Archive for the ‘Healthcare’ Category

Time Bomb of Longer Lives & Magic by Numbers

October 20, 2010

Few very interesting and thought-provoking articles appeared in New York Times over the last few days

The Financial Time Bomb of Longer Lives -

Talks about the good and bad news. The good news is that “we are all living longer and healthier lives than ever before” and then comes the bad news “at this rate we also cannot afford to live so long!”.

Source of this article as been the Global Aging report from Standard and Poor’s (S&P) titled – “Global Aging 2010: An Irreversible Truth

Few thought provoking points from this article -

  • For the first time in human history, people aged 65 and over are about to outnumber children under 5.
  • The average life expectancy of human beings around the world has nearly doubled since the start of the Nineteenth century (around 47 in 1900 to about 80-82 in 2010)
  • However, in the same period the retirement age across the globe has merely increased from about 58 to about 62-63 years.
  • As the article says – no other force is likely to shape the future of national economic health, public finances, and policymaking as the irreversible rate at which the world’s population is aging.

On the side note – the way NY Times reported this concept of imbalance in age group across the world in a pictorial format is commendable. I am linking it to the same below.

 

The Financial Time Bomb of Longer Lives

The Financial Time Bomb of Longer Lives (NY Times)

 

Magic by Numbers -

Daniel Gilbert, Professor of Psychology at Harvard describes nicely how certain numbers (he calls them as the magic numbers) don’t just dominate our thoughts and dictates our words; but also drive our most important decisions.

For example -

  • Weekly or the 10 day medicine prescription dose given by the doctors are most of the times not driven by any scientific or medical evidence – but more from the psychology around the comfortableness around certain numbers.
  • Stock prices typically tended to be clustered around numbers around 5 or 0.
  • Sound of how the numbers sound to the ear can influence our decisions many a times.

Strategies used by Doctors for Diagnosis

February 19, 2010

[This blog is part of the series which I had been writing about various aspects of Doctor - Patient Relationship. and how the function of diagnosis and treatment are at its core. In my previous blog, I had talked about why disease name identification was a very important step of the diagnosis process. This particular blog talks about what are the strategies which doctors use to diagnose.]

In my previous set of blogs in this series I had started talking about what diagnosis means from medical perspective. DiagnosisOne important realization I had was that Diagnosis is about finding the name of the disease (and the dictionary definition of Diagnosis – “process of determining the identity of (a disease, illness, etc.) by a medical examination” – also conveys the same thing) and not really about treating a patient. As commonsensical as this may sound – I have seen many do tend to miss out on this. According to me though – understanding this subtle difference is important considering that it can have a direct impact on how doctors and patients understand each other.

Now that I think I figured out what the real goal of Diagnosis process was i.e. the ‘why’ part; my next goal was to understand the ‘how’ part. Curiosity in my mind was how do doctor’s diagnose and arrive at a conclusion. Was it through a logic or some magic or by simply looking through a crystal mirror? The blog post from my brother – “What is in the Name?” gave me some insights as to what goes in the doctor’s mind during the diagnosis. My next step was to read and understand if there were any particular strategies using which doctors typically came to a conclusion.

Towards this, I thought the four-strategy model suggested by D. L. Sackett et. all. was a good starting point to start understanding how the typical clinical diagnosis happens (src – “The diagnostic process in general practice: has it a two-phase structure?” by Anders Baerheim). This blog is a summary of what those four strategies are.

Before I summarize them, I think it is important to keep in mind that these strategies are categorized based on the characteristics of the approach used in it. I do not think doctors pre-plan about the type of strategy they are going to use when they see a patient. Most of the times it is a sub-conscious decision and also there is a good chance that hybrids of these approaches are also used in real life practices. So beware – if you were to pop a question to your doc about which technique he was going to use to diagnose you – don’t be surprised if he gives you a blank stare!

So the four techniques described by Sackett et. all. are -

Pattern Recognition strategy -

Subconscious Recognition

Subconscious Recognition

While many can think about medical diagnosis as synonymous to any problem-solving technique where some kind of scientific method is applied to come to a solution, this technique of diagnosis is more instinctive especially when certain configuration of symptoms/clues appears very classical. This results in a instant/unconscious generation of a hypothesis. For example, diagnosing down syndrome after one look at the patient.

This technique of diagnosis for diseases/ailments is possibly the most common strategy/technique used by the doctors – especially the ones who are the most seasoned. More the experience of the doctor (probably clinical and not in terms of years) – better the doctor gets at this. Majority of the time this technique is reflexive and possibly not reflective. Interestingly this is not the technique which doctors are taught in their classrooms; but is learnt on patients. This technique also forms the basis for ‘first’ diagnosis majority of the time.

