The Pitfalls of the Traditional Model
For years, Western medicine has taken an imprecise approach to new drugs: Test new drugs on as large a group as possible in a clinical trial, and if enough of those participants benefit, make the drug available to the general public. Sure, this wide-cast net may not help everyone, goes the theory, but with such large numbers, it’s bound to catch a fair number. Plus, it appears efficient, as it deals with thousands of patients with a single trial and a single drug. However, medical professionals are beginning to remark on the flaws in this system.
Even drugs that pass rigorous clinical trials may help surprisingly few patients: the top ten highest-grossing drugs in the US only help between 1/4 and 1/25 of the people who take them. These disappointing figures are exacerbated by the fact that clinical trials disproportionately enlist white participants, whose responses to given drugs are not necessarily identical to other ethnicities’ responses. Trials also tend to focus heavily on chemical analyses to the point of ignoring genetic and environmental factors that play an important role in medication.
Moving Towards Personalized Medicine
Perhaps, it’s time to explore a “precision” approach. Generally, this model means taking into account more factors that affect individuals’ responsiveness to drugs. It may even involve ultra-personalized, one-person studies. In these, the participant would test out a drug, and be tracked in a detailed way over a long period of time, with attention given to genetic and environmental factors. The story wouldn’t end with studying a single person; the results of all these trials together would be aggregated to yield information that is predictive for members of the wider population. By using patterns found in the aggregate data, doctors may be able to more accurately predict how well a treatment will work for a given subset of the population.
Of course, there are significant barriers to the use of one-person studies, chief among them cost. Tailoring trials to individuals tends to cost more than running a broad, one-size-fits all study. Nonetheless, this new model seems slowly to be gaining traction. In January 2015, President Obama announced that he would seek $215 million for the Precision Medicine Initiative, which proposes to use patients’ specific genetic and physiological characteristics to better treat them. Of this, the FDA would receive $10 million to build personalized-medicine databases and to examine its regulatory processes for personalized treatments. Following suit, this year the state of California also unveiled a $3 million precision-medicine project to investigate personalized treatments and diagnoses. As time goes on, we may see a real paradigm shift in how doctors study and treat patients, to understand them as unique individuals whose data points reveal truths about the wider population, rather than the other way around.
The practice of medicine has gone through big changes over the years, and how medical schools train our future professionals has also undergone a significant shift – not only via rising tuition costs. For a long period of time, training to become a medical professional followed a standard set of processes, but training is finally catching up with new technologies and some top medical educational centers are starting over, from scratch.
Many medical schools operate on a model that had been pioneered by educator Abraham Flexner in the early 1900’s. Some medical schools, such as at the University of Michigan, are engaged in an update and full overhaul of how they train doctors. The students are not only studying the standards of medical practice – anatomy and biochemistry – but are focusing on increasing their ability to communicate. Doctors are forced to communicate very serious issues to patients and other medical professionals, and the ability to communicate clearly and in the correct manner is of great importance. Teamwork is necessary in medicine, which has become specialized rather than broad. The doctor who cannot work effectively on a team can be expected to have trouble in his or her future career.
The practice of medicine requires that the person is extremely flexible, as advances in treatment are released frequently, and no medical professional can become stuck in older methods – he/she must be prepared to learn new treatments as their career progresses. They also must understand how the digital age is changing the landscape in modern medicine. The ability to create written reports that can be shared digitally is now a critical point in patient care, as it can greatly reduce the likelihood of medical errors – which are at an all-time high. The Journal of Patient Safety released an article in which it was revealed that the numbers of patients who suffer some type of preventable harm was in the range of 210,000 to 440,000 each year, and that this is the third leading cause of death in the USA.
Medical students face big challenges, even in medical schools that are still operating on the older model. Those students who hope to survive in the world of medicine must reach beyond the current methods of training to gain the skills needed for teamwork, interaction with patients and families, and technological prowess, especially as medical records are increasingly digitized. A scribbled, unreadable note will no longer make the cut, and the students that have the skills to function in the new world of medicine are far more likely to make a successful career.
How to Recognize Early Symptoms
While it’s true that it isn’t always easy to detect cancer in its early stages, early diagnosis is a huge advantage in treatment. Therefore, it’s a good idea to inform yourself of cancer’s possible warning signs to help you look out for the health of yourself and your loved ones. The American Cancer Society provides a checklist of some general red flags to watch out for:
- Change in bowel/bladder habits
- Unexplained weight loss
- Persistent fever or fatigue
- Obvious changes in the shape/color/size of birthmarks, moles or sores, or general changes in one’s skin: itching, redness, etc.
