Articles of Interest This Week

My weekly articles of interest:

Cancer

To CT scan or not: What is the ultimate goal of patients? reminds us that what we want, as patients, is not just tests but rather the information we need to know whether we should worry or not, and whether a test is in fact needed.

In a similar vein, Do Oncologists Lie to Their Patients About Their Prognoses? outlines just how hard it is for oncologists to give accurate information when the odds are not good, and just like all of us, are subject to the same emotional pulls. My doctors have been good in that way – outlining the bleak odds, but indicating the factors that may help me be on the right side of the curve.

Some good news to those of you stressed out at work. Work stress link to cancer in doubt cites a large-scale study (over 100,000) showing stressful work situations to not increase the risk of cancer (colorectal, lung, breast or prostate). Of course, stress is not good, and the same study showed an increase of risk for coronary heart disease.

A good overview of recent treatment developments in a detailed slide set in Lymphoma, covering mantle cell lymphoma, other B-cell lymphomas, T-cell lymphomas and Hodgkins lymphoma. More for patients at the beginning of their journey to discuss treatment options with their medical team.

Study finds potentially dangerous errors in chemo use at hospitals is frightening, but reading through the article and comparing to my experience, find that many of the recommendations already in practice at The Ottawa Hospital, where I was treated (e.g., having a second person confirm the dose and drip settings).

Building on labelling for tobacco products, World Cancer Day: How meat can be murder reminds us of the risks of processed meats for colon cancer, and suggests similar labelling.

And in the same week of my Writing as Cancer Therapy piece, Finding Poetry in Cancer talks about how people living with cancer have used poetry to express and help them through their journey. Susan Gubar in Living With Cancer: Waking in the Dark cites a number of poems in her reflections of getting through the worries, anxieties and fear of death, which often emerge at night, and keep us awake. She ends up with the guarded realism in lines from Theodore Roethke:

I wake to sleep, and take my waking slow.
I learn by going where I have to go.

Health and Wellness

Behind the fetish of vitamin B12 shots discusses the medicine and science behind B12 deficiency, and how pills are as effective as shots. My medical team never suggested shots but prescribed pills to address my post stem cell transplant deficiency.

Dr. Google: Tips for patients who diagnose online provides good tips: remember which sites you visit, ask your medical team for recommended sites, and go to sites affiliated with medical or health institutions. My only addition would be moderation as there is a limit to what one can absorb, and how much time one should spend.

Not surprising, for those of us with exercise playlists, but nice confirmation of how beat helps us increase the tempo in Getting Into Your Exercise Groove.

And for the policy wonks among us, a discussion of some of the choices and options facing Canadian healthcare according to Janice MacKinnon, a former Finance Minister of Saskatchewan (where Canadian medicare started) in Saskatchewan knows what Tommy Douglas would do.

Other

The truth about lying: Research shows how famous fibbers give the game away provides some concrete examples of how some of the famous lyers in history (e.g., Clinton, Armstrong) had some visual clues that for the experts suggested things were not as presented. Nice list of top 10 clues, but the bottom line is that lying requires considerable effort and suppression of emotion, which tend to give them away.

For those interested in debates between the faith and atheism, an old conversation between Christopher Hitchens and Andrew Sullivan in Hitch And Sully: Is Religion Fossilized Philosophy? and Hitch And Sully: “Who Is This Herr Ratzinger?”.  While I like much of what Hitchens writes, some of his strident atheism (as in Dawkins) is ironically akin to fundamentalist religious views.

David Brooks on The Philosophy of Data discusses how data can correct for biases and help us develop new insights. Nothing too new here but a good discussion. The most recent example, of course, was the 2012 elections where the pundits lost badly to the data nerd Nate Silver.