While Pattern Recognition strategy is the most popular strategy and majority of correct diagnosis happen around using this technique – this technique of medical diagnosis also has some inherent risks associated with it. First and foremost of course, the doctor need to be very good at the skill of looking and sensing patterns. Second, there is always a good possibility that the doctors could fail to look beyond the obvious patterns and hence there is a increased risk of doctor’s tendency to close the diagnosis prematurely. Doctors are also human beings. And like any human beings there is also the risk of introduction of self-biases possibly for self-satisfaction. Unfortunately, this technique also seems to be quite prevalent in over-stressed doctors.

Hypothetico-deductive strategy -

Probabilistic Diagnosis

Probabilistic Diagnosis

Hypothetico-deductive strategy is a type of clinical reasoning model based on a combination of both cognitive science and probabilistic theory. In this strategy, for diagnosing doctors first do a restricted rule-outs i.e. possibilities or causes which they believe the patient is not suffering from. Then they start with a short list of potential hypothesis based on the available clues. This generation of hypotheses is followed by ongoing analysis of patient information in which further data/tests are collected and interpreted (typically in a cyclical manner). Continued hypothesis creation and evaluation take place as various hypotheses are confirmed or negated.

So in some sense in this technique the diagnosis moves from a generalization (multiple hypotheses) to a specific conclusion. This technique is typically used in diagnosing uncommon or rare diseases or where the doctor may not be experienced in a particular disease.

Pitfalls associated with this technique are that doctors require a very good understanding of probability theory. They should have a good knack to work out the horses vs. zebra confusion just based on hearing the hoof-beats. This technique can also turn out to be time and cost consuming.

Algorithm strategy -

Diagnosis Algorithm for Asthama in Older People

Sample Algorithm

This type of diagnosis process is based on Clinical Guidelines/Decision Rules which are typically previously very well defined. When this approach is used, doctors typically refer to the “step-by-step IF-THEN” logic or cause-effect logic well supplemented with bundles of additional supporting information to arrive at a diagnosis. Click on the thumbnail on the right to see a sample algorithm for diagnosis of asthma in older patients. Similar algorithms are available for many such diseases where plenty of historical data is available. Today tools and software are also available to assist doctors in such strategies.

While this method is typically suggested to reduce the diagnosis errors, unfortunately in reality it is estimated that this approach is used in less than 10% of the diagnosis which takes place out there.

Complete History strategy -

Permutations and Combinations

While the Hypothetico-deductive strategy described above can be categorized as ‘diagnosis by probability’, Complete History strategy is typically exhaustion-based and can be categorized as ‘diagnosis by possibility’. This is the approach where all the possibilities are assumed. Then medical facts of the patients are collected and the assumed possibilities are eliminated one by one till the time the diagnosis is reached.

This approach is typically used for diagnosing possibilities of a rare disease or possibly when usage of any of the above listed strategy has not brought in the success of correct diagnosis. In Doctor’s community – this approach is typically considered as the method of novice, impractical, and inefficient.

I would love to hear your thoughts and/or comments!

[Src - Snapshot of the sample algorithm for diagnosis of asthma in older patients is from the article - "An algorithmic approach to diagnosing asthma in older patients in general practice" by Richard E Ruffin, David H Wilson, Sarah L Appleton and Robert J Adams; published by the Medical Journal of Australia.]

Why should we care about the name of the Disease?

January 29, 2010

[In my previous blog, I had mentioned that I would be talking about various aspects of Doctor - Patient Relationship over the next few months. This blog is in line with the same.]

What is in the Disease Name? (img src - please see below)

What is in the Disease Name?
(img src - please see below)

Over the last weekend, my brother – Dr. Mukesh Rathi (as mentioned in my previous blogs – Mukesh is a practicing Gynecologist) published a blog titled “What is in the Name?“. I will encourage you all to check it out. As I had mentioned in my previous blog, I had been very curious about how patients typically get treated and also about what typically goes on in Doctor’s mind while diagnosing a patient. Mukesh and I have had several conversations on the same in the last few months. He has tried to capture some portions of those conversations in this blog. He had sent me the first copy of his thoughts a week back. My contributions to his blog has been from the proof-reading side.

Mukesh’s blog talks about an interesting aspect – which IMHO – many a times sub-consciously is considered as non-important by many of us – “why is it so important to know or derive the disease name?” The reason I say it is interesting is because – how many times ‘we‘ patients have walked out of  the doctor’s room without asking him/her – what is the name of the disease/illness which I am suffering from?

