Acceleration in the spread of digital imaging technology has already outpaced society’s ability to forestall its unwanted effects, whether they are disturbingly real images from Abu Ghraib prison or disturbingly unreal images from Hwang Woo-suk’s stem cell research lab.

Acceleration in the pace of change in healthcare is pressuring both the patient and the physician. Patients are being pressured, in part through a projected shortage of physicians, to take more direct care of themselves. Shortage doomsayers do not appear to take into account the effects of growing patient self-care (and other factors, such as changes in the very nature of medicine) yet are ready to rush into a costly crash expansion of medical school enrollment.

For example: Signs of a trend toward young people self-diagnosing and self-prescribing prescription drugs, which are increasingly obtainable without going to a doctor, are indications that the “Patient: Heal Thyself” paradigm of the healthcare of the future — driven by patient-friendly interventions, patient-targeted information on the Internet, and growing barriers of access to the traditional healthcare (non-)system in the US — is right on track.

One reason for the trend toward patient self-care is that patients, according to one study, trust the Internet for health information more than they trust doctors. They just don’t like to admit it.

Another brick is added to the growing edifice of patient self-care with the arrival of a hand-held pump for patients with rare immune disorders, who now have the ability to treat themselves at home instead of taking half-days off work or school to visit the doctor’s office for their regular intravenous infusions. Add telemedicine (see the Telemdicine section in this issue) to the mix, and the Revolution is clear.

Other items of interest in the policy or practice arena:

• A credible pundit suggests that “only people who have some sort of organized political influence” can do anything about the crisis in healthcare costs and access disparitiesin the US. This seems to rule out the de-unionized American worker if not the effectively disenfranchised American electorate. 

   

• The latest report cardshows that the self-proclaimed “best healthcare system in the world” is getting worse. Measures of public health in the US improved by only 0.3 percent a year since 2000, versus 1.5 percent a year for the decade of the 1990s. 

   

• The dearth of new drugsapproved in the US in 2005 is not an indicator of the future. In fact, it seems to us, growing pressure in the pipeline of drugs in development must eventually result in a gusher. 

   

• An article in the Tennessean newspaper discusses the financial impact on home healthcarecompanies of recent Medicare cuts in reimbursement for medical equipment for the home. The article does not mention the impact on patients, or the potential impact on healthcare costs, which could rise by much more than is saved when Medicare patients, unable to afford care at home, end up in nursing homes and hospital emergency rooms. 

   

• Refurbished single-use medical devices appear set to become a viable market on eBay. This raises obvious concerns for patient safety, but if handled with regulatory care it could help bring down hospital costs. 

   

• The average hospital has difficulty adding “ity” to its name and reputation. Above-average hospitals do it to stay above average.

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Harvard Law School has established a center to study legal issues raised by advances in healthcare and related areas. The Center’s faculty director, Einer Elhauge, told New York Times writer Katie Zezima that “… with new technology we face bigger issues in the future that require thoughtful interdisciplinary legal analysis.”

Harvard joins a growing number of law schools starting to establish similar programs. Bioethicist Arthur Caplan, who heads a similar center at the University of Pennsylvania said interest in the subject has been generated among law students by myriad high-profile issues where the law is murky, including stem cell research and the liability of drug makers.

Technology and Research Fraud

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Cheap, ubiquitous digital photography and photo editing software make it easy for unscrupulous researchers to fake experimental evidence, reports Gareth Cook in the Boston Globe. Evidence that such unscrupulous researchers exist is to be found, first, in a massive rise in image-manipulation investigations conducted by the US Office of Research Integrity from 2.5 percent of all cases in 1989-90 to 40.4 percent in 2003-04; and second in the infamous cases of South Korean stem cell scientist Hwang Woo Suk and MIT biologist Luk Van Parijs.

In evident distrust of the academic community’s ability to police itself, at least one academic journal (the Journal of Cell Biology runs its own checks on the veracity of images submitted with articles for publication, by examining the images in the software program Photoshop to see if they have been altered. The journal Science has said it will now adopt similar measures. Other biology journals may soon follow their lead.

