Posts Tagged ‘Harvard Medical School’

US News Names New Hospital as Best

Monday, July 23rd, 2012

Massachusetts General Hospital or Mass General is No. 1 for the first time, according to the US News & World Report Best Hospitals rankings. It marks the end of a 21-year run for Johns Hopkins that started in 1991, the year after U.S. News began publishing Best Hospitals.

When Mass General was founded, James Madison was President, Napoleon was Emperor of France and the Juliana, the first ever steam-powered ferryboat, began operation.   Only Pennsylvania Hospital (1751) and New York–Presbyterian Hospital (1771) are older. The fact that Mass General hasn’t taken the top spot before may come as a surprise to some, given its pedigree: It was the original teaching affiliate and flagship of Harvard Medical School; it remains the largest hospital-based research program in the United States, with an annual research budget of more than $400 million; and is renowned in such specialties as diabetes & Endocrinology, Ear, Nose & Throat, Neurology & Neurosurgery, Ophthalmology, Orthopedics, and Psychiatry.

The 950-bed medical center each year admits about 48,000 inpatients and handles nearly 1.5 million visits in its outpatient programs at the main campus and satellite facilities. It also delivers more than 3,600 babies annually. It is now the largest non-government employer in the city of Boston, with more than 19,000 employees, including a nursing staff of 2,900. In addition, its 3,600-member medical staff includes physicians, dentists, psychologists, podiatrists, residents and fellows.

MGH is owned by Partners HealthCare, which was formed by MGH and Brigham and Women’s Hospital in 1994. MGH is also a member of the consortium which operates Boston MedFlight.

Living Solo Can Be Hazardous to Your Health

Monday, June 25th, 2012

Living to a ripe old age may depend on a person’s relationship to family, friends and community, according to research that finds lonely older adults are more likely to die sooner than their more socially active peers.  Lonely people who are 60 and older tend to have a 45 percent higher risk of dying over the next six years, according to research in the Archives of Internal Medicine.  Another study showed that people who live alone and had heart disease were 25 percent more likely to die from the illness.

Approximately one in seven Americans live by themselves.  The first study to examine the link between social isolation and death points to the importance of addressing psychosocial needs along with medical ones in improving the health of older adults, according to Carla Perissinotto, a study author.  “We cannot continue to ignore the other things that are happening in people’s lives,” said Perissinotto, an assistant professor of medicine and geriatrics at the University of California San Francisco.  “If we turn a blind eye to what our patients are experiencing at home, we may be missing a place to make a difference in someone’s health.”

The lonely people studied were more likely to have limited mobility and greater difficulty performing basic tasks like grooming and cleaning. Approximately 25 percent of lonely people were likely to develop trouble compared to 13 percent who weren’t lonely.  While the connection between well-being and friendships isn’t new, the latest findings look specifically at people who self-identified as lonely, regardless of how extensive their social network.  “It’s about connectivity,” Carla M. Perissinotto said.  “Someone can have multiple social contacts but still somehow feel that they’re not connecting.”

One study followed nearly 45,000 people aged 45 and older who suffered from heart disease or had a high risk of developing it.  Those who lived alone were more likely to die from heart attacks, strokes, or other heart complications over a four-year period than people living with family or friends, or in some other communal arrangement.  The risk was highest in middle-aged people, just 14 percent of whom lived alone. Solo living increased the risk of heart problems and early death by 24 percent among people ages 45 to 65, and by only 12 percent among people ages 66 to 80.  And there was no association at all in people age 80 and older, a group in which living alone is widespread.

Additional research is needed to confirm the findings, but it may not be a bad idea for physicians to ask heart patients about their living situation, said senior author Dr. Deepak L. Bhatt, M.D., a cardiologist at Brigham and Women’s Hospital, in Boston.  Living solo “could be a little red flag that a patient may be at a higher risk of bad outcomes,” Bhatt said.  But living alone could impact health in more immediate ways.  For example, people who live along may skip their medications or ignore the warning signs of heart trouble, according to Bhatt.