Based on lots of reading and research, I have come to the realization that almost all human ailments typically tend to have a name i. e. a disease name. These names either are a derived name from a primary classification of diseases or could be combination of multiple of disease names. The second realization (and I thought an important one too) for me was that any prescribed treatment in medical books/literature are always associated with a disease name. A very simple example – there is a prescribed treatment plan set for H1N1 (Swine Flu). So a patient possibly suffering from H1N1 would undergo the treatment associated with it only after it has been validated that he/she is suffering from H1N1. In other words – the treatment is linked to the disease name. So the key (from doctor’s perspective) here is to identify the disease name (note that there are millions of diseases out there) from the set of symptoms which the patient is exhibiting. Once the disease name is correctly identified – prescribing the treatment is easy as most of the treatments are very well documented in the medical literature. This is the gist of Mukesh’s blog.

So why is disease name identification so important – you may ask? Well, if the disease name is not correctly identified – logically the treatment which a patient might be undergoing may also be incorrect. Simple as that. Incorrect identification of the disease name to start with is the major cause of medical errors/misdiagnosis.

To get an essence of Mukesh’s thoughts from a doctor-patient relationship perspective – it might be worthwhile to consider what Federation of State Medical Boards of United States has mentioned in their model guidelines on when do they think a typical relationship between a doctor and a patient starts evolving -

“A typical physician-patient relationship tends to begin when an individual seeks assistance from a physician with a health-related matter for which the physician may provide assistance. However, the relationship is clearly established when the physician agrees to undertake diagnosis and treatment of the patient and the patient agrees, whether or not there has been a personal encounter between the physician (or other supervised health care practitioner) and patient.”

As the above guideline states – the function of diagnosis and treatment are at the core of a good Doctor-Patient relationship. And as I had mentioned in my previous blog (link above) – if we all were to understand the behavioral drivers behind these functions – it can only ultimately result in better doctor-patient relationship and communication. Hence I felt that Mukesh’s blog was highly relevant.

Deriving the name of the disease correctly as part of the diagnosis process can be tough many a times and can be prone to trial and error. Contrary to common perception that it is doctor’s responsibility to derive the name – patients also have to play a big role in this investigative process. I will be talking more about this in my future blogs.

I would welcome your thoughts and comments.

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Doctor – Patient Relationship – Peeling the Onion Layers

January 21, 2010

As I had mentioned in one of my previous blog about my interest in thinking/brainstorming on various aspects of healthcare from a consumer perspective i.e. from a Patients’s perspective. I have now started to think and understand more about ‘Doctor – Patient Relationships‘ and ‘How do patients get treated?‘. After a lot of reading/research, personal experiences, and talking/debating with many doctors including my brother – I think now I am able to come to some kind of better understanding and hypothesis in this area.

One such point of curiosity for me was to understand how do patients get treated in general. What drives a patient to a doctor? What are his/her real pain-points or drivers? I also had the curiosity from doctor’s perspective.

Doctor and Patient Relationship

Doctor and Patient Relationship (img src - National Human Genome Research Institute)

How do doctors treat a patient? What goes on in their mind from the moment they see the patient? What logic do they use to prescribe the treatment which they prescribe? Do they have a crystal ball which tells them what the patient is suffering from? Do they have cheat-sheets which they look at? Or sometimes very simply put – do they really listen to what the patients are saying? I really wanted to get into their brains! I started talking with few of my friends and soon they got curious too.

So we started reading and researching and talking with many closely associated with this profession. Very soon, we realized that this is not the area where lots have been researched about or talked about. It is just assumed that both doctors and patients act and behave in a certain way – without each party completely knowing or understanding the ‘why‘ part. For example – no two doctors have given me a coherent/similar answer on my question as to why they think many patients have difficulty in communicating or describing their health problems to them. Neither have many regular patients been logically able to tell us about why do they think doctors misdiagnose some times.  Our point was not that either party have a fault that they don’t know this. But it is that both parties (doctors and patients) have probably been operating under lots of assumptions about each other which sometimes are not the most correct ones. It just felt that there was lot of mystery in the ‘why‘ aspect of the behavior/approach of both the parties than there really should be.

The first question in our mind – should we start demystifying this? Should both the parties (again doctor and patient) make an effort to understand why the other behaves/acts in a certain manner? And our straight-forward answer for this was – absolutely! Our reasoning was that if both patients and doctors understand these aspects of behavioral drivers – it can only ultimately result in better doctor-patient communication. This would certainly result in better Doctor-Patient Relationship and hence potentially better healthcare. While all the progress and development which has been happening in the area of Healthcare-associated services and technology is a good thing – the physician-patient relationship remains (and will continue to remain) fundamental to the provision of acceptable medical care.

So over the next few weeks/months – as we are in process of exploring this aspect of doctor-patient relationship – I will be blogging about what we are learning. As has been my typical style of blogging – I am thinking about breaking these findings into several but discrete blogs. My aim is also to continue getting your thoughts and comments also on the same.

