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Monthly Archives: August 2013

The Digital Health Revolution: A Mixed Blessing

digital health records

The recent revelation of the NSA’s top-secret mass surveillance program by Edward Snowden has spotlighted the benefits and burdens of our increasingly digitally connected world.  According to President Obama, monitoring our phone calls, emails, and web activity has helped thwart dozens of terrorist attacks.  But the idea of the government keeping track of what had hitherto seemed private raises the specter of an Orwellian world in which everyone is under constant surveillance by “Big Brother.”

The growing and changing use of information technology in the delivery of health care is likewise a mixed blessing.  As a primary care physician, I often encounter patients and their problems without access to a record of the care they received elsewhere.  Knowing what tests have been run and treatments tried would enable me to provide more effective, efficient care and avoid wastefully duplicating services.  To this end, governments and hospital systems are establishing health information exchanges (HIEs) that allow patients’ data to be seamlessly shared by practitioners.  These exchanges also promise to provide a rich database for researchers and public health authorities.

But electronically collecting and sharing millions of Americans’ health information presents the real risk of large-scale privacy violations.  A wide variety of individuals, from clinicians and clerks to government and insurance company employees will have access to among the most sensitive and intimate aspects of our lives.  It is all too plausible that somebody seeking notoriety or a thrilling display of power could take it upon himself  (a la Wikileaks) to disseminate millions of individuals’ health data on the world wide web.  Perhaps more concerning are the subtler yet still serious privacy violations that are likely to regularly occur.  Thus, it is crucial that our ethics, laws, and privacy protection technologies keep pace with the threats to privacy inherent in the growing and evolving use of health information technology.

Health information technology will also play an increasing role in how we pay for health care and judge its quality.  The current fee for service system rewards the volume of services delivered rather than how well they make us.  This is believed to result in a number of excessive and sometimes even harmful interventions.  Health information technology should facilitate better measuring quality of care.  Utilizing this data will enable the government and insurers to pay for good results, rather than for merely more tests, hospitalizations, office visits, and procedures.  Patients will also be better equipped to select hospitals and practitioners with a record of robust outcomes.

But this commendable quest to measure and pay for performance carries the risk of overshadowing and deemphasizing less quantifiable yet equally vital components of the healing profession.  It is surely important to control blood pressure, cholesterol, and diabetes, to avoid complications from surgeries and hospitalizations, and to prescribe the best medications.  But there is much more to being a good doctor than this.  There is pulling together the disparate elements of a long-suffering patient’s story and arriving at an elusive diagnosis.  There is breaking the bad news of dementia, autism, or cancer honestly, but without taking away all hope.   There is discerning when an anxious patient with a headache needs reassurance or an urgent MRI.   There is being a compassionate presence and a trustworthy guide during the most trying moments of a person’s life.  There is taking the time to learn what gives meaning and purpose to a patient’s life and arranging his or her care accordingly.   It is quite difficult, if not impossible to measure these virtues and character traits, to put a numerical value on these essential elements of the healing arts.   So if quality is defined solely by what can be quantified, we risk creating a culture that values certain marks of technical excellence, but neglects the human, personal art of care.  The result could be a practice of medicine greatly impoverished for both patient and physician.

Preserving the human touch in healthcare does not mean resisting its growing use of information technology.  It is inevitable that the digital revolution will transform the way healthcare is delivered, yielding improvements in quality, cost, and convenience.  But even as we enjoy and celebrate these changes, it is essential to honor and preserve important values such as patient privacy and the personal art of care.

 
 

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How to Get a Good Night’s Sleep

sleep

Scientists studying sleep are still working out what exactly goes on in our brains during our nightly shut-eye.  But we do know that getting sufficient high-quality sleep is important.  Inadequate sleep has been tied to higher risks of heart disease, obesity, diabetes, and other maladies.  And just as important, we have all experienced the fatigue, emotional lability, and mental fogginess that come with not getting enough Zzzzzzz’s.

But getting sufficient sleep is easier said than done.  I can relate with many of my patients in sometimes finding it difficult to get and stay asleep.  Here are some evidenced-based tips for getting the sleep you need.

Keep a consistent bedtime and wake-time.  Our bodies get used to going to bed and getting up at certain times.  Disrupting this internal rhythm, by excessive napping, staying up late, or sleeping in is a recipe for insomnia.

Avoid caffeine after noon.  The stimulatory effects of caffeine stay in your system several hours after intake.

