just by saying that a patient of this nature in some ways is on one extreme of the spectrum. As an obstetrician, I view the loss of her pregnancy as an inevitability. I think we would all agree with that. So, taking part in the termination [another word for abortion] of her pregnancy is different to me than doing that for someone whose pregnancy, but for my involvement, would continue in a healthy and normal fashion.

Opponents and supporters of an abortion bill hold signs outside the Texas Capitol on July 9 in Austin. (Eric Gay/AP)

Opponents and supporters of an abortion bill hold signs outside the Texas Capitol on July 9 in Austin. (Eric Gay/AP)

JV: Would your opinion change if she were 22 or 23 weeks and theoretically could make it to viability [the concept that a fetus could survive outside of the mother. Currently, in the U.S., the generally accepted definition of viability is 24 weeks gestation or approximately six months pregnant]?

Resident 2: Personally, it wouldn’t, because I feel there is a very slim chance of an intact survival [refers to an infant not having significant mental or disabilities] of an infant. If she were 22 or 23 weeks gestation and could potentially make it to the point of a survivable child, that likelihood is so rare. But for my involvement, she will still lose this pregnancy. My point is, if I help terminate this pregnancy, I am not playing an integral role in the loss of this pregnancy. I feel that supporting her in proceeding in the safest possible way, protecting her while accepting the loss of her pregnancy, is my job.

Future Health Of The Child

JV: Does the future health of the child really play a role in it for you?

Continue reading

Practicing Restraint In A No-Empathy Zone: At The Cancer Surgeon’s Office With My Son

Cathy Corman
Guest Contributor

I carry a genetic mutation increasing my risk of developing breast and ovarian cancer. My children have a 50 percent chance of inheriting the mutation. My 22-year-old son recently noticed a breast lump and asked me to join him when he met with a surgical oncologist to be evaluated.

The surgeon performed a skillful physical exam but provided neither effective risk assessment nor empathetic counsel. Afterward, I sent an email to friends briefly explaining what had gone wrong during the appointment. “We want to know how you managed not to hit him,” they asked. I did it by practicing restraint: slowly counting backwards from 10 and taking very deep breaths.

Here’s my countdown:

10. I did not correct the icy-blue-eyed surgeon with steel-grey hair and steady hands — 50? 60? — when he dissuaded my son from pursuing genetic testing. The surgeon had shaken my son’s hand, looked him in the eye, and palpated my son’s slender, muscular chest, identifying the small lump under my son’s left nipple. A positive finding of a mutation, the surgeon said, adjusting the top of his surgical scrubs, could expose my son to discrimination in the workplace and in obtaining health insurance. That is, I did not say, “The scenario you describe is illegal in this country.” As of March 23, 2010, with the passage of the Patient Protection and Affordable Care Act (aka “Obamacare”), if anyone were to attempt to discriminate against this young man in the workplace or in the process of applying for health insurance because of a positive finding for a genetic mutation (a pre-existing condition), this person would be subject to a massive lawsuit.

Cathy Corman (Courtesy)

Cathy Corman (Courtesy)

9. When this surgeon used the word “anxiety” for the eighth time to a) describe my son and myself and b) provide his vision of a course of action, I did not refer this man to Leslie Jamison’s collection of essays, “The Empathy Exams.”  “Empathy,” writes Jamison, “isn’t just remembering to say that must really be hard — it’s figuring out how to bring difficulty into the light so it can be seen at all. Empathy isn’t just listening, it’s asking the questions whose answers need to be listened to. Empathy requires inquiry as much as imagination. Empathy requires knowing you know nothing. Empathy means acknowledging a horizon of context that extends perpetually beyond what you can see…”

8.  I did not bring up this statistic: Though men make up only 1 percent of breast cancer diagnoses annually in the U.S., they may be up to 25 percent likelier than women to die from the disease, probably because of lack of awareness and late detection. Nor did I mention that generally male breast cancer presents with a detectable lump and is almost always linked to radiation exposure, unusually high levels of estrogen or a genetic mutation. Surely the surgeon knew these statistics? But my son did not. And I did not want to scare him.

7. I said nothing to this surgeon’s response to my son’s question, “But wouldn’t it be relevant to know if I carry the mutation?” His answer: No, you know you have a family history of breast cancer.

