Chiropractic

Here at Safer Health Care we try to focus on positive interventions and encourage patients and physicians to question. We have specifically avoided the chiropractic- allopathic schism in health care.

Unfortunately the British Chiropractic Association (BCA) has forced us to ask some serious questions. Dr Simon Singh allegedly libelled the chiropractors according to a suit filed by the BCA against Singh.

The ruckus began when Singh noted that the BCA supports “bogus” therapies. Surely chiropractic as practiced by many chiropractors has some benefit in the care of musculoskeletal pain and injuries. Yet the BCA and many chiropractors (on both sides of the Atlantic) promote manipulations for organic illness such as lupus or asthma. Singh’s concern relates primarily to the complete lack of meaningful evidence for the use of chiropractic in these other illnesses.

We agree with Singh. All physicians- chiropractic, osteopathic, and allopathic must be willing to subject their treatments to the scrutiny of scientific rigor. Barring such scrutiny we become charlatans.

Patients should always ask about the science in their treatment. Make your physician explain in simple, lay terms what the therapy might legitimately be expected to do for you. It’s not science for the physician to simply describe his/her own experience- that’s not science.

It’s your health. Take charge and take care.

Back Pain

We’ve been away for a while but we’re back.

Readers recall that we’ve frequently written about conflicts of interest in the doctor-patient relationship. Conflicts arise anytime a physician’s judgment is altered by personal gain.

Our concerns have been validated again in a recent study published in the Archives of Internal Medicine (ARCH INTERN MED VOL 169 (NO. 10), MAY 25, 2009 ).

Study finds overuse of imaging in back-pain care more for nonclinical reasons than because the diagnostic tool was required. Overuse for imaging of uncomplicated lower-back pain was associated with incentives based on patient satisfaction, the type of doctor and the size of the practice. Medicaid patients treated in practices that relied more heavily on government revenue (typically those patients with less-desirable reimbursement for physicians) received less-rapid and less-advanced imaging for lower-back pain. Small and solo practices, and family and general practitioners also ordered fewer advanced imaging tests for their patients, according to a report by researchers at the Center for Studying Health System Change.

The interesting part for those of us who study this from a policy perspective is that the patients who had apparent “underuse” probably had proper management. The physicians’ incentives for overuse probably led to excessive use of imaging in the other groups.

When your doctor wants to do a test you should always ask:
1) Can you (the doctor) interpret the results?
2) Will the results change my therapy or offer new options?
3) Will the results or changed therapy let me live longer?
4) Will the results or changed therapy help me live better?

It’s your health. Take charge and take it seriously.

HIPAA

HIPAA stands for Health Insurance Portability and Accountability Act. HIPAA provides for broad protections for the privacy of your medical records. Each health care provider must observe the protections defined by HIPAA. It’s not just law it’s the right thing to do. Additionally, each health care provider must have in place a written agreement that contractually binds each of its business affiliates to the provisions of HIPAA.

That usually works. Some of our readers get their prescriptions through third-party prescription renewal services. One such service is Express Scripts. I mention Express Scripts specifically because it seems to neglect basic requirements for confidentiality. For over two years Express Scripts has been sending me refill requests and “courtesy notices” in which the prescription needs of its customers are disclosed. That would be fine if these were actually my patients. They are not. Despite the fact that I have notified Express Scripts on multiple occasions they continue to violate the privacy rights of patients by sending refill requests to me.

So? You ask. Well it’s fine if you’re refilling your antacid. But what if Express Scripts sends me the refill request for your anti-AIDS drugs or your viagra- and by the way you live next door to me? What if its your testosterone inhibitor to control your pedophilia? What if its a medication that you actually need refilled in a timely fashion- I don’t, by the way, refill these drugs. In fact after two years I simply discard the mailings unread into our secure shredder. I have found that notifying Express Scripts of these errors does not stop the mailings (Express Scripts now faxes the forms so I pay for the paper that I later shred).

So? You ask again. It’s your health care information. You should carefully screen who “touches” or controls your information. And, if you use Express Scripts you definitely need to make sure they’re not sharing your private information.

