In considering the future of a Great health care system, one of the most important components of the equation will be the patient and their participation in their care. So, when it comes to your health, what’s better for you as an individual — obsessively monitoring your personal health or opting for a “less-is-more” approach? A debate is raging between the medical and biohacker communities. Why are we, the purchasers of healthcare and healthcare insurance, listening to actresses and billionaires on how to stay healthy, what tests do we need and what vaccines are safe?
This lead me to a set of posts on Twitter by Mark Cuban, the billionaire owner of the professional NBA basketball team-the Dallas Mavericks, who posted his commentary on how the everyman should be tracking his own health last Wednesday.
Here’s the tech mogul’s prescription for well-being and longevity:
1) If you can afford to have your blood tested for everything available, do it quarterly so you have a baseline of your own personal health
3:33 PM – 1 Apr 2015
2) create your own personal health profile and history. It will help you and create a base of knowledge for your children, their children, etc.
3:36 PM – 1 Apr 2015
3) a big failing of medicine = we wait till we are sick to have our blood tested and compare the results to “comparable demographics”
3:34 PM – 1 Apr 2015
I thought that his statements were interesting and they indeed caused a lot of debate among health-care journalists and doctors, as it undermines the current public-health framework that is trying to detract from over-testing patients.
Cuban makes a good point although he goes to the opposite extreme. We all know healthcare has been rationed for a long time and it gets worse if you are part of an HMO. What does Mr. Cuban provide for his employees in light of his goal of profits as his number one goal? If the private sector has demonstrated one thing, it is that they want to pay as little for healthcare as possible. When members of the private sector, the actors, actresses and billionaires, act outraged about inferior care when they have created the financial environment for it, then the basis for their protest is disingenuous. There is a Big Failure in Medicine and it is the inability to say no to a bad deal and to think you can provide good service for free. However, even when healthcare insurance is “given” to those that need it we have seen no change in their behavior and the same problem of providing care through the ER, the most expensive delivery system, continuing to overload ER everywhere.
Mr. Cuban doesn’t take into account Baye’s theorem as it applies to medical testing, ie. that the predictive value of a test is a function of the pre test probability of an abnormal result, as well as the inherent accuracy of the test (eg. if EST is done on healthy 20 year olds, almost all the positives will be false positives). In endocrinology, we see lots of “shotgun” test ordering by primary care physicians and often there are consults for slightly abnormal blood hormone levels that were ordered with no corresponding clinical complaint. Lots of needless follow up ends up being done, to no one’s benefit, and at cost to the health care system. It is interesting that 5% of all blood tests are abnormal by definition, statistically 2 standard deviations from the mean. How much time, effort and money do we spend chasing some of those labs? If we do enough tests, there will beabnormal results that the care givers then have to work up. That is the whole controversy of PSA and mammograms…so we now want to increase that logarithmically??
Shannon Brownlee, senior vice president at the Lowe Institute, and author of the book Overtreated: Why Too Much Medicine In Making Us Sicker, stated the “Getting lab tests just because you can runs the risk of the same problems that plague screening tests, like the PSA. You’re looking at false positives that require a lot of follow up, which involves both worry and risk of physical harm.”
For every 1,000 men who get regularly screened for prostate cancer, about 2% of them will end up getting unneeded biopsies or even have their prostate unnecessarily removed because the data is wrong. It’s a clear representation of why more and more groups are advising fewer PSA tests. Even the leading association of urologists — who stand to benefit financially from annual tests — said many men should stop.
Here is a prime example of where pursuing tests for tests sake results is bad things happening. Consider the real case of Dorothy a 75-year-old lady, who was admitted to the ICU for 6 months before she died. She went to one of those $20.00 gets you 20 labs events that the Rotary puts on or small hospitals do to drum up business. Her bilirubin was a little bit elevated. Her local PCP – might have been a doctor or a nurse- sent her to a GI doc who preceded to ERCP for this the nice lady who had no significant health history. She developed necrotizing pancreatitis from the ERCP and got sent to the University hospital where she lived in the ICU. The physicians and nurses did washouts, debridements, done daily. For 6 months. The staff gained a little ground, and then she’d get worse. She had feeding jejeunostomy placed after the TPN (nutritional support) damaged her liver. She was terrified but was totally conscious when you’d ask her questions – she’d nod her head yes or no appropriately. She wanted to live. But she finally – her body – failed and she died.
Most of agree that patients should be in control of their health partly because the system has become dysfunctional due to hospital and insurance companies in control of practices, governmental over regulation and waste of billions of healthcare dollars on things like paying for Mr. Gruber of MIT as well as the internet web designing companies responsible for the Affordable Care Act roll out. Also-over 20 years- there has been a change in the mindset of MDs from physicians to MBA-providers-hustlers. The average encounter with the medical system involves being shoved around by rude and ignorant assistants on an assembly line and a very few moments with a physician who imparts little empathy, and is loathe to take the time to consider the patient’s problems in a holistic, comprehensive manner. Patients must be in charge of their own health and should be able to gather their own data like labs and use the Internet to decide if they want to seek the opinion of an MD. For patients not savvy enough to do this should be able to avail themselves of online expert advice. After all most MDs, do little more than look at the labs, don’t touch their patients and end the visit by trying to maximize the billing with more labs, tests, procedures or referrals to mail order drug companies from which they get a kickback. Actually all of this (easily available, cheap labs and readily available online personalized data analysis and care) is already formatted and will soon be up and running.