An interesting take on the link between fear and conservative views in Tendency to fear is strong political influence, and how familiarity can diminish fears. The degree to which more of us, right or left, live in real or virtual ‘bubbles’, the greater the potential for fear of the other or the unknown:

“It’s not that conservative people are more fearful, it’s that fearful people are more conservative. People who are scared of novelty, uncertainty, people they don’t know, and things they don’t understand, are more supportive of policies that provide them with a sense of surety and security,” ….

“In this way, the definition of unfamiliar may shift across time and location based on experience and education, and a genetically informed fear disposition is hardly permanent or fixed,”

Immediate health risk must be weighed against radiation-induced cancer risk

topnews.in

Many of us are familiar with this risk calculation with respect to CT and PET scans, or Total Body Irradiation. Not easy, but most of us make the willing trade-off being living now and the longer-term risks. Trade-off is different of course for children (see CT Scans and Cancer: What Parents Need to Know and Do), and it is always good practice to discuss the need for scans and the trade-offs with one’s doctors:

“This must be considered when physicians make imaging decisions for their patients, because the timing of risks changes their relevance,” Dr. Pandharipande said. “Risks incurred later in life are not the same as those faced in the present. If you had to choose between the chance of incurring a serious risk now or later in life, most people would choose the latter.”

Immediate health risk must be weighed against radiation-induced cancer risk.

‘Highest response rate ever reported’ in relapsed mantle cell lymphoma

A good summary if a bit technical of recent findings on new mantle cell lymphoma treatments from the American Society of Hematology annual meeting. Two new treatments for relapsed MCL with encouraging results:

• Ibrutinib
• Bortezomib (Velcade) – updating on longer-term outcomes

No sense from the article how this success rate compares to other approaches (e.g., allo stem cell transplants) but something to raise with your hematologists should you be in this situation.

‘Highest response rate ever reported’ in relapsed mantle cell lymphoma : IMNG Oncology Report.

Don’t overwhelm patients with unnecessary detail

On use of ‘medi-speak’ and the need for plain language in doctor-patient communications. Tongue-in-cheek in parts (the example is funny). Quote:

So docs: if you are frustrated that patients no longer accept your advice as if coming from a demi-God, just sprinkle in a few more big words, discuss a few more rare complications of each treatment choice, and the decision will be back in your hands. Your bewildered patient will be dependent upon you for your wisdom and counsel.

On the other hand, if you want to truly serve your patients’ best interests, and share the decision making burden with them, then please take care not to overwhelm them with unnecessary detail. And remember to use words that don’t require a medical degree to understand.

Don’t overwhelm patients with unnecessary detail.

Technology will replace 80% of what doctors do – Fortune Tech

More from Vinod Khosla on the future of health care (see previous posts Vinod Khosla: Technology Will Replace 80 Percent of Docs and AI will eventually drive healthcare, but not anytime soon), as well as Software Programs Help Doctors Diagnose, but Can’t Replace Them on how doctors and software can work better together.

I think he underestimates both the institutional barriers to change (his incentives para below) as well as the human side, and getting the balance right between better (and more) data and how to analyse it for treatment recommendations (e.g., may mean over screening and uneeded treatment). Quote:

Some critics of more automated healthcare argue that medicine isn’t just about inputting symptoms and receiving a diagnosis; it’s about building relationships between providers and patients. Providing good bedside manner and answering certain questions can often be handled better by a person than a machine, but you generally don’t need a medical degree to do that. Nurses, nurse practitioners, social workers, and other less expensive, non-MD caregivers could do this just as well as doctors (if not better) and spend more time providing personal, compassionate care. I’m not advocating the removal of the human front-end here. I’m arguing that we should build robust back-end sensor technology and diagnostics through sophisticated machine learning and artificial intelligence operating on data in greater volumes than humans can handle.

A transition to automation has already happened in other areas where we once thought human judgment was required. Most commercial flying is now done by auto-pilot, not by the captain. Algorithmic trading now drives most stock market volume. Google’s (GOOG) self-driving car has had zero accidents driving 300,000 miles on normal streets. The same replacement of human involvement by computers will also happen in healthcare. This will create a more comprehensive understanding of patients and improve health outcomes with more personalized treatment. Physicians will have MORE time to spend talking to their patients, making sure they understand, socializing care, and finding out the harder-to-measure pieces of information because they’ll spend a less time gathering data and referring to old notes. And, they will be able to handle many more patients, reducing costs.