Its you health care. Take it seriously and take charge.

Autism

The relationship between autism and vaccines has been at issue since 1998. Now there appears to credible evidence that the entire study was faked.

Regardless of the relationship with autism the reduction in vaccination rates has led to a direct increase in the incidence of measles in the UK and subsequent measles deaths. Unfortunately, Andrew Wakefield’s scientific fraud is not an isolated incident. Dr. Scott Reuben, also fabricated data related to perioperative pain relief. While we might see the adverse effects of Wakefield’s malfeasance now the effects of Reuben’s remains incalculable. That’s because Reuben’s work forms the basis of an enormous body of subsequent research.

The average patient could not possibly have understood these occurrences. In fact few of us in clinical medicine understood these occurrences. So what should you do? First, always be skeptical of “breakthroughs.” Next, always ask your doctor to explain new information. You should also use reputable print and electronic media for information. Do not rely on nut-job blogs and conspiratory-theory pundits. Last, watch for confirmation from other reputable scientists.

The medical literature may have more physicians seeking name recognition at the expense of scientific integrity. Use good judgement and be safe.

Conscience?

What happens if your doctor feels that you are morally bankrupt? We under federal rules she may not be required to refer you for proper care. In this case the rules are specifically about reproductive care.

So what should you do?
1) If you even contemplate that you might need reproductive services- contraceptives, emergency contraceptives, abortion services or information then ask at the very first visit. More important, ask before the start of the doctor’s history. Don’t even let her start (the reason in a minute).

2) If you and your doctor are incongruent on the provision of these services leave imediately. Don’t think about it, just leave.

3) Here’s the reason you do this first. Because you cannot be charged for services the doctor does not render,. Therefore you cannot be charged for a history and physical if the doctor does not complete one. Othert charges may be appropriate but the $350 history and compete physical will not be.

4) Once you leave, phone your insurance carrier and tell the service rep the story. Make sure you get everyone’s name with whom you speak.

It’s your health. Take charge and take care.

Nursing Shortage

One of the questions you should ask (read, must ask) when you check out a hospital is “What is the nurse-to-patient ratio?” Hospitals across the country are suffering under nurse shortages. Actually, that’s not quite true. Patients suffer from nursing shortages. Hospitals, especially administrators whose compensation is tied to year-end profit love nursing shortages. The reason? Simple, a full bed brings in revenue. If there are fewer nurses to care for the patients then the bed brings in the same revenue at a lower cost.

What does this mean for you- you want a hospital with the highest nurse to patient ratio. You should also check to see what percentage of nurses are “agency” nurses or “travelers.” These “rented” nurses are often very good and they allow a hospital to have flexible staffing at a lower overhead and less long-term employment committment. But if rental nurse percentage is too high then it may be a sign that the hosital is underpaying and therefore only attracting inferior nurses to permanent positions. Inferior nurses equal inferior nursing care. Don’t forget your nurse is the first person who will assess you if you become acutely worse while in the hospital.

So, what should you do?
1) Ask what percentage of nurses, by shift, are hospital employees as opposed to “contract” or “rental.” Ask specifically about the ward to which you will be admitted.

2) Ask if the CEO or other administrative staff is paid a bonus based on hospital profits. This means that administrators have a financial incentive to keep nursing costs down.

3) Ask how long the average nurse has been at the hospital. Be careful to have them exclude nursing administrators.

It’s your health. Take charge and take care.

Conflict of Interest

The relationship between your physician and manufacturers and vendors of products and services is important. In fact it’s never been more important.

Picture, if you will, a placid lake scene. A healthy looking, late middle-aged white man is rowing. The voice-over announces something about “I’m Dr. Robert Jarvik…” The problem is that isn’t Jarvik in the scene. Jarvik doesn’t row. So, you ask? Well it’s also not clear that Jarvik actually takes lipitor. So? Well he’s only a doctor in name. He holds no medical license. In fact he wasn’t sharp enough to get into an American medical school on the first go. When he did get into an Italian medical school. He dropped out after two years. He does not practice medicine. He’s not a healthcare provider in any realistic sense. In fact he’s only really well known for the 112 days of misery borne by Barney Clark from the Jarvik 7 artificial heart.

