WelchAllyn: Vital Signs Central

It is interesting how popular Dr Oz has become.  He is one of the most influential people in our culture.  I think this is because he is smart, honest and trustworthy.   He focuses on “the patient” and tries to help not only with medical issues, but with all issues that impact health and happiness.  He appeals to people’s emotions and emotions are the spices that motivate behavior changes.  Our emotions allow us to really “feel our health”.   Giving patients more information does not do much to change behavior.  Patients need to become more emotionally attached to their own health.  Patients  become emotionally attached to their health when they understand that it is not just about them….it is about those they love and are connected to.

So how do we make this emotional connection to feeling our health?  Will more knowledge help?  More Googling about complaints and symptoms?  We all know that eating foods closest to their natural state, regular exercise and having a purpose in life leads to good health. The exciting thing is that new technologies are making it easier to connect to our health.  It is easy to track how much we walked or ran with sensors in our shoes and applications on our smart phones.  A simple pedometer works too. It is not much of a problem to monitor the foods we consume with smart phone applications that track our foods and their nutritional value.  There is a Wi Fi weight scale and blood pressure monitor available that sends data to our smart phones.  Glucometers have been connected to our computers and phones for a fairly long time in “technology years”.  We have social networks that lend support when things get tough.  We can twitter and compute into the clouds and text when we are NOT driving!  We really have all the tools to get started on “feeling our health”.   We need to get mobile.  Our bodies are programmed to move and the individual cells will likely live to their maximum potential if we are active.  If we are not active, the body programs itself to slow down and eventually die.  There is even a medical term for “programmed cell death”.

 What do you do to “feel your health”?  Any special things you do or tricks to remain healthy?  Nature rewards efficiency and adaptability.  I’d love to hear your feeling healthy secrets!

 As I listened to the news this morning, I began to think about all the options we have for communicating with each other.   The local newsman was following a story by Tweeting and the anchorwoman announced that President Obama would be holding a press conference on Facebook.  I also heard this morning that Homeland Security will issue terror alerts on Facebook and Twitter!  Are you kidding me?  I am now going to get “Terror Tweets” from our government?  It sounds like something I should get on Halloween!  If using Twitter is called Tweeting then I guess using Facebook is called Facebooking.  What the heck do I know?  Anyway, it got me thinking.   When is it appropriate to Twitter? To Blog? To Facebook? And Finally To BLUF?

What are the decision criteria on which medium to use?  You only have 140 characters to Twitter so your thoughts need to be brief, maybe even pithy.  You can Blog for as long as you want…..of course nobody will ever read your ramblings if they are too long.    Facebook, I still don’t understand its value but I know it takes up a lot of people’s time.  I think it is a veiled tool that works to satisfy our primal need to gossip and see how everyone we know is aging.  My uncle calls it the “playground of the devil”. 

Since this is supposed to be a Blog about Medicine and Business, I wondered how all of this is or will impact medicine.  I have already seen the impact of iPhones, iPads, other smart phones, “apps” and texting in medicine and business.   It is pretty amazing. What will Tweeting, Facebooking and Blogging do to the business of medicine?  Will you schedule Twitter appointments for minor problems and follow-ups with your physician?   “Yes, Mr. Smith, I can get you in for a Twitter appointment next Monday.  Mondays and Tuesdays are for Twitter appointments, Dr. Jones does Blog appointments on Wednesdays, is in the operating room on Thursdays and has Fridays off.  Be sure to limit your complaint to 140 characters.”  Will your annual physical require a Blog appointment?  Will we be able to do pre-admission work-ups on Facebook and when you show up to the hospital for your elective plastic surgery will you just pull up your Facebook page with all your data instead of filling out all the admission forms……again and again?  Will the surgeon update your Facebook page in a HIPAA compliant manner of course, so all your family knows that your surgery went well when they check their Facebook page?   Or will the surgeon just Twitter from the OR?  Will your follow-up appointment be a Twitter appointment or a Blog?  Decisions….Decisions.

