Tumoriffic Rides Again!

Radiation, the Gift that Keeps on Giving!

You ever get that feeling that it's just too quiet? Well, it has been that way for me. Since the giant clivus* booger** in 2012 (see earlier posts), nothing truly exciting has happened in my health. For me, it's a kind of writer's block. Well, that just changed.

A few minutes ago, I got a phone call from Jill, my awesome NP at the Perini Cancer Survivors' Clinic at Dana Farber Cancer Institute. My yearly surveillance MRI shows something growing in my clivus, and it is extending into my braincase.*** That may not be as bad as it sounds. Jill has already gone over the films with a neurosurgeon at Brigham, and the neurosurgeon thinks the most likely diagnosis is post-radiation inflammation, which, relatively speaking, sounds delightful. On the other hand, I'll still need a biopsy to be sure.

The next question is, how do they get to this thing? It's on the wrong side of my clivus. If it were on the right side, someone with a really long, skinny finger could just scrape a bit off with a fingernail, but it's not. So, can some enterprising surgeon drill a little hole through my poor, beat-up clivus and snap up a bit of whatever it is? Or does someone have to crack open my cranium and get through one of the busiest, hardest-to-reach places ever. Probably the former, but it's always fun to get anxious about worst-case-scenarios.

So, expect more news over the next few weeks. Here we go again.

Love,

Tom

*The clivus is a bone in the skull. On one side of it is the back of your throat. On the other side, your brain. It was also a name we used to call each other in medical school.

**A booger is a nasal accretion of dried mucus (which is a type of schmutz). In this case, it wasn't literally a booger. It was a bone infection, but it's more comforting to think of it as a booger.

***Specifically, in the middle cranial fossa for all you medical geeks out there.

Massachusetts CDC Budget (State Public Health Laboratory Institute) Update

Quick budget update. (See previous post for details.) My friends and I have been hitting the State House and getting co-signers for Rep. Campbell's amendment. So far, we have Kane of Shrewsbury, Pignatelli of Lenox, Gentile of Sudbury, Balser of Newton, Keefe of Worcester, D'Emilia of Bridgewater, Khan of Newton, Koczera of New Bedford, Cantwell of Marshfield, Ultrino of Malden, Provost of Somerville, Barber of Somerville, Garballey of Arlington, Hecht of Watertown, Malia of Boston, Ashe of Longmeadow, Sannicandro of Ashland, Ayers of Quincy, Linsky of Natick, Benson of Lunenburg and Schmid of Westport, Stanley of Waltham/Lincoln, Smizik of Brookline, Dubois of Brockton and East and West Bridgewater, and Devers of Lawrence. If one of these is your legislator, please call and thank them.

That's the highest number of supporters we have ever had. We're going to continue to shake the trees for more until the deadline on Friday.

Unfortunately, given the undemocratic structure of the House, the only thing that really matters is the opinion of the top leadership. That mean Speaker DeLeo and Ways and Means Chairman Dempsey. In the next step, they look at all the amendments submitted by members and put the ones they like in the Omnibus Amendment. That always passes, so if we are in it, we win. If not, we lose. Our numbers may push them in the right direction, but sometimes, they cannot be swayed. We will keep our fingers crossed.

Please call your legislator (http://www.wheredoivotema.com/bal/MyElectionInfo.aspx) and ask them to sign on to Campbell's Amendment 1036. Also, call DeLeo (617-722-2500) and Dempsey (617-722-2990) and ask them to include it in the Omnibus Amendment.

Playing Public Health Chicken: Urgent! Share! Contact your Massachusetts Legislators ASAP!

Urgent! Please share this on Facebook:

Yesterday, I had my heart broken. To be frank, it was predictable. It has happened in the same way many times before.

For 13 years, my citizenship passion project has been tuberculosis and more general public-health-disaster-preparedness in Massachusetts. Our state and regional CDC (the Massachusetts State Public Health Laboratory Institute) is New England's bulwark against infectious potential epidemics and threats (TB, Ebola, mosquito and tick-borne illness, rabies, bioterrorism, chemical hazards, food poisoning, etc.), chemical hazards, and bioterrorism. And, for 13 years, as my colleagues and I have worked every budget season to educate legislators and attract press attention, the federal share of its budget has dropped, and state contributions have waxed and waned, a step or two forward, two steps or three back. With each shift in legislative leadership, we have to persuade a new crop, and they retire or fall to scandal, we start all over again. Each time, more essential staff are eroded away, retiring seeking stabler lives elsewhere and taking hundreds of years of collective expertise with them.