Bhatt notes that patients who live alone should never ignore changes that might be a sign of health problems.  “Many times people just adapt to their circumstances.  Perhaps just lower your threshold a little bit and realize it’s better to call (the doctor) than not to call.”  That might not be the entire story.  “Other mechanisms by which living alone could increase cardiac risk have to do with possible social isolation and loneliness, and these are more challenging to fix,” he said.

According to Emily M. Bucholz, M.P.H., a medical student and doctoral candidate at Yale University, “Living alone, in and of itself, could stand for many different things.  Does it mean you lack companionship?  Or is it that there is no one there to help you out with medications?  Does it have to do with mobility or nutrition?”

Writing in Time, Alice Park notes that “Loneliness can be detrimental in many ways, some of which are biological and some of which are more behavioral.  Feeling isolated can trigger changes in brain chemicals and hormones that can increase inflammation in the body, for example, which can exacerbate conditions like heart disease and arthritis.  Loneliness may also lead to other problems — poor sleep, depression, a disinterest in one’s own healthcare — which can in turn contribute to disability and early death.  Which is why the researchers were particularly concerned over another finding — many of the elderly who said they felt lonely were not actually living alone.

Rather, they were married or living with family members.  That suggests that the size of a person’s social network isn’t the only measure of loneliness, and that studies that look only at the number of people’s contacts may miss an entirely separate factor that can have a significant impact on health, said Perissinotto.  ‘I think that from a public health and policy level, we are doing a disservice by not asking (people) about their subjective feelings of loneliness.  We focus on their diabetes control and treating their hypertension, but are we missing something that may be more distressing to patients and have more of an impact on their health?’”

Loneliness is a common source of suffering in older persons,” according to the study’s authors.  “We demonstrated that it is also a risk factor for poor health outcomes including death and multiple measures of functional decline.  Assessment of loneliness is not routine in clinical practice and it may be viewed as beyond the scope of medical practice.  However, loneliness may be an important predictor of adverse health outcomes as many traditional medical risk factors.  Our results suggest that questioning older persons about loneliness may be a useful way of identifying elderly persons at risk of disability and poor health outcomes.”

Everybody’s Warming to Telemedicine

Tuesday, May 15th, 2012

Tired of feeling sick but worried about the cost of a doctor’s visit? A rural Minnesota woman recently logged onto an Internet site run by NowClinic Online Care, a subsidiary of health insurer UnitedHealthcare, and “met” with a doctor in Texas.  According to Kaiser Health News, after talking with the physician via text message and by telephone, the woman was diagnosed with an upper-respiratory infection and prescribed an antibiotic.  .The doctor’s “visit” cost just $45.  “I was as suspicious as anyone about getting treated over the computer,” said the woman, who did not have healthcare insurance.  “But I could not have been happier with the service.”

NowClinic, which debuted in 2010 and currently operates in 22 states, is part of the upsurge of Web- and telephone-based medical services that experts believe is transforming the delivery of primary healthcare.  The movement gives consumers easier access to reasonably priced, round-the-clock care for routine problems — often without having to leave home or work.

Insurers such as UnitedHealthcare, Aetna and Cigna, and employers such as General Electric and Delta Air Lines are getting on board, advocating telemedicine as a way to make doctor “visits” cheaper and more easily available.  Proponents also see it as an answer to a deteriorating physician shortage.  Nevertheless some physician and consumer groups worry about the trend.  “Getting medical advice over a computer or telephone is appropriate only when patients already know their doctors,” said Glen Stream, president of the American Academy of Family Physicians.  “Even for a minor illness, I think people are going to be shortchanged.”

Carmen Balber, a spokeswoman for Santa Monica-based Consumer Watchdog, is concerned that lower co-payments will cause people to see doctors or nurses online just to save money.  “People will choose the more economical option, even if it is not the option they want,” she said.