This list is designed to reflect a variety of cancers. However, there’s no need to panic if you think you exhibit one of the signs, as none of these are anything like surefire. It’s also not a comprehensive list–you should also get checked if you display more specific indicators such as: lumps in the breast or testicle tissue, sores in your mouth that do not quickly heal, frequent nausea or headaches, or fluid in the lungs (this last could be a sign of mesothelioma). Since cancer can develop nearly anywhere in the body, its signs and symptoms are highly variable. If you have experienced one of these symptoms for two weeks or more, it’s better to be safe than sorry and see a doctor, as early detection can greatly improve one’s prognosis.
What You Need to Know About Screenings
Because of the advantages of early detection for many types of cancer, even if you have no symptoms, your doctor will likely want to perform several screenings. The most common screenings are:
- Colonoscopies (colorectal cancer screenings). For people at average risk, these are recommended yearly between the ages of 50 and 75.
- Mammograms (breast cancer screenings). These are recommended for women between the ages of 40 and 74.
- Low-dose helical computed tomography (lung cancer screenings). Thesre are generally recommended only for smokers between the ages of 55 and 74.
- Pap smears (cervical cancer and HPV screenings). These are recommended for all women aged 21-65.
Depending on your risk factors, your doctor may recommend others, such as blood tests, skin exams, and breast MRI’s. Depending on family history, some people may even benefit from genetic testing. However, more screenings are not necessarily better, and some actually have associated risks. Colonoscopies, for example, can cause tears in the lining of the colon. In addition, both false-positive and false-negative results are possible.
In some cases, the cancer never actually displays serious symptoms—the patient could have lived quite happily without the detection and subsequent treatment of the disease. Since there are many factors involved, your decisions about screenings should be tailored to your situation and made in consultation with your doctor. Remember that when your doctor suggests a screening, it is purely preventative; it does not mean you have cancer. If you take the proper, informed preventative steps, you increase your chances of living a long and healthy life.
Do you peruse medical sites for information if you are experiencing symptoms? Technology has changed how people gain access to medical information. You can search your symptoms on various medical sites, or simply using the Google search bar or voice command, giving an unprecedented level of access to information about health issues that was unavailable in the past.
Earlier generations considered medical professionals to be the ultimate authorities and generally simply submitted to a prescribed treatment. Gen-Xers and millennials are far more likely to search out information about a disease or condition, including alternative treatments, and tend to be more suspicious of the medical community and have interest in being an active participant in making decisions about treatment.
Patients may be well-informed about a condition or illness and the various options for treatment even before seeing a doctor. Knowledge is power, and the data accessed from the internet can allow a patient to find the most advanced treatments available, seek out clinical trials, and discover alternative or natural treatments or cures.
How much information can be too much? Searching out diseases, illnesses and conditions can produce an overwhelming amount of data. It is also notable that medical sites such as WebMD sell advertising to big pharma, and you can “click through” to advertisements that advise you to “ask your doctor about _____,” the most productive all-time pharmaceutical marketing strategy. A patient may have already seen several online ads promoting certain medications before seeing a medical professional.
Using a “symptom checker” feature, you can search out what you are experiencing to discover what disease or condition you may have. The results can be frightening. For example, if you choose “food cravings” as a symptom, you are given the following options of possible diseases: bulimia, eating disorder, malnutrition and pica (eating disorder in which a person is compelled to consume non-food items).
Health providers are also going digital, and specialists review test results and charts on a computer and can make decisions about patient care, and prescribe treatment without ever seeing the patient in person, raising real concerns about quality of care. The jury is out, but it is hoped that the access to information will in the end, prove to be a positive.
Telemedicine is the remote diagnosis and treatment of patients through telecommunications technology. According to a January 2015 article in Forbes, telemedicine’s time has finally come in 2015 for the following reasons:
- Technology has matured enough that doctors can offer patients a good experience.
- Telemedicine technology now includes asynchronous messaging, so doctors can better utilize their time.
- There is a greater demand among patients for the convenience of telemedicine.
- The 60+ age group, which is not adverse to technology and has more difficulty getting to the doctor than younger patients, is expected to fully embrace the convenience of telemedicine.
- Telemedicine will save a great deal of money and increase the value of doctors’ time by reducing the amount of time spent with patients who do not need to be seen in the doctor’s office.
- It can keep patients engaged with their primary health care providers and their care integrated with existing health care records.
However, not everyone agrees that telemedicine is a good thing. The Texas medical board, for example, issued an emergency ruling on January 16, 2015 requiring doctors to meet personally with their patients before prescribing medications, as reported in a February 12, 2015 article in the Texas Tribune. The Tribune reports that the medical board felt these emergency measures were necessary to protect public health.