6. I said nothing when this surgeon dodged my son’s question: “If my grandfather didn’t have the mutation,” my son wanted to know, “wouldn’t he not have had breast cancer? And wouldn’t it be important for me to know if I carry the mutation, too, to assess my risk?” The surgeon’s reply: The only way you’ll know if you have cancer is to have the lump removed. The surgeon’s answer, while true, sidestepped the elephant in the room: whether my son carries a mutation elevating his risk of breast cancer.

5. When this surgeon ridiculed an actress whose name he could not remember for publicly disclosing her status as a mutation carrier and for undergoing prophylactic mastectomies, I offered him the actress’s name. Continue reading

Why The Primary Care Problem (Lower Status, Pay) Matters

By Jeff Levin-Scherz, M.D., M.B.A.
Guest Contributor

Medscape just published its annual physician compensation survey. The survey includes almost 20,000 physicians and is given online, so it’s probably not entirely representative.

Also, the survey results are self-reported, and physicians generally under-report their income. But the comparative reported income among specialties is informative. This survey is among the largest available, and does not require an expensive paid subscription.

(Courtesy of Medscape)

(Courtesy of Medscape)

The results are no surprise. But they’re worth noting: Specialists make 45 percent more than primary care physicians, and orthopedists make 224 percent more than pediatricians.

The majority of respondent physicians were employed, and men consistently make more than women in the same specialty. Women have the largest representation in specialties with the lowest incomes.

Physician income was a bit lower in the Northeast but higher in the Northwest. Massachusetts’ physicians report that their income is 46th in the nation.

Internists are the least satisfied in their job (47 percent), and the least likely to choose their specialty if they could choose again (25 percent), but high in the rankings of specialties where the respondent would choose medicine again (71 percent).

(Courtesy of Medscape)

(Courtesy of Medscape)

Family physicians were only slightly more likely to choose the same specialty again as internists (31 percent), yet they were the most likely to say they would choose to go into medicine again (74 percent).

Pediatrician income is among the lowest of all specialties, yet they are twice as likely to say that they would choose the same specialty. Internists and family physicians would go into medicine again, but they would go into sub-specialties, and not do general primary care. The high cost of health care in the U.S. is in part due not to a shortage of primary care physicians, but also due to a surplus of specialists.

Why does all this matter?

The American College of Physicians reported on the impending “collapse” of primary care in 2006. There have been efforts to change this situation since, including “patient centered medical homes,” and short-term enhanced Medicaid primary care fee schedules built into the Affordable Care Act.

The continued relatively lower pay of primary care physicians and the lack of job satisfaction of general internists and family physicians means that our historic way of delivering primary care is about to change. Much future primary care is likely to be delivered by nurse practitioners or physician assistants, and some office-based primary care will be supplanted by telehealth or by apps with underlying algorithms.

The Medscape survey suggests that we will continue to face serious challenges to continue to deliver the highly personalized primary care which many of us value, and the highly coordinated care needed by the frail elderly and those with serious chronic illnesses.

Continue reading

Predicting The Next Mental Health Crisis: Sometimes We Just Can’t Know



By Steve Schlozman, M.D.

When tragedies hit, it is in our nature to ask why. The co-pilot in the horrific Germanwings crash had serious mental health problems, according to reports. How could no one have known how serious his challenges were? How could no one have predicted this terrible outcome?  On its surface this line of questioning seems even a bit ludicrous.  After all, even in the murky face of mental illness, the potentially deliberate and fatal nose-dive of a commercial aircraft seems impossible to imagine.  Nevertheless, this is exactly the question that we’re seeing over and over in the coverage of the crash.

How could we not have known?

The fact is, however, that this particular question glosses over a profoundly uncomfortable quandary that is by no means unique to psychiatry. For all of modern medicine, predictions are surprisingly fraught with difficulty.  For all of medicine’s miracles, for all of its technological wonders and advances, medicine remains a quintessentially human endeavor.  You might even argue that phrases like “medical miracle” are indeed part of the problem.  This more we grant medicine undue and mystical prowess, the more resistant we grow to the grueling trial and error that characterize everyday medical practice.  Doctors are wrong all the time.  That’s a fact.

