Tuesday, March 15, 2011

Who is the Driver's Ed teacher?

In this study, primary care physicians were asked, "How important do you feel it is for patients to be well informed when making decisions about managing chronic conditions?  89% of the doctors felt it was very important.  At the same time, they felt only 15% of patients were well informed when making decisions about managing chronic conditions.  They felt 31% were not well informed.

To keep it real, what does the DSP blog think it for a diabetic to get an A?  In a nutshell, diabetics would need to know:  a) their goal A1C (typically <7%); b) their goal bp (typically <130/80); c) their goal LDL (depends, typically < 70 or <100); d) why they need to get a dilated eye exam once a year; e) why they need to have their kidneys checked for protein once / year.  That's pretty much it.  It seems pretty basic.  And yet the DSP blog would be concerned that most diabetics would not know theses answers.

This begs the obvious question--why so many driver's ed students getting low grades?  Who is responsible for how few patients get an A in this subject,  and how almost 1/3 are getting a D or F?

Obviously, this is a complicated question, and even though the DSP blog completely knows the answer, due to limited space here and the need for me to go to work, it will have to posit some thoughts to get the conversation started (at least that's the idea--come on, people, can you start pushing the comment button a few more times?):

1)  If being well informed translates into better outcomes (and that is a big if--driver's ed students have to be motivated to actually stop at the stop signs, stay within some approximation of the speed limit, for driver's ed to have much of an effect--then the DSP blog thinks driver's ed schools represent quite an opportunity for several key players affected by the high costs of poorly informed drivers.

2)  The DSP blog feels that doctors must take at least some of the blame for the low grades.  Some obviously seem to take a greater role playing driver's ed instructor than others.   The DSP blog is thinking about trying to find one of those kinds for itself.

3)  Patients deserve at least some of the blame for their low grades.  Perhaps Dr Google isn't the most effective way to learn how to drive.

Sunday, March 13, 2011

The Blob that Ate America

When doctors were asked:  "When patients come to you with information they have gathered on their own, are they generally more likely or less likely to end up getting screenings, treatments, or interventions they don’t really need?"

63% said such patients were MORE LIKELY to get unneeded screenings, treatments, or interventions they really DON'T NEED.

Aside from the fact that there are risks to medical treatments and screenings, and that in medicine, "the more you do, the more you do," (quoting one of my best teachers ever--lives in Ann Arbor, MI), there are much greater concerns here:  Patients pursuing unneeded treatments increase traffic on the road, are unable to be perusing the DSP blog, and are missing time in their backyard looking at the birds while listening to the DSP show.

However, the DSP blog was briefly encouraged when it realized a benefit to patients pursuing unneeded treatments--what better way to simplify one's life?  For if you are going down the path of unneeded treatments, your life consists of one of two things, a) arming yourself with info that will lead to unneeded treatment; or b) pursuing the unneeded treatment; or c) talking about it or blogging about it.  I suspect most of the time would be spent in category b, driving all over the kingdom in order to get forms filled out, blood drawn, unneeded surgery performed, resulting in back pain from all the driving around, which would lead to category a...

Because the DSP blog suspects some reading this may be "serious readers" (the DSP blog acknowledges the disturbing possibility that serious readers who stumbled across this blog's clip of Sarah Palin interview may have unfairly put it in the category of total buffoon and decided not to return), it offers the following:

1)  One health care expert, Jack Wennberg, (whom, by the way, the DSP blog met when he visited its professor's house in Champaign, IL, where the DSP blog learned that pistachios are best eaten after the shell has been removed (somehow, I had missed that memo, and had to learn this lesson by putting a handful of these disgusting things into my mouth, and then trying not to appear uncouth while amongst many learned professorial types), and also had the unpleasant experience of eating one of said professor's mom's cookies in front of the professor, only to realize, while it was in my mouth, that some of said professor's mom's hair had been baked into the cookie), has suggested that for many medical decisions, there is no clear winner re the "right treatment"

A perfect example would be prostate specific antigen screening, which the USPTF suggests it is just not clear whether this test should be pursued.  This could result in a situation where a patient gathers information on his ("or her" clearly unnecessary here) own and decides to get the PSA test, which the doctor feels is unneeded.  In this type of case, the DSP blog thinks this is not a horrible outcome at all--in these cases where the right strategy is unclear, if the patient should decides to pursue an intervention that the doctor thinks is unnecessary, does it really matter?  The only truly horrific outcome in this scenario would be the exam accompanying this screening test (the DSP blog formally apologizes for that image now running through your mind).

But alas, the above suggests that the DSP blog has clearly slipped back into its pollyannish ways (except for the part about the exam).

2)  To the extent that "informed patients" increase their doctors' fear of malpractice is driving unneeded pursuit of screening tests or interventions--this is bad and sad, and because I lost an hour last night due to daylight savings time, I don't have the emotional capacity to deal with that right now.

3)  If you just take it at face value--and the DSP blog thinks this might be the best approach--that doctors think (?correctly) that patients are informing themselves into unneeded interventions, then really the biggest take home point is this:

At this current time, patients in the driver's seat (in general) are seemingly looking at the wrong manuals and/or interacting with the doctor in the passenger seat in such a way that they are getting their oil changed too often, getting diagnostic testing they don't need, seeing mechanics they don't need to see, and in the end, this is causing them to spend too much time and money in the car and/or in waiting rooms talking to others about their adventures taking care of their car....

Does getting in the driver's seat affect your care?

It has long been known that there is widespread/geographic variation in rates of treatment for conditions like back surgery, breast cancer, prostate cancer. As this report suggests, the variation may be due to variation in how physicians practice and influence their patients. More is not always better. When treatment for a condition is proposed, ask questions such as, "Is this considered standard of care, or are there other acceptable alternatives?" If the proposed treatment is surgical, ask, "Do you perform the other alternatives?"

The ultimate goal is to get the right physician in the passenger seat, one that is competent, listens to you, and both of you like each other, and to collaborate with the physician to determine the destination and route that make the most sense for you. Probably wouldn't hurt if he's board certified as well. It's a bonus if the guy you get in the passenger seat shares the same tastes in music and/or talk shows.