Teladoc, one of largest telemedicine companies in Texas, obtained a temporary restraining order from a Travis County judge to prevent the ruling from going into effect four days after it was issued on the basis that there was no existing imminent danger to public safety, health, or welfare. The Tribune article quotes Tara Kepler, a telemedicine attorney, as saying that all medical boards across the nation are taking similar actions, and that Texas is just a little bolder.
According to the Tribune article, Dr. Russell Thomas, an osteopath, expressed the opinion that telemedicine services pose risks for patients, particularly when drugs are prescribed. He questioned the quality of service a physician would be able to provide sight unseen, with no relationship with the patient.
The Great Plains Telehealth Resource & Assistance Center (g pTRAC) argues that telemedicine is not meant to replace existing healthcare methods, but rather intended as a tool to complement them. According to g p TRAC, e-visits are not intended for new patients or for established patients with urgent medical conditions or conditions requiring a physical examination or with significant visible components, such as a rash.
Medicaid.gov describes telemedicine as “a cost effective alternative to the more traditional face-to-face way of providing medical care . . . that states can choose to cover under Medicaid. Within certain provider and facility guidelines, Medicaid allows states the option to determine whether or not to cover telemedicine, what types of telemedicine to cover, and where and how it is provided.
The consensus of opinion appears to be that telemedicine has a number of advantages, not the least of which is the convenience and the time and money it can save. However, the question remains whether or not virtual doctors can provide the standard of care that American patients are entitled to expect from their healthcare providers.
Surgical Errors Based on Wrong Medication Not Uncommon
You may have suffered a surgical error and are dealing with terrible consequences, or have lost a loved one due to a surgical error. Some surgical errors relate to instruments or sponges being left in the body after surgery, but there can be other causes. For example, administering a wrong medication or wrong dosage is also a common type of medical negligence.
How Could This Type of Error Happen?
Surgeons and other medical professionals (as well as people generally) have a tendency to see what they expect to see. This tendency even has a name – “ascertainment bias” – a form of cognitive error. A team of medical providers in a hospital setting who work together often may tend to trust each other based on prior knowledge. So, when a medication is brought to a surgeon to give to a patient, the surgeon may trust all those who handled that medication, beginning with the pharmacist and ending with the person holding the medication who hands it to him.
That expectation held by the surgeon that others can be trusted to provide the correct medication plays a role in this ascertainment bias.
A Quick Check of Medication Can Drastically Change a Patient’s Outcome
Medical malpractice errors related to giving the wrong medicine or an incorrect dosage can sometimes have terrible results. A recent tragic case in Massachusetts exemplifies the problem of a doctor having an ascertainment bias and trusting in all those who handled a medicine before him.
The surgeon looks at a drug handed over by a nurse, and is convinced that it is the right medication because it appears to be the correct medication – yet it is not. He did not read the label. The wrong medication can cause serious medical conditions, some permanent, or in many tragic cases, loss of life.
Although medical professionals must have a high level of trust in each other, every possible point at which an avoidable error is detectable should be part of standard safety protocols for surgery and all treatments involving the administration of medications. Surgeons and nurse practitioners should be required, for example, to submit detailed written prescriptions to pharmacists.
Avoidable Injuries in Hospitals at an All Time High
Medical errors are the third leading cause of death in the nation, following heart disease and cancer. Overdoses due to wrong amount of medication, or the wrong drug being administered are of great concern because these errors add to those unfortunate deaths.
A recent report estimates that 210,000 people die each year due to a preventable medical error, with the actual numbers estimated to be closer to 440,000. Serious harm to a patient is estimated to be 10 to 20 times more common than these lethal mistakes. These numbers are unnerving and are certainly cause for patients to be vigilant and proactively involved in their medical care. Sometimes simply stepping outside the norm of fully accepting all that a doctor says and does at face value and asking questions about treatment can be enough to make a doctor be more attentive. If a doctor knows he or she is being questioned, they may be more concerned about potential medical malpractice suits and therefore do their work more mindfully.
Roughly a sixth of all deaths in the USA could be attributed to a medical error, according to the report. Some disagreement exists about the numbers of deaths due to avoidable mistakes, but no one is disputing the fact that no matter what tracking system is used to measure the numbers, deaths resulting from medical errors is a serious problem.
A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. Journal of Patient Safety
How Many Die from Medical Mistakes in U.S. Hospitals? NPR
Computed tomography (CT) scans can help doctors to avoid missing or delaying a diagnosis of cancer or other serious medical conditions. However, the exposure to ionizing radiation that these tests involve may, at the same time, increase a patient’s risk of developing cancer.
This why many doctors and organizations are calling for patients to learn more and discuss the risks and benefits of a CT scan with their doctor before they undergo one, as ABC News/Health.com recently reported.
