Why and When Women Have Abortions

A well written editorial by Wendy Savage in the Guardian should be required reading across the globe for anyone who needs or wishes to understand the reality in which women make reproductive choices.

Savage wrote the piece in response to comments by Jeremy Hunt, Britian’s newly appointed secretary of health, who wants to lower the abortion limit in that country from 24 to 12 weeks.

Jeremy Hunt, the newly appointed secretary of state for health, has unwisely shown his bias against the legal abortion limit laid down by the1967 Abortion Act and amended by the 1990 Human Fertilisation and Embryology Act. He told the Times in response to a question about when life begins: “Everyone looks at the evidence and comes to a view about when they think that moment is and my view is that 12 weeks is the right point for it.” It is hard to understand what evidence he has read that leads him to the bizarre conclusion that the limit should be reduced to 12 weeks.

Savage challenges Hunt’s assertion that the evidence supports his views by first showing us how the current limit of 24 weeks in the UK was decided –  based on medical science,  not personal opinion.

In 2007 the House of Commons science and technology committee published its 12th report on Scientific Developments Relating to the Abortion Act 1967. It concluded that although improvements in survival of babies born over 24 weeks had occurred since the upper limit was reduced in 1990, that was not the case for those under 24 weeks. This was based on the first Epicure study, a study of 4,000 premature babies (born from 22 to 26 weeks) treated in all the neonatal intensive care units in the UK and Eire, in 1995.

Since then the second national study of babies born in 2006 has been published and there is no significant change in the number of extremely premature babies surviving.

She explains how an arbitrary limit of 12 weeks makes no sense in the real world, where free access is not universal and where obstacles to abortion abound  – some of those obstacles within the very health system that Hunt now leads.

Some 91% of abortions now take place below 13 weeks and delays in the system have been reduced considerably, but some women still face difficulties from GPs who make them wait for unnecessary pregnancy tests or refer to a hospital consultant whom they know does not perform abortions. About a third of GPs are not prochoice and they should tell women this and refer to another partner who does not share their views but this does not always happen despite the GMCC guidance. Sometimes women are erroneously told that they are too far advanced in the pregnancy to qualify for an abortion, and younger women are more likely to accept the doctor’s view. These problems are less common today than 10 years ago.

She explains how it is that some women don’t come to their decision to have an abortion until the second trimester.

Research by Ellie Lee and colleagues published in 2007 into why women present late found that irregular periods was cited by a third, and a fifth continued having periods. A third were using contraception. In a quarter their relationship had broken down and a quarter were frightened of telling their parents. Women could give more than one reason and 41% were unsure about having an abortion and a third suspected they were pregnant but did nothing about it-possibly using denial as a defence mechanism. This shows that however good the service, there will always be women who present in the second trimester.

Finally, she tells us why the 1% of abortions that occur in later gestation will always be necessary – because some fetal anomalies, many incompatible with life, are not diagnosed until later in gestation.

Although the nuchal screening test for Down’s syndrome is available in most areas now, and allows a termination soon after 13 weeks compared with after 20 weeks when an amniocentesis was needed, other abnormalities are not picked up until the anomaly scan which is done at 18-20 weeks. Women are often devastated to learn that their planned and wanted pregnancy has not developed normally. They need time to come to terms with this and decide whether to continue with the pregnancy or have an abortion. Sometimes more sophisticated ultrasound to look at structural defects in the heart or genetic studies to see if there is a chromosomal abnormality are needed to make a diagnosis so the woman and her partner can make a fully informed decision. This all takes time and reducing the limit, as David Cameron would like, to 20 or 22 weeks would put more pressure on women and might even increase the rate of abortion at this later stage.

The one piece of evidence Savage leaves out is that limiting access will not prevent abortion, but will only serve to move it into settings where the procedure will be unsafe. The decline in maternal mortality that occurs when abortion becomes legal is undeniable. We cannot go back.

This is the real world that women and their families inhabit. 

It’s a world where not every pregnancy is planned, where not all women are in the position to determine when and how they become pregnant and where  not every pregnancy is diagnosed in time to allow for abortion before an arbitrary 12 week time limit. A world where the healthcare system actually works against early abortion, and where devastating fetal anomalies still occur and are not always diagnosable early in pregnancy.

The evidence shows that the best way to limit abortion is to increase access to contraception

And the best way to limit the gestational age at which abortion occurs is to stop trying to limit abortion in the first place.

