Via John Goodman comes a story at LA Weekly reporting that the next released edition of the Diagnostic and Statistical Manual of Mental Disorders might include picky eating, or “Selective Eating Disorder.” One of the lead researchers into the “causes and severity of the disorder” explains it thusly:
She went on to explain that these finicky eaters often reject food not because of taste, but rather because they find the look or smell unappealing or have negative physical or emotional childhood associations with food.
I know I’m only one-eighth of the way to being a medical professional and so might be missing out on something here, but it seems to me that what she’s saying is that sometimes people base their eating decisions on subjective personal preferences about the food in question.
The implication seems to be that if you don’t like a given food for reasons other than taste, you may have a mental illness. I wonder if that covers my avoidance of foods like deep-fried Twinkies for the sake of my health.
Over the past few years I’ve seen many exhortations (such as this one) to be aware of the “hidden/shadow/unofficial/cultural curriculum” of medical school. The “hidden curriculum” is that part of training that imbues us freshly-minted medical students with the often-unspoken values, norms, stereotypes (surgeon jokes, anyone?), and attitudes common to the profession. Most often, this “hidden curriculum” is said to be imparted unintentionally by professors and clinical role models.
Sometimes, however, there’s nothing hidden or unintentional about it.
Our recently-started anatomy class actually begins with a couple of weeks of embryology. Here’s one of the questions from the textbook, and its answer. To be fair, the question itself wasn’t assigned, but rather the chapter in which it was located.
Question: “A 22-year-old woman who complained of a severe “chest cold” was sent for a radiograph of her thorax. Is it advisable to examine a healthy female’s chest radiographically during the last week of her menstrual cycle? Are birth defects likely to develop in her conceptus if she happens to be pregnant?”
Answer: “Yes, a chest radiograph could be taken because the patient’s uterus and ovaries are not directly in the x-ray beam. The only radiation that the ovaries receive would be a negligible, scattered amount. Furthermore, this small amount of radiation would be highly unlikely to damage the products of conception if the patient happened to be pregnant. Most physicians, however, would defer the radiographic examination of the thorax if at all possible, because if the woman had an abnormal child, she might sue the physician, claiming that the x-rays produced the abnormality. A jury may not accept the scientific evidence of the nonteratogenicity [doesn't cause birth defects --NWS] of low-dose radiation.” [emphasis added]
There you have it. Our first explicit lesson in defensive medicine before we even get near the cadavers in anatomy class. Some things you just can’t make up.
I hear the answer to that question in the next edition will include a helpful reminder to make sure to run the radiograph order by the patient’s insurer’s radiology management service first.
The Happy Hospitalist has a great proposal to improve the utility of EMRs. Right now, these systems are often plagued with what one blogger calls “Copy n Paste Gone Amok Syndrome.” Reams of redundant information is copied into the EMR, and physicians who want to extract the clinically useful information from a note have to expend a lot of effort to wade through the pro forma notations that are primarily there to satisfy E&M billing requirements. If you want to get paid for that high-level patient encounter, you had best document each point of the x-point review of systems, and so on. When every physician does this for a patient being bounced around to multiple specialists (or with frequent medical contact, generally), the length adds up.
Add to this the frequent proposals that some patient behaviour or another be tracked in the EMR by every treating physician, regardless of why the patient is there in the first place. Some of this is probably a result of the trend towards overmedicalization of everyday life that we see in North America. Some of this is probably a result of medical interest group politicking that seeks to enhance the profile/prestige/importance of their constituency. Some of this is probably a result of the “what harm can come from another checkbox in the record?” mentality, coupled with the fact that this data can actually be useful to policymakers, researchers, and sometimes even patients(!). Off the top of my head, I can think of proposals for medical monitoring (or notice-taking, or box-checking) of social markers as disparate as smoking status, BMI, domestic violence, seatbelt use, and texting-while-driving.
Happy’s open-source H&P would go a long way to restoring sanity. Unfortunately, as he points out, the payment system isn’t too conducive to that sanity. When every physician has to check all of those boxes in order to get paid… they’ll get checked, and then copied-and-pasted.
In some ways, his proposal reminds me of the way that record-keeping functioned when I worked for my campus IT department. The required drop-down lists for all the data the “higher-ups” wanted to collect was kept in a separate part of each case record, never impinging on the employee-written narrative reports that contained only the vital information. They got their data, we got to see what we needed about the case’s progress and past work history, without the former getting in the way of the latter. Data collection didn’t excessively impede workflow. Win-win.