Physician Shortage

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Lengthening wait times for cardiologists, dermatologists, orthopedic surgeons, obstetricians, and other specialists are harbingers of a shortage of as many as 96,000 US physicians by 2020, writes Julie Bell in the Baltimore Sun, citing the Council on Graduate Medical Education. The reasons include rising demand resulting from population growth and the aging boomers, and dwindling supply resulting from shorter physician work hours, fewer physicians entering certain specialties such as family medicine, and the looming mass retirement of physicians who are themselves boomers. An executive of a physician placement company said: “The shortage is not a joke. It’s true, and it’s serious.”

But the dean of at least one medical school disagrees, saying “Whether or not there’s an impending crisis depends on whose crystal ball you’re looking at” and pointing out that demand for physicians isn’t necessarily the same as need and that much depends on unknown or variable factors such as government funding of healthcare for the uninsured, physician office efficiency increases, the shifting of work to other medical professionals such as nurse practitioners, and physicians’ desires for fewer working hours. A Yale University study published in September’s Academic Medicine found that medical school graduates increasingly avoid specialties perceived to have less controllable schedules.

Policy responses to the perceived shortage include increasing medical school enrollments, more government funding for residencies.

Self-Care

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New York Times writer Amy Harmon presents evidence that a “sizable group” of young adults is turning inward rather than to medical professionals to diagnose medical and (especially) psychiatric conditions. They then trade prescription drugs, obtained legitimately but left unconsumed, or bought without prescription over the Internet, or obtained by convincing a harried and under-informed physician that they know more about their condition and its appropriate treatment than the physician does, or obtained by lying to the physician about their condition.

The goal is usually “not to get high but to feel better — less depressed, less stressed out, more focused, better rested.” The dangers are obvious. “But,” writes Harmon, “doctors and experts in drug abuse also say they are flummoxed about how to address the increasing casual misuse of prescription medications by young people for purposes other than getting high.”

Why mainly young adults? “If a person is having a problem in life, someone who is 42 might not know where to go — ‘Do I need acupuncture, do I need a new haircut, do I need to read [a well-known US personal finance guru]?'” one young adult told Harmon. “Someone my age will be like, ‘Do I need to switch from Paxil to Prozac?'” Another, who tells her doctors what to prescribe for her headaches and sleep problems, and sometimes gives her pills to friends, said: “I would never just do what the doctor told me because the person is a doctor. I’m sure lots of patients don’t know what they’re talking about. But lots of doctors don’t know what they’re talking about either.”

Harmon goes into considerable depth and detail, cataloguing the dramatic rise in prescriptions for young people over the past decade and providing many quotes and anecdotes describing how the deluge of medications is being used, misused, and abused. It is in our opinion a very important article.

Trend in Trust

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A study published in the December issue of the Archives of Internal Medicine found that patients in the United States are more likely to turn to the Internet than to a physician for health information, despite believing that physicians provide more accurate information. 62.4 percent of respondents said that they trusted physicians “a lot” for cancer information, compared with 23.9 percent for the Internet. Asked where they would prefer to go first for information about cancer, 49.5 percent reported wanting to go to their physicians, but only 10.9 percent of those who actually sought information about cancer reported having gone to the physician as the first source of information, whereas 48.6 percent went to the Internet first.

Self-Infusion

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The US Food and Drug Administration has approved Vivaglobin (immunoglobulins) for use at home by patients with rare immune disorders, using a small, handheld pump. The weekly treatment replaces intravenous infusions administered in a clinic or physician’s office, which can consume half a day.

US Healthcare Cost Record

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Healthcare now consumes a record 16 percent of US economic output, write Marc Kaufman and Rob Stein in the Washington Post, citing a government report. Spending for physicians and hospitals were sharply up in 2004 (the latest year for which figures are available) though spending on drugs was up less sharply. Even so, admitted Health and Human Services Secretary Mike Leavitt, “Disparities and inequities still exist. Outcomes vary. Treatments are not received equally.”

The cost and disparity situation can only get worse since, as the Kaiser Family Foundation president notes, “government regulation of prices and services is not in the cards.” The president of the bipartisan Alliance for Health Reform called the situation “alarming” but “more like a creeping infection than a broken bone, and so people get used to it.” He added: “Frankly, I don’t see major change until people who have some sort of organized political influence start hurting a little more.”