Buying a Hybrid

Our new Ford C-Max SEL

It was time to buy a new car. Our wonderful 2003 Ford Taurus had 130,000 miles, and we’d put in quite a bit of money  in upkeep and repairs in the past year. Nothing unusual, just the things that start to go after that many years and miles. TIme to move on.

With all the ranting we do against fracking (our cottage is on the Marcellus Shale), the decision to go hybrid was an easy one. But could we get the mileage we wanted in the car we needed at a price we could afford?

Our priorities were –

  • Price – We knew hybrid meant more money than we’d ever spent on a car before. (Our Taurus was an end of season used dealer  model for just 14K – did I mention we are cheapskates when it comes to cars? ) But there is a break even point on hybrids, and we knew we had to just do it.
  • Mileage – We were looking for something comfortably above 35 MPG city and highway. The higher the better.
  • Cargo room  – Our Taurus has a generous 16 foot trunk, and that’s barely enough for us on trips to the cottage, where the lack of local supermarket means schlepping groceries as well as luggage  for 4.
  • Comfort – Our Taurus is really, really comfy, especially in the back seat. But our kids said they’d rather have to use a pillow in the back seat on a long ride than sit with suitcases, so cargo room was more important.
  • Power Drivers Seat option  – I’m not tall. I need to pull the seat way up to drive and then back again to get out of the car comfortably  And I often adjust during the ride. I thought this would not be an issue with any model car. But I was wrong.
  • Solid feel – Mr TBTAM has an issue with lighter cars for both safety and drive feel. Not a deal breaker.
  • Leather interior – our Taurus leather interior still looks like new after 9 years.  No compromises on this.

We’re not yet empty nesters, so the tiny hybrids were out (great mileage, no cargo room). So were the hybrid minivans (great cargo room, not great mileage).

I’d been waiting for the C-max for two years, convinced that it would offer me what the Prius would not in terms of comfort and space. Then Toyota came out with the Prius V, and I knew we had to consider it.

Other Things We Considered

  • Going electric. Unfortunately, electric batteries eat into trunk space. Also, our garage is not yet equipped to charge us. (And where they are, it’s not cheap  – $98 a month or $3 an hour for charging.) Finally, most of our driving is distance – electric shines best for commuting. We could not see an advantage to electric at this point for us in NYC.
  • Giving up the car altogether. We were car-less our first 10 years in NYC, and had survived. But the price (and often limited availability) of car rentals in NYC , our addiction to Costco, and the ability to pop down to Philly and family on a moment’s notice kept us car owners.
  • Diesel – we didn’t see a big advantage over hybrid, and the diesel high mileage cars were too expensive anyway.
  • Non hybrid cars with good gas mileage – None came close to the hybrids we were considering in terms of fuel savings. Plus, it felt like taking baby steps –  our environmental stance demanded a leap.

Why we did not buy a Prius

We thought the Prius V had everything we needed. But not quite. Here’s why –

  • The driver’s seat in the V is not power adjustable, even on the highest end model! (What’s that about, Toyota?) You need to pump a lever to raise and lower it and reach below to move it back and forth.
  • The comfort factor – the Prius V had more cargo room, but less head and leg room than the C-max. We weren’t sure the added cargo space was worth it.
  • The weight of the car. Mr TBTAM likes a more substantial feel to a car, and the Prius feels a lot lighter than the C-max. (Others might see this the other way around, and call the C-Max too heavy  – it’s all in the buyer’s eye…)

The 3rd generation Prius came very close to being what we wanted. It has a power drivers seat in the higher end models and beats the Cmax in mileage and price (though not by much in either). The cargo room was acceptable, and it looked great. But it is smaller, lighter and noisier than the Cmax. Most importantly to me, visibility seemed compromised – there is a blind spot on the front window if you pull up the seat as I do to drive, and the back window is split and seems small. Although they say you get used to the small rear window, I couldn’t see past the salesman in the back seat on my test drive.  (Hint to Totyota dealers – don’t sit in the middle next time you take a customer out for a test drive…)

In the end, the benefits in terms of price and mileage on the 3rd generation Prius were not enough to beat the C-Max for us.

