Mammogram Screening Vital -- Don't Put it Off

The new mammography guidelines have created massive confusion for women. First, remember they are one small group’s guidelines. The upset about them is much more widespread. I imagine that the panel tried to come to the best conclusions they could based on the data they had. I don’t doubt positive intent. However, many, with equally good intent, are outraged.

I am not a physician. But I personally know a couple of women who had breast cancer who were under 50. Most were discovered by routine screening. Others were found because the woman, or her spouse/partner felt a lump. It is very disturbing to me that those women would not have gone for screenings if they followed the current recommendations and would probably be dead. And, others would have died because the same panel doesn’t think women need to be taught self-examination of their own breasts.

If anything, I think women need to be better taught how to examine their own breast. I am 59 and once, a very long time ago, a gynecologist told me and let me feel a model that had spots that felt like a BB. So that was better than nothing, but I never felt confident that I really knew or that I could distinguish the general changing lumpiness from something I should be concerned about. I wish physicians had helped me learn and practice regularly in visits.

The panel recommends mammograms every other year for women 50 and over. I personally know probably 8 women who had cancer diagnosed in routine mammograms. One year they were clear, the next year, they were diagnosed. These were not women who skip mammograms – they did them regularly. At least two I know had cancer that was already invasive (had penetrated the wall of the duct and were in the lymph node.

Mammograms are not perfect, but they are a powerful tool for women to find cancer early, and get less traumatic treatment and help women survive.

I for one will continue to get yearly mammograms, and will encourage anyone 40 or over to get them regularly. I also make sure I have a physician give me a clinical breast exam. I’m a big believer in minimizing chances of a bad outcome and maximizing chances of a good outcome. Finding cancer early is a clear way to do just that.

House Passed SGR Fix

I am quite amazed that any governmental body has actually passed something instead of just talking about the same things year after year after year. A couple of years ago, I watched live proceedings of one of the House committees. The head of the committee, plus a leading member of the minority party, loudly proclaimed how more than talk has to happen, that legislation needs to be passed, and how absurd it is that the SGR hasn't been fixed. Guess what happened! Nothing.

I haven't read the bill yet, but just an attempt to fix it is good news to me. Do you really think a 21% cut to physician reimbursement when they have increasing expenses is going to help healthcare? It is scheduled for 2010 if something doesn't happen to stop it. We are going to lose good physicians who finally give up if that happens. Cutting reimbursement will make it impossible for some to stay in practice, let alone compete against growing hospital employed networks.

Reform: The Health Exchange Idea

I am very curious about why, in all the media coverage of the health reform debate and drama, why aren't we hearing more about another significant part of most proposals -- the Health Exchange approach? This is was one of the key pieces of President Obama's campaign platform. Variations of it are in his proposal, the House proposal, the Senate Finance Committee proposal, and even the Former Majority Leaders (Senators Howard Baker, Tom Daschle and Bob Dole)

The essence of the Exchange is that private insurance companies would offer plans under the Exchange that were more affordable and more accountable in terms of premium rates, costs, pre-existing conditions and that they cannot drop you because you become ill. Accountability is one of the biggest needs in insurance reform, and the Exchange idea helps promote that and more affordability for middle-class individuals and families.

This is a supplement to a public option that allows private insurance companies to stay competitive, to be included in reform instead of shut out of it by solely a public option, and yet holds them significantly more accountable.

This makes sense to me.

For more information, go to http://www.kff.org/healthreform/7908.cfm and from there, you can download a PDF file of a Brief on the topic of Health Exchanges.

You can also go to their Side-by-Side Comparison of Proposals, select the proposals you want to compare, and then click on the issue of “changes to private insurance” to see at least some of what each proposal says.

Part 4 on Integrated Delivery Systems is up

Just to let you know that Part 4 of the series on integrated delivery systems is back up on the website. This section is on Community Need vs. Revenue and Market Share as driving forces in hospital employment of physicians.

In the near future, I will add a final section on some of the things I think could bring such systems into more ethical alignment with core values, patients and physicians.

Next installment of series up

For those of you wanting to read the series, Part 3 on some of the negative impacts on physicians and patients is back up and hopefully Part 4 will be back up by tomorrow -- or at least over the weekend.

Adventist Health/Integrated Delivery Series

Part 2 of the series is now back up -- The Power of Patient Steering by a Large Hospital System The graphs alone are worth a thousand words!