I would take this a step further and hope that some innovative billionaire is listening. In reality, the cost to run an actual blood test is not that expensive to begin with, it’s what we do to them that create the burden. We force most patients to see a physician first to get a script to get the test, then the patient must again take time off to get the lab drawn, then in many cases, take more time off to review the results with physicians who refuse to review tests over the phone creating a cost and time burden on patients which can make testing prohibitive. Then of course there are the patients who can never get their test results back. Allow patients to pay cash to get labs done without a script. Laboratories will compete for their business lowering the cost even more and offering various panels for discounts. The money hungry “business men and women” create lab testing kiosks where you punch in your demographics then answer a series of questions that will generate recommended tests or you can request your own. Imagine all the cases of diabetes that could be treated before complications. After having the tests done, you will get a copy of your labs immediately followed by a call from a telemedicine doctor (someone who is tired of the bureaucracy) who will review your labs and give you advice on what your next step is. Or, make it really fancy and have the test results ‘interactive’. This could help relieve the problem of ‘access’ for many despite being newly insured. For those who fear for ‘patient safety’, we allow everyone to drive cars and carry guns, which are more likely to lead to their demise than a blood test. For those who claim a machine can’t decide on blood tests, oh, yes it can and maybe better than us because it won’t have our level of distractions.
I found it interesting that Mr. Cuban becomes the expert through “social media, just like the actress who convinces people that vaccines cause autism. Mr. Cuban is a billionaire entrepreneur. He is a star of the “Shark Tank” reality TV show. He is the savvy owner of an NBA basketball team, the Dallas Mavericks. He’s even invested and here lies the important fact, in four health care companies. But Mark Cuban doesn’t understand health care except the profit that he can make in his investments. I would ask- Mr. Cuban you have cited no research that your suggested testing protocols does improve health care. If you recommend it, where is the data to back it up? I think that we should find ways for mutual agreement rather than immediately returning fire and calling in the artillery. He is right in so far as percent body fat, how far you can walk and lab data that is out of whack such as a non-HDL cholesterol above 90, or a BP > 125/75, or a % body fat above 11-22% for men and 15-27% for women. Triglycerides should be less than 100, A1C 5.5 or less at age 55 (to be interpreted and correlated. It’s for those younger and older), uric acid <5.5, BUN not above 12, Hb about 12-14…. These values will likely occur in lean, significantly exercising people with a very high fiber diet of foods at the 90% level = 18/21 meals per week with ANYTHING once in a while. Mr. Cuban is correct about checking these values within certain guidelines guidelines with the clear implication that the patient is willing to make changes in the relevant directions towards achieving these ideal goals which tend to guarantee freedom from multiple diseases simultaneously including Diabetes, coronary artery disease, etc.
There are just too many people, organizations, government agencies, watchdog groups, mainstream media, etc., etc. who want to oversee what we do as physicians. There are many ways to “skin a cat”. As a physician in practice for 30 years, I have developed an approach to evaluating and treating my patients, which has evolved with the times, takes into consideration the guidelines of my and other professional societies and organizations, and provides the best care I can deliver to my patients. Some patients need more frequent bloodwork, some need it once a year, some even less than that. I develop testing schedules for my patients according to their current medical issues, their past medical history, and the drugs they are currently taking. Same approach applies to stress testing, echocardiograms, heart monitors, radiologic procedures, etc. which I usually rely on their primary care or specialists to order the appropriate tests or procedures. Almost all of we physicians resent being told how to treat our patients. we resent being told that others (especially non-medical) are going to assess our competence as a physician. We resent not being able to electively and freely explore the areas of medicine, which are of benefit to our patients as well as satisfying our needs to remain current in our field.
This is partly what is wrong with medicine today. What we do as physicians should be (within reason) our own choice, not the choice of others. If a physician deviates too far from accepted practice norms, then he/she will find that patients, peers, and payers will not use them…and that should drive all of us to become the best doctor we can be! What ever happened to the basic medical concept that we evaluate and treat each patient as an individual, taking a careful history, assessing risk of disease, examining the patient, and then using diagnostics in a focused manner to complete the evaluation? This is not only the best medicine; it is the most cost-effective medicine. How we physicians order tests depends on patient age groups, medical history, family, etc. my patients have multiple medical problems and in the high risk group. The key word is managed appropriately. – adjust screening period as indicated, but a baseline is important. Screening and prevention are better than treating after patients suffer a stroke or heart attack etc. the basic labs are not that expensive. Go to a doctor you trust. Get the labs you need. Discuss with doctor you trust. Get the treatment you need.