Why we got the CMax-SEL

Mostly because I am totally in love with this car!  It has everything I want – 47 mpg city & hwy, power driver seat, decent cargo space (24.5 cu feet behind the second row), leather interior,  plus a few things I didn’t know I wanted  – back up camera, automatic foot operated hatch and sun roof.  And I could have given up the sun roof, but it really brightened the interior in a way I did not expect. (Another hint to dealers – if you want folks to buy sun roofs, take them out in a model that has one on a sunny October day…)

It seems as if I am not the only one who loves the C-max. While we were waiting for the salesman, another couple test drove the car we were looking at and by the time we came back from our test drive, they had already put an offer down on it. But that’s okay -it had options we did not need (like park assist – we know how to park, thank you). The one we’ve ordered will come in at our price limit – even with the sun roof – thanks to a dealer rebate.

I’ll post again after we’ve gotten our new car and driven it awhile

I am no stranger, after all, to post purchase regret. And real world mileage  can differ from posted MPG’s – though knowing my husband, he’ll be one of those hybrid drivers who tweak their driving style to get the best milage they can.

So stay tuned…

Now for the real question –

Does anyone want to buy a well-maintained used 2003 Taurus?

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Here’s a comparison on the three vehicles we looked at on Cars.com. And for the record, no one paid me to write this post. I just wanted to share our process thinking it may interest others making a similar purchase decision.

Vinod Khosla Thinks I’m Narrow-Minded

There’s a (tiny) bit of a discussion going on in Twitter about a post I wrote responding to Vinod Khosla’s statement that 80% of the work that doctors do will one day be replaced by computer algorithms.

(BTW, the title as cross-posted on the Health Care Blog -“The Day the Electronic Medical Record Tried to Kill Me“-  was not mine. My original post, if anyone is interested, was entitled “Will Doctors be Needed in the Future?” THCB’s new title made it look like my post was just another rant against the EMR. It was so much more than that.)

What I said

In my post, I talked a bit about the marketplace-driven IT innovations in healthcare, and medicine as seen through the eyes of the IT entrepeneurs. I questioned just how much of what doctors do today can really be replaced by algorithms, particularly the doctor-patient relationship.

I then asked if Khosla was right and answered myself – Maybe. I stated that we were in the midst of a huge disruption in healthcare, and reflected on how I was already seeing signs of that disruption in my current practice.  And while I still did not see anything changing too much just yet, as far as the future Khosla predicted? I wasn’t so sure.

I then stated that if there is a revolution in healthcare, we docs needed to make ourselves a part of it now. I urged my fellow physicians to become involved, in order to be sure that what happens in the IT-driven healthcare future actually improves our patients’ health beyond what we are doing today. 

It’s a completely legitimate concern, and, I believe, an extremely important one.  As an example, I cited the evolution of the EMR – a system that has created high hopes and caused huge disruption at enormous cost, even as we continue to struggle to find conclusive evidence that EMR use actually improves patient outcomes.

I then began to wonder what the future would look like if replacing 80% of doctor’s work with technology actually freed us up to do the real work of medicine. I imagined us then redistributing ourselves around the globe, virtually and actually, to take care of the entire planet. And called that the ultimate disruption in healthcare.

A pretty optimistic vision of the technological future if you ask me.

I thought my post was a thoughtful take on Khosla’s vision, not a takedown of it.

And yet, on Twitter, Khosla has called my post a “Usual muddy interpretation and narrow mindedness of what I said.”

How is my interpretation muddy or my take “narrow-minded”? As the end user whose work life has been radically impacted by technology, and a doctor who bears significant responsibility for the health outcomes of my patients, I think I have a right to discuss my thoughts about the healthcare technological revolution without being called “narrow-minded”.

What may be narrow-minded is Khosla’s representation of doctors as part of the problem and not the solution. I won’t get into his calling us “lazy”, or his implications that it is only the top 20% of docs – whoever they are – who are worth having around.

Maybe it’s simply that Khosla has decided that Steve Jobs was right when he said that  –  “A lot of times, people don’t know what they want until you show it to them.”

In which case, I guess we docs (and by extension, our patients) are just supposed to shut up and wait until Khosla and the rest of the IT gurus show us what we want.

Or risk being called “narrow-minded”.

Weill-Cornell Music & Medicine presents Mozart’s Requiem

NY1 News Story about us!

I’m so proud to be singing the Mozart Requiem with fellow faculty, students, residents and staff of Weill Cornell Medical College, New York Presbyterian Hospital, Memorial Sloan Kettering Cancer Center, Rockefeller University and Hospital for Special Surgery in our first collaborative choral concert. We’ll be performing under the direction of David Leibowitz, and will be joined by solists and several instrumentalists from the Julliard School.