Employers are getting mostly positive reviews.  “Our employees just love the convenience, the low cost and the efficiency,” said Lynn Zonakis, managing director of health strategy and resources at Delta Air Lines, which offers NowClinic for $10 a consultation.

The global telemedicine business is projected to almost triple to $27.3 billion in 2016, according to a report by BBC Research.  “Virtual care is a form of communication whose time has come and can be instrumental in fixing our current state of affairs within the healthcare system,” said Robert L. Smith, a family doctor in Canandaigua, NY, and co-founder of NowDox, a telemedicine consulting firm.  The field developed gradually over four decades as a way to deliver care to geographically isolated patients.  That’s changed over the past 10 years thanks to the development of high-speed communications networks and the push to cut health costs.  “It’s the wave of the future,” said Joe Kvedar, director of the Center for Connected Health, founded by Harvard Medical School.

Just one major hurdle remains: Many state medical boards make it complicated for doctors to practice telemedicine, particularly interstate care, by requiring a prior doctor-patient relationship, according to Gary Capistrant, senior director of public policy at the American Telemedicine Association.  “The situation seems to be getting worse, not better.”  He cited a 2010 ruling by the Texas Medical Board that effectively blocked a physician from treating new patients via telemedicine.  The sole exception is in cases where the patient has been referred by another physician who evaluated him or her in person.  “It’s about accountability,” said Dr. Humayun Chaudhry, CEO of the Federation of State Medical Boards.  State boards insist on licensing doctors treating patients in their states so that if patients are injured, they have a state agency they can go to for help.

“We want to enable telemedicine to flourish, but at the end of the day we want patients protected,” Chaudhry said.

OptumHealth, a UnitedHealth Group subsidiary that operates the NowClinic, said it leaves it to physicians to determine if they can diagnose a patient via computer.  “This is not intended to replace the intimacy of the doctor-patient relationship,” said Chris Stidman, senior vice president.  The company did not reveal the number of people have used the service or how many physicians it employs.

Don’t Text and Treat: How Mobile Technology Is Distracting Physicians

Tuesday, April 10th, 2012

Dr. Henry Feldman, nicknamed the iDoctor, of Boston’s Beth Israel Deaconess Medical Center is a hospitalist and programmer who is constantly armed with an iPhone and iPad.  According to Kaiser Health News, mobile technology has helped Feldman become a better, faster physician.  “It lets me do everything I could do if I was sitting at my desktop at the patient’s bedside, and actually some things I couldn’t easily do,” he said.  According to Kaiser Health News, this includes showing patients impressive apps, diagrams, medical records and even photos from their own surgeries.  Beth Israel, one of Harvard Medical School’s teaching hospitals, is one of the most technically sophisticated hospitals in the nation, particularly in terms of mobile technology.

A somewhat different viewpoint is offered by Dr. John Halamka, the hospital’s chief information officer who helped make Beth Israel electronically advanced.  Halamka warns that mobile technology has a serious downside — it can distract doctors from patient care.  Physicians who carry mobile devices often receive texts, e-mails, Facebook messages, tweets and other notifications that automatically appear on the screen, he said.  Because the vast majority of smart phones and tablets are personal devices, the problem can be virtually impossible for hospitals to control.  “I think all of us who use mobile devices have what I will call continuous partial attention,” Halamka said.  “We’re engaged in our work but at the same time we’re checking that e-mail or we’re glancing at that instant message.”

Last winter, Halamka wrote a case study for the federal Agency for Healthcare Research and Quality about an incident in which a 56-year-old man was admitted to have his feeding tube replaced.  A team of doctors decided to stop giving the patient a blood thinner, but as one of the residents was entering the new order into her smart phone, she got a text about a party.  Because she was busy responding, she never completed the drug order.  It wasn’t a minor mistake; the patient almost died.  “If you forgot to pick something up at grocery store, it’s an inconvenience,” according to Halamka.  “If you forgot to stop a blood thinner, it can result in significant harm.”

