Low-Tech Solution to a High-Tech Problem: Virtual Mentor

Commentary by David Anthony, MD, MSc

Mr. Jones visited Dr. Green because he had developed an infection on the bottom of his right foot. Before his appointment, Mr. Jones looked up his symptoms on the Internet and found that they could be indicative of type 2 diabetes. After examining Mr. Jones, Dr. Green ordered a fasting glucose test.

LEARNING OBJECTIVEUnderstand how physicians can use the knowledge and interest that web-savvy patients bring to the clinical encounter to improve disease management and the therapeutic relationship.

The test results showed a glucose level of 250 mg/dL, which indicated that Mr. Jones did indeed have type 2 diabetes. Dr. Green informed Mr. Jones of the results by telephone and asked him to come in to discuss treatment options and lifestyle changes that would help him get control of his diabetes.

“I have read about diet and exercise options for diabetic patients on the Internet, but I don’t think that I can make that sort of change,” Mr. Jones said. “I would prefer to start on medication right away.”

During the next visit, Dr. Green agreed that if Mr. Jones was not willing to make lifestyle changes he should start medication. He wrote a prescription for metformin, a first-line treatment for type 2 diabetes. When Mr. Jones looked at it, he said to Dr. Green, “I have also researched treatments for type 2 diabetes and would prefer to have the newest and best treatment. I can’t remember the name but it is a combination of two drugs.” While Dr. Green knew that this treatment was often an effective option, he was also concerned about using a more potent and expensive treatment before he had seen the effects that metformin had on Mr. Jones’s glucose levels.

Commentary

This scenario is becoming increasingly common as more patients access web-based health information prior to and after visiting a physician. The case displays the potential advantages and pitfalls of this new dynamic in medicine. Mr. Jones’s preparations for his second visit with Dr. Green have allowed him to make an informed choice about pursuing diet (or not, in his case), which most likely abbreviated Dr. Green’s efforts. Mr. Jones was also led to ask for a medication that, in Dr. Green’s judgment, might possibly harm him. The knowledge imbalance between patients and physicians has changed, producing situations in which physicians must learn to communicate with web-savvy patients and harness the power of the most potent source of information in history [1].

In 2005, an estimated 117 million Americans searched for health information on the web, a number that has increased dramatically over the past 10 years [2]. Approximately half of these individuals report discussing the results of their web-surfing with their doctors [2]. Another study found that 80 percent of adult Internet users reported searching for information about their own health [3]. The percentage of each age group that uses the Internet to access health information decreases as age increases [4]. Such individuals also tend to be from more affluent communities and are predominantly women [4-7].

A New Dynamic in the Office

The rise of web-savvy patients alters the power dynamic in the patient-doctor relationship. In the older model of care, physicians served as unchallenged content experts who were called upon to lay out therapeutic plans for patients. Patients were expected to trust their physicians and comply with the prescribed plans. This marked asymmetry simplified communication in the office (inasmuch as it was almost uniformly one-way), but it also led to misunderstandings and paternalistic patient-doctor relationships. Even before the Internet became such a tool, physicians and researchers recognized the challenges in the uneven relationship and began to develop a more patient-centered model of care.

Patient-centered medicine aims to level the playing field in the office so that the patient and his or her caregivers have an active role in the development of a treatment plan. The movement emphasizes understanding a patient’s cultural background, lifestyle, health beliefs, and personal preferences as essential to successfully negotiating a plan. Once a patient’s concerns and beliefs are understood, a physician can find common ground with the patient and settle upon mutual goals and plans. The rise of patient-centered medicine, which grew in part out of research conducted by family physician Ian McWinney and colleagues, is detailed in Patient-Centered Medicine: Transforming the Clinical Method[8]. Physicians who maintain more patient-centered relationships gain higher levels of trust and adherence to therapy from their patients [9-11]. The Institute of Medicine now considers patient-centered care one of the six domains of quality health care.

Patients with Information

The patient-centered model of care offers Dr. Green solutions in treating Mr. Jones. Patients have always come to physicians’ offices with varying levels of knowledge of allopathic medicine. Along with cultural background, personal preferences, and prior experiences, a patient’s understanding of medical information contributes to his or her health beliefs and expectations for treatment. Before the rise of the Internet, people obtained information from their family members, colleagues, books, newspapers, magazines, and television and tended to trust these sources, despite the fact that they could be remarkably misleading. The Internet simply ups the ante by providing access to a dramatically increased amount of medical information in an easily searchable format.