It’s all part of Cornell’s Music & Medicine Initiative, a program that encourages medical students to continue their ongoing relationship with music by providing rehearsal space, performance venues and opportunities to collaborate with NYC’s many arts organizations. Concert proceeds will benefit the Weill-Cornell student-run free clinic for the uninsured of New York City.

The concert will be held next Sunday, October 7 at 6:30 pm at St Bart’s Church on Park Ave in NYC.  There will be a pre-concert lecture on Sunday at 5:30 pm at St Bart’s and on Thursday,October 4, at 5:30 pm, a free symposium at the Medical College on Music, Medicine and Mozart. (Concert and lecture details here)

The Requiem is one of the most beautiful and enigmatic works ever composed by Mozart, who was composing the Requiem at the time of his death and left it unfinished. The circumstances surrounding Mozart’s death, the writing of the Requiem and its ultimate completion have been the subject of centuries of scholarly debate and speculation, making it a most appropriate choice for this unique choral collaboration.

We had our first rehearsal with the orchestra yesterday, and from how it sounded I can say tell you it’s going to be a fabulous concert.  If you’re free next Sunday evening, do come !

How Many Miles is the Central Park Loop?

I finally mapped it so I could accurately track my exercise for My Fitness Pal, supporting my latest effort at getting into shape. (More on that in a later post)

  • The big loop is just about 6.1 miles.  
  • The shorter loop (the souther 2/3 of the loop, cutting across around 104th St to avoid the 84-foot climb at the top of the park) is 5.2 miles.
  • The shortest loop (The southern most loop, cutting across the 72nd street transverse, mostly done by tourists on rentals) is 1.7 miles. 

I usually do the big loop, adding in the milage to and from the park for an 8.7 mile ride that takes me a little under an hour. (That’s 585 calories if you’re interested.)

Of course, my time depends on how many times I stop to take pics – because there’s always something I want to capture. Here’s today’s pic –

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10 years later, WHI Still Being Debated

ACP Internist has a nice article on the continuing debate on HRT. (Disclosure – I’m quoted in the article.)

The article summarizes nicely the absolute risks of HRT use as described in the Women’s Heath Initiative (WHI), the landmark study from 2002, as well as the ongoing debate around the strengths and weaknesses of the design and findings from that study.

It’s good to get caught up on the issues in anticipation of the release of early results from new clinical trials of HRT prescribed the way we docs tend to use it – starting at menopause.

You may recall that the biggest criticisms leveled at the WHI were that the average age of that study’s participants was over 60 years old and that women with menopausal symptoms were actually excluded from the study. Later subgroup analyses of younger women in that study suggest an absence of adverse cardiac effects and possible markers of cardio-protection when HRT is started at menopause rather than 10 years later. (The  so-called Window Hypothesis –  ie, there is a window of opportunity during which HRT, if started, is actually good for the heart. Exceed that window and it’s bad for the heart.)

Researchers are now studying to see if that elusive heart disease benefit of HRT might still be found when HRT is started at menopause. Early results from the Kronos Early Estrogen Prevention Study (KEEPS) are expected to be presented at the Annual Meeting of the North American Menopause Society in October. If evidence is reported for cardio-protection, that would certainly be reassuring information for symptomatic women looking to use HRT to combat symptoms.

I would be surprised, however, if KEEPS finds a difference in breast cancer risks from HRT in this age group compared to those in the WHI. It is this risk, in this docs humble opinion, that leads many women to take HRT off the table at menopause and beyond, or to limit its use to just a few years around the time of worst symptoms.

So stay tuned – it’s going to be an interesting season of HRT news.

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Essential reading on the HRT and the WHI from TBTAM

Chicken Breasts with Tarragon – A great dish with an even better afterlife

I needed to use two leftover uncooked chicken breasts in the freezer and the tarragon crop was bursting out of its pot on the terrace. Enter this quick and delicious chicken preparation from Thomas Keller via the  NY Times. Serve it over noodles or rice, with a side of roast broccoli or sauteed kale.

Because the original recipe was meant for 6 breasts, we had a good bit of the amazing sauce leftover, as well as the rest of the can of chicken broth I had opened to make it. So, we mixed the sauce and the broth together and used it to make corn chowder the following night, using some leftover corn I had frozen away two nights previous. (The broth mixture substituted for water in the recipe – we added about 1/4 cup of water to make up the difference).

