When I first sat down at a robotic surgery control console, little did I know how much this endeavor would impact my daily routine. I recall saying to my surgical team that I never would have imagined operating on a patient with such a device. Now, ten years later, I cannot imagine life without this technology.
So what was life like back then? The infancy of robotic technology was fraught with unknowns and detractors. Fortunately, extensive prior laparoscopic experience (a rarity for a urologist back then) and the possibility of better clinical outcomes were the driving forces that led us to where we are today. As difficult as those early years were, I would not trade that experience for anything.
I recently spoke to our first robotic prostate removal patient. Over the last ten years, he has enjoyed an undetectable PSA blood test, indicating total eradication of his prostate cancer. Furthermore, he has normal urinary and sexual function.
I am proud of the outcome resulting from the first robotic prostate removal performed in Georgia. As robotic technology continues to advance, I strive to make each procedure better than the last. Experience is a journey – not an ownership.
– Dr. Scott Miller
Dr. Scott Miller has been a regular guest and host of our program since its inception. Dr. Miller helps The Weekly Check-Up with Dr. Bruce Feinberg bring together guests from various healthcare fields, interviews with health and fitness experts, and provide tips to help listeners lead better, healthier lives. Scott D. Miller, MD practices at Georgia Urology, the largest urology practice in Atlanta and the Southeast. He is widely recognized as a pioneer in the field of laparoscopic and robotic surgery techniques.
Recently, a large review of the evidence regarding the healthiness of organic food was published. In previous posts I talked about how the study’s authors felt that there was not evidence to support eating organic, but the results were complex and often contradictory so a more nuanced look was warranted. In this post I will answer this: So what is there to make of this mess?
The real question we want answered – are people who eat organic healthier – has not been adequately addressed. The best way truly convince a room full of doctors that there is a health benefit to something, be it a medicine, surgery or a diet, is a randomized control trial. That is when you take a group of volunteers, give half of them organic food and the other half conventional food and see how their health changes by comparing the two groups. Obviously, this would be extremely expensive and you would need tons of people for many years to get truly convincing results. It is very unlikely that that study would ever be done, so there will likely always be a controversy.
There are some suggestions of health benefits but they are weak and hard to support buying organic food that is often 2x more expensive for only health reasons. I personally believe the reduced environmental impact and taste alone make organic foods preferable. Have you ever compared the bland, pulpy factory farmed tomato to its flavorful, deliciously juicy organically grown heirloom tomato cousin? It’s hard to believe they are considered the same fruit!
One other thing that is important to keep in mind is that from a healthy eating perspective, it’s more important for your health to eat a good mix of foods in reasonable portions than to keep organic. In other words, it is unhealthy if you eat burgers everyday, whether it’s fast food or Kobe beef.
Until a large clinical trail gets started to study if there is a benefit of eating organic, we have to trust our gut. Are you a person that can afford to eat organic and you get the willies thinking about the tiny risk of pesticides and drug resistant bacteria in your food? Do you think organic tastes better? Do you want to expose the environment to less chemicals? If you are a resounding yes to those questions then organic is the way to go. Is it hard for you to pay the extra money, or does the added expense makes buying vegetables a burden? Are you are not too convinced about the taste? Then do not feel guilty for not getting organic – you are not hurting you or your family’s health. There are numerous reasons to go organic, but as far as medical science can tell, your health is not one of them.
Dr. Bruce Feinberg
Last post I discussed the massive review recently published examining the available evidence for a health benefit from organic food. While the authors concluded that there was no evidence to support eating organic for health reasons, the actual results deserve a bit more analysis.
The review found the only nutrient that was more abundant in organic food compared to it’s conventional counterpart was Phosphorus, a widely available nutrient that is only deficient during starvation. There was also a significant but only slightly higher amount of Omega-3 fatty acids in organic foods. While this seems a definite positive health benefit, the results of the studies reviewed were contradictory and the differences were not very large.
There was also a 30% higher chance of there being pesticides detected in non-organic food and the levels of pesticide residue in children’s urine did decrease slightly after switching to an organic diet. These results seem like a slam dunk benefit but studies in adults failed to find similar results. There did not seem to be much of a difference in how often pesticide levels were above the maximum legal limit between organic and conventional food. The low levels of pesticides do not appear to have any health impact, but long term studies are difficult and expensive so there could be subtle effects that have not been discovered. There was no difference in the amount of bacterial contamination in meat. In some seasons, for some bacteria, organic meat actually has more contamination, but there was less antibiotic resistant germs in organic meats.
Few studies have tried to answer the direct question: are people who eat organic food healthier? In the handful of small and poorly designed studies that did ask the question, none found any difference between folks that ate organic and those who didn’t. Because food and metabolism are so complicated, varied, and not entirely understood, the effects of what we do know about organic food on human health remains unclear. Check back soon where I will divulge what I make of the study.