Lots of people have rightly pointed out that EMR vendors would do well to design their products based on how medical practices actually operate, instead of assuming that medical practice should be shoehorned into the constraints of the electronic record. For some good ideas, they need not look beyond their own industry’s analogues.
One of the problems that comes up frequently in health economics/policy, and discussions of other economic issues, is the definition and especially the measurement of cost. Is a given cost a real economic cost, or just an accounting cost to one particular entity? Whose cost is it? What kind of cost? Depending on the question that’s being asked, these sorts of questions need to be answered in order for an analysis to be valid and accurate.
The issue of cost in health care is obviously a huge one, but a recent post by The Happy Hospitalist provides a timely reminder about the fact that certain costs are liable to be systematically under-counted by policy analyses. I’m talking about “convenience” costs.
“Convenience,” broadly defined, implies a lack of necessity… you can get rid of it, because it doesn’t really affect the important stuff. That’s as true in health care as it is everywhere else. However, just because something is “only a convenience” doesn’t mean that it doesn’t improve people’s lives in a real way; conversely, reduced convenience does make its erstwhile beneficiaries worse off.
When Canada Post decides to stop house-by-house mail delivery in favour of neighbourhood postbox stations, it might reduce its cost of delivery, but does so by increasing the cost to the neighbourhood of receiving its mail. It doesn’t cost more money to pick up one’s mail from a neighbourhood mail station; the additional cost is in terms of time (and potentially a psychological “hassle factor”). Whether this switch is desirable overall depends on the relative magnitude of the two costs in question. The same goes for health care.
Time is sometimes the forgotten factor in health reform discussions. Perhaps not coincidentally, it’s patients (and physicians) who probably bear the brunt of the time costs the system imposes. Patients spend time waiting… waiting in the waiting room at the doctor’s office, waiting for the next available appointment, or as in Happy’s case, waiting for a VA hospital bed to open up, waiting for a VA doctor to be available, and waiting for an opportunity to travel 75 miles to the nearest VA pharmacy.
Sometimes the “inconvenience” costs more than just time. The wages forgone while waiting to see the doctor, the childcare to pay for on the day of the appointment, the cost of fuel or fare to the distant healthcare facility… these are real costs of “inconvenience,” too.
In most analyses, it seems, these costs aren’t factored in. On one level, that’s understandable because this sort of thing is probably insanely difficult to measure and value accurately. That doesn’t mean that it can be safely forgotten.
When a study shows that making certain changes cut cost to the “system” without affecting whatever quality metric was being examined, that doesn’t mean that the change is truly costless. As Happy’s example shows, a healthcare system (an HMO, an insurer, the VA) can cut its own costs without affecting quality by increasing the “inconvenience cost” to its patients. Even though there’s no “real” effect on the clinical quality of care, I challenge anyone to read the linked story and say that the cost to the patient is non-trivial.
These decisions about convenience can only increase in relevance as we move forward. To pick one example, with the decline of the solo general practitioner and the rise of the ACO/PCMH/hospital-owned group practice, it’s worth asking what minimum community size is required to sustain the presence of a medical professional, and which of our rural communities won’t make the cut. Another might be the desired number of home care physicians, given the existing limitations of the primary care physician workforce.
Sometimes, the cost to the patient of added inconvenience will be outweighed by the decreased cost to the system of providing more inconvenient care of the same or similar clinical quality. There will be many occasions, I suspect, where the magnitudes of these two costs will be much closer than is presently acknowledged.
So what to make of Happy’s assertion about the VA? Maybe they keep their costs artificially low by forcing the patient and his community physicians to spend more of their time and money doing what the VA won’t do. Maybe the savings the VA gets from reducing their physician and pharmacy availability outweigh whatever additional cost is imposed on the patient and on Happy’s hospital. Regardless of what the right answers are to these questions, it would be nice to see an attempt to answer them that doesn’t pretend that the patient’s time isn’t worth anything. Health care already is, and will continue to be, rationed by one system or another. For people to have faith in that system, they need to see that when the numbers are being run, their preferences aren’t being ignored.
Fun tidbits, health-related and otherwise, from around the ‘tubes:
- How do the media deal with new research? How should the media, or anyone else for that matter, interpret new research? Unfortunately, the New York times only devotes a couple of paragraphs to this first question, but even that is enough to illuminate the complex web of incentives facing those in the science communications industry, and what it means for the science coverage that you see. A blogger at Foreign Policy provides some useful advice in response to the second question.
- The Placebo Journal Blog takes on a proposal to save family practice… by extending the residency to 4 years from 3 (in contrast, FP residency in Canada is 2 years). The comments are harsher than the post itself. A family practitioner blogging at Better Health gives an example of how opting out of Medicare can be win-win for the doctor and the patient. This strikes me as a better option than an extended residency. Even if primary care can be saved, it probably won’t happen soon enough to stave off what could be a massive increase in Emergency Department utilization by newly insured patients as a result of the PPACA.