And finally BLUFFing.   One of my military friends once told me that in military medicine you need to BLUF.  Bottom Line Up Front.  When my wife starts telling a story and my eyes glaze over and my O2 saturation drops, I usually plead with her to BLUF.   This does not win me any points with her but it does save precious time.  I Googled (a verb) BLUF and found in Wikipedia (the new encyclopedia of the 21^st Century) that BLUF has a medical assessment definition.  It states “BLUF is a key medical assessment to determine quickly the pressing problem facing a patient”.  To determine quickly the pressing problem facing a patient.  That seems like a good thing.  It might be the solution to our health care crisis!  Let’s all push for BLUF in health care.  I think it would be good for business too!  What do you think?

Our local newspaper recently published an article about a physician who works in the intensive care unit at Upstate Golisano Children’s Hospital.  (Click here to read it.)  It started out: “Dr. Kevin Ragosta has a DO after his name, rather than MD. The doctor of osteopathy works alongside medical doctors in the Upstate Golisano Children’s Hospital intensive care unit.  Dr. Kevin Ragosta looks like the rest of the doctors in the intensive care unit of Upstate Golisano Children’s Hospital, but instead of an “MD” on his nametag, he wears a “DO,” for doctor of osteopathic medicine.”

The article got me thinking. Many people ask me the question, “what do the letters DO after your name mean?”  Is a DO a medical doctor?  It amazes me that some of my business colleagues don’t understand what DO means and yet they sell them medical devices every day. We have tens of thousands of physician customers that have DO as their letters of medical degree designation.  I have been answering the question, “What does DO mean?” much of my adult life.  The quickest answer I can give is DO are the letters used to designate an osteopathic physician and an osteopathic physician is a fully trained physician……just like our MD colleagues.  So only DOs and MDs are trained and licensed to practice in all the medical and surgical specialties.  A DO can be a neurosurgeon, a cardiologist, a pediatrician or a neuropathologist (like me).  There are no restrictions.  Let me present to you the definition given by the United States Library of Medicine/National Institutes of Health:

“Like allopathic physicians (or M.D.s), osteopathic physicians (D.O.’s) complete 4 years of medical school and can choose to practice in any specialty of medicine. However, osteopathic physicians receive an additional 300 – 500 hours in the study of hands-on manual medicine and the body’s musculoskeletal system. Osteopathic physicians who wish to specialize may become “board certified” (in the same manner as M.D.s) by completing a 2- to 6-year residency within the specialty area and possibly a fellowship in a sub-specialty area and passing the board certification exams. D.O.s practice in all specialties of medicine, ranging from emergency medicine and cardiovascular surgery to psychiatry and geriatrics.”

I hope the definition above helps with the understanding.  As I stated previously, I am an osteopathic physician who specializes in neuropathology.  I trained at both osteopathic (DO) and allopathic (MD) institutions.   I teach at an allopathic medical school.  Confused?  I know it is hard to keep all the letters straight.  My close friends and even my parents remain confused.  I tell them it is like a DDS and a DMD.  Both are dentists but their degrees are different because of the dental schools they went to.

I hope my explanation helps readers understand osteopathic medicine.  I had never heard of a “DO” until my college pre-med years.  My exposure to a “DO” started with my lymph node enlargement in an area typical for a form of lymphoma.  I went to our college health center and the doctor there told me I likely had lymphoma and needed a biopsy.  I was really scared so I went to see my pre-med advisor and she told me to go see a new doctor in the community to get another opinion.  She called him an “old fashioned” family doctor who delivered babies and first assisted on his patients when they had surgery.  She told me he was a “DO”….whatever that meant.  When I saw this physician, he spent a long time getting my history and doing a physical exam.  He actually did a thorough physical exam! He then asked me if I “had a cat”.  I thought…. what in the heck did that have to do with my lymph node?  Interestingly I did have a cat.   He then asked me if the cat had scratched me recently.  I told him he scratched my chest a few weeks ago.  The osteopathic physician then told me that he thought I did not have lymphoma but I had “Cat Scratch Disease”….or “Cat Scratch Fever” for you Ted Nugent fans.   I had my lymph node biopsy the next week and the report came back as: “lymph node with follicular hyperplasia, central stellate necrosis with neutrophils, surrounded by palisading histiocytes, and sinuses packed with monocytoid B cells.   For those of you who don’t read pathologese, it was an entity called a granuloma which is consistent with Cat Scratch Disease and not lymphoma. 

