From DPC to CPC – part 1

An extraordinary case in a direct primary care setting

"Sherlock Holmes Museum 007" by User:FA2010 - Own work. Licensed under Public Domain via Wikimedia Commons
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A couple of years ago, as I was trying to determine the best business model for my practice, I offered direct primary care (DPC) services to a few patients.  Among them was WW, a then 57-year-old man who was well when I first saw him, but who ended up dying a year later in a very sad and dramatic way from a rare condition.

The extraordinary illness that struck W is worth describing simply on account of its rarity and its highly unusual manifestations.  But in addition, it occurred to me that my experience with W may be of particular interest to the growing number of physicians and health care professionals intrigued by, or involved in, DPC as a practice model.  This case exemplified the challenges and rewards of taking care of people with no insurance and with limited financial means.

I hope you will find this “clinico-pathological conference” to be of value.  Although W’s ultimate outcome would likely have been the same under any circumstance, I’m sure his clinical course may have been tackled differently by another doctor. 

Feel-good medicine: yesterday and today

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I’m on summer break but I thought you might enjoy this piece, published a year ago in the August 2014 issue of the Nob Hill Gazette.  The version below is slightly edited compared to the original.

In their recent book titled, Dr. Feelgood: The Shocking Story of the Doctor Who May Have Changed History by Treating and Drugging JFK, Marilyn, Elvis, and Other Prominent Figures, Richard Lertzman and William Birnes chronicle the startling career of Max Jacobson, a physician who specialized for decades in treating celebrities with his personally concocted injections of vitamins, human gland extracts, and high doses of amphetamines.

Operating from a filthy office in Manhattan, Jacobson showed no regard for basic medical hygiene and never obtained a basic medical history from his patients. Yet, over the years, he dispensed untold quantities of his “cocktails” to political and show business superstars suffering from fatigue, pain, or lack of stamina. For some of his patients, such as Cecil B. DeMille, the German-born doctor was a paragon of modern medicine. But others saw their careers and personal lives ruined as they became addicted to the treatments, and a few might have actually died as a result of it. The authors of the book relate instances where, under the influence of Jacobson’s amphetamines, President Kennedy’s behavior became wildly erratic. They even speculate that a motive for his assassination might have ensued.

Max Jacobson’s story might seem like a sordidly entertaining tale from a bygone era. Nevertheless, given our current love affair with medications (one in five adult Americans takes a psychiatric drug, and 70 percent of the U.S. population takes some form of chronic prescription medication), it behooves us to reflect on the professional and ethical failings of Jacobson’s practice to help keep our way of “better living through pharmaceuticals” within healthy boundaries.

Canadian medicosclerosis and American medicomania

Impossible to compare

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I follow several physicians from Canada on Twitter.  Since I do not have first hand experience of that health care system, I find their accounts instructive.

Some tweets are sadly biting:

Shawn Whatley, a Canadian physician I also follow, wrote in a recent blog post entitled “Medicine resists change” that:

Canadians took a bold, progressive move in the 1960s and created Medicare. And we’ve blocked change ever since.

Sure, we dribble in new technology. Embarrassment demands we buy at least a few PET scanners and robotic surgical assists. But our core system is unchanged.

Government and Organized Medicine insist that basic clinical services work the same as in the 1960s. Patients see their family doctor. Doctors send patients for ‘high-tech’ X-Rays, ultrasounds or blood tests. Patients drive to licensed and controlled lab facilities. Then they trudge back for results days later.

That sounds grim.

How experts really decide

(Hint: they don't follow guidelines)

Photo credit:  cracked experience Hamed Parham via Flickr.
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I opened my last post with a question I never came around to really answer: How should doctors make decisions?

That wasn’t an oversight.  To try to provide an answer seemed daunting, plus I wouldn’t have resisted the urge to wax philosophical about praxeology or phronesis.  And how sexy is that?  Surely my Alexa ranking would have suffered!

Perhaps sensing my predicament, Dr. Saurabh Jha tactfully suggested a book which I have since ordered and read.  (And what a great call that was.  Thank you, @RogueRad!)  The book is Streetlights and Shadows: Searching for the Keys to Adaptive Decision Making by Gary Klein.

According to his Wikipedia entry, Klein is a cognitive psychologist credited with pioneering the field of naturalistic decision-making, a research endeavor where people’s decisions are examined in real life setting, not under contrived laboratory experiments.

The book, published in 2011 by The MIT Press, summarizes the fruits of his research.  It’s a captivating work.

Make decisions, not calculations

How should doctors deal with uncertainty?

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How should doctors make decisions?

In the last post, we reviewed the conceptual difficulty of applying risk estimates derived from population studies to individuals, and I proposed that medical decisions should NOT be modeled on the following scheme:

  • Step 1: weigh the probability of future pluses and minuses.
  • Step 2: make a decision on the basis of “probability of pluses > probability of minuses.”