To avoid such errors from occurring at Beth Israel, Halamka has implemented policies advising doctors on minimizing distraction on their mobile devices.  The hospital is testing software products that separate the devices’ personal and professional functions and wants to launch the new programs within the next six months.  The problem is that new technology fast outpaces the policies that regulate its use.  “The consumer technology industry is bringing more tech to doctor hands faster than policy can be made,” he said.  “How long did it take to pass laws against texting while driving,” Halamka noted.  “And we had how many people die because they were distracted drivers. There was a lag. I think maybe we’re at that point in healthcare.”

Writing on, Dr. Kevin Pho “We’re encouraging more doctors to use ‘point-of-care’ apps, which, in theory, should benefit patients. But unaccounted for is the fact that smartphones and tablets carry many other functions that are non-clinical — like Facebook, for instance.  A simple answer, some say, would be to ban non-medical use of smart phone and tablet apps.  But like trying to ban texting and driving, that would be near impossible to enforce.  A better way would be to increase awareness and education of the phenomenon.  I had no idea how bad the problem was.  In medical school and residency, there are few courses on online professionalism.  Perhaps that needs to be part of the curriculum.  We need social media and health 2.0 role models who can teach physicians, residents and medical students not only how to act professional online, but also on appropriate mobile technology use in the clinic and hospital.  The problem is, there are too few of these role models.  In their absence, much of what we do to address this issue will be reactionary, and likely after a well-publicized malpractice case.”

Jonathan Mack, director of clinical research and development with the West Wireless Health Institute, a San Diego-based non-profit that focuses on cutting the cost of healthcare through new technology, believes that distraction from mobile technology “is case by case, but it’s not a huge problem overall.  It’s a learning curve” as hospitals adapt to the new technology.  Hospital administrators should be comfortable calling doctors on bad behavior if they see it and offer training so that they don’t become a barrier to care.

Writing for, Larry Seltzer says that “But of course, like the rest of us, doctors are going to use these devices for non-business reasons from time to time.  Yes, smart phones are especially good distractions, but it’s not like they invented distraction.  If nurses and techs weren’t playing Angry Birds 10 years ago when they had nothing to do, they might have been reading People magazine or doing a crossword puzzle.  Surgeons might not have been making personal phone calls while sewing up patients, but they might have been having personal conversations with others in the room.  What’s the difference?  There are good reasons why doctors and techs might want to access computers or the Internet while working on patients, and there are bad reasons.  These are people who we already entrust with a lot.  It’s just common sense to expect them to use these devices responsibly.”

Brain Scans a Tool In Early Alzheimer’s Detection

Tuesday, January 3rd, 2012

Researchers believe they can see revealing brain shrinkage years before a person develops memory loss or other symptoms of Alzheimer’s disease. The new finding may ultimately let physicians detect the disease and treat patients earlier with the goal of keeping them functional longer.

Massachusetts General Hospital and the University of Pennsylvania researchers used magnetic resonance imaging (MRI) scans to measure how thick the brain’s outer layer is in 159 people who did not suffer from memory loss.  Earlier studies have linked Alzheimer’s disease with distinctive shrinkage in nine regions of the brain’s gray matter, or cerebral cortex.  This is what physicians call the “Alzheimer’s signature.”

According to researchers, the brain shrinks as it loses nerve cells – more commonly known as neurons.  They aren’t entirely sure what causes this.  One theory is that the cells die after they become choked by excess amounts of two kinds of protein — beta amyloid and tau.  “The neurons degenerating over time are really what we think causes the shrinkage,” said researcher Brad Dickerson, M.D., an associate professor of neurology at Harvard Medical School and director of the frontotemporal disorders unit at Massachusetts General Hospital.  “And that shrinkage in their size is something you can measure with an MRI scan.”

Alzheimer’s is the sixth leading cause of death in the United States, according to the Alzheimer’s Association.  The number of deaths has increased in recent years, and there is no cure.  In the new study, researchers focused on how thick the edges of the brain are.  “We’re looking at the parts of the cortex that are particularly vulnerable to Alzheimer’s disease, parts that are important for memory, problem-solving skills and higher-language functions,” Dickerson said.