Get regular exercise. Studies show that exercise improves sleep quality.

Keep your bedroom cool.  Our bodies’ temperature decreases when we sleep.  A cool sleep environment mimics this activity.

Take time to calm your mind before bed.  Dedicate 30-60 minutes before bedtime to something that relaxes you.  A warm bath, a pleasurable novel, meditation, etc. Doing this will not only help you get to sleep, but improve your sleep quality.  Avoid bright lights from your computer, phone, or television since this simulates the activating effect of the sun.

Don’t clock-watch.  If you get up during the night, avoid looking at what time it is.  This will likely cause anxiety about how much time you have left to get the sleep you need.  Revving up your system with such thoughts will make it even harder to get back to sleep.  So hide your alarm clock in a drawer or cover it with a book.

Limit alcohol before bedtime. Although alcohol may help you get to sleep, it impairs sleep quality and makes you more likely to wake up during the night.

Keep your bedroom dark and quiet.  

Use your bed only for sleep and sex.  You want to condition your mind to associate your bed with sleep, not reading, thinking, talking, and other activities.

If you wake up during the night and can’t go back to sleep, get up and do something relaxing.  Don’t try to fight your way back into unconsciousness.

 

 
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Posted by on August 18, 2013 in Sleep

 

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Reflections on Transhumanism

transhumanism

I recently listened to the sociologist and bioethicist James Hughes explain the content and merits of transhumanism, “the belief or theory that the human race can evolve beyond its current physical and mental limitations, especially by means of science and technology.“  According to Hughes, transhumanism traces its origins to the beginning of civilization, when humans first aspired to transcend the limits of their condition.   While we have been working at this enterprise of self and species improvement and empowerment ever since, the arrival of the scientific method radically accelerated the pace of change.  Hughes casted a compelling vision of the wonderful future human ingenuity will deliver—a world in which, to paraphrase John of Patmos, technology will wipe away every tear from our eyes.  And beyond conquering perennial maladies, transhumanism looks forward to humans developing ever-growing capacities to enhance the experience of life.

Listening to Hughes expound his philosophy, I was impressed by the logic of his arguments and even caught up in his enthusiasm for what the future might hold.  But I also felt something was missing.

The case of Thalidomide came to my mind.  Viewed as a scientific triumph over age-old ills such as insomnia and morning sickness, Thalidomide was dispensed to thousands of pregnant women to relieve their symptoms.   By the time its teratogenicity was detected and its use banned, more than 10,000 children, mostly in Europe, had been born with birth defects such as phocomelia.  Thalidomide’s story is only one of many times in the history of medicine that unexpected and devastating consequences have resulted from promising technologies.  Indeed, my own current experience of medical practice regularly reveals the wisdom of William Osler’s advice to “remember how much you do not know.”  For example, I once took care of a patient who had been prescribed the commonly used antibiotic Bactrim for a mild urinary tract infection.   Days later, she was in a hospital ICU, hanging on for dear life after she experienced an extremely rare and severe type of drug reaction.  So medical history and my own experience as a practitioner suggest that the transhumanist vision should be tempered by humility and caution. Such humility should flow from a greater awareness of our epistemic and moral fallibility.

Remembering our historical situation should drive home the reality of our epistemic fallibility.  It is estimated that life on began about 4 billion years ago and that it was not until roughly 100, 000 years ago that Homo Sapiens evolved into existence.  Human beings are thus the product of natural selection and other evolutionary forces operating over a vast period of time to create a staggering degree of complexity.  When we gravitate toward food and medicines that are more “natural” rather than recently created, perhaps we intuit that that it is safer to consume that which has stood the test of time.  Maybe we sense, notwithstanding the cocksure confidence of some futurists, that life and the human body are immensely complex systems and that manipulating them may yield unforeseeable, unintended consequences.  This is the insight of resonant stories such as Doctor Faustus, Frankenstein, and Jurassic Park. 

 

Humans’ moral fallibility should be another cause for caution in our quest to master and manipulate the world to our liking.  Technological innovations may someday overcome diseases such as dementia, cancer, and schizophrenia.  But much of the suffering in our world comes from moral deficiencies, not technological limitations.  War, crime, child abuse, sex trafficking, the subjugation of women and minorities, abject poverty, corrupt governance, terrorist attacks: Are these problems amenable to technological solutions?  While technical innovations can be applied to fight these evils, they can also be used to exacerbate them.  The history of the 20th century testifies to this reality.  Filled at its dawn with hope and optimism, the century would soon bear witness to the worst wars, genocides, and famines in human history, only to be followed by the threat of worldwide nuclear annihilation.   Perhaps it is no accident that one of the 20th century’s towering myths, J.R.R. Tolkien’s Lord of the Rings, spoke to the great perils of power.