I almost built my career around it, but my rapid succession of tumors caused me to abandon my plans to become an infectious disease specialist. But, still, I have stuck to the original foundation.

This was the worst year. This year, I put in more effort than I have in a long time. The Massachusetts CDC is beginning to show the cracks that my colleagues and I have long warned would appear. We hear a new desperation of our hard-working friends on the inside as they struggle to maintain our defenses. This new threats have emerged, such as West Nile Virus, new Borrelia species (a group of tickborne illnesses that includes Lyme); Middle East Respiratory Syndrome, and Ebola; old diseases have reappeared (measles, mumps, whooping cough--'thanks,' anti-vaxers!) or morphed into worse monsters (multi-drug resistant tuberculosis); terrorists have attacked (marathon bombers). I really thought that we had an iron-clad case. The rank and file of the legislature seem to have been persuaded, but those at the top are focused only on indiscriminate fiscal austerity even as a terrifying TB crisis took place in Speaker of the House Robert DeLeo's own district, Winthrop (http://commonhealth.wbur.org/2016/04/tb-cuts-zika-ebola).

Yesterday, the Massachusetts House Ways and Means Committee budget recommendation for the Institute for FY17 came out at $12.2 million (3% of a total Massachusetts state budget of $40 billion). This has dropped from the inadequate $14.1 million in FY15. The Institute, instead being able to respond to infrequent by inevitable public health disasters by getting staff to work overtime and keep the Institute running well 24/7 for weeks, can, at best, limp along 24/5. There can be no cavalry to ride quickly to the rescue, since the CDC in our region is the Institute.

I will recover. I always do. My main partner in the endeavor, Cynthia Tschampl, and her boundless energy, will rally me again. Ways and Means may be stingy, but there is an amendment to push (thank you Rep. Cambell! https://malegislature.gov/People/Profile/LDC1) in the House, and the Senate to persuade.

If you live in Massachusetts, go to http://www.wheredoivotema.com/bal/MyElectionInfo.aspx and find your Massachusetts representative. Then, click on the link to get their contact info. Call and leave a message or e-mail them. Tell them you do not feel safe with our public health system disarmed and ask them to sign on to Cambell's amendment for a $13.1 million dollar budget for the State Public Health Laboratory Institute by contacting Sascha Alach in Rep. Campbell’s office before 2:00pm this Friday the 15th, or at least by Friday the 22nd by e-mailing sascha.alach@mahouse.gov or calling x8463. And you can contact Ways and Means Chairman Dempsey (Brian.Dempsey@mahouse.gov / 617-722-2990) and Speaker DeLeo (Robert.DeLeo@mahouse.gov / 617-722-2500/Robert.DeLeo@mahouse.gov) and tell them this cannot continue.

And be well, everybody,

Tom

Magic Seatbelts and Measles; and why I am truly upset.

A patient says that they were in a car accident once without a seatbelt. They got a few bruises, but it wasn't so bad. In fact, they have had friends who died because of seatbelts, because sometimes, seatbelts do that. They correctly point out that most accidents do not kill you even if you are not wearing a seatbelt. (This is true. In fact, I wouldn't be surprised if the chance of death from an accident without a seatbelt is less than 1 in a 1000.) And seatbelts make them uncomfortable, so they think seatbelts are a terrible idea. Even a conspiracy of Big Auto. (This is not just allegorical. People do say these things.)

What if there were a magic seatbelt? For only $2, you could wear that seatbelt twice and reduce your chance of dying in a car accident or ever even getting in a fender bender by 95% and would protect the drivers around you. What if, if everyone alive today did that, no one would ever get in a car accident or have to wear a seatbelt ever again? Who would be a seatbelt skeptic then?

*   *   *

Measles kills 1 in a 1000 people who get the disease. Most people who get it have an uncomfortable illness that leaves no lasting damage. That's nice for them. But this most contagious disease on Earth can infect a lot of people, and that means that it kills a lot of people.

But there is a 'magic seatbelt.' For $2, a pair of doses of the vaccine reduces your chance of getting the measles by 95%. (It reduces your chance of dying of it by more, but I don't know that number.) Now, like a seatbelt, it can be uncomfortable, and, in a infinitesimal number of cases it kills. But, since there are no animal vectors of the disease, through herd immunity, it would possible to eliminate measles entirely, making the vaccine obsolete.