Series on Adventist Health & Integrated Delivery

For those of you searching for the series on integrated delivery systems like Adventist Health in Central Florida, I temporarily took down the pages to fix some formatting. They will be going up little by little this week. Right now, you can find the following sections:
Ethical Issues in Hospital Based Healthcare Delivery Systems (Intro to the series)
Part 1: Hidden Ownership/Employment of Physicians
Current Online List of Adventist Health/FPMG Physicians in Central Florida This has questions to ask to help you make more informed decisions when you seek a physician or are referred to another physician. I have also added in some from surrounding counties. (Updated 9-21-09)
Downloadable related items: Report for Physicians on the Impact of Adventist Hiring on Independent Practice and downloadable list of FPMG/Adventist Physicians (As of 9-21-09, does not yet include the updates I did yesterday to the online version. I will be working on that today.

NOTE: On the downloadable report, the front page incorrectly lists my e-mail as dawn@ethicalhealthpartnerships.com -- it should be dawn@ethicalhealthpartnerships.org I will correct that on the PDF this week as well.

Trying to Separate Fact from Fiction in Healthcare?

Check out the Politifact.com truth ratings on healthcare reform statements. Because this is updated regularly, and not only about healthcare. Each healthcare statement is rated on the 'truth-o-meter' and by clicking on the meter, you can find a more in-depth review of the issue.

Another good one is Kaiser Family Foundation's site on reform, including a section where you can do a side-by-side comparison of major issues in different proposals.

Still another good site is Factcheck.org Several things on healthcare and more.

CNN is broadcasting as I am writing this about truth checking and answering questions on healthcare reform. Their new website checks some of the facts and also has links to download the bills.

Send these sites to your friends so that they too can find out more accurate answers to some of their questions. This debate is too important to resort to reactivity on either side.

The Fears about Ezekiel Emanuel, MD

Some of the viral chain e-mails quote Rep. Michele Bachmann (MN) or Betsy McCaughey blasting Ezekiel I think misrepresent him, what he thinks, and how that effects healthcare reform.

First and foremost, neither Emanuel or Blumenthal will ‘decide’ what is in or out of a public plan option. It will be a group process as government always is. But I think it is still important to put Emanuel in perspective:

Ezekiel Emanual is a renowned bioethicist and oncologist. He has worked with sick and dying people for over 25 years, of all ages. Interestingly enough, while they portray him as someone who would kill off disabled people, he has a sister with cerebral palsy! He is known as a warm and compassionate physician. (Here is some about him )

And, ironically, Ezekiel Emanuel is actually opposed to euthanasia and forms of assisted suicide!!! In a case about assisted suicide that was going before the Supreme court in 1997, Emanuel wrote a piece in the Wall Street Journal opposing euthanasia. He said,

“For the vast majority of dying patients, legalizing euthanasia or physician-assisted suicide would be of no benefit. To the contrary, it would be a way of avoiding the complex and arduous efforts required of doctors and other health-care providers to ensure that dying patients receive humane, dignified care.”

He is furious about what is being said about him in these e-mails and the protrayal of him in these scare tactics is against what his whole life and career has been about. Here is his response to all the allegations flying around about him.

What I Have Read and Think:

The chain e-mail talks about Emanuel’s remark about changing how doctors think about their patients: "Doctors take the Hippocratic Oath too seriously as an imperative to do everything for the patient regardless of the cost or effects on others" and they cite the Journal of the American Medical Association, June 18, 2008).

In the entire article, he is talking about the factors that have led to overutilization of costly care. I have read numerous other articles that talk about some of the same things. Too many unnecessary tests are ordered – for a variety of reasons: 1) the patient demands it and the doctor is both worried about being sued, 2) It is easier to give in to a demanding patient --
even if the physician does refuse, the patient usually goes somewhere else and gets the test. 2) 3. Another reason they overutilize is that, according to one of my clients in healthcare, many physicians are now trained to rely on tests instead of learning how to really examine and explore for a good diagnosis. It also takes way less time, but significantly raises the cost of care. 4. Emanuel also talks about the way doctors are trained to be meticulous and do everything possible.

THAT is the kind of 'overutilization' that Emanuel was talking about in JAMA. (Read the article online(subscription or payment for the article required unless you access through a university or hospital) OR you can usually find a copy at your local hospital's library, so you can make up your own mind!) Overutilization has been written about extensively by economists, physicians, policy makers, etc in nearly all the major medical journals.