Patients’ ability to become well-informed about their health conditions through the Internet has potential advantages. Greater patient understanding can close the knowledge gap between patients and physicians slightly and thus ease physicians’ efforts to achieve common ground. Particularly in cases of chronic disease such as diabetes, where successful treatment requires patients to take an active role in understanding and applying their treatment plans (e.g., diet, exercise, glucose testing), quality information can improve patients’ ability to care for themselves. Unfortunately, physicians often make the mistake of reacting negatively to an assertive, informed patient, taking it as an affront to their authority and expertise. Such responses handicap the physician’s ability to establish a connection with a patient and can inhibit trust and adherence.

Solutions

In responding to Mr. Jones’s statements, Dr. Green should seek further understanding of his patient’s beliefs, by saying, for example, “I’m interested by your comment about metformin; can you explain why you believe newer medicines are better for you?” Or asking, “What have you read that led you to say that you cannot make dietary changes?”  Dr. Green should ask Mr. Jones where he found the information on which he is basing his beliefs; blogs and Internet forums are far less reliable sources than sites devoted to patient education. Upon hearing about his patient’s beliefs, an affirming statement can help generate trust without placing undue support on those beliefs: “I can understand how reading that could lead you to say you do not want to take metformin.”

Dr. Green should then share his own beliefs with Mr. Jones, formulating his comments to respond to his patient’s specific concerns and needs. If Mr. Jones thinks he will need two medications to control his sugar because his mother is diabetic and she takes two, Dr. Green can describe the natural history of diabetes and its tendency to worsen with time. Alternately, if Mr. Jones wants the newer combination pill because “the latest advances are always better,” Dr. Green can explain his concerns about the safety record of new medications, perhaps citing the recent association of rosiglitazone (a compound in the newer drug) with incidence of heart disease in the management of diabetes. Finally, before settling upon a plan, Dr. Green can seek common ground by clarifying their shared goals, “I am impressed by your concern about your new diagnosis, and I assure you that I will strive to help you achieve excellent control of your sugar.”

The skills described above are basic communication tools that can help resolve most perceived disagreements between patients and physicians. There is one important skill, however, that is specific to working with web-savvy patients: physicians should become familiar with trustworthy web resources and be able to guide their patients’ web surfing. There are many excellent patient-education web sites. With regard to diabetes, for example, Dr. Green could direct Mr. Jones to the National Diabetes Clearinghouse for current information in English and Spanish from the National Institutes of Health.

The rise of the Internet has exponentially increased patients’ access to health information, potentially altering the patient-physician relationship by raising the level of patients’ medical knowledge (and perhaps their level of misunderstanding). While the Internet is a high-tech tool, the key to communicating with web-savvy patients is remarkably low-tech. A patient-centered approach emphasizes understanding patients’ concerns, beliefs, and goals, as well as establishing common ground in the development of a mutually understood plan. Physicians who successfully negotiate treatment plans with their patients will achieve higher levels of trust and adherence in return and increase the likelihood that patients will log onto recommended sites, further improving their understanding and treatment.

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References

1. Wald HS, Dube CE, Anthony DC. Untangling the web—the impact of Internet use on healthcare and the physician-patient relationship. Patient Edu Couns. 2007;68(3):218-224.
2. Krane D. Number of cyberchondriacs—U.S. adults who go online for health information—increases to estimated 117 million. Healthcare News. 2005;5(8):1-7. http://www.harrisinteractive.com/ news/newsletters/healthnews/HI_HealthCareNews2005Vol5_Iss08.pdf.
3. Fox S. Online health search 2006. Pew Internet & American Life Project. http://www.pewinternet.org/pdfs/PIP_Online_Health_2006.pdf. Accessed January 30, 2009.
4. Taylor H. Cyberchondriac update. 2002. http://www.harrisinteractive.com/harris_poll/index.asp?PID=299. Accessed January 30, 2009.
5. Campbell RJ, Nolfi DA. Teaching elderly adults to use the internet to access health care information: before-after study. J Med Internet Res. 2005;7(2):e19.
6. Ferguson T. Online patient-helpers and physicians working together: a new partnership for high quality health care. BMJ. 2000;321(7269):1129-1132.
7. Robinson C, Flowers CW, Alperson BL, Norris KC. Internet access and use among disadvantaged inner-city patients. JAMA. 1999;281(11):988-989.
8. Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam C, Freeman TR. Patient-Centered Medicine: Transforming the Clinical Method. Thousand Oaks, California: Sage Publications; 1995.
9. Stewart M, Brown JB, Donner A, et al. The impact of patient-centered care on outcomes. J Fam Pract. 2000;49(9):796-804.
10. Fiscella K, Meldrum S, Franks P, et al. Patient trust: is it related to patient-centered behavior of primary care physicians? Med Care. 2004;42(11):1049-1055.
11. Mauksch LB, Dugdale DC, Dodson S, Epstein R. Relationship, communication, and efficiency in the medical encounter: creating a clinical model from a literature review. Arch Intern Med. 2008;168(13):1387-1395.