US Healthcare Report Card

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A recent study released at the American Public Health Association’s annual meeting in December “raises doubt whether the nation is making real progress toward bettering people’s health,” writes Marian Uhlman in the Philadelphia Inquirer. “Headway on some measures, such as violent crime and infectious disease, has been offset by growing troubles in other areas. Obesity has doubled in prevalence since 1990. The percentage of people without health insurance has climbed. And fewer students are graduating from high school in four years — a health concern because they may be less prepared to understand and follow medical advice. Gains in reducing infant mortality and smoking also have leveled off.”

The Year in Drugs

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The US Food and Drug Administration approved only 20 new drugs in 2005, compared to 36 in 2004. And most of the approvals were for drugs to treat rare diseases. Despite the highest-ever spending on research by the drug industry (US$38 billion) “progress in the laboratory has not translated so far into many new drugs on the market,” notes Alex Berenson in the New York Times. Possible causes include: A cyclical downturn that will automatically right itself; caution induced by the Vioxx debacle; and a too-tardy process for testing and developing new drugs. Yet even as the FDA looks for ways to speed the approval of new treatments, some members of Congress and consumer groups are calling for even more testing before drugs are approved.

Citing a December 2005 report from Merrill Lynch, Berenson notes that the pipeline of potential new drugs in Phase I and II clinical trials has nearly doubled in the last decade, while the number of drugs in Phase III has been flat. A drug industry analyst told Berenson: “It’s almost like we know too much, because for everything that we learn, it almost brings up two new questions.” But, he added, “I think we will get there, but we’re only 15 years into this [i.e., biotechnology-based drug discovery]. It just takes time.”

Home Care Financing

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During 2005, the US government’s universal health insurance plan for senior citizens, Medicare, cut reimbursements for home medical equipment, oxygen, and inhalation drugs. Among those feeling the heat are home health-care companies, who are losing millions of dollars as a result.

Medical Devices on eBay

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Single-use medical devices are meant to be thrown away after one use, but refurbished ones — such as a tube designed to be inserted into a patient’s jugular — are appearing for sale on eBay by a seller who, according to the Washington Post‘s Alec Klein, could not be identified. And neither could the buyer.

ClearMedical Inc., one of the five largest reprocessors in the United States, openly sold reused single-use medical devices in a three-month experiment last year, but sold only items it considered “noninvasive” such as pulse oximeter sensors and compression sleeves. ClearMedical’s CEO told Klein the test went so well, “we have bigger plans in process,” though he declined to elaborate.

Changing the Culture of a Hospital

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Taking heed of the rather obvious need to start catering to consumers in a new health-consumerist world, and of a Medicare plan to post the results of patient-satisfaction surveys online starting in 2007, Boston’s famous teaching hospitals are turning to the hospitality industry for hospitality lessons.

Massachusetts General Hospital is taking advice from the Ritz-Carlton. Beth Israel Deaconess Medical Center is offering patients à la carte hotel-quality meals. Brigham and Women’s Hospital gives beepers to patients so they can avoid waiting room hell by visiting the shops or cafeteria while waiting to be seen. At all three hospitals, phones are — at last — answered promptly, politely, and efficiently.

Boston Medical Center has appointed ”ambassadors” who visit inpatients to ask about the service they are getting, check patient rooms for cleanliness, and ensure that the names of doctors and nurses are written on white boards in each room. Receptionists at Brigham and Women’s now focus solely on welcoming patients, while other employees answer the phone and yet others check insurance and billing information and complaints.

Beth Israel asked all 13 operators in a call center to reapply for their jobs, and re-hired only three of them. Mass. General retrained its food servers to speak directly to each patient they serve, call the patient by name, announce their own name, where they are from, and why they are there. Children’s Hospital Boston, Tufts-New England Medical Center, Beth Israel, and the maternity ward at Brigham and Women’s offer when-you-want-it room service meals served within 30 minutes.

In just one department at Brigham and Women’s, unanswered telephone calls dropped from 40 percent down to 10 percent within a month, and the number of bills rejected by insurance companies for incomplete or inaccurate information dropped from about 8 percent to less than 4 percent.