The source of healthcare innovation

Where will all this innovation come from? Some believe we have to work within the constraints of the medical establishment. I disagree.

Innovation seldom happens from the inside because existing incentives are usually set up to discourage disruption. Pharma companies push marginally different drugs instead of potentially better generic solutions because they want you to be a drug subscriber and generate recurring revenue for as long as possible. Medical device manufacturers don’t want to cannibalize sales of their expensive equipment by providing cheaper, more accessible monitoring devices. The traditional players will lobby/goad/pay/intimidate doctors and regulators to reject innovation. Expecting the medical establishment to do anything different is expecting them to reduce their own profits. Granted, these are generalizations and there are many great and ethical doctors and organizations.

Technology will replace 80% of what doctors do – Fortune Tech.

Do annual physicals do more harm than good?

wecaremd.org

More on the value of annual physicals  (see Let’s not get rid of the annual physical, Death of the Physical? Primary Care and its ‘Archaic’ Exam). In essence, to be useful, a physical should not be like a ‘fishing expedition’ through tests to find abnormalities, but more a review of family history and discussion with the patient on health issues, targeting tests where appropriate. Quote:

Other primary care experts agree. Welch says that as a primary care physician himself, he is not suggesting that patients skip annual visits. It’s just that he views these as “check-ins” not “check-ups.” The difference is that instead of running a battery of screening tests on every healthy patient, doctors would do better to assess a baseline of where patients are in their lives. Welch sees more benefit in asking patients questions that include; Are you working? How is your family situation? How do you feel? What are your goals for the future? The answers to these and other insights into family history of illness and other risk factors can help guide the physical exam. `

The Cochrane editorial concurs; “Practitioners should continue to investigate and treat patients with symptoms or clinical clues to underlying disease or its risk factors.” When it comes to the annual check-up, “ practitioners should focus on tests that are targeted to the patient’s age, sex, and specific risk factors, and that are supported by high-quality evidence.”

Do annual physicals do more harm than good?.

A healthcare scenario for 2040 | Forum:Blog | The World Economic Forum

The science fiction view of the future of healthcare. These exercises are always useful in testing future directions. The biggest fallacy, in my mind, is to view healthcare through a consumer lens; choosing hospitals and providers, even where possible financially, requires a higher level of expertise than other ‘shopping’ activities. While greater transparency and better outcome indicators will help move towards that direction, the complexity of many diseases, the ongoing impact of socioeconomic factors on health and healthcare, and the potential cost implications of extreme personalization of health care, make this vision unlikely. But a good thought experiment, and given it comes from McKinsey, likely will have some influence in future thinking. Quote:

Governments have reformed their health care services to work with these new organizations [global knowledge brokers] using learnings from their past contributions to risk factors and poor healthcare delivery. OECD countries still struggle to fund equal access to all the new possible interventions for everyone, but citizens and health coaches are active shoppers for the most effective interventions, and are able to identify the right care and right provider based on high-quality data.

The age of precision medicine is rich in data, information and creativity. It is an age of “my health” customized to me – an age of better health and longer life for at least the richest two-thirds of the world’s population.

A healthcare scenario for 2040 | Forum:Blog | The World Economic Forum.