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David Anthony, MD, MSc, is an assistant professor of family medicine and the director of the Family Medicine Clerkship at the Warren Alpert School of Medicine at Brown University in Providence, Rhode Island. His interests include quality of care at hospital discharge, statistics in primary care, and electronic solutions to the model family practice.

Related in VM

Type 2 Diabetes: Lifestyle Changes and Drug Treatment, March 2009

Through the Physician's Eyes: The Patient (Internet)-Physician Relationship, November 2001

AMA Supports President's Decision to Fund Stem Cell Research

For immediate release

March 9, 2009

Statement attributable to:
Joseph Heyman, MD
Board Chair, American Medical Association

"The American Medical Association supports President Obama's decision to lift the ban on federal funding of stem cell research. Stem cell research holds great promise to treat diseases that science has so far been unable to cure, and this change in policy will allow researchers to accelerate their efforts by applying for federal research funds.

"The AMA supports biomedical research on stem cells and has encouraged strong public support of federal funding for this research. Today's action by President Obama will help scientists realize the potential of stem cell research to benefit the many Americans living with diseases such as diabetes, Parkinson's and Alzheimer's."

The script for getting fit: Help your patients move off the couch

Sometimes getting patients to exercise takes more than just talk. It requires giving specific tips for starting a fitness program and sticking with it injury-free.

By Geri Aston , AMNews correspondent. Posted March 2, 2009.

By now, physicians are familiar with the push to treat patients' physical activity level like any other vital sign measured at each visit. The idea is to encourage people to exercise to improve their health status.

But talking about the importance of exercise and getting a patient to exercise are two different things. The latter can be difficult. "The biggest thing that we've recognized is that most patients hate exercise," says American Medical Association President-elect J. James Rohack, MD, a cardiologist from Bryan, Texas.

So what can doctors do to get patients off the couch? And once they do, how can physicians help patients avoid injuring themselves?

One way to motivate patients is to discuss the benefits of activity, says Robert S. Gotlin, DO, director of the orthopedics and sports rehabilitation program at Beth Israel Medical Center in New York. "There are definitive correlations with healthy living and longevity." Centers for Disease Control and Prevention data show that regular exercise can decrease the risk of cardiovascular disease, diabetes and certain cancers, while improving mental and bone health.

Once that message has sunk in, it's time to work with the patient to set goals and discuss what activities he or she likes. If the patient enjoys the exercise, he or she is more likely to stick with it, Dr. Gotlin says.

But how much exercise is enough? The Dept. of Health and Human Services in October 2008 issued its Physical Activity Guidelines for Americans. They recommend that adults get 2½ hours of moderate-intensity aerobic activity or 1¼ hours of vigorous activity weekly.

People can determine whether they're exercising hard enough by keeping tabs on their heart rates, which during moderate exercise should be 50% to 75% of their optimal maximums. The maximum heart rate can be calculated by subtracting one's age from 220. Multiplying that figure by 0.5 and by 0.75 will give the beats-per-minute range for moderate activity.

But that can be confusing, says Robert E. Sallis, MD, immediate past president of the American College of Sports Medicine and chair of Exercise is Medicine, an initiative founded by the ACSM and the AMA. An easier technique to share with patients is the sing/talk test, he says. "You should exercise at an intensity level high enough that you couldn't sing, but not so intense that you couldn't talk."

