Last weekend U.S. News & World Report had a fascinating article called “The 18-second Doctor”.  The article is an interview with Dr. Jerome Groopman, author of How Doctors Think, a book that examines how physicians analyze information and make (occasionally wrong) decisions.

The article gives some examples of how taking the time to listen to the patient can be critical for arriving at the correct diagnosis.  I encourage all of you to read it.  I just added the book to my Amazon list.

I’m grateful to my patient Andy Raymond for pointing me to the story.

Tangential Miscellany:

My wife and I wish a happy Easter and a happy Passover to all of you who are celebrating.

Yesterday’s L.A. Daily News business section featured an interesting story about concierge medicine.  I was delighted to be one of the physicians interviewed for the story.  I’m grateful to Barbara Correa for shining some light on a practice model that has received very little attention – a model that I’m convinced is better for patients, better for doctors, and better for the healthcare system.  I’m also grateful to my patient Deborah Bradley for taking the time to talk to her.

The story is called “Ca$h Care”, which is a cute headline, but highlights what a strange marketplace healthcare has become.  We expect customers to pay for their own food, housing and transportation, but we’re still not used to patients paying for their own routine healthcare.  We would never let our employer decide for us who can sell us a car, or where we can shop for clothes, but we’ve become used to the idea that our employers should determine our healthcare options.  The only solution that will work nationally is the solution that has worked in the distribution of every other good and service.  Routine care should be paid by patients who should be free to seek care from any physician they choose.  The price for that care should be set by the patients and physicians.  Health insurance should only cover unaffordable catastrophes, and like life insurance or car insurance, should be removed entirely from the responsibility of employers.

So please help me spread the word.  Otherwise, when patient-sponsored medicine makes quality affordable healthcare widely available, the L.A. Daily News will get all the credit.

This week’s New England Journal of Medicine has an interesting study about how differently emergencies are handled outside of normal working hours.  The study looked at every patient in New Jersey hospitalized with his or her first heart attack between the years of 1987 and 2002.  The authors separated the patients into two groups: those who were admitted on a Saturday or Sunday, and those admitted on a weekday.  For each of the two groups the study looked at the fraction of these patients who received angioplasty or bypass surgery and the fraction of them who died within the year following their admission.

The patients admitted on the weekend were less likely to receive bypass surgery or angioplasty, and received these interventions longer after admission than the patients admitted on a weekday.  The patients admitted on the weekend also had a 1% higher rate of mortality than those admitted during the week.  This means that for every 100 patients admitted on the weekend there was 1 excess death over the number of deaths in 100 patients admitted during the week.  Interestingly, the difference persisted even when the authors only considered hospitals that were supposedly equipped and staffed for emergency angioplasty around the clock.

Obviously these results have nothing to do with what patients should do.  Don’t wait until Monday to get hospitalized if you get crushing chest pain on Saturday!  But for hospital administrators this provides much to think about.  For a disease as lethal as heart attacks, even a tiny improvement in the quality or timing of care might make a huge difference in the numbers of lives saved.

Tangential Miscellany:

I was contacted recently by the owner of a website called The Walker Tracker.  He had noticed my Pedometer Project and wanted my readers to know about his site.  His website allows you to keep track of your steps, chart your progress, and connect with other walkers for encouragement and support.  It’s free.  Check it out.

Losing weight is the second hardest thing I ask my patients to do.  (Quitting smoking is the hardest.)  Typically, physicians have generally recommended a low-fat diet which is still the diet recommended by national guidelines.  Despite this, several different kinds of diets have become popular recently with varying amounts of carbohydrates, most notably the Atkins diet which is very low in carbohydrates and very high in fat.

This week’s Journal of the American Medical Association contains the first study comparing several such diets.  The study enrolled overweight women who had not yet gone through menopause and randomized them to four diets.  In order of carbohydrate intake the diets were the Atkins diet (very low in carbohydrates), the Zone diet (low in carbohydrates), a diet based on national guidelines (low in fat and high in carbohydrates), and the Ornish diet (very high in carbohydrates).  The women’s weights were followed for 12 months.

Women on the Atkins diet lost the most weight, 10.4 lbs on average.  The other three groups had approximately the same weight loss (the differences were not statistically significant) of on average 4.7 lbs.  Interestingly the number of calories consumed by the four groups was not statistically different.  The Atkins diet, because of its high fat intake is occasionally criticized for increasing cholesterol, but in this study cholesterol decreased by the same amount in all groups.

So the Atkins diet is a sensible choice for overweight women.  What I find most sobering is that even in the best diet after a whole year the average weight loss was only about 10 lbs.

Tangential Miscellany:

The results from the first month of the Pedometer Project are in!  In February participants tallied over 2.4 million steps.

The winner with most steps was Marcia W.  In her honor I’ll be donating platelets at Cedars-Sinai on March 20.

The winner for most improved walker in February was Richard T.  In his honor I volunteered at the Simms/Mann Clinic yesterday afternoon.

My congratulations to all the participants.

Garlic is frequently touted as a natural treatment for high cholesterol, and many garlic extracts are sold with the suggestion that they improve cholesterol levels.  The current issue of the Archives of Internal Medicine has an article reporting the most definitive study yet looking at the effects of garlic on cholesterol.  Volunteers were randomized into four groups:  raw garlic, powdered garlic supplement, aged garlic extract supplement, or placebo.  None of the groups had a significant change in their cholesterol, though the raw garlic group reported much more bad breath and body odor.

The results are also reported in this Los Angeles Times article.  This statement from the study’s principal author summarized it well.

“It just doesn’t work,” said Christopher Gardner, a Stanford professor of medicine who led the study. “If garlic was going to work, in one form or another, then it would have worked in our study. The lack of effect was compelling and clear.”

Nevertheless, I still think it’s yummy.

Tangential Miscellany:

I wrote last summer about my involvement with the Society for Innovative Medical Practice Design (SIMPD), a national organization of physicians who work for their patients, not for insurance companies.  Because of my long-standing interest in medical ethics, I had the honor to serve with Dr. Robert Briskin and Dr. Garrison Bliss on the SIMPD ethics committee.  We were charged with the task of crafting a statement of ethical principles that would guide us and future physicians in our new practice models.  I’m very happy with the product of our work.  Our statement of ethical principles demonstrate that concierge physicians take ethics seriously, and that practices that align physician interest with patient interest can avoid many of the ethical pitfalls of traditional practices.  If you have an interest in medical or business ethics, I’d love to hear your feedback.