In both the Lancet article and the old Hastings Center Report, that the chain e-mail quotes, he is discussing bioethics and how we make tough decision in healthcare, especially in situations where there is scarcity of resources – vaccines, organs, etc. What he is talking about just happened this past week when the government decided who would get swine flu vaccine first because there is not enough for everyone – pregnant women first because they are high risk, healthcare workers and I forget who comes next – I think children and then the elderly, but I’m not sure. Kids are much more likely to get swine flu than adults.) There is no outcry about that even though the 'government' decided who would get what care and who would not.

Another example would be who gets an organ transplant -- if you have a 6 month old baby, a 21 year old college student, and my mother with dementia – all of whom would die within a week or two without a new liver – and you have only one liver available – who do you give it to? Currently we use a list – and probably other things. Emanuel’s writing about bioethics is primarily about exploring the PROCESS, the HOW of coming to those decisions and creating ways that are the best when none are perfect, as he consistently acknowledges.

In both articles that quote him, he explores different models and where they lead, and in both say that there is no one size fits all that does not raise moral and ethical questions that are extremely challenging. That's why we have a field called bioethics!

In the first article from the Hastings Center Reports (1996) in which he contrasts two constructs in making those kind of decisions and concludes that neither is adequate and that more public discussion would be needed to come up with how those decisions are made.

In the Lancet article (again you can usually read it for free at your local hospital library), he and the other authors look at 6 or 7 models of decision making for things like ‘who do you give the organ to’? He finds them all lacking in and of themselves and thinks it has to be multi-principled with flexibility and considering numerous factors. Even the combined model that uses several of the principles explored that he and the others think would be better than a single principle model, he acknowledges that it still raises important moral issues.

They are tough questions that patients don’t usually think about, unless you or someone you love needs what is in scarcity.

So if YOU had to decide TODAY about that one liver for 3 people who would die in 2 weeks dilemma, what criterion would YOU use to make that decision of who gets the liver? How do YOU think we should make those decisions?

I, personally, --this is just ME talking -- do not think that one liver is best used for my mother who is in her 80s and with dementia, even though I dearly love her and want to enjoy every moment I can with her. Even if I were 80 and with full mental faculties, in one way I would want the liver because I love life. And yet, on the other hand, I would think twice -- I would have lived a long and full life and my getting the liver instead of the 6 month old or the 21 year old, deprives them of that opportunity. I think and hope I would be big enough to give one of those others the chance to have what I have had.

But no matter what I think, someone else will be making those decisions -- whether or not there is healthcare reform. I would hope that they, like Ezekiel Emanuel, would have thought long and hard about how to make the best decision possible in very heart wrenching situations.

Whither Reform?

Hopefully I will be in a different frame of mind tomorrow, but tonight, I am uncharacteristically disheartened. I am concerned that the dis-information, appeal to the dinosaur parts of brains, and too little too late response from the White House, will result in a very watered down proposal that won't upset anyone because it really won't contain much different than what we have. There are rumors (hopefully they are just rumors) that they may consider taking out the provision to actually pay doctors for their time if patients would like to discuss end-of-life issues, that we won't get the public option -- which I think (and hoped) would be the centerpiece. And now the news, that they copped out, caved in and are not requiring pharma companies to negotiate better prices for Medicare.

I was hoping for visionary, bold, a real improvement. I'm thinking we're getting more of the same old, same old of politics before the good of the people. I hope we don't get saddled with something in name only that costs a fortune and that simply maintains the status quo.

And I'm profoundly disappointed in politicians who engaged and continue to engage in fear-mongering, stirring hysteria and de-railing one of the most important issues of public policy, something that so profoundly affects so many of us. I love disagreement and debate, but that is not what this has been. It's been road rage screaming about 'death panels'. It has been inaccurate statements designed to scare -- like Sen. Grassley, "You have every right to fear." Give me a break! I think it is a sad commentary on what the once respected Republican Party has become. I'm furious with Sarah Palin. I can't help but wonder if her 'source' for her 'information' was a chain e-mail! She loved getting the crowds whipped up about Obama and terrorism. This is like more of the same. I'm disappointed in the media for not addressing the rumors swiftly and with their own fact-checking to put it out to the public. I'm disappointed in the level of non-thinking and effort to read for ourselves the sections people are concerned about.

Wow -- am I in a funk about this tonight! My hope is that I am completely wrong about everything I just said! THAT would make my day!