Although getting aerobic exercise to maintain cardiovascular health is the most important component of a regimen, activities that promote muscle strength also are necessary, Dr. Sallis says. HHS recommends that adults work muscle-strengthening exercises into their routine at least two days a week.

Working out for 30 minutes five times a week might seem like too much for some people. In this case, doctors can suggest that patients break it into three 10-minute bouts of activity. The benefits from these bursts are indistinguishable from those derived from a half-hour of sustained exercise, Dr. Sallis notes.

For particularly resistant patients, Dr. Rohack doesn't even talk about exercise. Instead, he promotes "quality movement." He discusses how patients can work it into their daily lives. For example, they can park farther from the store, take the stairs instead of the elevator, walk in the mall, or garden.

The HHS recommendations are a good standard to have in mind, says Brian Halpern, MD, a primary care sports medicine specialist who serves as assistant attending physician at the Hospital for Special Surgery in New York. If some patients won't buy into the five-days-a-week plan, it's OK, as long as they start doing something. "A little bit of exercise is better than none," he says. After time, the physician can try to escalate the patient's program.

Safety first

So once patients get on board with the concept of regular exercise, how can physicians help them proceed safely? One of the first issues to consider is whether a physical exam is necessary. Doctors disagree slightly on this point. Some always recommend that patients get a physical before starting an exercise program. Others say patients who see their physicians regularly and are otherwise healthy can get started without one. Doctors do agree that patients with a personal or family history of certain conditions, such as cardiovascular disease or high blood pressure, should get checked out first.

Physicians also should be on the lookout for medical red flags, Dr. Rohack says. For example, if a person in his 40s or 50s says he needs to start exercising because he's so out of shape that he gets winded easily, the physician should screen the patient for heart disease or other problems.

Doctors should go over warning signs with patients who have a known condition, Dr. Gotlin says. A patient "may be taking their blood pressure medication and thinking they're immune to anything going wrong. No. You've got to be aware of chest pain, shortness of breath, arm pain, tingling in the hand."

But having a chronic disease does not rule out exercise in most cases, and indeed physical activity helps control several conditions, such as diabetes, high blood pressure and heart disease. These patients just have to be more prepared. "If you're a diabetic, make sure you have something sweet with you," Dr. Gotlin says. "If you're an asthmatic, make sure you have your inhaler."

Osteoarthritis of the knee or hips also can complicate exercise. The easiest activity to prescribe -- walking -- can be too hard for arthritic patients. Swimming and water aerobics, which take weight off the joints, are good alternatives.

Doctors have to give special consideration to heavy patients, Dr. Rohack notes. They get hot faster, and their weight puts more stress on their joints. Water activities are a good option for these patients.

Starting at square one

Once the patient starts being active, the risk of injury is always present. Dr. Halpern frequently sees people who have hurt themselves exercising. Common problems include knee pain, arthritis flare-ups, sciatica, neck strain, tendonitis in the elbow and rotator cuff injuries.

Most often, the injured patient is someone who tried to go from zero to 60 when they first started exercising or is a weekend warrior who hasn't conditioned properly.

"Somebody says, 'I'm going to start a running program,' and they start running every day for a mile or two," Dr. Halpern says. They end up developing a stress fracture or some other type of overuse injury. "The bad part of that is it can turn a person off to exercise permanently."

For the patient starting out, the best advice is to begin slowly. Patients who decide their exercise goal is to return to a sport after years of hiatus will need help working up to a safe participation level.

Basketball is an example of a wonderful aerobic sport, Dr. Rohack says. "But if you haven't played in a while and you say, 'I'm going to go start doing the stuff I did 10 years ago,' sorry, but the body, the hand-eye coordination and the endurance isn't going to be there." The sport requires a lot of stamina, so the patient should start out walking, and work up to a fitness level at which he or she can jog for 45 minutes, he recommends.

Weekend warriors are prone to making the same mistake as exercise newbies. "On the weekend, suddenly they're going to weight lift, they're going to jog, they're going to bike, and they're not used to that high intensity," says Kevin Plancher, MD, associate clinical professor in orthopedic surgery at Albert Einstein College of Medicine in New York. These patients, too, need to condition properly to avoid injury.

People also get hurt when they haven't warmed up before exercise, Dr. Rohack says. He advises patients to do simple stretching for a couple of minutes to get the blood flowing and the joints limber.

