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NYT Op-Ed - "Are Good Doctors Bad for Your Health?"

by Mark11 on Mon Nov 23, 2015 9:11 pm

This op-ed from the New York Times does not have anything to do directly with myeloma / blood cancer, but I thought it was interesting. It think the most often given piece of information here is to tell patients to go and see the most senior myeloma specialist you can. If myeloma is anything like cardiology, that may not be the best advice!

I also found the part interesting about the study from Israel about the patients that cut back on their prescription meds.

Article:

Ezekiel J. Emanuel, "Are Good Doctors Bad for Your Health," The New York Times, Nov 21, 2015

Excerpts:

“Get me the best cardiologist” is our natural response to any heart problem. Unfortunately, it is probably wrong. Surprisingly, the right question is almost its exact opposite: At which hospital are all the famous, senior cardiologists away?

One of the more surprising – and genuinely scary – research papers published recently appeared in JAMA Internal Medicine. It examined 10 years of data involving tens of thousands of hospital admissions. It found that patients with acute, life-threatening cardiac conditions did better when the senior cardiologists were out of town. And this was at the best hospitals in the United States, our academic teaching hospitals. As the article concludes, high-risk patients with heart failure and cardiac arrest, hospitalized in teaching hospitals, had lower 30-day mortality when cardiologists were away from the hospital attending national cardiology meetings. And the differences were not trivial – mortality decreased by about a third for some patients when those top doctors were away ...

This is not the only recent finding that suggests that more care can produce worse health outcomes. A study from Israel of elderly patients with multiple health prob­lems but still living in the community tried discontinuing medicines to see if patients got better. Not unusual for these types of elderly patients, on average, they were taking more than seven medications.

In a systematic, data-driven fashion, the researchers discontinued almost five drugs per patient for more than 90 percent of the patients. In only 2 percent of cases did the drugs have to be restarted. No patients had serious side effects and no patients died from stopping the drugs. Instead, almost all of the patients reported improve­ments in health, not to mention the saving of drug money.

We – both physicians and patients – usually think more treatment means better treatment. We often forget that every test and treatment can go wrong, produce side effects or lead to additional interventions that themselves can go wrong. We have learned this lesson with treatments like antibiotics for simple medical problems from sore throats to ear infections. Despite often repeating the mantra “First, do no harm,” doctors have difficulty with doing less –even nothing. We find it hard to refrain from trying another drug, blood test, imaging study or surgery.

Mark11

Re: NYT Op-Ed - "Are Good Doctors Bad for Your Health?"

by smarty on Tue Nov 24, 2015 5:43 am

How very true, Mark 11.

I had a dear friend who was pretty much left to die at age 96 when her assisted living had transferred her to their nursing home facility. I contacted her daughter in another state, who then fired her doctor and got a new one who took her off most of her medications. This allowed her to get well, return to assisted living, and live well to the age of 100 plus 3 months.

I learned a very important lesson about too much medication. Thanks for reminding us.

Marti

smarty
Name: Marti
Who do you know with myeloma?: myself Smoldering Myeloma
When were you/they diagnosed?: May 1, 2015
Age at diagnosis: 76

Re: NYT Op-Ed - "Are Good Doctors Bad for Your Health?"

by NStewart on Tue Nov 24, 2015 2:09 pm

A woman I knew with rapidly deteriorating health from myeloma was in the hospital and was becoming delirious. Multiple specialists were in attendance trying to figure out why her mental status was quickly deteriorating. It took a first year resident to suggest that maybe her kidney function was tanking or that maybe she had a urinary tract infection (UTI). A simple urine culture found that she had a kidney infection. When that was treated, her mental status returned to normal. Unfortunately, her myeloma was no longer responding, and she died a few months later.

At one of my support group sessions another person who was getting ready for a stem cell transplant stated that she told her doctors that no one except the experts could treat her while in the hospital. I relayed the above story to her to let her know that many times the "newbies" think more outside of the box. Teaching hospitals should not only be teaching the new, young doctors, but should also be teaching the experienced ones, too.

Along the same line of thought, a few years ago my ophthalmologist had his fellow do a sophisticated test on my eyes to look for damage that he suspected from my bout of shingles in one of my eyes. When it was done, he told me that he had the fellow do the test because she did a lot more of them than he did and was much better at it. That takes a good doctor to admit that kind of thing to his patient.

Nancy in Phila

NStewart
Name: Nancy Stewart
Who do you know with myeloma?: self
When were you/they diagnosed?: 3/08
Age at diagnosis: 60

Re: NYT Op-Ed - "Are Good Doctors Bad for Your Health?"

by Mark11 on Wed Dec 09, 2015 3:30 pm

Thanks for the stories, Nancy. I can relate to this article. I think it is safe to say that I am one of the few 5 year myeloma survivors whose doctor recommends more natural products (probiotics, vitamin D, calcium) than she prescribes me medications (only quarterly Zometa)!

Mark11

Re: NYT Op-Ed - "Are Good Doctors Bad for Your Health?"

by Mike F on Wed Dec 09, 2015 4:04 pm

I'll add this quick experience to the list: Both of my primary oncologists have been fellows (as opposed to faculty at the university med center I go to). When I first told my direct supervisor (a DVM/PhD with a lot of experience with the human health system) about my myeloma, I mentioned that my oncologist was a fellow. She told me that this is exactly what I want. All fellows do is treat patients. They aren't running committees, they aren't doing research, they aren't running off to speak at conferences. While I have no personal basis for comparison, I can say that my two oncologists have done very well for me.