The reality of human fallibility does not mean we should resist our natural desire to learn about the world and improve our lot.  As a physician, I daily try to apply the latest knowledge and best technology to ease the ills of those entrusted to my care.  I am grateful for the scientists and engineers who make my work possible.  Being appropriately humble about our epistemic and moral capacities will enable us to most effectively and ethically use our growing knowledge and power.

 
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Posted by on August 16, 2013 in Transhumanism

 

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Are EMRs making healthcare more or less patient-centered?

EMR-centered care

EMR-centered care

A new study in the Journal of General Internal Medicine revealed that doctors spend substantially more time with their computers than they do with their patients.  Reflecting on this study, physician Danielle Ofri argues that “we need to rethink the role of technology in medicine, especially the EMR.  The new mantra of ‘patient-centered care’ needs to apply equally to our computerized systems.  With each new iteration of the EMR, we need to ask ourselves how patients are benefiting, as opposed to whether we are merely satisfying administrative documentation mandates.  The EMR needs to exist in service to patient care, not simply as an end in itself.”

I first became aware of the challenges of EMR use while rotating through the VA in my third year of medical school.  After meeting a pleasant physician I’ll call Dr. Smith, we began our first day together seeing patients.  Following handshakes with patients and their family members, Dr. Smith face turned to his computer screen for most the remainder of the clinic visits.   Asking patients questions about their conditions, Dr. Smith typed away as they responded, recording the relevant data they produced.  After a brief physical exam, patients were handed their prescriptions before being ushered out to the nurse or clerk.  I remember thinking that the encounter seemed more like a business transaction than something to do with healing.  The patients had completed a necessary errand and were moving on with the rest of their day.  The following morning, it was my turn to take over patient care and be supervised by Dr. Smith.  As I negotiated the demands of computer data entry and providing care, I began to sympathize with and adopt his approach.  To listen with eye contact as patients talked and then afterward type what they had just said while they continued to talk and present more information was not practical.  And if I gave the patients my undivided attention during the visit and tried to document afterward, I found myself getting quite behind schedule, to the chagrin of Dr. Smith, the staff, and patients.  Soon I too was shouting out questions as I furiously typed away, rationalizing that this was the only practical way to get through the day.

My story echoes many doctors’ experience of EMRs as a hindrance to effective physician-patient communication.  As pediatrician Anne Armstrong-Coben writes in the New York Times, “Doctors in every specialty struggle daily to figure out a way to keep the computer from interfering with what should be going on in the exam room — making that crucial connection between doctor and patient. I find myself apologizing often, as I stare at a series of questions and boxes to be clicked on the screen and try to adapt them to the patient sitting before me. I am forced to bring up questions in the order they appear, to ask the parents of a laughing 2-year-old if she is “in pain,” and to restrain my potty mouth when the computer malfunctions or the screen locks up.”

Why is recording data often more difficult and time-consuming using an EMR than it is utilizing paper charts?  Part of the problem is that the EMR documentation format is not designed solely for the purpose of providing quality care.  It also aims to ensure that adequate data is provided to justify payment for services should an insurance company or the Center for Medicare and Medicaid Service (CMS) audit the chart.  Since incentives and other forms of reimbursement from CMS are affected by Meaningful Use (MU) of the EMR, EMRs must also ensure that they meet MU standards. This may require physicians to enter data and perform EMR tasks that are not necessarily germane to helping the patient address their health issues.

How can physicians effectively respond to the greater time demanded by EMR documentation?  One approach is using staff to do some of the data entry work.  For example, some physicians have hired scribes to enter data so that the physician can concentrate on being fully attentive to the patient and responding to his or her health issue.  But the expense of paying for a scribe is not an attractive option for many physicians, particularly those in primary care.   There is also hope that as dissatisfaction with the current EMR data entry technology becomes better recognized, software engineers will work with physicians to develop more functional systems.  Already, some EMRs are using improved voice-recognition technology to recover some of the greater efficiency that traditional dictation delivered.

Has using an EMR enhanced or hurt your ability to communicate with patients? Does entering data in the EMR take away time from the other parts of patient care?