Another valuable bit of counsel doctors can give patients is to cross train to avoid overuse injuries. "Don't put all your eggs in one basket," Dr. Gotlin says. Patients should vary their activities so that different muscle groups are targeted on different days.

Dangers lurk at the gym, too. The most common mistake is improper use of weights. Some people lift heavy weights and do few repetitions, Dr. Plancher says, when they should be using lighter weights and doing more repetitions. People also use bad form. When lifting weights on a machine, patients' hands should be in their peripheral vision to avoid shoulder injury, he says.

Leg extensions are another frequent misstep because they put too much strain on the patella tendon, Dr. Plancher cautions. People also err by doing deep squats and knee bends instead of simply doing one-third squats and bends, which are safer and work the quadriceps just as well.

At the gym, patients also should take the same precautions to avoid catching communicable diseases -- from coughs and colds to methicillin-resistant Staphylococcus aureus -- as they use everywhere else. People should wipe equipment with an alcohol-based product before using it, wash their hands after working out, and avoid touching their eyes or mouth, Dr. Halpern says.

How a person exercises isn't the only factor in injury prevention. Personal equipment is important as well. For most people, all that's required is a pair of good shoes with ample arch support and padding. This is especially important for patients with plantar fasciitis or arthritis, doctors say. Patients with orthopedic problems might need a referral to a specialist to make sure they have the right shoes and inserts. Other advice is common sense -- wear a helmet when cycling and layer clothing in cold weather.

Once patients are active, doctors may want to check periodically on their progress. The conversation could alert the physician to a problem resulting from exercise, says Matthew J. Matava, MD, associate professor of orthopedic surgery at Washington University School of Medicine in St. Louis. Asking a patient how his or her golf game is going could lead to a discussion about how the patient has back pain on the course, he says.

Some physicians might not be comfortable taking on exercise counseling in the first place, Dr. Rohack notes. For these doctors, referrals are always an option. Most communities have choices -- exercise physiologists, physical therapists or athletic trainers. In this circumstance, the doctor can make a "fitness prescription," noting any underlying conditions or necessary limitations, and let the exercise professional develop the program.

Patient-Physician Relationships: Gone or Evolving?

Encounters between individuals are as an essential part of medicine as they are of life. The cases in this issue of Virtual Mentor describe challenging encounters in clinical medicine, and their commentaries share an emphasis on the importance of communication between a patient and physician. The articles that fill out the issue explain the importance of the patient-physician relationship and the factors that are shaping it, examine connections between poor communication and risk of litigation, recount an unlikely situation in which a relationship between a “frequent flyer” and physician developed, and introduce a program designed to help medical students build relationships with patients. Patient-physician relationships, as well as encounters between professionals, are often difficult, complicated by both internal and external factors. Yet there are ways that we, as physicians, residents, and medical students, can improve our ability to develop and nurture these relationships.

In the first case, a web-savvy patient researches his symptoms and treatment options on the Internet and relays what he thinks his treatment should be to the physician. David Anthony describes how the rise of accessible medical web resources has slightly changed the patient-physician balance of information in a way some physicians view as a challenge to their authority and expertise. But, he suggests, physicians can use the knowledge of their patients to improve patient care and develop patient-centered relationships that further enhance shared decision making. He also challenges physicians to become familiar with trustworthy web resources so they can guide their patients to reliable online sources.

The physician in case two is contemplating whether or not to offer participation in a phase I trial to the parents of a teenager who has aggressive terminal cancer. Thomas W. LeBlanc and Philip M. Rosoff explain how the mere offer of trial participation can create a therapeutic misconception in the patient and his parents—to the extent that they believe the trial has a real chance of providing therapeutic benefit, when in reality the chance of benefit is virtually nonexistent. The commentators examine the physician’s duty to act in the patient’s best interest versus his or her duty to inform patients of all options and the broader topic of the importance of phase I oncology trials for the advancement of medicine. In their commentary, Courtenay R. Bruce and Anne Lederman Flamm focus on the duty of physicians to inform patients and allow for autonomous decisions. While they acknowledge the reality of the therapeutic misconception, they argue that full disclosure in the informed-consent process provides patients (and parents, in this case) with the information they need to make a decision, thereby respecting their autonomy. They also discuss the concept of assent in situations in which the patient is not legally competent to give consent.