Dr. Bruce Feinberg
The past decade has seen an explosion in the popularity of Organic food, that is, food produce d with no synthetic fertilizers, pesticides, hormones, genetic modification or antibiotics. Animals used to pr odu ce organic food typically can move around, have access to direct sunlight and eat organically produced feed. In an era where food production is done on an industrial scale that looks more like a factory than a garden, its no surprise that this new trend is so popular. There are numerous clear benefits of organic food, many say it tastes better and that it has less of an environmental impact. Another commonly stated reason to go organic are the supposed health benefits. A review of the available evidence of the health benefits of organic food was recently published in a major medical journal, The Annals of Internal Medicine. This review is massive, covering 22 pages of small text. This review only addresses the health related reasons to go organic. There is no mention of the ecological benefits of reduced pesticides, antibiotics, chemicals, lack of genetically modified organisms or the improved taste of organic food. While the review’s authors conclude that there is not much evidence to support a health benefit, a closer look at the results show that the real answer is a bit more nuanced.
The review was very complicated and looked a thousands of other people’s research studies and tried to come to conclusions based on all of them. The studies examined were very diverse, often contradictory, and many were asking different questions using different methods. This made the results of each study hard to compare to each other and is a major weakness of the review. There is lots of variability in the nutrient contents of foods based on location, breed and season which makes organic and conventional foods hard to compare. Another weakness was that most of the studies were looking at level of contamination, or chemicals or nutrients in food, but very few actually studied how people’s health changed when they ate organic. Despite these weaknesses, some conclusions seem likely based on trends in the data. Check back here soon when I will go over the findings of this comprehensive review.
In my previous post I explained why Clinical Decision Support Systems (CDSS) represent an exciting way to help a doctor stay current and keep the numerous and easy to forget details often required to take care of patients straight. These CDSSs are often built in to the electronic medical record computer program and have generated buzz, especially because of evidence that similar tools, checklists, have reduced some serious complications in certain settings.
A recent meta-analysis (a type study that looks at many of the studies on a particular subject and makes conclusions based on compiled data) looked at 148 previous studies that examined various outcomes from using a CDSS. They found that institutional goals, for example making sure patients with heart failure got on the correct medication or hospitalized patients got adequate preventative measures for blood clots, did improve. Unfortunately, they did not find any reduction in cost, or bad outcomes, such as death and disability.
This is a mix of good and bad news. The good news is that it is possible to change physician behavior using health information technology in a directed way. If specific enough, it is possible to alter what doctors do in a potentially beneficial way. Unfortunately we have not been making the right things change. Despite the effort and expense of adding a CDSS, costs remain high and the main things healthcare tries to prevent – rates of death and disability – does not seem to change.
This study is not a deathblow to CDSSs by any means; it just means they need some tweaking. Electronic medical records and other health information technology is expensive and complicated and this study shows just how complicated it is. Just because something seems like it will make an improvement does not mean it will. Just as with a new medication, new healthcare information technology needs to be studied and reworked and fiddled with for a long time before it’s full potential can be reached.
Dr. Bruce Feinberg
Last post, I had discussed the standardization and adoption of electronic medical records in the Affordable Care Act (ACA), the huge healthcare reform law that was just declared constitutional by the Supreme Court. One of the benefits of an electronic medical record that most non-medical people do not know about are referred to as Clinical Decision Support Systems (CDSS). These are computer programs built into the medical record computer program that aid physicians in making decision on how to manage care.
Some of these CDSSs remind doctors to prescribe certain medications or certain doses for common medical conditions, enroll them in preventative healthcare or other important but easy to forget things. Some CDSSs provide summarized medical literature that is updated regularly to keep doctors informed and others provide relevant patient information to the doctor automatically. These CDSSs have lots of promise and can, in theory, make keeping up with all of the information a doctor has to know much simpler and allow them to focus on taking care of the patient.
As medical science has become more and more advanced, the body of knowledge required to be a doctor has increased as well. At the current rate of growth, the amount of information a medical student has to learn in medical school just to be a doctor in training, or resident, doubles every 8 to 10 years. One way that medicine has dealt with this is by having doctors be increasingly specialized, but even this solution is not sufficient. Doctors have to engage in life long learning to stay on top of all the new developments and discoveries and CDSSs represent a way to help doctors stay current.
In the past medicine was simple enough to be managed by a bright doctor with a few years experience under his belt. Now, with so many complex treatment and diagnostic options each requiring numerous steps that change all of the time, no human can be expected to keep every thing straight and done correctly. Even the best doctor will forget a small step or have an oversight and potentially cause harm to their patient. There have been suggestions that doctors begin using checklists, much like pilots do, especially in complex and error prone situations such as in the Intensive Care Unit or in surgery. There have been very promising results from initial studies looking at the use of checklists. Infections originating from central lines, the tubes that bring medication to the large veins near the heart, are a common complication that can be all but eliminated using these checklists. Similar results have come from the use of checklists in preventing pneumonia from the ventilator and making sure pain is well controlled. Checklists are slowly catching on and could be a way to reduce healthcare spending.
