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Howard Brody, a family physician at the University of Texas Medical Branch, recently proposed, in The New England Journal of Medicine, that every medical specialty identify five procedures—diagnostic or therapeutic—that are done a lot and cost a lot but provide no benefits to some or all of the patients who receive them. Five is just a suggestion, high enough to be meaningful but low enough to exclude procedures in which the science is still open to debate, such as annual mammograms for women under 50. “I’m pretty convinced that each specialty could come up with 15 or 20, but in calling for five I think we can find uncontroversial ones,” says Brody. It’s not just about saving money, either. Any time a doctor performs a procedure, there is the risk of medical error and side effects, such as an elevated risk of cancer from CT scans. Unnecessary care kills 30,000 Americans every year, estimates Dr. Elliott Fisher of Dartmouth Medical School—and that figure includes only Medicare patients.
Medical groups have not exactly beaten a path to Brody’s door, so NEWSWEEK contacted several to see if they would play along. Reactions ranged from “we do no unnecessary care” (dermatology) to “only five?!” (emergency medicine). Allen Lichter, CEO of the American Society of Clinical Oncology, nominates what he calls “nth-line therapy”—the third or fourth or fifth chemotherapy drug for a patient whose cancer has not been felled by the first or second. “I don’t know what n should be,” he says. “But at some point chemotherapy has an extremely low chance of extending life and a high chance of shortening life due to toxicity.”
Begley, "Medicine We Can Live Without"
I completely forgot to mention this short series that was running last week on the New York Times Opinion blog, focused entirely around sleep and insomnia. The link above will take you to all the essays, and they’re all equally worth reading!
While in theory “sleep hygiene” makes sense, in today’s culture, which affords no time for relaxation, it’s hard to put into practice. We’re on the computer at all hours and then we snuggle with our Blackberries. Our kids are even more hyperactive, texting way past their bedtimes, although today even the concept of “bedtime” sounds quaint. To compensate for being so tired in the mornings, they eat caffeinated foods, gulp energy drinks, and pop Adderall and Ritalin…As the anthropologist Matthew Wolf-Meyer notes, “If a society can’t rest, how can it sleep?”
Nwk has been fascinated by sleep, and lack thereof, for years. We love this series.
The annual number of American medical students who go into primary care has dropped by more than half since 1997. It’s hard to get an appointment with the doctors who remain. In some surveys, as many as half of primary-care providers have stopped taking new patients. The other half are increasingly overworked and harried. Clearly we need to find a way to increase their ranks, and both the congressional health-care bills and President Obama’s reform proposal make moves in that direction. But those efforts are somewhat limited, and a more comprehensive solution could be thwarted by the same thing that’s stalled the rest of health-care reform so far: politics.
The reason behind America’s doctor gap is a matter of money. The average income in primary care is somewhere in the mid-$100,000s, which sounds like a lot but is less than half what specialists such as radiologists and dermatologists make. Given that doctors may graduate with as much as $200,000 in med-school debt, it’s easy to see why primary care started hemorrhaging recruits more than a decade ago and why radiology and other well-paid, high-tech specialties took off in popularity.
Mary Carmichael, on the growing primary-care doctor shortage
Begley, on cultural neuroscience.
In college I wrote a piece about Adderall and for a little while after that I was contacted occasionally by outlets looking for an Adderall-using teen specimen. Random people also emailed me asking where they could get Adderall, and a very well-spoken long-time speed addict told me to stop noodling around with it, which I did.
Not considering myself a specimen of anything, I declined all of the requests (except one to anthologize the essay in a college sociological textbook about cheating—sweet!). When Newsweek got in touch about using me as an anonymous source for a piece, however, I said yes, because I love being an anonymous source. If you comb through issues of Teen Vogue from 2003-2004 you will find anonymous quotes from me about many things, including the size of Beyoncé’s butt.
During the Newsweek interview I tried to be candid and interesting. Then I graduated and moved to Los Angeles. When the magazine contacted me about a photoshoot, I agreed; I’ve always wanted to be one of those “anonymous source” photos with my face in dense chiaroscuro or photographed through a pill bottle.
I was living in a bungalow in Los Feliz at the time. When the photographer and stylist arrived I expected we’d go somewhere else, but they liked the backdrop of the house. For some reason I’d fixed my hair in Heidi braids. The stylist did not like this but accepted it.
The first set-up involved me watering plants in the front-yard (they were all cactuses which did not need water) with the spray blocking my face. Next I stood behind a tree with a banana leaf concealing my face. Finally we moved to the back patio, where I showed them my zucchini plants and stood bisected by a trellis.
After the shoot I heard nothing for eight or twelve weeks. Then I got an email notifying me that the piece had been killed, which was a relief. In the intervening months I had grown more cautious about going on the record, and was feeling guilty about doing so in exchange for an anecdote. I saved the email, considered the whole thing over, and forgot about it.
That was two years ago, more or less. This morning I opened a long-unread book and discovered, wedged between chapters, a test Polaroid from the shoot—one determined “not anonymous enough”, for obvious reasons. It was like finding the old canceled stamp from a specific, significant letter.