The third case presents a mother who takes her 4-year-old daughter to several pediatricians, and ultimately settles on one who is willing to prescribe antibiotics for her daughter. The case also includes a disagreement between two physicians in the same office over the child’s treatment. D. Micah Hester views the case as a series of missed opportunities for good communication, not only between the physician and the parent, but also between the two physicians who treat the child. Benjamin Levi speaks to miscommunication in the scenario, but also comments on problematic aspects of the second physician’s clinical judgment in prescribing treatment that was not medically indicated.

In the clinical pearl, Natalie A. Brooks outlines management strategies for type 2 diabetes, the chronic condition that is the basis for the first clinical case. She emphasizes that treatment decisions must be tailored to individual patients.

One question that is central to this issue is whether or not a good patient-physician relationship even matters. In the journal discussion, Scott B. Grant addresses the questions not only of whether or not the patient-physician relationship is important, but what factors improve or stress it. He explains and critiques two models that the journal article authors propose as blueprints for a good relationship.

Kelly Dineen tells a compelling story in the policy forum of the importance of professional caregivers’ adherence to their scope of practice. In the new model of comprehensive patient care, physicians alone cannot meet the full range of the patients’ medical and health-promotion needs, and because of this, physician assistants and advanced practice registered nurses are included in health care delivery. She identifies physicians’ responsibilities for overseeing and collaborating with them.

In the medicine and society article, Howard A. Brody describes two forces that are shaping the patient-physician relationship: the medical home and pay-for-performance. He argues that, while the idea of the medical home threatens the one-on-one nature of the traditional patient-physician relationship, it broadens and enhances the relationship in ways that are, on balance, more significant. On the other hand, he believes that pay-for-performance will not improve relationships between patients and physicians and recommends approaching this concept with wariness. As technology progresses, physicians have the ability to treat patients more competently. These advances do not necessarily have to replace the relationships between patients and physicians that are the core of medical practice.

At a time when many physicians are lamenting changes in medicine that have significantly diminished their ability to develop relationships with patients (e.g., increased amounts of paperwork, shorter office visits), Chris Brooks relates the story of patient-physician relationships in an unlikely setting—the emergency room. He describes a “frequent flyer” patient who visited the emergency room on an almost daily basis and developed relationships with staff members that allowed them to care for him more compassionately and in a resource-conscious way.

As medicine has become more technical, medical education has increasingly focused on the knowledge of disease processes, often squeezing out time for considering the important relationships between patients and physicians. In light of this, some medical schools have attempted to renew the emphasis on relationships in medicine. Arno K. Kumagai discusses the 2-year Family Centered Experience at the University of Michigan, which pairs medical students with community members who have chronic or serious diseases. He describes the goals, benefits, and challenges of this program.

Kristin E. Schleiter, in the health law piece, explores the subject of medical malpractice litigation. According to documented studies, patients who have good relationships with their physicians are less likely to file complaints in the event of an adverse medical outcome.

Relationships in medicine are as important now as they were in the past. Today’s technology allows physicians to do much more to treat diseases, but this enhanced ability need not replace physicians’ communication and ability to empathize with patients. In other words, the ability to treat the disease must not undermine the ability to treat the patient with the disease. As the articles in this issue demonstrate, relationships are still, and will continue to be, an essential element of medicine. With so many factors competing for the physician’s time and energy, we must not lose sight of the importance of communication, empathy, and knowledge of the patient as a person.

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Anji WallMD/PhD studentSaint Louis University

Calif. court denies extra MCAT time for students with learning disabilities

Recent amendments to the Americans with Disabilities Act may help address some concerns at issue in the case.

By Amy Lynn Sorrel, AMNews staff. Posted March 2, 2009.

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In California, aspiring medical school students with learning disabilities lost their bid to get extra time or other accommodations when taking the Medical College Admission Test.

The state Supreme Court in February declined to review the case. The decision leaves intact an appeals court ruling that California's disability and antidiscrimination laws do not require the Assn. of American Medical Colleges to grant special treatment to candidates diagnosed with dyslexia, attention-deficit/hyperactivity disorder or other learning disabilities.