Not only was this experience life changing in that I did not have lymphoma, it made me want to learn more about osteopathic medicine.  I learned it was started by an “MD” who was frustrated with the medicine he was practicing so he started a new way of thinking and practicing medicine.  That was a long time ago and DOs and MDs have been practicing medicine and surgery together for many years.   I owe a lot to the DOs that educated me.  They were incredible role models.  But I also owe a lot to many of the MDs who trained me in my career.   Many of them have become my friends and colleagues and I can only try to repay them by doing my best to teach the next generation of DOs and MDs.

So what does this have to do with a blog focused on business and medicine?  I hope it reinforces the idea of how important talking to patients and doing a thorough physical exam is in making the appropriate diagnosis.  I love technology as much as the next doctor but it needs to used judiciously.  In this time of great awareness of the need for health care reform including cost reduction, the appropriate use of technology has to be part of the solution.

I hope my story motivates people to think broadly about all the components of healing…….to use one’s imagination to stretch the mind.  The great innovations in medicine will come from people who are passionate about solving problems and relieving people’s suffering.  The great ideas will come from the healers in the trenches and the patients who are experiencing frustrations with the present medical system.  I’d like to hear from you on your ideas that will help create a better healing environment.

A friend of mine sent me an image of a skin lesion attached to a text message and asked me for a diagnosis.   The person wanted to know if it was Lyme’s Disease. When I replied that it “could be” but hard to make the diagnosis on a two dimensional image, viewed on a device less than the dimensions of a deck of cards and of mediocre image quality…….I got a reply “what about ringworm?”  Interesting expectation that the technology was not the problem.

The Washington Post had an article this week about physicians using cell phone photos to deliver mobile health.  They categorized it as a form of telemedicine. I’m used to working with big technology systems for telemedicine.  In fact, making the diagnosis of a brain tumor via a telepathology system began my journey into the medical device industry.  As more capability is enabled in our mobile devices, it only makes sense that telemedicine will gravitate to mobile devices.  It may happen faster than we think.  I just hope we don’t see doctors getting in trouble for “diagnosing while driving”.  Would that be a DWD?

Rashes, infections, “moles”, bruises, etc.   Is there any limit to diagnosis via mobile device images?   Imagine sending a picture of your rash to a global network of dermatologists.  Wouldn’t that be cool?  We clearly are at a point where the technology can significantly change the way we capture and communicate medical information.  Twittering signs and symptoms, a Facebook network of patients with similar medical conditions, iPhone applications to help manage chronic diseases……the possibilities are enormous.  I am interested in your ideas.  Drop me a “communication.”

Am I losing my mind?   Some of us may say this without truly believing that we are losing our minds but many of us live in real fear that someday we may “lose our mind”.     We all forget why we walked into a room, forget what we were going to say and forget where we put our car keys.  But for many people they worry that experiences like this mean something more than just a little “brain gas”. More specifically, they worry that they may be suffering from Alzheimer ’s disease.

If any of you read the article in last week’s New York Times, you know of the controversy regarding the recommendation for testing to screen for the early changes of Alzheimer’s Disease.   The idea is that if we catch the disease before the significant symptoms begin, we will give patients and their families time to “plan for the disease”.  There is also some thought that it will be a stimulus for drug companies to accelerate the development of new therapeutic drugs that will slow the progress of the disease or maybe someday even cure it.  The reactions were predictable.   Physicians who deal with this problem daily, urged caution.  One neurologist stated “I really don’t see the possible benefit conferred when an asymptomatic or minimally symptomatic patient is told he or she has an inexorable and untreatable degenerative brain condition whose course may be unpredictable and fluctuating…….at least until effective treatment is developed – it just sounds like a very expensive way to make a lot of otherwise content and functional people (and their families) very sad.”  The other responses were from hopeful patients with early mild cognitive impairment and caregivers who pray for therapies that will relieve the suffering of their loved ones.  There were several other comments about the increased cost to an already expensive system.  How can an already costly and strained medical system handle the bolus of new patients getting tested, diagnosed and then monitored for a disease that is poorly understood and has no real therapy?