Mike F
Name: Mike F
Who do you know with myeloma?: Me
When were you/they diagnosed?: May 18, 2012
Age at diagnosis: 53

Re: NYT Op-Ed - "Are Good Doctors Bad for Your Health?"

by Mark11 on Sat Apr 23, 2016 10:57 pm

Here is another related article with regard to how much medication older Americans are using. The article was just in the New York Times. It also discusses supplements. I am fortunate that both my myeloma specialist and GP are open minded / suggest I use certain natural supple­ments, so I can discuss them with both of them.

Excerpt:

"In the meantime, though, patients and families can ask their physicians for brown bag reviews, including every supplement, and discuss whether to continue or change their regimens. Pharmacists, often underused as information sources, can help coordinate medications, and some patients qualify for medication reviews through Medicare.

“We spend an awful lot of money and effort trying to figure out when to start medications,” Dr. Alexander said, “and shockingly little on when to stop.”"


Reference:

Paula Span, "The Dangers of ‘Polypharmacy,’ the Ever-Mounting Pile of Pills," The New York Times, April 22, 2016 (full text of article)

Just to follow up on Mike F.'s point, I have had a lot of interaction with fellows over the years and I have learned a lot from them and view them as valuable members on my team.

"I relayed the above story to her to let her know that many times the "newbies" think more outside of the box. Teaching hospitals should not only be teaching the new, young doctors, but should also be teaching the experienced ones, too."

I could not agree more, Nancy.

Mark11

Re: NYT Op-Ed - "Are Good Doctors Bad for Your Health?"

by MrPotatohead on Wed May 04, 2016 1:16 am

Very interesting, but there are alternative explanations for the findings of the referenced study -- explanations apart from the notion that the "best" doctors may be bad for your health -- as the authors of the study themselves admit.

One alternative explanation is very simple. At teaching hospitals, part of the workload of less senior staff consists of supporting more senior staff, among whom the "best" doctors are likely to be distributed. Administrative tasks, research support, and teaching assistantships may consume a significant amount of the time of more junior staff.

But when the more senior staff, which presumably include the more experienced, more well-known, and more acclaimed cardiologists, are off to meetings, the more junior staff may no longer be performing what are essentially support staff services for the "experts", or may be performing fewer tasks of this sort, and therefore have more time to treat patients. More time for patient care may be the explanation for the better outcomes at teaching hospitals during conferences or meetings, not care by less "expert" providers.

I am not saying that this is in fact the explanation for the better outcomes, but it is a possibility, and the cited study does not appear to control for this possibility.

MrPotatohead
Name: MrPotatohead
Who do you know with myeloma?: Me
When were you/they diagnosed?: March, 2015
Age at diagnosis: 65

Re: NYT Op-Ed - "Are Good Doctors Bad for Your Health?"

by Mark11 on Wed May 04, 2016 10:33 am

Hi Mr. Potatohead,

You wrote:
But when the more senior staff, which presumably include the more experienced, more well-known, and more acclaimed cardiologists, are off to meetings, the more junior staff may no longer be performing what are essentially support staff services for the "experts", or may be performing fewer tasks of this sort, and therefore have more time to treat patients. More time for patient care may be the explanation for the better outcomes at teaching hospitals during conferences or meetings, not care by less "expert" providers.

I think that is the point. The less experienced providers are making the treatment decisions as opposed to acting as support to the more experienced decision makers that are away at conferences.

If you read the conclusion of the actual study it is in line with the point the New York Times article was trying to make. The article I posted was an Op-Ed piece, so by definition you will get studies and interpretations of studies that make the author's point. The point of the Op-Ed is that more care / drugs is not always better for the patient. The study itself has a long discussion that is very interesting and thought provoking. This next part is from the Op-Ed.

"It is not clear why having senior cardiologists around actually seems to increase mortality for patients with life-threatening heart problems. One possible explanation is that while senior cardiologists are great researchers, the junior physicians — recently out of training — may actually be more adept clinically. Another potential explanation suggested by the data is that senior cardiologists try more interventions. When the cardiologists were around, patients in cardiac arrest, for example, were significantly more likely to get interventions, like stents, to open up their coronary blood vessels."

Here is a link to the actual study for those interested in reading.

Jena, AB, et al "Mortality and treatment patterns among patients hospitalized with acute cardiovascular conditions during dates of national cardiology meetings," JAMA Internal Medicine, February 2015 (full text of article)

Mark

Mark11

Re: NYT Op-Ed - "Are Good Doctors Bad for Your Health?"

by MrPotatohead on Wed May 04, 2016 5:15 pm

Hi Mark

I was actually making a slightly different point (I did read the original study that the Op-Ed piece referenced).

My point was this. An alternative explanation is not that the treatment decisions are shifted to the more junior staff when the more experienced/renowned/"expert" staff are away, but that when they are away, the non-clinical support functions that the junior doctors perform for them are either reduced or eliminated, and as a result the more junior cardiologists spend more time with the patients.

Both when the senior folks are away at a conference and when they are not, the bulk or all of the treatment decisions are made by the more junior (or less "expert" cardiologists), and when the experts are away, the more junior MDs have more time to spend with their patients because they are spending less time supporting "the experts", and hence the patients get better treatment.

I am not saying this is in fact the case, but it is a possibility.

MrPotatohead
Name: MrPotatohead
Who do you know with myeloma?: Me
When were you/they diagnosed?: March, 2015
Age at diagnosis: 65


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