you can pay me now…

Sunday, November 6, 2016

For football fans, there is nothing worse than a penalty that wipes out a touchdown or erases an interception. Coaches and players work on execution and avoiding errors, especially those that are self-inflicted by penalty. The team that makes the fewest mistakes tends to win the game. So it should come as no surprise that in the real world medical care, the doctor and patient who minimize their error tends to win as well. But while football has officials on the field and in the replay booth, making the right call for medical care is tougher.

Medicine is all about delayed reward. Controlling diseases like high blood pressure, high cholesterol and diabetes can increase quality and quantity of life. But the health care community can only give advice; they can’t go hope with the patient and demand the patient do the right thing. And there are no referees to throw a flag and call out actions that can erase life’s touchdowns.

Some behaviors are not well known and tough to fix. Medications for chronic diseases are supposed to be taken on a regular basis to prevent complications. High blood pressure, high cholesterol and diabetes medications (including insulin) are used to control these diseases to prevent complications. Heart attacks, strokes, blindness and amputations are potentially preventable, but the reward for taking a pill and watching what you eat is 10, 20 or 30 years down the road. Not taking medicine has no upfront risk and there is nobody in a replay booth reminding you to take your emaciation every day.

What is the cost? Individually, it can be an early death or significant disability. For the society, research suggests that failure to comply with medication prescriptions increases medical costs by up to $290 billion a year. 20-30 percent of all prescriptions go unfilled and up to 50% of the time, medication is not taken as directed. This leads to up to 10 percent of all hospital stays and more importantly, 125,000 deaths a year.

Specifically, for diabetes, the numbers are even worse. For those who need medication, not keeping blood sugars under control can increase deaths directly related to diabetes by 50%, and the noncompliance rate does not count deaths from heart disease or kidney failure.

Some behaviors are easy to see and still tough to make better. Drunk driving is unacceptable behavior and it is a societal norm not to drink and drive. Yet while police and the courts are there to throw yellow flags, more than 28 million people admit to that behavior every year and it leads to almost 10,000 deaths a year. Smoking is a behavior that has no positive benefit to the body, and is highly addictive. There are 1 billion smokers worldwide, it directly kills 5 million people a year (167,000 cancer victims in the US) and indirectly kills another 500,000 from second hand smoke. There is no striped shirt blowing the play dead when a person buys a pack of cigarettes.

Why do we care what other people do? The bottom line is that we are our brother’s keepers and resources that are spent on avoidable cancer care, dialysis for kidney failure or nursing homes for stroke victims might be better spent on primary care, preventive medicine, providing good nutrition for the poor and better mental health for those in need. But it’s tough to tell people who have self-inflicted their disease or injury, that society will not look after them…so we pick up the pieces and try to put them back together again. Sometimes, again and again and again.

Financial resources are not unlimited. Taking money out of one bucket, to care for behavior errors leaves less in other buckets. Once upon a time there was a wise commercial for Fram oil filters to increase your cars longevity:

“you can pay me now…or you can pay me later”


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getting the call wrong

Tuesday, September 27, 2016

One wonders why anybody would aspire to be a referee. It is a thankless job that somebody has to do, especially in the amateur ranks. There is some glamour in being on the field, ice or court as the best players in the world perform, and in that regard professional referees and umpires are also the best at what they do. Less glamourous are the little league umpires or soccer referees who suffer just as much scorn ads the pros. But it’s the beginning of the week and fans, especially those of the losing team, are vocal in blaming officiating as the cause of their favorite team’s demise.

There are very few sports that have black and white results. Racing against the clock provides an arbitrary score but most team sports are at the mercy of the officials. The same is true in medicine. One would think that doctors could agree on the results of an X-ray, blood test or EKG, but one might be wrong. Black and white don’t often exist in medicine and even grey is often in dispute. Not that one shouldn’t trust test results, but they are just one part of a patient’s evaluation and need to be taken into context.



Let’s consider the basic X-ray. The radiologist can take as long as needed to interpret the images, but the in box is always being filled with new cases to read and there is a time crunch. It’s no different than instant replay; the referees could take forever to review play to the detriment of the game and the enjoyment of the fan. Many studies have looked at the radiology miss rate and it tends to be about 3-5%. Interestingly, that percent stays about the same whether the radiologist quickly looks at the film or whether inordinate amount of time is spent reviewing the images. One study reviewed chest X-rays and defined visual dwell as spending too much time on one specific part of the film. Those who spent too much time had the same error rate as the radiologist who spent less than 4 seconds reading an X-ray. The researchers’ conclusion: “Common experience in radiology suggests that many errors are of little or no significance to the patient, and some significant errors remain undiscovered.”




Like radiologists, cardiologists (heart specialists) often interpret tests without physically seeing and touching the patient. Presumably, a test result is a test result, but just like fans from opposing teams who can’t agree on what constitutes a catch in the NFL, cardiologists reading the same test may come to different conclusions. Echocardiograms are ultrasounds of the heart that help diagnose structural abnormalities. Add exercise (or inject a chemical to get the heart to do more work and the echo can help diagnose narrowing of the coronary arteries. Researchers had two or more cardiologists review echocardiograms and compared their interpretations. In patients with normal hearts and those with bad heart disease, the docs agreed. But is patients with intermediate disease, cardiologists could only agree 75% of the time.

For most patients, diagnosis and treatment involves being touched by a health care provider and test results are put in perspective. Clinical situation and tests have to make sense together and the art of medicine involves interpreting the situation. There may not be a wrong, just a gray shade of not right. This perhaps does not satisfy the Monday morning quarterback since everybody, including medical people strive for perfect. But in the imprecise world that is medicine, black and white don’t routinely exist.

Radiology Quality Institute. White Paper: Diagnostic Accuracy in Radiology 2012

Brady A, etal. Discrepancy and Error in Radiology. Ulster Med J. 2012 81(1).

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