The  tarragon flavor and richness of that leftover broth added to an already wonderful soup, and it was the best corn chowder we’d ever made.

Living Till You Die

I just found out that one of my favorite patients has died.

She had metastatic cancer that presented some years after she had survived a previous and different cancer. Despite her diagnosis, she lived the final few years of her life in an ever-moving forward state of joy and self-satisfaction – working, exercising, developing new relationships, changing her hair style and color, buying great new clothes, traveling, even taking a lover. At her last visit, shortly after yet a new focus of cancer had been found, she was packing for a trip to Spain.

I think she packed more of life into those last years than many people do in a lifetime. This even more remarkable when I tell you that, at the time her metastatic cancer was diagnosed, she was already past the age at which most folks would have retired.

She was fortunate that she did not have significant pain or disability from her cancer. Also fortunate that her cancer was slow-growing, until it finally took her, at which point it was fast. Just a week or so from full steam ahead mode to the end, and only one of those days spent in the hospital.

She was also fortunate because she had a wonderful oncologist, who supported her desire not to be treated with with the kind of chemotherapy that could have destroyed the quality of any of her last days, even if there was some small chance it could lengthen those days. She also had a team of providers at the end who did not push for futile interventions, and family who were willing to let her go when it became clear that her time had come.

Of course, not every cancer lends itself to this kind of living or this kind of end. For some, the only treatments available, even those that are palliative, have tremendous side effects.  For others, things move too quickly, and the pain and disability overwhelm any chance of finding joy in one’s last days. And when the cancer strikes at a much younger age, when there are so many more years of life and love to lose, who can blame folks for being willing to suffer though agonizing treatments as long as there is even a tiny chance of a cure?

So this post is not meant to be a judgement on how others with cancer ultimately face their diagnosis or their death.

It’s just me being happy for one that was able to find so much joy in facing hers.

And being inspired to live the days of my life, however long, with that same sense of joy and self-satisfaction that she lived hers.
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Image created using Caption.it with a screenshot

Beautiful Caterpillar

I found this little guy on the terrace in the parsley pot when I went out to snip some herbs for dinner this evening. Now I know why our parsley crop is so measly –  it’s being eaten!

This black swallowtail (also known as a parsley worm) will be a gorgeous Monarch butterfly very soon if the birds don’t get him. I think I”ll leave him alone for now. The season is almost over, and he’s too pretty to squash.

EMR Use May Interfere with Depression Screening – Why Face Time is Important

Awhile back, I wrote about how a simple change in office workflow (and a smart office layout) allowed me to get back some of the face time with my patients that I had lost when we transitioned to an  electronic medical record (EMR). As a result, I am happier, my patients are happier and I like to think I am providing better care.

Now, a new study shows that my instincts were right on – face time with patients is important. Researchers found that providers using an EMR detected and treated less depression in their patients than those still using paper, although the differences were only found in patients with three or more chronic conditions. The authors theorized that EMR using providers are spending more time looking at the computer screen than at their patients, and missing cues in facial expression and body language that in the past tipped them off to depression in their patients.

…EMRs have been observed to have a negative impact on psychosocial exchange, with screen gaze being inversely related to physician engagement in psychosocial questioning and emotional responsiveness. It is possible that the clinical work flows embedded in EMRs inadvertently encourage physicians to focus on these multiple physical problems and push depression treatment “off the radar screen” even after physicians diagnosed the condition…

…it has shown that physicians often find that EMR interfaces create additional work by forcing them to click through many screens and options as well as imposing tasks previously handled by others, especially when placing orders. Similar effects in primary care may take away significant visit time and reduce physician’s cognitive performance in terms of ability to provide comprehensive care. Such effects are also likely to be significantly greater during visits by patients with multiple chronic conditions than patients with few chronic conditions.

Even with my new work flow, I find that I still frequently have to consciously pull my eyes away from the screen and force myself to stop typing and look at my patients while they talk. This research study has me thinking that I meed to keep tweaking my work flows to see if I can improve face time even more than I already have.

Yellow Squash & Almond Saute

Remember what I said once about great recipes being infectious? Well, here’s another one.

Looking for a good way to prepare two gorgeous yellow squash we picked up at the 79th St Greenmarket on Sunday, I came across a recipe for quick zucchini and almond saute on Deb Perelman’s blog Smitten Kitchen. And then the same recipe on Adam Robert’s blog The Amateur Gourmet. And then on Confessions of a Picky Eater. And then on about another million and a half other food and mommy blog sites, all inspired by Deb’s recipe.