The 15 percent of participants – who averaged 76 years old –who had the thinnest brain areas performed poorly on the tests: About one in five of them were experiencing cognitive decline, as well as increases in signs of abnormal spinal fluid, a possible sign of developing Alzheimer’s disease.  “That suggests they may be developing symptoms,” according to Dickerson.

Susan Resnick, PhD, who works at the National Institute of Aging, wrote:  “The ability to identify people who are not showing memory problems and other symptoms but may be at a higher risk for cognitive decline is a very important step toward developing new ways for doctors to detect Alzheimer’s disease.”

Dr. Simon Ridley, from the charity Alzheimer’s Research UK, said, “The ability to predict who will develop Alzheimer’s disease is a key target for dementia research, as it would allow new treatments to be tried early, when they are more likely to be effective.  These findings add weight to existing evidence that Alzheimer’s begins long before symptoms appear, although it’s important to note that the study did not assess who went on to develop the disease.  This research provides a potential new avenue to follow, but we need to see larger and longer-term studies before we can know whether this type of brain scan could accurately predict Alzheimer’s.”

Writing in Time, Alice Park notes that “Alzheimer’s disease has always been difficult to diagnose — the only way to identify it definitively is by autopsying the brain after death — but scientists may now have an easier way to spot the degenerative brain disease long before that, even before symptoms appear, using brain scans.  By studying people’s brain scans over time, they were able to see that these nine brain regions appear to be thinner in people who eventually go on to develop Alzheimer’s — but that it takes many years for this structural difference to show up as symptoms of memory loss or cognitive problems.  Using this brain-size signature as a yardstick, the researchers decided to confirm the correlation by testing the patients’ cognitive abilities three years after a baseline brain scan.  Indeed, they found that 21 percent of participants, who had the thinnest Alzheimer’s-related brain regions but showed no signs of memory problems or other cognitive deficits at the start of the study did show signs of cognitive decline three years later, compared with none of the subjects who did not have the same brain thinning and seven percent who showed moderately thinner brain areas.”

America’s Healthcare System Needs Improvement: Study

Wednesday, November 2nd, 2011

The American healthcare system is not very healthy, according to a wide-ranging new assessment of the system that covers 42 measures of healthcare delivery, the United States scored just 64 out of 100.  “Costs are up sharply, access to care deteriorated, health system efficiency remains low, disparities persisted, and health outcomes fail to keep pace with benchmarks,” concluded the 2011 National Scorecard on U.S. Health System Performance. The report was issued by the Commonwealth Fund, a nonprofit healthcare policy foundation.

There are some bright spots on the report.  For one, the number of Americans who are controlling their high blood pressure rose from 31 percent in 2008 to 50 percent in 2009.  Additionally hospitals have improved their ability to care for patients with heart attacks, pneumonia, and other common conditions.

The Commonwealth Fund report also determined that the typical U.S. infant mortality rate is 35 percent higher than the top-performing states.  Other wealthy countries still have infant mortality rates that are significantly lower than the best-performing states in the United States.  If the U.S. did as well as the top-performing country in that category — France — 91,000 fewer babies would die prematurely each year, Cathy Schoen, senior vice president at Commonwealth Fund said.  “These statistics are real,” she said.  “They are real human lives.”  Other “areas of concern” include childhood obesity, preventive care and infant mortality.

Another issue is cost, an oft-cited statistic that the U.S. spends more per person on healthcare than any other country.  According to the Commonwealth Fund report, the nation in general spends twice as much as comparable countries, but doesn’t have better care to show for it.  “We are headed toward spending $1 of every $5 of national income on healthcare,” the report’s authors said.  “We should expect a better return on this investment.”  The high cost of healthcare takes a toll on personal finances, the report said.  By 2010, 40 percent of working-age adults had medical debt or difficulties paying medical bills, an increase of 34 percent when compared with 2005.