- File these under “overutilization” for sure: Dinosaur accuses the American College of Obstetrics and Gynecology of “usurping” primary care’s scope of practice with new guidelines recommending OB/GYN visits for younger teenagers; MD Whistleblower blows the whistle on various “pre-emptive” CT scans that are being advertised to patients despite the fact that they don’t do much good for anyone.
- Science-Based Medicine writes a rebuttal to a Slate piece linked to in the last edition of AtM: Why Big Pharma should not buy your doctor lunch. SBM also featured some well-written commentary about new CMS head Don Berwick, touching on his lax attitude towards pseudoscience, and the Central Berwick Paradox of supporting unlimited patient choice and top-down government rationing. Or something like that.
- Via EconThoughts and Megan McArdle, we find a story in the WSJ describing how some unions hire non-union labour to staff their picket lines. Delicious. Less delicious is the story told by House Appropriations Committee Chairman David Obey (D-Wis) of how the White House suggested paying for spending on teachers by cutting food stamp benefits. Does anybody remember who the largest donors to federal Democrats are? I’m having trouble, but I don’t think it’s food stamp recipients.
- TJIC and Coyote Blog talk about “big picture jobs,” adding real value through real work, and what Scott Greenfield would call the “Slackoisie” that is much of my generation (I hope not to fall in with that crowd). We have critiques of recent NY Times letter-writer Arielle Eirienne, Washington Post interviewee “little-miss-altruist Beth Hanley,” and “big-picture jobs” and the people who think they should have one. They use lots of harsh words (well, TJIC does), but honestly… they’re right, painful as it may be for some of my contemporaries (heck, a number of my former classmates) to acknowledge.
- Let’s talk safety. It’s important, right? Important enough to flex some muscle and shut down a business just for the hell of it? Coyote finds that some agencies would say “yes” to that. Toyota and the NHTSA, in a move that didn’t surprise those who cared to think about the issue, announced that virtually all of the so-called “sudden acceleration” issues are attributable to driver error “pedal misapplication.” Whoops. Coyote asks “how safe is safe enough” in the context of dioxin, pointing out that new EPA efforts at regulation are probably superfluous, as is their existing safety standard. Lastly, can we afford to hire government employees to supervise children’s dietary intake? What’s scary is that there are people out there who take the question seriously.
- Doctors aren’t the only ones who deal with emergencies. There is such a thing as a legal emergency as well. Why not regulate emergency legal services in the same we that we do emergency medical care? Of course, like physicians, sometimes lawyers can be breathtakingly, hilariously incompetent.
- Economic mismanagement was a common theme this past week. From EconThoughts we have Obama’s Dirty Dozen; InsureBlog explains how his state is implementing the PPACA’s high-risk pool provision (not very well, it seems). Coyote explains why a government program’s popularity is a terrible metric by which to judge it, just as high corporate profits can sometimes spell bad news for the larger economy.
- Ending on a lighter note, we have an interpretation of Toy Story 3 as a libertarian-inspired parable, and an animation of an orthopedist consulting with an anesthesiologist. “There is a fracture. I need to fix it.“ Hilarious.
I’ve been reading through the Cato Institute’s new white paper on the new health reform bill. The PPACA does a lot of different things, so it was helpful for me to see detailed exposition and analysis of most of the whole thing in one document. There’s a lot in there to digest, particularly regarding the potential long-term impact of the CLASS Act (long-term disability insurance) program, but the passage that really caught my attention was this [in the section dealing with consumer-directed health plans, PDF page 20]:
President Obama has always been hostile to consumer-directed health care. In his book, The Audacity of Hope, for example, he dismisses health savings accounts as being based on the idea that people have “an irrational desire to purchase more than they need.”
Let’s leave aside the question of whether people make decisions perfectly rationally, even when dealing with health, life, and death. Let’s even set aside the question of whether HSAs are a positive market development (my take is that they are, but that’s neither here nor there for this post). Is it really so inconceivable that people might want to purchase more medical goods and services than they “need?”
Apparently we now live in a world in which moral hazard doesn’t exist, demand curves don’t slope downwards, patients never demand antibiotics for their colds, super-gee-whiz-ultra-shiny-full-body-CT-scans aren’t regarded as “newer and shinier” by consumers, and the RAND Health Insurance Experiment never occurred, among numerous other things that seem to have changed.
Somehow I don’t think that I’m the one who missed the memo.