Deb herself was inspired by Jimmy Bradley, the chef at The Red Cat – a restaurant I’d passed by on Tenth Ave in Chelsea, but have never thought to try. Of course now that I’ve made this recipe, the Red Cat is at the top of my list of must-eat places. Jimmy  has been sharing his recipe for Quick Sauté of Zucchini with Toasted Almonds and Pecorino all over the internet, TV and radio since The Red Cat Cookbook came out in 2006. So if you google Jim’s name and zucchini, you’ll see a whole ‘nother spate of food bloggers who’ve made this dish.

Now, this recipe had mutated a bit from its source. While Bradley makes his preparation with 1/4  cup of oil and two separate fry pans, Deb uses only 2 tbsp of oil and makes it all in one pan, mentioning Bradley’s tent of pecorino as more of an afterthought.  Hmm…easier to make and lower calories and fat. I knew which version I was making.

But wait – Mine would have yellow summer squash instead of zucchini. Another mutation!

Let’s see how far this one spreads….

[amd-recipeseo-recipe:4]

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How to Julienne a zucchini – great video comparing a knife to mandoline. Wish I’d found it before I cut up my squash!

Ovarian Cancer Screening Not Effective in Women at Average Risk

The United States Preventive Services Task Force has recommended against routine screening with ultrasounds or blood tests for ovarian cancer in asymptomatic women at average risk for the disease.

The reason is simple – these tests are not effective screening.

“There is no existing method of screening for ovarian cancer that is effective in reducing deaths,” Dr. Virginia Moyer, the chairwoman of the expert panel, said in a statement from the group, the United States Preventive Services Task Force. “In fact, a high percentage of women who undergo screening experience false-positive test results and consequently may be subjected to unnecessary harms, such as major surgery.”Yes, there is ultrasound and CA125. But doing these tests in healthy women without symptoms and at average risk causes more problems than it prevents, and most importantly, it does not prevent deaths from ovarian cancer.

Screening is recommended for women who carry genetic mutations that increase their risk of ovarian cancer (such as BRCA or MLH1 mutations), although its impact is still not entirely certain even in this group. More effective in this group is prevention by prophylactically removing the ovaries and fallopian tubes, which will prevent 95% of the ovarian cancers that occur  in these women.

While ultrasound has no role in routine screening for ovarian cancer, it remains an important diagnostic tool when women present with symptoms that could be signs of ovarian cancer – bloating, abdominal pain, decreased appetite or early fullness after eating and new onset urgency and frequency of urination not due to other causes such as a UTI. Of course, almost all of the time these symptoms will not be due to ovarian cancer, but it’s important to rule it out.

We May Not Have Effective Screening, But We Do Have Effective Prevention for Ovarian Cancer

What does prevent ovarian cancer is birth control pills. Women who use the pill for as little as 1-2 years will see a 22% reduction in risk, and in long term users get a 60% reduction in risk.  Although protection wanes with time, it persists as long as 30 years after stopping the pill. It is estimated that birth control pills have prevented over 100,000 deaths from ovarian cancer to date. (Not to mention pregnancy prevention and other health benefits.)

Users of Depo-Provera may get a similar reduction in  risk as pill users do. In addition, tubal ligation may also reduce ovarian cancer risks. Studies are underway in high risk women to see if removal of all or part of the fallopian tube is effective as removal of the ovaries.

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More Posts on Ovarian Cancer from The Blog that Ate Manhattan

Will Doctors Be Needed in the Future?

There’s a big discussion going on in the health tech community about a controversial keynote speech given by Vinod Khosla at the Health Innovation Summit (HIS), in which he stated that 80% of what doctors do could be replaced by machines.

If you’re a doc like me who has no idea who the heck Vinod Khosisa is (he’s a venture capitalist and co-founder of Sun Microsysstems), why he’d be a keynote speaker at a healthcare event and what the heck HIS is, well, that’s the point of this post.

You see, there are a whole lot of folks like Khosia out there – investors, entrepreneurs, tech types – who are attempting to redefine healthcare according to their own personal vision.  Where we see a healthcare system in crisis, they see opportunity – just another problem with a technological solution.  Computer-driven algorithms are the answer to mis-diagnosis and medical error, IPhone apps can replace physician visits, video connectivity can increase access.

