As 2011 fades into 2012 and the inevitable roll of “best of” lists begins to infiltrate the print, online, and broadcast media universe, healthcare policy is sure to be included. One of those bridging year-end/new year issues apprears to be headed in a more assured direction, as the House GOP and Senate Dems have agreed on a 2 month extension of the payroll tax cut — including the Medicare “doc-fix” provision. Here’s hoping GOP Speaker Boehner does the right thing and continues to push for a yearlong extension…

Of course, this saga is the first of many issues sure to keep the health policy flames ablaze in ’12. Concerns by states of rising Medicaid expenses as reform draws closer; more permanent solutions to incremental and programmatic Medicare reimbursements to be sought; continued legal challenges to the ACA (which the SCOTUS will be taking up in an unprecedented 3-day affair); and last — but certainly not least — the 2012 campaign itself. Will an Obama defeat mean the end of reform as we presently are getting to know it, or will a (narrow?) victory for the president bring greater sympathy for cause, establishing the type of legacy for his top domestic issue he so desperately desires after two terms in office? As always, stay tuned. Next year looks to be an exciting one.

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When she was diagnosed with multiple sclerosis, a Minnesota woman thought that her carefully chosen neurologist had her best interests in mind when prescribing initial treatments to modify the disease. That was before a little detective work uncovered the real motivation for her physician’s patterns of prescribing that left her even more debilitated than when she was initially showing symptoms.

It worried me that none of them ever suggested that I discontinue treatment—or switch to another treatment—even after I reported that my injection site reactions were affecting my quality of life. Despite the fact that my neurologist insisted that I begin disease-modifying therapy, I was never contacted by him, his nurse, or anyone else in the neurology clinic with questions about how my Copaxone injections were going.

The patient, a U of M philosophy graduate student, puts into her own words the ethical issue she gradually uncovered while under the specialist’s care. Just how influential are pharma companies’ financial compensations for physicians who choose to prescribe their products? Just how willing are they to prescribe knowingly untested medications without concern as to their problematic and potentially lethal adverse effects? Her answer came at her next appointment, after enduring months of increasingly debilitating pain and enfeebling function from the trial with the first drug.

[M]y neurologist informed me that I’d begun to develop lesions inside my brain stem. He explained that this was a very bad place to have lesions, occupied as it is with regulating some of the body’s basic functions, such as breathing. He strongly recommended that I go back on MS treatment, suggesting this time a drug called Tysabri (natalizumab), which had worked wonders for some of his patients but also carried some amount of risk. Worried about the new lesions, but knowing little about the drug he was advising, I told him I’d think about it. I needed to be convinced through my own investigations that this drug would be worth taking.

Her investigations were not only telling, but they are also indicative of an all-to-familiar refrain for patients of (mostly specialist) physicians who pocket major coin from pharma companies to get these ridiculously expensive agents to the marketplace, at the risk of patient harm. In Minnesota, the patient was assisted by a database which lists pharmaceutical third parties with which a prescribing physician has a financial interest. She makes little doubt of her eagerness for this requirement to spread nationally as the result of the reform law. | PDF LINK

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The year was 1989. Late summer. The pressure was on to perform. Whether it was due to studying inertia, laziness, or simply hubris — I elected to take the dreaded MCAT (the medical college admissions test) at the latest possible offering. Yes, I was reasonably confident of my standardized test-taking abilities, and I knew that my GPA could definitely hold its own. Still, as I look back on my senior year in college, delaying such an important and redoubtable requirement was pretty foolhardy.

Nineteen eighty-nine was also approximately the period in which the test gurus who formulated the exam took a curious turn and seemed to bend over backwards answering critics’ and educators’ assertions that the exam was too narrowly focused on the left-brain aspect of scholarship. What was needed, the sage designers of the MCAT decided, was a tool to measure the non-scientific literacy of those who were audacious enough to consider a career in medicine. Thus, the maligned essay question was introduced.

The body tasked with reviewing the MCAT’s current state of affairs has made its concerns with the exam’s future known, and it reflects a growing reality in the state of preparing those with an interest in medicine to be able to succeed in medical school. That medicine is constantly changing with respect to rapid advances in basic science research and social and economic healthcare policy trends is a complete understatement, one that is highlighted by the committee’s recommendations.

The new MCAT will preserve the best features of the previous exam, while ineffective sections (e.g.,the writing sample) will be jettisoned. The two natural science sections will be revised to focus on relevance to living systems, emphasis on critical analysis, and reasoning skills will increase in a revised verbal section; and a section on behavioral and social sciences will be added.

Yes, it has taken the testing gods some twenty years to kill the essay section. Well, here’s hoping that future practitioners of medicine will have the intestinal fortitude that successive iterations of the MCAT (starting in 2015) will now require — the quality of endurance. As it stands, testing length will increase by over 40 percent — to 6 hrs and 15 min. Ouch! Guess I’m glad my laziness didn’t get the best of me some 22 years ago! | LINK [PDF]

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It seems a little simplistic, as a well as little troublesome, to place the entire immediate future of healthcare reform as it relates to the individual mandate in the hands of such an august body. (Image via KFF.)