Nevertheless, physicians are asked to prognosticate. That’s the verb form of “prognosis.” As patients and families, we look to our doctors daily for prognostic estimates.  (Emphasis on estimates.)  These estimates are really hypotheses necessarily based on incomplete data. Rare complications and twists of fate befuddle even the best.

For psychiatry this truth can be especially hard to swallow.  A neurologist might not be able to predict every migraine, but it is the rare migraine that results in tragedy.  Still, remember that psychiatrists cannot read minds. Like all physicians, psychiatrists will try their best to understand what is the cause of suffering.  And, as with all clinicians, psychiatrists will sometimes be right and sometimes not.  Medicine remains an art even as the science continues to improve.

The fact that someone suffers a psychiatric disorder, even a recurrent psychiatric disorder, is not remarkable when compared to the rest of medicine.  The same occurs with ulcers, asthma, allergies, orthopedic injuries, sinus infections and so forth. Most medical illnesses are chronic and many are intermittent. No medical professional can predict with absolute certainty when an episode is going to occur or how severe it may be. To be fair, physicians can and do identify triggers, but the intensity of a presumed reaction is outside anyone’s ability to predict.

And this is where society gets especially flummoxed. No one would argue that the art of medicine is infallible. No one would suggest that medical practice is right 100% of the time. But faced with tragedy, we are much more comfortable as a species pretending that our predictions are foolproof and that our mishaps are exceedingly rare.

Why can’t we always know? Medicine is post-modern. We cannot know because we can’t. Continue reading

Pathologist: What Women Need To Know About Breast Biopsy Accuracy

A breast biopsy which illustrates the grey zone of pre-cancer (Courtesy of Dr. Michael J. Misialek)

A breast biopsy which illustrates the grey zone of pre-cancer (Courtesy of Dr. Michael J. Misialek)

By Michael J. Misialek, MD

If you’re a woman who has ever had a breast biopsy, you may be asking yourself a few serious questions:

“How do I know if my breast biopsy is completely accurate?” And, “Who is the pathologist reading the biopsy, and what is their level of training?”

Many more patients are asking these and similar questions following widespread media coverage on a Journal of the American Medical Association (JAMA) study, which casts doubt about the accuracy of interpreting these biopsies.

Let’s break the study down and ease some anxiety. Perhaps most importantly, this provides a great opportunity to learn about one of the lesser know medical specialties, pathology…which is what I do.

The JAMA study, “Diagnostic Concordance Among Pathologists Interpreting Breast Biopsy Specimens,” revealed the following key finding:

• Overall agreement between individual pathologists’ interpretations and that of an expert consensus panel was 75 percent, with the highest agreement on invasive breast cancer and lower levels of agreement for ductal carcinoma in situ (DCIS) and atypical hyperplasia.

What this means is that the agreement between a general pathologist and an expert was excellent for breast cancer (those with the ability for metastasis), but varied significantly for early cancers and high-risk pre-cancers.

While the study’s findings may not be surprising to physicians who understand the challenges of diagnosing complex breast cases, news of the article could lead to unnecessarily heightened anxiety for patients and the public as breast cancer is a highly publicized and pervasive disease.

The study confirmed that the majority of breast pathology diagnoses, especially at either end of the spectrum (benign disease and invasive breast cancer) are accurately made by practicing pathologists regardless of practice setting. The overall rate of agreement for invasive breast cancer cases was 96 percent.

Issues with diagnostic disagreement mainly center on the borderline cases, between atypical hyperplasia, that is, pre-cancer, and DCIS, early cancer.

Why does this matter? Overdiagnosis can lead to unnecessary surgery, treatment and anxiety. Underdiagnois can lead to a delay in treatment. The bottom line is that experience matters.

Factors that contributed to greater disagreement included: a low case volume, small practice size, nonacademic practice and high breast density.

The study has many weaknesses. Chief among them was that only a single slide per case was given to each pathologist. As a practicing pathologist, this never happens. I will review multiple slides, often ordering several additional deeper sections and ancillary special stains, studying each carefully. This practice was prohibited in the study.