As you know, I am a neuropathologist and make the diagnosis of Alzheimer’s Disease quite often.  I do this based on the interpretation of brain tissue under a microscope.  Without getting too detailed, the diagnosis is not always clear cut.  There are patients that were diagnosed with Alzheimer’s disease during life who do not have the tissue changes in the brain to make the diagnosis of Alzheimer’s disease and then there are other patients who never had symptoms of Alzheimer’s disease but have the tissue changes in the brain that we normally attribute to Alzheimer’s disease.   There is still much debate about the cause of Alzheimer’s disease as well as the nervous system pathologic changes involved.  So what exactly are we testing with these newly recommended tests?  How specific will the results be or are we just going to be creating a new group of people with a vague diagnosis who will worry about something they are not sure they will ever get based on non-specific tests that predict they will or will not get a disease that we don’t fully understand?  I think I just had brain gas. The brain is a very complex organ and we have a long way to go to understand much of it.  It is a complex collection of billions of cells with many connections suspended in a structure resembling a 3 dimensional melon made of tofu.  Let’s not get ahead of ourselves.

So why are these brain diseases so hard to figure out?  In a sense we are trying to use our own brains to figure out what is going wrong with our brains.  Interesting……..Maybe we need to use our hearts to figure out our brains.  You can see why there were all the “gut” reactions to the proposal of using expensive brain imaging and biomarker tests that are not very specific to diagnose something ten years before symptoms develop or that you may never develop.  Especially considering how little we really understand about the “disease” and have no therapy to slow the progress or cure it. 

So have we lost our mind in recommending that we test everyone early before they might develop symptoms of the disease?  It has been said that the mind is what the brain does.  What do you think?

Considering my interest in medical technology, you probably thought I was going to say something like…"the Star Trek Tricorder” is missing from the medical office.  While there is room for product innovation in the medical office, I don’t think it is some technology that is the big thing missing.  Optical biopsies, digital stethoscopes, LED based video ophthalmoscopes, non invasive glucose measurement  devices and diagnostic gloves are exciting technologies but are not what I am thinking about.  I think the most important thing missing is a healing environment for patients, health care providers and staff. 

The medical office used to be a place where patients could go and experience a healing relationship with their doctor or nurse.  There was a real conversation that happened.  There was a therapeutic connection….a ritual of healing.   It seems now that the experience is rushed, tense and often confrontational.  As you know, I am a brain pathologist and would like to share with you an experience I had this week. I had a meeting with a family whose loved one had a brain tumor which was originally classified as “benign” a few years ago.  The tumor recently turned malignant as brain tumors of this type often do.  The brain tumor therapy destroyed a great deal of this patient’s brain tissue and the patient’s quality of life was deteriorating.   The family understood the significance of the diagnosis and was not looking for false hope.  What they were looking for was someone to have a discussion with them so they could be realistic regarding their expectations for the future of the patient’s remaining life and their life after the patient’s death.   They sought a compassionate listener.  An intelligent, compassionate, caring and highly communicative health care provider is what every patient desires.  An interested, courteous and compliant patient is what every health provider desires.  Mutual respect is something both parties deserve.

It is a tough environment in the medical office these days.  Reform is being pushed down on the medical office, some outside forces think computerizing medical records will solve most of the major problems and the gap between the different stake holders widens.   So what is missing?   Listening, understanding, compassion, kindness and wisdom.  Human decency costs very little and brings great value to both sides of the clinical encounter.   What do you think?

New imaging technology and recent advances in molecular biology capture the news headlines. They produce impressive results in the diagnosis and treatment of human diseases. The “sizzle” of these new technologies might make one imagine that the physical examination is as relevant to medicine as the typewriter is to modern communications. 

Humans are very social creatures and good health partially depends on healthy relationships with other humans (and other some other life forms….in my case my dogs).  Humans have evolved through many years of interacting with each other to be quite skilled at reading the “physical language” or body language of other humans.  So in essence, humans have been refining the art of physical diagnosis for thousands of years.  Hippocrates saw the value of physical diagnosis in medicine but it seems that the art is losing ground in modern medicine.