Here is Anonymous Molly:
We love this, and wish the story had run…
Willett/Underwood, "How Public Policy Can Prevent Heart Disease"
Until last year, the residents of Albert Lea, Minn., were no healthier than any other Americans. Then the city became the first American town to sign on to the AARP/Blue Zones Vitality Project—the brainchild of writer Dan Buettner, whose 2008 book, The Blue Zones, detailed the health habits of the world’s longest-lived people. His goal was to bring the same benefits to middle America—not by forcing people to diet and exercise, but by changing their everyday environments in ways that encourage a healthier lifestyle.
What followed was a sort of townwide makeover. The city laid new sidewalks linking residential areas with schools and shopping centers. It built a recreational path around a lake and dug new plots for community gardens. Restaurants made healthy changes to their menus. Schools banned eating in hallways (reducing the opportunities for kids to munch on snack food) and stopped selling candy for fundraisers. (They sold wreaths instead.) More than 2,600 of the city’s 18,000 residents volunteered, too, selecting from more than a dozen heart-healthy measures—for example, ridding their kitchens of supersize dinner plates (which encourage larger portions) and forming “walking schoolbuses” to escort kids to school on foot.
The results were stunning. In six months, participants lost an average of 2.6 pounds and boosted their estimated life expectancy by 3.1 years. Even more impressive, health-care claims for city and school employees fell for the first time in a decade—by 32 percent over 10 months. And benefits didn’t accrue solely to volunteers. Thanks to the influence of social networks, says Buettner, “even the curmudgeons who didn’t want to be involved ended up modifying their behaviors.”
Isn’t it time we all followed Albert Lea’s example? Diet and exercise programs routinely fail not for lack of willpower, but because the society in which we live favors unhealthy behaviors. In 2006, cardiovascular disease cost $403 billion in medical bills and lost productivity. By 2025 an aging population is expected to drive up the total by as much as 54 percent.
Is not feeling sad worth a face full of botulism? (maybe?)
“The idea was to see whether the treatment affected their ability to feel certain emotions. We already know that Botox affects the ability to convey emotions such as anger, and a 2006 study found that it might even alleviate depression, as NEWSWEEK reported, presumably by the same mechanism: block the facial expression of sadness, prevent the related emotion.”
Read Chaos and Organization in Health Care by James Mongan and Thomas Lee, both doctors. Mongan is the recently retired head of Partners HealthCare System in Boston, and Lee is a senior manager. Partners is a network of two Harvard-affiliated teaching hospitals, six community hospitals and 6,000 doctors. From personal experience and studies, Mongan and Lee describe an increasingly fragmented system that often raises costs and lowers quality.
A typical primary-care doctor has 2,500 patients and works 50 to 60 hours a week. By some surveys, doctors have increased the time they spend with individual patients; but it often feels like less because there is “so much more to do than a generation ago,” Mongan and Lee write. Paradoxically, medical “progress”—better diagnostics, drugs and treatments—fosters “chaos” by increasing specialization. Information-sharing becomes harder, and patients find the system more impersonal. A typical Medicare recipient sees seven doctors in a year. In 1986, almost half of internists performed treadmill tests in their offices; by 2004, only 29 percent did. Tests had shifted to cardiologists.
Hospitals and outside doctors often don’t coordinate. One study found that two-thirds of patients leave the hospital without proper “discharge summaries” detailing tests and drug treatments. In early 2008, fewer than 20 percent of doctors used “electronic medical records” in their offices. High start-up costs were a major obstacle.
In early January a friend mentioned that his New Year’s resolution was to beat his chronic depression once and for all. Over the years he had tried a medicine chest’s worth of antidepressants, but none had really helped in any enduring way, and when the side effects became so unpleasant that he stopped taking them, the withdrawal symptoms (cramps, dizziness, headaches) were torture. Did I know of any research that might help him decide whether a new antidepressant his doctor recommended might finally lift his chronic darkness at noon?
The moral dilemma was this: oh, yes, I knew of 20-plus years of research on antidepressants, from the old tricyclics to the newer selective serotonin reuptake inhibitors (SSRIs) that target serotonin (Zoloft, Paxil, and the granddaddy of them all, Prozac, as well as their generic descendants) to even newer ones that also target norepinephrine (Effexor, Wellbutrin). The research had shown that antidepressants help about three quarters of people with depression who take them, a consistent finding that serves as the basis for the oft-repeated mantra “There is no question that the safety and efficacy of antidepressants rest on solid scientific evidence,” as psychiatry professor Richard Friedman of Weill Cornell Medical College recently wrote in The New York Times. But ever since a seminal study in 1998, whose findings were reinforced by landmark research in The Journal of the American Medical Association last month, that evidence has come with a big asterisk. Yes, the drugs are effective, in that they lift depression in most patients. But that benefit is hardly more than what patients get when they, unknowingly and as part of a study, take a dummy pill—a placebo. As more and more scientists who study depression and the drugs that treat it are concluding, that suggests that antidepressants are basically expensive Tic Tacs.