Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

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Archive for February, 2015

Evidence Based Medicine? Preferred Practice Patterns? You Are Behind the Times

If you practice Evidence-Based Medicine (EBM), or religiously follow a Preferred Practice Pattern (PPF) such as one published in a white paper by a specialty society or organization, you and your patients can be assured of one very important fact: you are providing care that is neither up to date nor care that can be described as “Best Practices”.

You might be increasing the likelihood that your patient’s medical insurance will pay for their care, in part because insurance companies have already figured out how to make money on older treatments and protocols. I guess you can feel good about that, or at least feel good that your staff won’t be forced to fill out all of those appeals forms when state of the art care is denied. So you’ve got that going for you. What used to be considered good enough care might feel better to you if your patient isn’t avoiding the older treatment because of payment issues like they do with the newer. Adherence to some care is better than non-adherence to “Best Practices”, right?

There are certainly some of you out there in doctor land who think that citing EBM or fidelity to a PPP will inoculate you from medical malpractice tort. Sadly, nothing is further from the truth. Not only will your adversary nullify a PPP by citing a “Standard of Care” that is up to the minute when it comes to how to treat literally anything (though as we know “Standard of Care” is neither Best Practices nor EBM), but there are so many instances of EBM not allowed as evidence at trial that it’s nearly useless to try. Even the strongest body of research can be nullified at trial by introducing a single non-peer reviewed study with opposite findings to a naive jury of lay people.

EBM and PPP are the result of years of studies that were launched based on prevailing thoughts at that time. They are subject not only to what is fashionable among the medical intelligentsia, but also what is fundable. The potential ROI from the industry side of the medical pie has a direct impact on not only what is studied but what treatments are available at all. A company with a blockbuster drug that has years of patent protection remaining will be unlikely to support the study and use of its own competitor or successor until under the gun of generic competition. Governmental funding of maladies without either a popular champion or sympathetic victim is slow in coming, if it arrives at all. Both EBM and PPP enter the public arena only after months or years of time spent “in committee” with old data.

At the end of the clinic day both EBM and various PPP’s suffer from being out of date on the day they are published. Because of this they create at least as many problems as they attempt to solve. In addition to providing ammunition to insurers all too happy to avoid paying for newer, more effective care that might be more expensive, the wide dissemination of various articles on EBM or PPP’s can sow confusion and doubt in the minds of those patients most in need of Best Practices, particularly those with severe or complex problems.

Any specialty in medicine could provide examples, but since I’m an eye doc let me offer one that illustrates most of the nuances involved. We’ve long known that elevated tear osmolarity (salt content) is a component of dry eye (DES). Prior to 2009 testing the osmolarity of human tears required a complex, time-consuming process that also suffered from the twin-blade cut of being both expensive and not covered by any insurance plans. Consequently the use of tear osmolarity as a core diagnostic test in the care of DES was pretty much a non-starter.

In 2009 TearLab introduced a much simpler, much less expensive test that could be done in the course of a regular office visit, and in 2010 the company received a waiver from the FDA which allowed doctors to use the test in an office setting without being certified as a clinical laboratory. Approval for payment by insurance companies, including Medicare, came shortly thereafter. As with any new test that becomes widely available it took a couple of years for clinicians to figure out the full extent of the meaning and application of the results. The short version of this part of the story is that tear osmolarity testing has become an integral part in both the diagnostic work-up and ongoing follow-up of DES patients in any advanced DES clinic due to its clear therapeutic value. It also fits into the prevailing financial model and patient mindset in which diagnostic testing is an insurance covered benefit.

What’s the problem then? Our largest professional organization, the American Association of Ophthalmology (AAO) publishes a series of PPP’s addressing many common entities in eye care, and DES is one of them. The latest version was published in 2013 after more than a year of discussion in committee based on practice patterns  and publications from 2011 when Tear Osmolarity was not yet in widespread use. The PPP made much of the fact that this at the time new test had not yet been widely adopted and that there was still some discussion about its true clinical worth. BOOM! In rushed a Medicare administrator in January 2015 with a proposal to withdraw payment for this “non-essential” test of “unproven” value.