Physical diagnosis is practiced by humans who have special training and have developed special skills.  They use unique tools to light and magnify signals given off from the human body.  The special physical diagnosis tools used by modern clinicians enhance the signals that need to be interpreted by human sensory systems. Malcolm Gladwell writes about how good humans have become in decision making based on processing the information through what he calls “thin slicing”.  It is rapid processing of sensory data, associating it with our own internal knowledge and rendering a decision….a diagnosis.   In most cases, just the right amount of information yields the best decisions.  Too much information can confuse the thinking and too little can often lead to a wrong conclusion.  In many of medical encounters, the physical exam gives just the right amount of information and is the fastest, most convenient, most cost effective and most satisfying way to care for patients.

Clinicians who are skilled at the bedside exami­nation make better use of diagnostic tests and order fewer unnecessary tests. The clinical examination has tremendous value, especially when practicing in resource poor settings, where the value of such skills is more obvious.  The physical exam is part data gathering, part hypothesis testing but most of all it involves human connection.  It defines the doctor/patient relationship and the “ritual” brings trust, compassion and the beginning of healing and/or acceptance to the patient.  If it is done quickly and without skill and consid­eration, the therapeutic part­nership and the healing process does not take place. It usually leads to dissatisfaction for both the patients and doctors.

What about results?  Advances in both invasive and noninvasive monitoring patients have led to tremendous volumes of new data.  However, many have not been clearly shown to improve outcomes in patients. They don’t pass the “so what and who cares” test.  In contrast, physical examination techniques have been used in clinical medicine for over a thousand years. Hippocrates noted observations and interpretations of patients’ complaints and physical manifestations of diseases long ago.

New technology will not make the physical examination obsolete; it will only enhance its importance.  In fact, the physical examination space is ripe for innovation.  It is time to redesign the experience of the physical exam. Our ability to hear cardiopulmonary sounds was greatly enhanced by the stethoscope. It is still a great tool but it is time for new innovations.  It is time to pick up new signature sounds in the body. It is time for an easy to use ophthalmoscope that facilitates a comprehensive look into the “window of the brain”. Enhancing our ability to hear, see or feel may motivate a renewed attention to the ancient practices of smelling disease as an example. Can we develop an instrument to detect the distinctive odors of certain illnesses? 

The physical examination will continue to be central to clinical practice as it is highly valued, especially where some medical tests are too expensive or unavailable. It is one of the keys to controlling health care costs as it can reduce our reliance on expensive tests that have not resulted in improved outcomes. It improves both the patients experience and the clinician’s satisfaction. I have no illusions about the limitations of the physical exam, but I don’t accept that it is less relevant in the care of humans (and animals) in our modern health care system.  It is key component to how humans take care of one another.  What do you think?

It appears we are on the road to the “meaningful use” of health care IT. The Health Information Technology for Economic and Clinical Health Act (HITECH) is aimed at bringing US Health Care into the information age. Many people who have never used an EHR can’t understand why we aren’t already using IT technology like banks and travel organizations already do. Funny but I observed that when the airlines switched to e-tickets, we now bring more paper to the airport to get through security than we did when we used old-fashioned paper airline tickets. With only 6% of the physicians and 2% of the hospitals (government statistics) using a complete EHR, there seems to be a lot of room for increased use. The paperless medical office and hospital sounds great but there needs to be a little reality facilitation in my opinion.

Why the low level of market adoption? Are those stubborn Luddite doctors the problem? There are some physicians who seem to always resist new technology and there are some who just love technology and can’t get enough. Then there are others who look at the new financial incentives in HITECH and just want to know “what do I need to do to get the government money in the program”? They want to check the box and don’t have a clue what meaningful use really is. Many clinicians who have tried to make EHRs work in their practice realize that most of the time the performance of present day EHRs are as exciting as that of an 8 track tape player. The EMR options available today have taken a hundred plus year old documentation process, computerized it and amplified all of the dysfunction into “the solution”.