Stay tuned!

Suffering from Cyberchondria? Then you should know this -

November 18, 2009

“Chondria what? What did you say?” I can literally hear you saying! “All I had always heard was about hypochondria!”.

This week Washington Post staff writer – Carolyn Butler – posted an interesting article titled “A glut of Google can give you a virtual fever” (registration may be required to read) in which I for the first time came across this term – cyberchondria. Yes, I somehow had missed on that! Wikipedia defines cyberchondria as -

“Excessive preoccupation or worry about having a particular disease based on medical information gleaned from the Internet”

Cyberchondria - Escalation of Medical Concerns (img src - http://howtosplitanatom.com/)

Cyberchondria - Escalation of Medical Concerns (img src - howtosplitanatom.com)

Seems like this word (derived from the word hypochondria) was keyed around at the start of this decade but got into prominence after two Microsoft Researchers – Eric Horvitz and Ryen White – released this study titled – “Cyberchondria: Studies of the Escalation of Medical Concerns in Web Search” and New York Times carried a follow-up article about the same. This paper from Microsoft Research studied various patterns of web searches associated with healthcare information and found that people’s medical concerns got escalated because of the kind of results shown by the web search engines. These researchers concluded this when they saw that the online healthcare information searchers started searching for and reviewing content on serious and more rare conditions that were linked with their symptoms in the same web surfing session. The paper is an interesting read and I would recommend you all to read it. I am also capturing some of my learnings from the paper below -

  • Majority of us tend to miss out on checking key quality indicators for any online health information - As I had mentioned in my presentation about Healthcare from Consumer Perspective too, this paper also confirms that substantial number (more than 70%) of internet users search for healthcare related information on the web. However more than 75% of these searchers also fail to check for the key quality indicators such as validity and creation date of such information. (Some additional studies have pointed out that more than 70% of the healthcare content on the internet may not be of appropriate quality)
  • Online search results tend to over-exaggerate possible causes based on symptoms –  The probability of a cause for a particular symptom based on what seems to be implied from web-based search results and the probability of occurrence of the same cause in real world seem to be differing dramatically. Sounds slightly confusing? Let me simplify it. For example – as the paper points out – for a symptom such as headache if you were to search it through a search engine – you might feel that there is a 3% probability of you having a brain tumor. Whereas the actual occurrence rate for brain tumor is possibly less than 0.001%. This over-exaggeration due to coarse linkages done by the present-day search engines between the symptoms and the content tends to increase unwarranted anxiety among the web searchers.
  • Cyberchondriat’s trust in Doctors is minimalistic – Studies have shown that Cyberchondriats – assuming that they suffer from hypercondria – typically tend to express doubt and disbelief in their physician’s diagnosis and typically are not easily satisfied by their doctor’s reassurances.
  • Mapping a disease online based on symptoms is inherently flawed - Having hung around a family of doctors and seen them practicing – I personally had always been skeptical (and thought it was risky too) about the increasing number of healthcare websites which have mushroomed on the “you tell us your symptoms” and “we will tell you what you suffer from” information model. Diagnosing (will be blogging more on this in future blogs) as done by doctors requires intricate probing and building an hypothesis around the subtleties of the symptoms and various findings – along with giving enough consideration to characteristics of the patient (typically done face-to-face). This is not feasible with the web-based search. Well, atleast the ones which are available today!  Almost all of the search engine or querying mechanism today are not designed to perform coherent diagnostic or probabilistic reasoning (a key tool for medical diagnosis). Cyberchondriates need to be aware of this.
  • Individuals themselves have core biases while pursuing for online medical diagnosis - The authors of the paper point to studies in Cognitive Psychology wherein they had presented evidences that humans tend to employ heuristics or speculative approaches in determining likelihood of a particular theory when presented with large amount of possibilities. Authors believe that this tendency of human beings plays a big role in cyberchondria too. Because of this habit – human beings tend to be biased towards certain medical content – which in turn drives their assumptions of what they suffer from.
  • Lastly, there seems to be more online information on Rare Diseases than to Common ones - The authors believe that for the sake of garnering more attention (nothing wrong in that though), there is a lots of literature and online discussions devoted to rare disorders than to common ones. However, the flip side of this is that this abundance of information may lead to biasing the search engines and ultimately the online searchers towards the possibility of they getting diagnosed with a more critical or serious disease.

Personally, I have always been vary of the potential use of the abundant healthcare related information which is available freely and easily on the internet today. My challenge is not against the content part – but on the context part! How does that content or the information apply to the individual himself/herself? This article clearly alludes to my fears – that increasing amount of healthcare information on the internet while needed can also bring in side-effects too.

Thoughts and/or comments are most welcome!


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