Where we see illness and distress, they see a market.

And what business folks like to call disruption in the marketplace. Think about what happened to downtown small town USA after the first shopping mall opened. Or what happened to movie houses when Netflix started offering DVD rentals online. Or where all the independent bookstores went when the first Borders opened up, and what happened to Borders when the Kindle hit the market.

Out with the old, in with the new.

If  Khosla is right, the we docs in our offices and hospitals are the old downtown department stores, the bookstores and the bricks and mortar businesses in an online revolution.

We’re replaceable. At least most of us.

Is Khosla right?

Maybe.

The therapeutic relationship between a doctor and a patient can never be replicated by an IPhone app. Not when so many of my patients leave my office on a daily basis telling me how much better they feel just having spoken to me. It’s a powerful and sacred relationship that is irreplaceable.

These days, however, almost all of my patients have googled their symptoms, and many have done a over the counter diagnostic test or treatment  before coming in to see me. I’ll never see the ones who got their questions answered online or their symptoms cured by that over the counter med – I see what’s left after self-diagnosis and self-treatment has failed, or google told them to see me.

That’s disruption, isn’t it?

One day very soon, women will be able to screen themselves for cervical cancer and std’s using a self-administered vaginal swab. No need to see me unless the test is abnormal, or there are symptoms.

Disruption.

Of course, computer driven diagnostic algorithms, apps and programs can create a whole new set of problems in over-diagnosis, since “there’s nothing seriously wrong with you” is rarely an output.  In my office, that’s a very frequent clinical assessment. Functional ovarian pain.  The occasional errant menstrual cycle or missed period. Anxiety. Stress. Depression. Lack of sleep. Over-eating, over-drinking, over-medicating.  What computer is going to pick that up?

Not to mention trauma care, surgery, childbirth, respiratory distress and any one of thousands of health emergencies that you can’t treat with an IPad.  I don’t see any of that work going away for docs anytime soon, do you? Some of it, of course, is being shared with trained non-physicians, and even robots. But docs are still an indispensable part of the healthcare mix.

So while the mix is changing, we docs are still in it. And I don’t see that changing. At least for here and for now. But the future?

I don’t know.

Docs need to be part of the digital revolution

I do know that if this is the new revolution in healthcare, we docs better get in on it.

Take the EMR as an example of what happens when docs let non-docs innovate in healthcare without significant physician input. We become typists, not physicians. Clerical work that used to be done by lower paid staff – entering lab and radiology orders – becomes ours to do. We spend the majority of a patient visit looking at a computer screen and not the patient. Retrieving relevant clinical information is like searching for a needle in the haystack of required fields of entry, most of which are not necessary to provide care.

Indeed, we have not yet shown definitively that EMR’s improve outcomes.

And yet we’re all using them, aren’t we?

If we are not part of the digital revolution and leave it to the venture capitalists and entrepreneurs, they will develop products that may sell, but if they don’t improve outcomes, all that will have been accomplished is a disruption in a marketplace.

Wouldn’t it be so much better if we could disrupt disease?

The real opportunity in Healthcare Innovation

There are millions upon millions of folks – some in American, but most in the undeveloped world – who have never had, and will never have the opportunity for a patient-physician therapeutic relationship such as that I’ve described above. They have no one to call when Google tells them to “talk to your doctor”.

But the overwhelming majority of the do have cell phones. Amazing, really. We can’t get indoor plumbing modern contraception or malaria tents to those in need, but 80% of folks in the developing word have cellphones. If that’s not an opportunity and a potential market for healthcare innovation, then nothing is. If we can get any healthcare into the hands of these folks, even if it’s healthcare delivered by a mobile app, we have the potential to improve their lives.

Now, imagine that we docs were able to free ourselves from the 80% of our work that can be replaced by technology, and then redistributed ourselves (virtually and personally) across the globe where we were truly needed, so that we could provide needed healthcare to the entire planet?

Now that’s disprution.

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Recommended reading

 

Poached Nectarines

Poached fruit is one of my favorite desserts, especially in September when the cooler evenings beckon us to eat outdoors on picnic tables covered in cotton tablecloths, a sweater at hand for when the sun sets. And that moment, when the crickets start and the fireflies come out, is the perfect time to ladle warm, sweet  fruit atop cold vanilla ice cream, top it with a sprig of fresh mint and bring it out to the porch. If you haven’t finished that bottle of wine you opened at dinner, now is the time.

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