Let’s look at the initial deception. Medical school graduates are not physicians until they complete additional training and licensure any more than law school graduates are lawyers until they complete a licensure exam. Is Jarvik smart, probably. He got paid more for those commercials than I make and I know way more medicine. Is he a doctor? Yes. Is he a physician? No. Would I let him treat me- no way.

The real problem is that Jarvik has some name recognition. Most people, even real physicians, can’t place him. It’s like saying you had dinner with Sally Ride last night. There’s just enough name recognition to give that meeting some importance. The vast majority of physicians don’t know that Jarvik is a clinical non-entity. How could we expect better of lay people? Sally Field hawks Boniva. But no one could legitimately expect that Gidget was offering healthcare advice beyond “ask your doctor.”

Even so, every dollar that pharmaceutical companies spend for high-dollar direct-to-consumer advertising is money that can’t be used to defray direct costs to consumers or actually improve products. While high-profile (and even low-profile celebrities like Jarvik) make for interesting advertising the bigger problem is the money spent by pharmaceutical companies to directly influence you physicians judgement. How would you feel knowing that your doctor’s decision to write a particular prescription was influenced by the airfare to a conference provided by the drug rep? Your cost for a long-term, name brand medication, is determined not by efficacy and legitimate medical economics but by the relative value of “freebies” you physician received. How about your surgeon who prescribes a particular a post-operative “pain pump” because the company representative is “cute?”

It’s not enough to demand full-disclosure of conflicts of interest. You must understand them. These conflicts shape your healthcare- and not always to your benefit.

Understand your physician’s relationships and where you fit in. You are not a vehicle for supplemental physician income.

Medicine, Evidence, and Opposition

With the new administration only a month away many physicians and other healthcare providers are anxious about the future. A recent entry over at The Hastings Center addresses the question regarding the political activity of physicians. Your physician may be actively political but that’s not necessarily bad- as long as it does not engender a simultaneous conflict of interest.

Ask your physician. Take charge of your health and healthcare.

Disgruntled Docs

A basic concept in a fee-market economy is that parties are allowed to enter into agreements consensually. In essence each party to a contract voluntarily enters.

The current physician dysphoria seems to turn this principle on its head. A recent survey indicates that a huge number of primary care physicians would leave practice or reduce their workload if they could. That’s the part I don’t understand. If they really hate practing that much why don’t they quit? Could it be that the pay is too good? Could it be that they are financially over-extended and can’t quit because the pay is too good? Virtually every physician in the US earns income at the 95 percentile or higher.

Many readers are wondering why I bring this issue up. It’s simple. If your physician is one of those who hates what he is doing for a living how much can he actually care about you? If you are little more than a burdensome revenue-generating unit to your doctor how will you be treated by him?

So what should you do? Ask questions? Ask him “Do you enjoy your work?” be direct “What’s more important to you my myocardial infaction or your kids soccer game?” You deserve to know if you have one of the thousands of physicians on the verge of throwing in the towel and walking away- possibly when you need him most.

It’s your health. Take charge and take care.

Placebo

What’s your doctor giving you? A recent survery indicates that over half of American physicians prescibe placebos for patients. Mind you these physicians aren’t prescribing, in many cases, the traditional non-medicinal “sugar pill.” Some of them are actually prescribing powerful medications such as antibiotics or even tranquilizers.

That’s not placebo. That’s barely one step away from tying a patient up and injecting him with drugs involuntarily. The practice is so reprehensible that even the AMA’s Council on Ethical and Judicial Affairs (CEJA) condems it.

You must understand each and every drug your physician prescribes. Take each pill and verify it’s use and action- use the internet or textbooks. Using powerful medications as placebo is the healthcare equivalent of drugging and raping someone.

It’s your health. Take it seriously and stay in charge.