In 2013, AIDS killed 1.5 million people. In contrast, in 1980, before the vaccine was widely available, measles killed 2.6 million people, most of them children under 5. In 2013, when 84% of all children had received at least one dose of the measles vaccine before age 1, measles caused 145,700 deaths. Meanwhile, in the United States in the years just before the vaccine was introduced, there were about 450 deaths a year, but there were 48,000 hospitalizations and 4000 cases of encephalitis (brain inflammation) with high risk of permanent impairment.*

The fact that anyone would think to stand in the way of a vaccine that prevents millions of deaths each year is unfathomable. The fact that people believe that there could be an evil conspiracy to spread a vaccine that could cause its own obsolescence is amazing.

And I do take it personally when people who have not spent decades studying this sort of thing not only disagree, they publicly shout their opinion. Not only are they telling me that one of the most valuable tools of my calling is evil, they are telling me that my friends, colleagues, and I are fools or monsters. My pediatrician colleagues lose money administering vaccines that are undercompensated by insurance companies and overpriced by pharmaceutical companies.

So, yeah, I have a chip in my shoulder about this issue.

PS: Maybe the antivaccine movement is a conspiracy of Big Pharma. If the measles vaccine is used widely enough, they will never be able to sell it again. The smallpox vaccine was such a bust! If they keep this antivaccine thing going, they could rake in the profits forever! That's it!

* http://jid.oxfordjournals.org/content/189/Supplement_1/S1.long

Death by a Thousand Clicks

The Giant Experiment That is Killing Medicine

Introduction

What if you and everyone you know were the subject of a giant medical experiment? What if no one warned you or asked your permission before including you? What if that experiment drastically changed everything your doctor did? Guess what? That's exactly what started in 2009, when Obama passed the Health Information Technology for Economic and Clinical Health Act (HITECH Act). This is not the same thing as the Affordable Care Act (a.k.a., Obamacare), and I think it is far more ominous.

The HITECH Act allocated $44 billion of Medicare and Medicaid money to subsidize the adoption of privately-made, government-certified ‘Electronic Health Record’ (EHR) systems, and encourage (bribe and penalize) medical practices and hospitals to use them to carry out certain tasks in patient care. These tasks are called 'Meaningful Use' (MU) of the EHR as defined by regulation.

As time progresses, the bribes will taper to nothing and become penalties levied on practices or hospitals that do not reach these goals will have to pay penalties. So, effectively, HITECH is forcing doctors and hospitals to adopt these private programs for all of their patients or stop accepting Medicare and Medicaid--which means stop serving most of the sickest patients.

Based on my personal experience, I think this program misses the forest for the trees and sets up a series of incentives that impair doctors’ abilities to help patients. It is a reckless, unethical experiment, which, if it were a pharmaceutical, would be illegal. No one should have the authority to impose such a change on the entire system without scientific evidence that it will improve the concrete outcomes of longer, healthier, and happier lives.

Part 1. The Mismeasure of Medicine

There are dozens of Meaningful Use goals. Many seem appropriate for individual patients. Some seem deeply flawed to begin with. The sum of all of them may do more harm than good.

One Meaningful Use measure that at least seems sensible, at least in individual cases, is the requirement to document smoking status. But does documenting in the medical record the smoking status of every single patient lead to fewer patients smoking over all? Does it lead to fewer heart attacks and cancer and extend lives? How do you know the documentation is accurate? Are there more efficient ways to approach smoking? Apparently, nobody has tried systematically to find out.

There are Meaningful Use measures that are based on science that is in dispute or becomes obsolete before regulators can adapt the regulations. For instance, blood pressure control is one Meaningful Use measure, but acceptable systolic blood pressure for a diabetic patient over the age of 60 has gone up by 10 points since I have been in practice. So steps I took a few years ago trying to comply with this goal may have actually harmed my patients.

Meaningful Use does not necessarily measure real world activity. It is data entry, and data entry can be manipulated to suit the person entering the data. I can meet Meaningful Use goals to minimize inappropriate antibiotic prescription by describing the same symptoms as ‘cough’ instead of ‘bronchitis.’