 
 

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Do Omega-3 fatty acids cause prostate cancer?

Do Omega-3 fatty acids cause prostate cancer?

Omega-3 fatty acids have long been one of the most commonly used medical supplements.  In the 1970s, researchers studying the Greenland Intuit Tribe noted that while they consumed large amounts of fat from fish, they displayed virtually no cardiovascular disease.  This finding was attributed to the high amount of omega-3 fatty acids in their fish-rich diet.

The main reason I prescribe omega-3 fatty acids is to lower triglycerides, a type of bad cholesterol that can inflame the pancreas if their level in the blood gets too high.  But omega-3s are taken to treat many other conditions, including dry eyes, depression, and attention deficit disorder (ADD).  The evidence of their efficacy for these other indications is not robust.  But since Omega-3s occur in nature and are not thought to have many serious side effects (aside from possibly fishy breath!), many doctors and patients ask themselves “why not try them?”  Many people take Omega-3s not for any specific reason, but as a general measure to maintain good health.  Such an attitude seemed validated by a 2010 study published in the Journal of the American Medical Association (JAMA) which showed that people with a higher concentration of omega-fatty acids in their blood seemed to be aging slower. The ends of chromosomes, called telomeres, are shortened with aging.  The telomeres in people with higher serum levels of omega-3s were shortening at a slower rate than others.’

With all this omega-enthusiasm, it came as a surprise when a recent study in the Journal of the National Cancer Institute suggested a possible downside to the fishy pills.  Studying men over age 50, it found that those with the highest levels of omega-3 fatty acids in the serum had a 43% higher risk of developing prostate cancer, and a 71% higher chance of developing high-grade prostate cancer, which is more likely to be fatal.  The study did not examine whether the men with higher omega-3 levels had them due to supplements or their diet.

Does this mean Omega-3s cause prostate cancer?  Not necessarily.  We would need a different kind of study to answer this question.  One possible partial explanation for the association between prostate cancer and higher omega- 3 levels is that men who ingest more omega-3 fatty acids may be the kind of guys who get regular check-ups and are screened for prostate cancer.  More prostate cancer was detected in men with higher omega-3 levels, but maybe men with lower levels had prostate cancer that was never screened for and detected. A similar kind of study bias accounts for why taking hormone replacement therapy was long associated with a reduced risk of coronary artery disease in women after menopause.  It turned out that women receiving hormone replacement therapy were more likely to being seeing their doctor and taking other steps (exercising, eating healthy, controlling blood pressure) that reduce heart disease risk.  It was not until a later prospective, interventional trial (the Women’s Health Initiative) that we came to see that taking hormone replacement therapy actually increases the risk of coronary artery disease.   We would need a similar type of study to see if ingesting more omega-3 fatty acids really increases men’s risk of developing prostate cancer.

One important take-away from this study is that nutritional supplements are not always as safe as they seem.  It is wise to have a specific reason for taking a supplement that is supported by strong scientific evidence.

 
 

Acknowledging Death is Scary

fear of death

By diminishing the taboo around discussing and studying death, the fields of hospice and palliative care have lessened the isolation of dying and in other ways helped people die better deaths. On the other hand, there is a tendency among those of us who regularly work the very sick to lose sight of just how terrifying death can be. For instance, death-and-dying pioneer Elizabeth Kubler-Ross wrote that ”I always say that death can be one of the greatest experiences ever.” Indeed, for some people the prospect of death prompts them to be fully present to life, to take in each moment of our precious and fleeting existence.

But I have also observed people be consumed by a sickening dread and despair when they face the reality of the mortality. Consider a poignant passage from Tolstoy’s Anna Karenina, in which Levin sees his brother sick with consumption. “Death, the inevitable end of all, for the first time presented itself to him with irresistible force. And death, which was here in this loved brother. . . was not so remote as it had hitherto seemed to him. It was in himself too, he felt that. If not today, tomorrow, if not tomorrow, in thirty years, wasn’t it all the same! And what was this inevitable death–he did not know, had never thought about it, and what was more, had not the power, had not the courage to think about it. I work, I want to do something, but I had forgotten it must all end; I had forgotten–death.” If we do not acknowledge death’s power, we will likely remain befuddled at why people go to such burdensome, costly, and sometimes futile lengths to have the chance at just a bit more life.

 
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Posted by on August 13, 2013 in Death, Palliative Care

 
 
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