Additionally, the study cases were a mixture of core biopsy and excision specimens. A core biopsy is obtained using a needle, often by a radiologist, in which a small core of tissue is removed. An excision is a “lumpectomy” which is done in the operating room where a large section of breast tissue is removed. Diagnostic criteria vary between a needle core and excision. Often times it is not necessary to render an exact diagnosis on the core biopsy, but rather recognize an abnormality and recommend an excision for which additional tissue will clarify the diagnosis.

Even the experts disagreed in the study (75 percent initial agreement then 90 percent after discussion).

This illustrates the fact that pathology is both a science and art. Experts may stress slightly different criteria in their pathology training programs. The “eye of a pathologist” is a difficult measure to quantify and is dependent on multiple factors that best function in real time, not an artificial study.

Another weakness is that there is no evidence that the experts were more accurate in predicting outcomes than test subjects. Perhaps most importantly, a second opinion was not allowed in the study, even when study participants indicated uncertainty. These are in fact the very cases that would most likely have been shown around, sent out for consult and further worked up.

It is not realistic to introduce such a large caseload of breast biopsies that are heavily weighted towards atypical hyperplasia and DCIS. Since these borderline cases represent only a small fraction of breast biopsies in actual practice, diagnostic agreement in routine practice is higher than that reported in this study. No clinical information other than patient’s age was given to the study pathologists, and no imaging findings were included. In actual practice, integration of the clinical setting and imaging findings is routinely used in making a diagnosis.

The findings are not unique to pathology. All of medicine has grey zones, where controversy often exists. The study does have an important message for pathologists. As noted in the accompanying editorial, it should serve as a “call to action.” A better, more reproducible definition of atypical hyperplasia is needed.

The article highlights the need for an active quality management program in surgical pathology that includes targeted review of difficult or high risk cases. The College of American Pathologists (CAP) and the Association of Directors of Anatomic and Surgical Pathology have been developing an evidence-based guideline expected to be released in May to provide recommendations to reduce interpretive diagnostic errors in anatomic pathology.

The CAP is proactively addressing educational opportunities through advanced breast pathology training programs designed to provide a route for pathologists to demonstrate their expertise regardless of the setting in which they practice.

Patients can take steps to help ensure their breast biopsy is read accurately:

o Inquire about the pathology laboratory that will examine your tissue sample. Is the laboratory accredited? The CAP accredits more than 7,600 laboratories worldwide and provides an online directory for patients. Continue reading

Delirious: Study Finds Simple, Humane Fixes For Aged, Disoriented Patients

(Xavi Talleda/Flickr)

(Xavi Talleda/Flickr)

By Alison Bruzek
Guest Contributor

The patient was an older man, living at a nursing facility. He’d originally been admitted to the hospital for surgery to treat a urinary tract infection. But now, lying in his bed at the hospital after the operation, he was convinced that two people were standing outside his room and planning to blow it up.

“We could tell this person was delirious,” says Dr. Eyal Kimchi, a neurologist at Massachusetts General Hospital

Delirium is a complicated syndrome, most common among the hospitalized elderly where it’s estimated 29 to 64 percent of patients have it. However, it’s underreported and researchers estimate as many as two-thirds of cases go undiagnosed.

While usually temporary, it leaves people feeling severely confused. Their brains switch rapidly between mental states, increasing their risk of falling and later brain problems like dementia.

Though the patient’s mind was muddled, the idea of an explosion hadn’t appeared to him out of the blue — he was at the hospital around the time of the Boston Marathon bombing. What had likely happened, says Kimchi, is the patient had begun misattributing the news reports he saw playing on the television to actual life.

And even though that patient fully recovered, some of those delirious thoughts remained. “Ultimately this person said, ‘I know I’m better, I know I was confused, but I also know they were trying to blow up the place,’ ” says Kimchi.

People with delirium can often run the gamut of states, from hyperactive and aggressive to withdrawn and nearly comatose. The causes are not well understood but it’s a combination of a person’s predisposition to delirium as well as an event that sets it off, says Kimchi. These could be “surgery, infections, other sorts of brain injuries like trauma,” he says. “It’s still very hard to predict on an individual basis.”

While there’s not a lot of research on the predictors of delirium, there are ways to prevent it, according to a study released this week in the Journal of the American Medical Association Internal Medicine.