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Just under 13 percent of skilled long term care facilities here in Minnesota are part of a project that is aimed at reducing the “supply side” of potentially unnecessary hospitalizations in the care of their elderly patients. The three year initiative is based upon data already gleaned from smaller tests and it essentially involves going back to the fundamentals of physical diagnosis — from all members of the skilled provider team.

“The problem is the doctors,” [Dr. Robert Kane, a University of Minnesota aging expert who is helping lead the experiment, said.] “Physicians familiar with nursing homes learn quickly to trust the precise information from nurses using the Interact tools. But for the others, especially nights or weekends, the default is hospitalization.”

I like to think of this as a recognition about what physicians have always known about medicine. Nothing substitutes for a thorough physical exam, regardless of who the examiner is. Any effort to utilize the good ol’ noggin to diagnose and treat without the knee-jerk rush to the hospital ED to provide primary care is always preferred, and it saves the proverbial bean counters on the acute care side of things (hospitals) of having to deal with yet another inappropriate admission. | LINK

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One axiom is certain in medicine: there is always room for controversy. And that’s good, because it spurs further scholarly thought and research — both qualities can only help patients and providers in the long run. With the current discussion in the media regarding the utilization of the PSA in determining the course of action in prostate cancer screening, so many fundamental issues surrounding patient informed consent, unnecessary treatments, and the potential harms from treatments — can serve as valuable teaching points for patients and current and future physicians alike. The discussion — highlighted in the current NEJM — really brings this point home.

Watchful waiting and active surveillance may help prevent the conversion of overdiagnosis to overtreatment, mitigating the harms of screening that are so accurately portrayed by the task force. … we primary care clinicians must ensure there is no more routine, indiscriminate PSA screening — and no washing our hands of responsibility once the patient is referred to a specialist for prostate-cancer treatment. We owe it to our patients to provide them with the kind of guidance about this screening test that they need and deserve…

LINK | USPSTF guidelines on PSA screening here

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As a geriatrician, another reminder of the work that I do and why it is so important in today’s delivery of healthcare as it relates to chronic, complex diseases (especially with the explosion  in the sheer numbers of Boomers into that hallowed 65-and-older territory):

Some 89 percent of the state’s medium and larger hospitals offer palliative care — which focuses on easing pain and discomfort while often continuing aggressive treatment. That placed Minnesota among seven states getting an A in a report released Wednesday by the Center to Advance Palliative Care at Mount Sinai School of Medicine in New York City.

The report also cites cost-of-care decreases in aspects of delivery of care to the very infirmed while noting the provisions of dignified, compassionate care characteristic of established palliative care programs. Imagine that. | PDF LINK to report

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Sign of the times: social media’s use in increasing interaction among patients with dementia. A researcher, part of a team, is busy at work on a web-based app based upon Facebook for utilization among cognitively impaired elders. She states:

“We have already carried out some practical testing of other web-based communications systems. Among other things, we have tested a “digital diary” and a “scrapbook” containing personal photos, newspaper cuttings and information found online.”

What is both curious and puzzling at the same time regarding this research is that it is being conducted in Norway, of all places. Why not here in the good ol’ U.S. of A? Innovation of this type began and germinated here. Social media’s global function of “keeping one in the loop”, including the elderly, can not be understated in its potential in non-pharmacologic dementia research. Here’s to hoping it gains ground on these shores.

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I have a hard time taking in this news item. It is at once troubling and loathsome:

Even after the researchers accounted for other factors that could help explain the discrepancy, such as differences in scientists’ education and training, black applicants were still about 10 percentage points less likely than whites to get NIH funding, the researchers reported. About 27 percent of white applicants’ requests were successful, compared with only about 17 percent of blacks’.

The audit results are somewhat surprising, as training in the healthcare sciences should remain race-neutral, without a doubt, especially since the study took into account and controlled for regional/educational variances on the path toward similar training trajectories.

Asians applying for money appeared to be slightly less likely than whites to get grants, but that gap disappeared when the researchers matched equally qualified white and Asian U.S. citizens. Hispanics were about as successful as whites.

I suppose I should take some solace in the fact that this issue is being addressed within the NIH, but, ivory tower bias in grant-funded research contracts in 21st century America is a very serous issue that carries real world ramifications for a rapidly evolving, technologically-driven healthcare delivery that may leave some patient demographics shut out of appropriate care. | LINK

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Some may or may not be aware, but my role as the proprietor of this blog took a back seat recently for two weeks, as I had to deal with the sudden death of my partner of over 13 years, David McCaffrey. He was a central and creative figure in so many lives — even coming up with the name and identity of this blog. I will slowly be writing posts up to normal speed over the next few days, and I just want to thank the many who have supported me emotionally over the past two weeks here in Minnesota, and from points farther away. I know I will always carry David in my heart; from this point on, this blog is dedicated to his memory. Thank you, David.

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