It is important to note that the majority of the report’s data is from 2007 – 2009, prior to the passage of the Patient Protection and Affordable Care Act (ACA).  The healthcare reform law is likely to lead to improved scores on some of the categories, particularly access and affordability.  For example, 25 percent of residents in 15 states lacked health insurance.  The ACA will require that all Americans have health insurance in 2014.  It also will reduce eligibility requirements for Medicaid so more low-income people will be eligible, and provide government subsidies to others who can’t buy insurance on their own.

The report’s authors remain optimistic that the health reform law will address many of the problems highlighted in the report.  This scorecard illustrates that focused efforts to change the healthcare system for the better are working and are worth the investment,” said Maureen Bisognano, president and CEO of the Boston-based Institute for Healthcare Improvement.  “If we target areas where we fall short and learn from high-performing innovators with the United States, we should see significant progress in the future,” said Dr. David Blumenthal, commission chair and professor of medicine and healthcare policy at Massachusetts General Hospital and Harvard Medical School.

Writing in the Huffington Post, a Social Epidemiologist at Columbia University, thinks that the price Americans pay for their healthcare is too high.  “It’s well known that Americans pay more for less when it comes to healthcare than just about any other country in the world.  In 2009, we spent nearly $8,000 per person to provide medical care to just over 80 percent of our population — that compares, for example, to just under $3,500 spent per person in the U.K. to provide care for the entire population.  To add injury to insult: our counterparts across the pond get an extra year of life for their $3,500 than we do for our $8,000.

“Why do we pay more for less when it comes to our health?  Every policy wonk has his theory.  Common ones include the high cost of American medical education (which is too expensive), or that permissive tort laws in the U.S. enable lawyers to profit from the health system (which is true).  But while each of these theories, and others, explain small quirks in our health system that certainly contribute to it’s gargantuan price tag, they don’t address the fundamental issue with our health system.  And that’s that our market-driven system introduces perverse financial incentives for medical providers that don’t align with the health or wellbeing of Americans.  This leads to wasted money and lost lives.

“In our healthcare system, the fundamental billing unit is the “procedure” — doctors charge per action, diagnostic or curative, taken on the part of a patient.  While, on the surface, rewarding doctors for each step they take to make a patient better may seem fair, it has disastrous consequences for the structure of our health system.  Chief among them is our top-heavy specialty physician structure,” El-Sayed concluded.

I’m So Sleepy…

Tuesday, September 13th, 2011

People who can’t sleep at night tend not to consider their problem to be an illness that requires treatment, or a good reason to call in sick.  That mindset could hurt employers and employees by making insomniacs drag themselves to work and sleepwalk through the day, according to a new study.  Researchers surveyed 7,428 employed people and found that 23 percent experienced some form of insomnia — such as difficulty falling asleep or waking up during the night — at least three times a week during the previous month, for at least one-half hour at a time.  It should come as no surprise that these sleep problems carry over to their jobs.  Insomniacs were no more likely than their coworkers who slept well to miss work, but were so consistently tired that they cost their employers the equivalent of 7.8 days of work in lost productivity every year — an amount equal to an average of roughly $2,280 in salary per person.  That adds up to $63.2 billion (and 252.7 workdays) for the entire nation.

The majority of study participants did not physically miss work as a result of insomnia, said lead author Ronald Kessler, Ph.D., a psychiatric epidemiologist at Harvard Medical School.  They frequently show up too tired to perform their job effectively (a phenomenon known as “presenteeism”).  “Employers these days want their workers to stay home if they’re sick.  If they know you’re absent, they can at least find ways to fill in for you,” Kessler said.  “But you can’t stay home every day if you’re chronically sleep deprived, so these people get in the habit of going to work and then not performing.”

According to Kessler, “It’s an underappreciated problem. Americans are not missing work because of insomnia.  They are still going to their jobs but accomplishing less because they’re tired.  In an information-based economy, it’s difficult to find a condition that has a greater effect on productivity.”