According to the article, CT scans have become increasingly used by doctors to check a patient for cancer due to the fact that they are cheaper and faster than MRIs or exploratory surgery and provide more detail than traditional X-rays. Between 1980 and 2013, the number of CT scans performed each year in the U.S. soared from around 3 million to 76 million, the article states.
However, a patient undergoing a CT scan generally receives a high dose of ionizing radiation. While the body can repair damage caused by small doses of radiation, the high dosage in a CT scan is one that simply overwhelms the body’s “repair mechanisms,” potentially leading to cancer, the article states.
The cancer risk is higher if a patient undergoes multiple CT scans, and women may face a higher possibility of developing cancer from the radiation than men, according to ABC News/Health.com.
The report cites a 2009 National Cancer Institute study which found that 29,000 future cases of cancer could result from 72 million CT scans that were performed in the U.S. in 2007.
Cardiologists Call for Patient-Doctor Discussion About CT Scans
As Reuters reports, several medical organizations issued a statement in September2014 in the medical journal, Circulation, which urged doctors to carefully discuss the risks and benefits of chest CT scans with their patients and to explain to patients why a CT scan was being used in their case.
Ultimately, a patient and doctor must “share” the decision to go forward with the test, according to the statement, which was signed by organizations that included the American Heart Association and American College of Cardiology.
Dr. Andrew J Einstein of Columbia University in New York told Reuters that patients should not necessarily be “scared off” by the discussion or refuse undergoing what could be a potentially life-saving test.
Still, Einstein said, “As doctors, it is our obligation to make sure that we, our colleagues and our patients understand the potential benefits of a medical imaging study as well as potential risks,” according to Reuters.
Questions You Should Ask Your Doctor
If you are suffering symptoms of cancer or any other serious medical condition, your doctor may tell you that he or she would like to order a CT scan. Before you agree to undergo the test, ask your doctor:
- What specific symptoms make the CT scan necessary?
- Could alternatives such as X-rays, MRIs or ultrasounds be used instead, and how do those alternatives compare to a CT scan in terms of risks and benefits? You may also ask about how the alternatives compare in terms of cost and the amount of time involved to perform each one.
- If a CT scan is needed, what is the typical dosage of radiation for such a scan and/or the actual dosage that will be used in this specific test?
- Will there be additional CT scans? If so, how many more tests? What are the risks and benefits of multiple CT scans?
The bottom line is that you have the right, as a patient, to have as much information as possible about the tests your doctor orders you to undergo. Ultimately, if you find that the risks outweigh the benefits, you have a right to withhold consent and seek a second medical opinion.
Confidentiality between doctor and patient has always been a given in the United States, and it’s something we have long taken for granted. However, that confidentiality isn’t as airtight as many may think. On the contrary, pharmacies such as CVS and Express Scripts have been selling anonymous prescription information to data mining companies for years. Why? It’s an effort to target advertisements to patient’s prescriptions and health conditions. The process is called matchback, and it has rightfully raised concerns about federal medical privacy laws.
How ‘Anonymous’ is It?
Matchback is allowed because the names of the patients are said to be concealed, though to many, that doesn’t justify the breach of confidentiality. IMS Health Holdings and other data brokers have collected prescription records numbering in the hundreds of millions, and they say the names of the patients are replaced by unique codes that are generated using algorithms. But, opponents of the practice are concerned that such technological advances undermine privacy laws, specifically the Health Insurance Portability and Accountability Act (HIPAA).
Confidentiality and Transparent Disclosure Concerns
While advocates of the matchback process claim that patient’s names are not directly connected to the prescription information, not all pharmaceutical companies are comfortable with it. For example, industry giant, GlaxoSmithKlinePlc, stopped engaging in the practice after its leadership became concerned about the potential for violating consumer privacy, and because not all websites were notifying users. The company’s legitimate concerns about transparent disclosure for internet users and breeches of confidentiality are at odds with other pharmaceutical companies, like Sanofi, that do use matchback to target consumers.
Money to be Made
Not all internet giants are on board with the selling of ‘anonymous’ prescription records though. Like SmithGlaxoKlinePlc, Facebook, Google and Microsoft don’t use matchbacks in their ad targeting strategies either. Perhaps the money to be made just isn’t worth the risk to them, especially given the breaches of information that occur. Opponents of matchback point to such breeches as evidence that long term tracking poses a risk to patient privacy regardless of how the data is presented, or who is in control of it.
Whether or not the mining of prescription data is legal, many believe that it is unethical. Opponents of the process argue that all health records should be kept confidential. Regardless of whether there is a name or random number attached to it, they claim, medical information is too personal to expose to any level of risk.