The April 2010 Health Affairs Journal has one report on how the EHR falls short in support of the new practice model. This is the future health care model that many thought leaders believe is necessary to truly reform health care. The innovative practice model includes: “extensive use of nonphysician health coaches, a higher staff-to-patient ratio, daily interdisciplinary meetings, close tracking of chronic disease markers to guide therapy, population health management using IT to target interventions, integrated pharmacy, mental health, social work and nutrition services and frequent evaluation of work flows”. The challenges found in applying the EHR to this new model of care were “sluggish and unreliable software, e-prescribing problems, problems with communication of lab results, clinical alerts and warnings, an excessive burden on physicians, inaccurate medication lists and an overall stifling of innovation”. The authors of the paper encourage “providers and policy makers to consider alternative software and informatics models before investing in currently available systems”. Investing in new informatics innovations would be a better use of taxpayer money than the present proposed model of government paying for products that the market has not found acceptable. The meaningful use requirements seem a bit incestuous to me. Advisors to the government that are establishing the criteria for meaningful use have a vested interest in maintaining the status quo. Products that claim to provide high value and that have been available for many years should not have a 6% adoption rate.

I struggle to think of other professional communities that have the same pressure to use electronic records. There is no congressional electronic record, legal electronic record, executive electronic record because nobody has been able to figure out the secret sauce. These professionals still use paper because it works.

Humans have been communicating by writing on physical objects from cave walls to paper for hundreds of years. It is a communication standard that is tough to match. The EHRs of today are not there yet. Maybe you can understand why physicians and nurses are not that excited about computerized patient records/electronic health records. The EHR will be adopted when the value is obvious to all. It will be embraced when it is easy to use and does not disrupt the clinical work flow.

Maybe some of the innovations to make the computer user interface seem more like using paper, watching TV and listening to music will make the use of EHRs more compelling for clinicians. Isn’t it interesting that books on the computer seek to mimic the paper experience (turning pages and taking books off the shelf as in iBooks). Clinicians seem to be the largest professional group embracing the iPad . It is a very tactile product….kind of like paper. The tangibility of “touching the information” can’t be underestimated. Stay tuned, your EHR might soon be on iTunes.

I intended to blog about innovations in medicine but it seemed so trivial compared to all the news about health care reform. Instead I’ve decided to blog about a very meaningful experience that recently happened while I was flying home from a vacation trip. I encountered the awkward situation on my return flight involving someone having the exact same seat assignment as me. He had the advantage….he was already in the seat. I asked for help from the flight attendant. She replied, “I don’t know what to tell you…..it is not a full flight….just sit in any empty seat”. Very impressive customer service I thought to myself. I had to pay $25 to check my bag. Maybe in the near future, when the airlines make a mistake, they intend to charge passengers for their inconvenience …..blog for another day.

I picked the seat across the aisle from my wife and son. Sitting next to me was a 25 year “kid” with his audio headset on. I will call him “Luke” for this blog. I immediately learned that he was a Veteran of our Armed Services. After a few minutes of conversation, he showed me where he was shot in the forearm and in the head. He described many of the fire fights he experienced and the friends he lost in the recent Iraqi War. I learned he was flying to attend his military buddy’s funeral who had just committed suicide. His buddy had been severely depressed and not coping well. It was a sad story especially when I learned that he just had a new baby daughter. “Luke” just shrugged his shoulders and said very little regarding his friend after that. He proceeded to tell me that he also suffered from traumatic brain injury, post traumatic stress disorder and depression. He struggled with travel so his grandfather was traveling with him. He showed me the tattoos on his forearm and explained what each one meant to him. I thanked him for his service and he smiled and said “no problem”. I looked over at my own son sleeping in his seat and my wife peacefully reading. I thought of how lucky we are to have brave soldiers like Luke make such life changing sacrifices for our freedom. I have heard stories from Veterans that have been very interesting and touching but Luke’s stories hit me in the gut. Maybe it is my age or the fact that some of my children are close to Luke’s age. A few years ago one army medic sent me his ophthalmoscope handle with a letter stating that he felt it saved his life. It was in his pocket when he was shot and “took the bullet”. A surgeon who went to the same undergraduate college and medical school as me was named a “hero” a few years ago by Newsweek Magazine. He put himself in significant danger to save the lives of many Marines. Stories like the bullet to the ophthalmoscope handle and heroic saves by military surgeons are always fascinating but sitting next to this Veteran was a reality check for me. It made me think about what I can do to give back to those who sacrifice so much for us. Is our medical technology engine innovating with some focus on addressing the unique needs of our veterans? I have seen some dedicated and talented researchers and clinicians who are devoting their lives to the care of our Veterans.