Fully 23 percent of employees were estimated to have insomnia; that statistic was verified by sleep medicine experts, who independently evaluated a sub-sample of the study group.  Researchers also found that employees aged over 65 are less likely to be insomniacs (14 percent) and that men were less likely (20 percent) to have trouble sleeping than women (27 percent).  Because the typical cost of insomnia treatment ranges from $200 annually for a sleep aid to $1,200 per year for behavior modification therapy, the study’s author believes that screening and treating workers’ sleep issues may be worthwhile for employers.

“When we actually did the calculations we were amazed at the extent of the problem,” Kessler said. “It seems unbelievable that more than 250 million days a year of lost productivity can be attributed to insomnia.  Yet this hasn’t really been on anyone’s radar.  Worker screening programs and programs to teach workers good sleep hygiene may be very effective and could actually save employers money.  These programs might help people feel a lot better and get more done on the job.”

Donna Arand, Ph.D., a spokeswoman for the American Academy of Sleep Medicine, says the study underlines a problem that is well recognized by sleep specialists.  “What struck me most about the study was the fact that workers really weren’t calling in sick,” she says. “People with chronic insomnia are going to work but they aren’t functioning at their maximum.  We all experience this from time to time, but for people with insomnia it could be happening every day.  One of the most important things is to try to get up at the same time every day and go to bed at the same time every night, even on the weekends.  Routine is the key.”

People can be described as insomniacs when they have trouble sleeping for at least a month.  The causes can be alcoholism, anxiety, coffee, and stress; it can also result from medical conditions like depression.  The more insomniacs think about getting enough sleep, the more stressed they become, and that results in even less sleep.

“Now that we know how much insomnia costs the American workplace, the question for employers is whether the price of intervention is worthwhile,” Kessler said.  “Can U.S. employers afford not to address insomnia in workplace?”

Healthcare: Saving Lives or Prolonging Suffering?

Thursday, August 12th, 2010

There is a cacophony of voices in the media talking about healthcare reform, but it’s more heat than light.  That why Atul Gawande’s most recent article in The New Yorker is so important. Boston-based Brigham and Women’s Hospital general and endocrine surgeon Gawande examines how the trend to prolonging life is one of the reasons behind soaring healthcare costs.Is healthcare saving lives or prolonging suffering?  Everyone needs to read this.

According to Dr. Gawande in Letting Go, “Twenty-five percent of all Medicare spending is for the five percent of patients who are in the final year of life, and most of that money goes for care in their last couple of months which is of little apparent benefit.  Medical spending for a breast-cancer survivor, for example, averaged an estimated $54,000 in 2003, the vast majority of it for the initial diagnostic testing, surgery, and, where necessary, radiation and chemotherapy.  For a patient with a fatal version of the disease, though, the cost curve is U-shaped, rising again toward the end – to an average of $63,000 during the last six months of life with incurable breast cancer.

The big question Gawande poses is thus:  What are we getting in return?  “Patients who were put on a mechanical ventilator,” Dr. Gawande continues, “given electrical defibrillation or chest compressions, or admitted, near death, to intensive care, had a substantially worse quality of life in their last week than those who received no such interventions.  And, six months after their death, their caregivers were three times as likely to suffer major depression.”

Dr. Gawande notes that in one study, “Researchers followed 4,493 Medicare patients with either terminal cancer or congestive heart failure.  Surprisingly, they found no difference in survival time between hospice and non-hospice patients with breast cancer, prostate cancer, and colon cancer.  Curiously, hospice care seemed to extend survival for some patients; those with pancreatic cancer gained an average of three weeks, those with lung cancer gained six weeks, and those with congestive heart failure gained three months.  The lesson seems almost Zen:  you live longer only when you stop trying to live longer.”