Prevention may be as simple as reminders and attentive care, says, Dr. Tammy Hshieh, a researcher of aging and geriatrics at Brigham and Women’s Hospital and author of the JAMA study. She suggests preventative measures like reorienting patients to where they are, keeping them hydrated and healthy, and ensuring they have hearing aids or glasses or other physical assistance is an effective method to stop delirium. Continue reading

White Coats For Black Lives: Toward Racial Equality In Health Care

Kaitlyn Veto/flickr

Kaitlyn Veto/flickr

Acknowledging the public health impact of racism and deep disparities in the quality and accessibility of medical care for patients of color, a national organization, White Coats for Black Lives, says it’s launching a new effort today, in celebration of Martin Luther King, Jr.

Dorothy Charles, one of the group’s organizers and a first year medical student at the University of Pennsylvania’s Perelman School of Medicine, offers some context in an email:

Racism profoundly impacts people of color: the black-white mortality gap in 2002, for example, accounted for 83,570 excess deaths. As future physicians, we are responsible for addressing the perpetuation of racism by medical institutions and seek policy change to eliminate disparities in outcomes.

Here’s a statement from the White Coats for Black Lives National Steering Committee:

Upon matriculating in medical school, students recite the Hippocratic Oath, declaring their commitment to promoting the health and well-being of their communities. On December 10, 2014, students from over 80 medical schools across the United States acted in the spirit of that oath as we participated in a “die in” to protest racism and police brutality. In our action, we called attention to grim facts about the public health consequences of racism, acknowledged the complicity of the medical profession in sustaining racial inequality, and challenged a system of medical care that denies necessary treatment to patients unable to pay for it, disproportionately patients of color.

Today, in celebration of the legacy of Dr. Martin Luther King Jr., we announce the founding of a national medical student organization, White Coats for Black Lives. This organization brings together medical students from across the country to pursue three primary goals:

1. To eliminate racism as a public health hazard

Racism has a devastating impact on the health and well-being of people of color. Tremendous disparities in housing, education, and job opportunities cut short the average Black life by four years. Physicians, physician organizations, and medical institutions must therefore publicly recognize and fight against the significant adverse effects of racism on public health. We additionally advocate for increased funding and promotion of research on the health effects of racism.

2. To end racial discrimination in medical care

We recognize that insurance status serves in our healthcare system as a “colorblind” means of racial discrimination. While it is illegal to turn patients away from a hospital or practice because of their race, patients across the country are frequently denied care because they have public insurance or lack health insurance. We support the creation of a single payer national health insurance system that would give all Americans equal access to the healthcare they need. Such a system would create a payment structure that reflects the fact that “Black lives matter.” Moreover, ample evidence suggests that patients of color receive inferior care even when they are able to see a doctor or nurse; we therefore advocate for the allocation of funding for research on unconscious bias and racism in the delivery of medical care. Continue reading

Got A Headache? Study Finds Flaws In Treatment, ‘Alarming’ Rise In Imaging Tests



Sometimes less really is more. A case in point: the treatment of routine headaches.

Doctors are increasingly ordering pricey, advanced imaging tests and referring patients to specialists, which, it turns out, offers little help to headache sufferers, a new study concludes.

Researchers from Boston’s Beth Israel Deaconess Medical Center suggest that patients might be better served (and the health care system might save money) by instead focusing more on lifestyle changes for people seeking headache relief.

For the study, published online in the Journal of General Internal Medicine, researchers used a nationally representative database to analyze practice patterns among physicians treating headache patients.

I asked the lead author, John N. Mafi, MD, a fellow in the Division of General Medicine and Primary Care at BIDMC, to sum up the bottom line results. Here (slightly edited) is his emailed response:

“…We found alarming rises in use of advanced imaging (CT/MRI), referrals to other physicians (presumably specialists), and a decline in first-line recommended life-style modification counseling, meant to prevent headaches. We also saw no change in use of discouraged medications, with opioids and barbiturates ordered in about 18% of visits throughout the study period.

These findings represent alarming trends in the management of headache, and to me, they reflect a larger trend in the U.S. healthcare system where over-hurried doctors are ordering more tests, more medications, more referrals to specialists and less time talking and connecting with their patients.

To me this suggests that the visit-based model of healthcare is broken, Continue reading