I want to thank “Luke” and all of the service personnel who keep us free and safe. I hope we can repay you for your service by continuing to provide you with the best medical care in the world. I’d love to hear your thoughts about how the health care profession can improve the lives of our veterans.

I listened to part of the “health care summit” occurring in Washington, DC. and didn’t get the feeling that real health care reform was around the corner. Everyone seems to have an opinion on what needs to be done. But opinions are like butts (keeping with last blog’s butt theme), everyone has one. I was at a medical conference last week and one of the speakers, while on stage during his presentation, called his Senator from his cell phone and gave him a piece of his mind. He told the Senator he was in a room with 1300 other doctors and the consensus opinion in the room is that “government needs to fix the payment system”. I have heard patients tell me we need a system like Canada. Seems like a reasonable proposal. After all, it works for our friends from the Great White North and they beat us in hockey. Then you read that the Newfoundland and Labrador Premier recently had cardiac surgery in Miami, Fl . Why is he having surgery in Miami if his system works? One Canadian citizen wrote on a web site, “Gee it must be nice to be able to afford to bypass Canada’s crappy health-care system and its dangerously long waiting lists for surgery”. It appears to be an international pastime to complain about your health care system. I guess my wife was correct when she recently said to me about my own complaining; “if you keep peeing on your own lawn, the grass will be greener on the other side”. I don’t pretend to have the right solution for health care reform but I do believe one thing I heard a health care policy analyst recently say at a conference in Boston, “everyone wants health care reform as long as it is their brand; otherwise they are happy with the status quo”.

What I am observing as I go around the country talking to doctors, nurses and patients is a sense of feeling helpless, frustrated and cynical. One physician told me it is all about “eating what you kill”; so “don’t bring me new technologies that don’t improve my bottom line”. One CEO of a Catholic Hospital who also happens to be a Nun told me “no margin, no mission”. These stories remind me of one of my own experiences. I was an excited new medical director at Welch Allyn with about a decade of clinical experience under my belt. We had a brand new technology that could detect a chronic eye disease much sooner than the state-of-the- art technology. It hit all the buzz words….cheaper, faster, better. But it didn’t hit one. It didn’t hit the “so what and who cares” mark. I made my presentation on this technology to the medical director of one of the largest HMOs in the US.  I presented the information that this device could detect one of the major chronic eye diseases 5 years before symptoms or severe eye damage occurs. He said “why would I want to detect a disease 5 years earlier than we presently do?” I looked at him confused (kind of like when I dropped a dumbbell on my head in my high school weight room…explains a lot). He then said “most of those patients will be in another HMO in 5 years, so I am not interested in paying now to prevent higher costs for the next HMO”. To me, this story captures the essence of the problem in achieving real health care reform. Who is ultimately responsible for our health and who ultimately pays for it? We all quickl point our fingers. Government, insurance companies, my doctors, my patients, my employer…..nobody seems to be pointing in their own direction. If someone “owned” preventing the eye disease that would cost less to manage if detected early then that someone would have embraced our new technology. But the questions of who owns the problems and who pays are complicated. Who is responsible when patients repeatedly dismisses the recommendations to lose weight, stop smoking, exercise and eat a reasonable diet to prevent or at least control many of the chronic diseases whose costs are crippling our health care system? Who is responsible for reckless behaviors that cause traumas that require expensive acute care? Who is responsible when a patient is “unlucky” and gets a disease because their genes say they should or they were born into an environment that is less than optimal for disease prevention?

So what if we can detect Alzheimer’s disease with a new technology 20 years before symptoms? What can we really do about it, who should know the results and who should pay? The big problem is that health care reform requires making value judgments. Placing a “value” requires cost data and quality data. What is valuable to me may not be valuable to you….and most people aren’t interested in paying for things they don’t find provides them with value. I am interested in your comments!