With such a benefit from a simple checklist, it is no wonder that CDSS are seen as another way to help doctors stay current, well informed and armed with the correct information in the face of increasing medical knowledge. But just as a new medication, diagnostic test and even checklist must be studied to prove that it is effective, the CDSSs have also been studied. Check back soon for what researchers looking at all of these studies concluded and what that means for CDSSs.
Dr. Bruce Feinberg
The Affordable Care Act (ACA) has been deemed constitutional and is poised to make sweeping changes in the way health insurance is regulated and healthcare is paid for. One of the major long-term issues with healthcare that the ACA is trying to address is the rapid and unsustainable increase in the cost of healthcare. While the ACA primarily seeks to ensure wider access to healthcare, it does have many provisions to reduce cost.
One such provision is expanding the use of electronic health records and other health care information technologies in slowing the drastic rise in healthcare costs. This seems like a no-brainer. Despite being one of the largest and most technologically advanced industries in the country, much of the record keeping in healthcare is still handwritten horribly by rushed doctors. The benefits of an electronic medical record (EMR), and the corresponding computerized physician order entry (CPOE) system used to communicate physician orders to the pharmacy, nurses and other healthcare providers go beyond correcting the notoriously bad penmanship of physicians.
The ACA will begin enacting regulations in October that standardize much of the billing and health records, allowing for easy, yet secure, transferability and access. Currently, if a doctor wants to obtain records from another office or hospital, the patient has to fill out a form, and then the form then has to be faxed to the institution that has the desired records. Then the records must be faxed back to the requesting doctor. The records are often not the ones requested, the quality of the fax can be poor, and the time it takes for the records to be sent can be long. This inefficient system often leads to the unnecessary repeating of tests because it can be quicker and easier to get results by performing the test again. This ends up driving the cost of care up.
In addition to increasing the efficiency of medical record sharing, many EMRs have built in clinical decision support systems (CDSS). CDSSs are a group of programs that provide information to the physician that help them make better decisions when managing a patient’s care. There are several types of these CDSSs and they have been generating lots of buzz in certain parts of the medical community.
Check back soon, in my next post I will discuss CDSSs in more detail and talk about the buzz they are generating.
My way of thinking has challenged by so much of the recent news cycle, from the contraception debate, and new data that shows more children are born to single parents than couples (a first).
I believe as a nation and civil society we share certain core values. One of those core values is the aspiration that every child is conceived by intention to loving parents who have the physical, financial, and emotional means to nurture them with a set of values that will allow them to become psychologically well-adjusted adults who make meaningful contributions to society.
Unfortunately, our reality today is very different from that aspiration and by not focusing on it, the discussion degrades into nonsense rather than, as a civil society, how we can achieve our aspirations. What is your opinion?
Dr. Bruce Feinberg
Whether we consider healthcare a privilege or a right, healthcare in this country is available to all except that some of us pay for it in insurance premiums and taxes while some only in taxes and some not at all. As the baby boomers age and medical advances make once life threatening diseases chronic the healthcare economy has doubled in just one generation from 10% of the economy to soon being 20%. With that increase in cost the average premium for a family of four has more than doubled in <10 years and now eclipses $20,000; at the current pace the cost will eclipse avg income in ten years. Had the personal mandate been ruled unconstitutional and given that the single payer solution was a politically unacceptable alternative then we would have been back to square one with unaffordable premiums, cost to businesses that make them unable to compete in a global economy, 50 million uninsured Americans seeking expensive emergency care that we all pay for and defacto rationing through policies like pre-exisiting illness denials, annual caps, lifetime caps, prior authorizations, etc.
It’s time to get serious and stop deluding ourselves that there are simple solutions.
My daughter is debating vaccinations for her kids because of the autism side effect controversy. I am wary myself, because I think pharmaceutical companies would hide any research done about autism as a side effect. I’m writing to see if you know a pediatrician that is like you – on top of the game and has a plan to minimize risk of autism from vaccines. I want to find someone that grasps this…
- A Concerned Grandpa
Dear Concerned Grandpa,
I rarely speak so candidly but I will on this subject since I feel so strongly about it. THERE IS NO CONTROVERSY! THERE IS NO RISK OF AUTISM!
Check the CDC website or the American Academy of Pediatrics. The real issue way back when wasn’t even the vaccines themselves but the mercury containing preservative Thimerosal.
Most of us are not old enough to have witnessed first-hand the devastation of small pox, polio and measles but it’s worth doing a bit of reading to understand how catastrophic these illnesses were. Vaccine programs only work if populations are uniformly treated otherwise the virus persists, mutates and continues to wreak havoc.
The anti-vaccine movement is NOT founded upon science and is supported with cult-like fanaticism mostly by those looking for conspiracies to assuage misplaced unresolved guilt for a spectrum of diseases that remain poorly understood and tragic in their impact on affected children and their families. Please, please, please don’t let your daughter be misled by the zealots, and vaccinate your grandkids!
Dr. Bruce Feinberg