The problem, of course, is that Tear Osmolarity is now widely and quite rightly accepted as a part of today’s “Best Practices” of DES care. Ironically, the use of Tear Osmolarity is actually an example of EBM, but that evidence has emerged subsequent to the initiation of the PPP process. Removing insurance payments will erect a barrier between patients and their best chance at treating their disease.

Thought leaders in my field as well as other, more nimble professional organizations than the AAO have offered assistance to TearLab to prevent a change in the insurance payment for tear osmolarity testing. Both eye doctors and their patients will likely survive this misguided attack on an extremely useful technology. It does make one wonder how many other instances exist where a seemingly good idea (PPP, EBM) is misused in the eternal battle between those who provide medical care and those who are charged with allocating the monies used to pay for that care. Funny, isn’t it, how the medical powers that be, professional organizations like the AAO, are always a bit behind the times, and the payment powers that be (and often plaintiff’s attorneys) use that to their advantage?

Preferred Practice Patterns and many examples of Evidence Based Medicine need to come with an expiration date, or at least a warning that using them cannot be construed as either “Best Practices” or cutting edge. Even at the time they are first published.



Sunday musings 2/22/15

Sunday musings…

1) Hooptie. A comically old and partially functional vehicle. Totally new word for me, much to the amusement of some of my co-workers.

Especially since this describes my daily driver to a ‘T’.

2) 0.31%. The percentage of Americans who do CrossFit. ~5%: the percentage of Americans who are regular gym goers. That’s an awful lot of Americans exercising and not doing CrossFit, let alone Americans not exercising at all. Seems like a target-rich environment, no? If we simply increase the percentage of gym goers to 10% that doubles the number of CrossFit gym members, and it’s still only 0.62%.

Tell me again why there is so much strum und drang about competition between local CrossFit Affiliates?

3) Tuba. “The tragedy of the unhappy tuba player.” –Ben Bergeron

We are blessed in the CrossFit community by the presence of many, many fine speakers. Indeed, every Flowmaster at CrossFit Level 1 trainer seminars is a polished speaker able to tell a tale while effectively transferring their message. It goes without saying that Coach and all of the original SME’s are somewhere way into the stratosphere of excellence.

Beth and I attended a seminar at CFNE yesterday where we spent the ay with Ben Bergeron. That, my friends, was some treat! It wasn’t enough just to point out the importance of moving from a macro to a micro view while leading a class. Not even enough to liken the views to watching a great marching band perform. Nope, the description and example was nearly poetic:

“From the stands you watch a band in full bloom, moving as one, the epitome of applied excellence. The macro view; your class from the front of the room. You want to reach out to congratulate the bandleader. Then you zoom in on individual players and you come across a disheveled tuba player who isn’t playing at all. Indeed, his mouth is not even connected to his instrument as he trudges along a quarter beat off, tears streaming down his face. The micro view as you walk among your athletes.”

No chance I’ll be forgetting macro/micro after that! Kudos and thanks to Ben for hosting us.

3) Belfry. The mind is a wild, mostly wonderful, occasionally wacky place. The more I learn about how our minds work, the connections, neuroplasticity and all, the more mysterious it becomes. Beth and I are visiting my Dad, two parts of a team filling in for my Mom, front row seats to watch a mind careen between what is and what is not. As frightening as it is to be a passenger on this journey it must be simply terrifying to be driving the bus.

The science I get. Bad plumbing results in insufficient O2, not enough fuel over a lifetime, and delicate circuitry is lost. Or sludge of some sort builds up in a critical part of the wiring. Insufficient flow becomes no flow, and thoughts become trapped, diverted, or even worse, stillborn. Juliane Moore may win an Oscar tonight portraying a woman so afflicted. I’ve not seen the movie and most likely won’t; it just cuts too close to the bone.

Tragically, some of this is unavoidable at this point in time. We know not why certain types of age-related diseases rob us of our memories, our faculties, and in time our very selves. Ms. Moore portrays a character who is ambushed this way. Others, like my Dad, suffer from a version that likely results in part from self-inflicted trauma of a sorts. Smoking. Diabetes resulting from nutrition and inactivity. Use or abuse of mind-altering substances, most commonly alcohol. The mind is a terrible thing to which you lay waste.