Meaningful use takes money and resources away from interventions proven to work. There are hundreds of thousands of bureaucrats dedicated to implement this program that has no proven positive impact. In a world of limited resources wouldn’t it be better to improve access to prenatal care or life-saving medications? How about reimbursing mental health work decently?

Most personally galling to me, my time spent even on worthy Meaningful Use goals may take away from my time spent pursuing goals that are more important but not measured or even measurable.

There is the time learning these measures that I could otherwise spend learning more medicine. Lunch meeting after lunch meeting is taken up with Meaningful Use lessons. I would rather discuss the evidence behind new hypertension recommendations, or how I can best care for a difficult case.

And there is my time with the patients. I get 15 minutes for most visits. Many doctors get as few as 8 minutes. The average is 12. Meaningful Use takes a lot of that time. When can I comb through the record and catch mistakes or opportunities to improve care? When can I listen closely to my patient and examine them carefully? When can I look into their eyes and explain my reasoning in plain language? When can I practice meaningful medicine?

I am ready and willing to learn new rules and do boring, repetitive tasks, but only if they lead to meaningful outcomes for my patients—years of happy, healthy life. Until Meaningful Use has been proven to do that, it is a game for harvesting government money at the expense of patient care and the biggest unethical experiment of our time.

Next: Part 2. Electronic Health Records, the Hope, and the Reality

Center for Medicare and Medicaid Services Guidance on Meaningful Use

Campbell-Scherer, DL, et. al., ACC/AHA Guideline Update for the Management of ST-Segment Elevation of Myocardial Infarction, Am Fam Physician 2009:79(12)1080-1086.

Everyone Should Take This Pill!

Just kidding. Such a pill has yet to be discovered, and I increasingly doubt it ever will. Nevertheless, every so often, the medical community settles on some supplement or pharmaceutical that everyone (or everyone past a certain age) needs to be on. For a while, it was vitamin C. Then it was a multivitamin a day or maybe just anti-oxidants. But every time this happens, it seems, later studies are published that show the superpill of the month actually does not have any measurable positive effect and may even cause a little harm. The lay press usually never gets the retraction. Meanwhile, many in the 'alternative medicine' community will adopt it as a cause. So people accumulate more useless pills that they dutifully take every day.

The latest to go the way of the dodo is the daily aspirin. The US Preventative Task Force has recommended for years that men over 45 and women over 55 should take a daily aspirin prevent heart attacks. Now, the FDA has warned that for people of any age not at high risk, the small risks of aspirin outweigh its small benefits.

http://www.wcvb.com/health/aspirin-a-day-not-recommended-by-fda/25819604?tru=KLwLP#.U2g914zW2eM.facebook*

I say it all the time, and I'm beginning to believe it. Healthy people should not take pills.

*Thankyou, Dr. Zachary Sholem Berger for posting this article on Facebook.

Blue Cross Blue Shield's Medicare Blue: Another Member of the Insurance Hall of Shame

My patient has had two heart attacks. You would think that his insurance company would try to prevent him from having another one. After all, you might say, heart attacks are expensive, and they wouldn't want to pay for that. You would be wrong on both counts.

Medicare does not pay for outpatient medications. This may have made sense when Medicare was created, since the cost and number of medications for the elderly were relatively low. However, nowadays, it's very tough to pay for the average senior citizen's medications. Hence, the Medicare Part B plans. These were put in place by the Bush Administration to encourage private companies to offer medication insurance for Medicare beneficiaries. Perhaps one problem with these plans is that they have less of an incentive to pay for prevention than traditional plans. After all, why pay for a medication to prevent a heart attack if you don't have to pay for the hospital stay or the bypass surgery? At least, that what I think is happening.

 So, back to my patient. As overused as they may be for other indications, statins prevent heart attacks in patients who have already had one or more heart attacks. (Statins are cholesterol-lowering medications such as atorvastatin, a.k.a. Lipitor.) The American Heart Association and the American College of Cardiology recommend only the two most potent statins, atorvastatin and rosuvastatin, for these patients.

My patient had severe muscle aches on atorvastatin, and it barely touched his cholesterol. He tolerates rosuvastatin, and it is the more potent drug. There is no question that he should be on it. Yes, it's expensive, but he needs it, and it costs less than a bypass. Medicare Blue won't pay for it. I've appealed twice, and the second time, their letter basically said, "we'll cover this when hell freezes over."

Keep it classy, Blue Cross, Blue Shield.