And another piece from the same series, capturing a comparable vision but without the consumer spin, in the form of a top 10 list:

1. Your smartphone will be a more useful medical instrument to the doctor than a stethoscope or an otoscope; it will be used for SMS consults, remote diagnostics and access information, among other things.
2. Distance learning and consults as well as telemedicine will be routine.
3. Doctors and nurses will have jobs that are very different than today; new types of health workers will emerge, like health coaches and technology-empowered paramedical professionals.
4. One’s health status will be monitored and tracked in real time through the use of sensors in the body, on pills, in devices and in medical transport vehicles like ambulances.
5. Your personal health data will explode and be more accessible and portable; electronic health records, genomic profiles, behaviours and consumption patterns will allow better prediction of disease and tailoring of prevention and treatment.
6. Preserving wellness and preventing the preventable will displace treatment of disease in the priorities of providers and payers.
7. Regenerating and replacing damaged body parts will become a reality through the use of regenerative medicine, pluripotent stem cells, gene therapy and advanced prosthetics.
8. Best practices developed by leading institutions will be globalized – a “Bloomberg for health” will bring transparency of best outcomes to the practice of medicine.
9. Health delivery will occur in venues that are even more polarized than today. Much preventive and primary care will occur in homes and in communities. Centres of excellence in tertiary care will exist on the other end of the spectrum while secondary care centres become less critical.
10. Health technologies will be more hybrid in nature, where new products are developed with combined diagnostic, drug, biologic, ICT and medical device attributes.

Ten things you need to know about the future of health

The elephant in the room

A somewhat lengthy reflection on some of the drivers of healthcare costs, particularly the incentive systems and the lack of consistency among practitioners. Well worth reading for those interested in health policy. Article ends up with some good questions for the medical profession and policy makers:

• The key question is ‘How should healthcare decisions be made?’ Or rather, ‘How do we spend the healthcare budget?’
• Are there treatments we all agree deliver value for money to our patients?
• Are there specific treatments that we all agree are poor value?
• Should the medical profession as a whole take responsibility for treatment decisions that most of us consider to be wrong? Personally I consider that we should. We are best placed to understand and advise on the issues, and the public looks to us to provide the best possible care and dispassionate advice.
• Would any doctor who took on this battle be prepared for the inevitable media backlash when disgruntled colleagues (and angry patients) discover they are on the losing end of the process? This might be the biggest stumbling block.

There have been some efforts in the US to establish guidelines (see Doctors call for end to five cancer tests, treatments), and public healthcare systems do tend to have these kind of review processes, imperfect as they are.

The elephant in the room.

Patient education is often an afterthought

hohclinic.org

Good points on the current limits of patient education. While my experience in Canada has been much better than my mother-in-law’s experience in Switzerland, it still falls far short of the potential. Quote:

What if the simple fact of receiving a diagnosis- say diabetes, cancer, or multiple sclerosis- set in motion a series of automatic events. What if short videos on this patient’s condition were made available to her on a laptop or iPad during her hospital stay? What if a text was sent to her mom’s cell phone with a link to an e-patient community that could provide support and information? What if I could ask my EMR to print out a handout in the patient’s language and specify that it be modified to the appropriate reading level? What if a week after they went home this family was automatically sent a series of questions that assessed their understanding of medications or recommended care and their primary care doctor was emailed regarding any significant areas of concern?

Patient education is often an afterthought.

Pros and cons of letting patients record doctor visits – amednews.com

drcate.com

As one of my hematologists suggested recording key patient-doctor discussions given his sense that note taking, either by the patient or caregiver, was less accurate, I was interested in this piece of the pros and cons of recording. While much of the article is about situations when a family member wants a recording, not the actual patient, where privacy concerns increase, nevertheless captures some of the issues well.

My own sense is that if this helps the patient, and the doctor is comfortable, the advantages likely outweigh the disadvantages. Quote:

A middle path that could avoid these risks while preserving the benefits might be to record only the beginning and end of the visit, leaving out the physical examination and providing patient and doctor with some privacy to discuss matters that should not be shared. In this case, the patient and physician would decide together what is to be recorded. Perhaps the taped record would include only the patient’s discussion of symptoms (to let him or her discover later whether everything was presented to the doctor) and the physician’s summary of instructions, explanations of prescriptions, follow-up appointments and so on.

Pros and cons of letting patients record doctor visits – amednews.com.