What is there to do? Well, for me, for Beth, for my siblings and for any of you who may find yourself in similar straits there is little left but to apply the lessons of kindness, understanding, and empathy I have shared here and elsewhere. That and to have handy a healthy supply of tissues, for there is no balm to sooth these wounds for us or for my Dad. For those of us who do CrossFit we have already been given a prescription in 100 concise and precise words that is so far the most likely preventative medicine known to mankind:

“Eat meat and vegetables, nuts and seeds, some fruit, little starch and no sugar. Keep intake to levels that will support exercise but not body fat.

Practice and train major lifts: Deadlift, clean, squat, presses, C&J, and snatch. Similarly, master the basics of gymnastics: pull-ups, dips, rope climb, push-ups, sit-ups, presses to handstand, pirouettes, flips, splits, and holds. Bike, run, swim, row, etc, hard and fast.

Five or six days per week mix these elements in as many combinations and patterns as creativity will allow. Routine is the enemy. Keep workouts short and intense.

Regularly learn and play new sports.”

I’ll see you next week…

Posted by bingo at February 22, 2015 8:28 AM

Sunday musings 2/15/15

Sunday musings (from the tundra)…

1) Climate. Why is it no longer called “Global Warming”?

2) Stroll. I could walk to Toronto in a straight line. 57 miles, direct. Except for the fact that it’s presently -3 degrees.

See #2.

3) Godwink. Someone who comes into a place or a life at exactly the time their arrival was needed and makes everything better. First encountered in reference to Joe Madden, new manager of the Cubs.

I like that. Gonna ponder it a bit while I stay on the lookout for Godwinks in the wild.

4) Paleo. “I’m on a low duck-fat diet.” –Kim Gordon

Now that’s just funny. It reminds me of a line in “The House of God” when the street savvy intern who saved the life of a chocking patient by removing the foodstuff obstructing the airway. When asked by his supervisor how he would treat the patient going forward:

“Well darling, that’s easy. I’m putting her on a low broccoli diet.”

Sonic Youth in the gym for me today.

5) Culture. “When you decline to create or to curate a culture in your spaces, you’re responsible for what spawns in the vacuum.” –Leigh Alexander

Nature abhors a vacuum. In all ways and in all places. While I have never seen this immutable law applied to group culture that only speaks to my own lack of imagination and insight, and by extension Alexander’s surfeit of both. I use “spaces” a bit differently, preferring the term as a reference to internal or personal geography (timespace, brainspace, emotionalspace). Alexander’s choice of “space” rather than “place” adds to the brilliance, the “aha”-ness of the insight in that it specifically includes the virtual as well as the physical.

Some people exert, or could exert, enormous influence over very large spaces by either actively tending to the culture or by standing aside and simply observing what fills the vacuum. The CEO of our local medical behemoth has imposed his will at a very granular level on an organization that employs 10’s of thousands. Rules and regulations abound there. Here, chez CrossFit, the culture arose primarily from the founder’s philosophy and worldview. Pretty freewheeling, rough and tumble, then and now.

Think for a moment about your own spaces, maybe looking initially at the ones over which you might have a bit of control or influence. Work. Home. Box, whether owner or member. What has your role been in the creation and ongoing curation of the culture of those spaces? It’s a rather Taoist proposition, I think: to act is precisely equal to not acting, because one or the other course must be chosen. At my day job we actually did go about the task of creating a culture (A Tribe of Adults), and we knowingly curate that space by culling the tribe of those who don’t, won’t, or can’t acculturate.

In the end this is probably just another entreaty to consciously examine your own spaces, your world, and seek to exert whatever control you can wherever you can in order to live well. Whatever “well” means to you. Again, the Tao te Ching gives us some useful vocabulary, imagery we might reference. In the end we are all more like the pebble in the stream than the reed in the field. We may aspire to live as the reed, flexible and ever able to flow with whatever breeze may blow through. The reality is that an untended culture surrounding us flows so powerfully that it, like the water in a stream, eventually reshapes us as it inevitably sculpts the stone in the stream.

The difference, as both Lao-tse and Leigh Alexander teach us, is that you have the ability to control the flow.

I’ll see you next week…

Posted by bingo at February 15, 2015 6:50 AM

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