Yet that scheme implicitly serves as a rationale for pay-for-performance measures and justifies legal impositions on the content of informed consent procedures (e.g., precise disclosure of risks, probability of benefit, risks of alternative treatments, etc.).

Today, I will add a some perspectives that I think buttress my case.

Disclaimer:   This discussion is not meant to entice you to violate the standard of care, to forego the established procedures for informed consent, to incite you into civil disobedience, or to put your medical license at risk!

Let’s start with two anecdotes:

A few years ago, the New York Times detailed the extraordinary story of Michael DeBakey’s aortic repair operation.

Risky decisions

Pay-for-performance, shared decisions, and the science of risk

Photo: Relación Médico-Paciente by By Jorgejesus4 via Wikimedia Commons Public Domain
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I had a sort of epiphany about risk and medical decision-making last Thursday evening, even though I was particularly tired and in a state of mental fog.

I had been thinking about two recent articles dealing with risk prediction, but I also was preoccupied with risky career decisions I have made, and how these are affecting me and my family (I am pursuing a quixotic version of the “triple threat:” independent physician, apprentice schoolman, blogger).  So risk was very much on my mind.

One of the articles I had read was a recent viewpoint in JAMA by Allan Sniderman, Ralph d’Agostino, and Michael Pencina titled “The role of the physician in the era of predictive analytics.”  The other was a response to that article written by Bill Gardner at the Incidental Economist blog.

In their paper, Sniderman et al. discuss an important difficulty in the medical science of risk prediction.  The difficulty is apparent when one contrasts the notion of population risk with the notion of individual risk.

Overdiagnosis: The disease that cannot be diagnosed

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Some say mammograms don’t save lives, and we order too many of them. That may be true, but which ones should we eliminate? The answer is not so easy after all.

Today’s post will deal with overdiagnosis, a concept preoccupying health care analysts, academics, and policy makers, and one whose importance is confirmed by the distinction of having its own dedicated Twitter hashtag.

And if you follow the #overdiagnosis hashtag these days, you will surely encounter the following chart, excerpted from a recent JAMA Internal Medicine paper:

A documentary about doctors and widowmakers

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An award-winning documentary entitled The Widowmaker was just released on Netflix.  It shouldn’t leave viewers indifferent, and doctors in particular are likely to be thoroughly captivated.

Cardiologists can identify the title as the nickname commonly given to a threatening plaque near the origin of the left anterior descending artery, the major of the coronary arteries of the heart.  A clot forming at that site is frequently fatal.  Since middle-aged men are more prone to heart attacks than middle-aged women, such a clot often leaves behind a widow and fatherless children, hence the name for the plaque.

Cardiologists who watch this movie will also recognize some familiar figures:  Drs. Steve Nissen, Matthew Budoff, Bruce Brundage, Martin Leon, Arthur Agaston, Shamin Sharma, Joseph Loscalzo, Julio Palmaz, Douglas Boyd, Harvey Hecht, and many other high profile clinicians, innovators, and academics are featured in a suspenseful tale of heroes and villains.

Reasons to MOC®: Board certification revisited

Detail of The Apotheosis of George Washington by  Brumidi. Capital Dome, Washongton, DC. (Photo credit Ron Cogswell via Flickr).
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Bob Wachter has written a lengthy defense of the American Board of Internal Medicine (ABIM) and its Maintenance of Certification (MOC®) program, addressing contentions that the ABIM may have engaged in questionable financial practices, and that MOC® is irrelevant, time consuming, and onerous.

These allegations, however, are not the only questions board organizations may need to confront.  Along with several recent articles devoted to the topic of professionalism, Wachter’s piece provides us with an opportunity to examine three foundational arguments that board leaders invariably bring forth to justify the commerce of certification.

Skills, Knowledge, and Prediction

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The following letter to the editor was published in the American Journal of Cardiology in response to an excellent article by George Diamond and Sanjay Kaul who highlighted the limitations of quantitative methods for achieving relevant “risk-stratification” at the individual level.  Comments made by these authors prompted me to reflect on the tension between the appeal of quantitative methods and the value of unquantifiable clinical skills.  I hope you will find these remarks stimulating.

In the March 15, 2012, issue of The American Journal of Cardiology, Diamond and Kaul1 provided an insightful analysis of the complex relation between risk stratification schemes and therapeutic decision making. The investigators clearly identified some of the reasons why predicting response to treatment at the individual level is difficult. However, they conclude their report with a caution against “wholesale abandonment of evidence-based guidelines in favor of idiosyncratic clinical judgment,” which, in their opinion, runs the risk of “intellectual gerrymandering” and “wasteful utilization of high-cost technology.”

Proponents of quantitative methods of clinical assessment frequently portray critics as Luddites ready to “jettison” objective evaluation in favor of personal opinion rooted solely in clinical experience.2 This is an unfair characterization.