In one case Dr. Gawande describes, “Aetna decided to let a group of policy-holders with a life expectancy of less than one year receive hospice services without forgoing other treatments.  A patient like Sara Monopoli (who was diagnosed with terminal lung cancer at the age of 34) could continue to try chemotherapy and radiation, and go to the hospital when she wished – but also have a hospice team at home focusing on what she needed for the best possible life now and for that morning when she might wake up unable to breathe.  A two-year study of this ‘concurrent care’ program found that enrolled patients were more likely to use hospice:  the figure leaped from 26 percent to 70 percent.  That was no surprise, since they weren’t forced to give up anything.  The surprising result was that they did give up things.  They visited the emergency room almost half as often as the control patients did.  Their use of hospitals and I.C.U.s dropped by more than two-thirds.  Overall costs fell by almost a quarter.”

President Obama Sneaks Dr. Donald Berwick Past Republican Opposition to Head CMS

Wednesday, July 14th, 2010

President Obama bypasses Senate to make Dr. Donald Berwick the head of Medicare and Medicaid.  Facing a hostile approval process from Republicans in the Senate, President Barack Obama is making a recess appointment of Dr. Donald Berwick to head the Centers for Medicare and Medicaid Services (CMS), the agency that oversees Medicare and Medicaid.

A sharp critic of the way healthcare is delivered in the United States, Berwick believes the system is inefficient and lacks an efficient information-sharing apparatus.  In addition to his practice and academic work, Berwick is the founder of the Institute for Health Care Improvement, a think tank that focuses on “cultivating promising concepts for improving patient care and turning those ideas into action.”

Berwick, a Harvard-educated pediatrician and Harvard Medical School professor, believes in improving the quality of healthcare so physicians are rewarded for better outcomes rather than on a per-procedure basis.  Although it’s unlikely that this idea could be applied to the whole medical profession, Medicare and Medicaid are large enough that changing the traditional way healthcare is delivered would echo throughout medicine.  Together, Medicare and Medicaid cover 100 million Americans – approximately one-third – and accounted for $750 billion of federal spending in 2009.  According to the Congressional Budget Office, that totals 20 percent of the federal budget.

“Many Republicans in Congress have made it clear in recent weeks that they were going to stall the nomination as long as they could, solely to score political points,” according to Dan Pfeiffer, White House Communications Director.  “But with the agency facing new responsibilities to protect seniors’ care under the Affordable Care Act, there’s no time to waste with Washington game-playing.”

Postpartum Depression Hits New Dads, Too

Monday, June 7th, 2010

As many as 10.4 percent in fathers of new babies suffer from postpartum depression.  It’s not only mothers of newborns who sometimes grapple with postpartum depression after childbirth.  Fathers of new babies also can suffer from the condition, according to a study from the Journal of the American Medical Association.  In fact, JAMA notes, approximately 10 percent of new fathers experience the condition.

“Other fathers felt happy and joyous,” said Joel Schwartzberg, who suffered postpartum depression after the birth of his son 10 years ago.  “Inside, I felt like my world had collapsed, and along with that, I felt a great and incredible sense of responsibility.  I thought I was the only person in the world who was a bad dad.  I thought I was deficient, that I was handicapped.  What I learned was that I was not alone by any stretch.  It helped me relax; it helped me not be so hard on myself.”  Eventually, Schwartzberg sought medical treatment for his postpartum depression.

The study, performed by researchers at Eastern Virginia Medical School in Norfolk, analyzed 43 studies involving 28,004 men and found that just 4.8 percent of men fit the diagnosis of depression under normal circumstances.  That number climbed to 10.4 percent in fathers of new babies; three months following birth, the study found that approximately one fourth of the men studied were depressed.  Sleep deprivation could be a root cause, says William Courtenay, a researcher, psychotherapist and founder of, who noted that men often act out through anger and irritability.  “A man who’s depressed can look like someone who’s stressed, angry, irritable and getting into conflict with others, or being withdrawn or drinking,” Courtenay said.  “We can also see classic signs of depression, a sense of worthlessness and helplessness and sad mood.”

“Also, he may be grieving because he no longer has his wife to himself,” said Jean Cirillo, PhD.  “He has to share her with the baby, and the baby’s needs get taken care of first. This can be hard for a man.”