Four applicants diagnosed with reading-related or other learning disorders sued the association in a class-action lawsuit in 2004 after their requests for more time and a private room to take the MCAT were denied. In evaluating the petitions, the AAMC, which administers the test, relied on a narrower definition of disability under the federal Americans with Disabilities Act. But the students had argued that broader state standards should apply.

The 1st District Court of Appeal disagreed in an October 2008 opinion, saying that such accommodations were required only to the extent that they met the federal standard. There were no allegations that the AAMC failed to comply with the ADA, court records show.

"This is just one case in a larger struggle," said the students' lawyer, Joshua Konecky. "The goal at the end of all this is to make sure people with dyslexia or other learning disabilities are evaluated on the merits of their individual record, without the suspicion they are taking advantage of the system and with the understanding they do need accommodations for exams to be a fair measure of their knowledge and skills."

Defining disability

Despite the setback, Konecky noted that amendments to the ADA passed last year provide a wider definition of disability. That likely will make it more difficult for testing organizations to deny students with learning disabilities requests for reasonable accommodations, he said.

The AAMC is reviewing the amendments, which may affect some cases, said the organization's attorney, Robert A. Burgoyne. Nevertheless, the California high court's decision helps ensure the integrity of the nationwide MCAT.

"This leaves in place the AAMC's ability to have a single, uniform policy for handling accommodation requests, regardless of the state in which the examinee is located. It's about fairness to the examinees," Burgoyne said.

The AAMC continues to evaluate requests for assistance based on documentation of a cognitive impairment and whether it substantially limits a student's test-taking ability, he said. The organization may allow for additional time or a separate room, and it flags test scores to notify medical schools of any special circumstances.

Three of the four plaintiffs in the case since have gone to medical school, Konecky said. According to court records, two of the students who sued were allowed to take the MCAT with the accommodations they requested, after submitting additional documentation of their disabilities. The two other plaintiffs took the test without extra help, scoring in the 90th to 92nd and 69th to 74th percentiles.

Recession, Medicare cuts not enough to stop skyrocketing health spending growth

President Obama holds a budget summit and calls rising health care costs the "single most pressing fiscal challenge" faced by the nation.

By Doug Trapp, AMNews staff. Posted March 2, 2009.

Washington -- Although a projected 21% cut to Medicare physician pay and the downturn in the economy are poised to restrain national health spending growth in 2010, overall health spending is still expected to nearly double between 2009 and 2018, reaching $4.4 trillion.

The spending projections, from the Centers for Medicare & Medicaid Services Office of the Actuary, were published online by the journalHealth Affairs on Feb. 24. The actuaries estimated that next year's Medicare physician fee cut required by law would help hold national health spending growth to only 4.6% in 2010. But if Congress averts the cuts, as it has every year since 2002, national spending would grow by 5.4%, about the same rate as expected in 2009.

The report provides more evidence that Medicare's pay formula needs to be reformed, because it casts doubt on both physicians' pay and overall health spending projections, said American Medical Association President-elect J. James Rohack, MD. "It's clear that to achieve the goal of health system and Medicare reform, we must address rising health care costs, but we must have realistic forecasts of what those costs are going to be."

The economic recession is shifting health care costs from the private to the public sector, the report said. Growing unemployment and the resulting loss of private health coverage is expected to decelerate private health spending growth to 3.9% in 2009, its lowest increase in 15 years. Similar trends are expected for prescription drug and hospital spending.

Public spending, on the other hand, is expected to increase by 7.4% in 2009, due largely to higher enrollment in Medicaid. That projection does not include the effect of the recent expansion of the Children's Health Insurance Program and the $787 billion stimulus package, which included about $150 billion in health spending.

Public spending accounted for 46% of total national health spending in 2007.

But even with Medicare fee cuts and the recession, CMS anticipates that annual growth in national health care spending will start creeping up again starting in 2011. The rate is expected to exceed 7.0% by 2018, in part because baby boomers will move from private coverage to Medicare. That estimate assumes an economic recovery beginning in 2010.

Spending growth on physicians and clinical services is expected to slow from 6.0% in 2009 to 5.0% in 2010 should Congress avert the Medicare pay cuts, the report said. If lawmakers allow the cuts to go through, growth would slow to 2.3%. Under either scenario, a healthier economy is expected to return spending growth on physicians to a more historical rate of about 6.0% by the end of the decade.

Higher enrollment in Medicare, which on the whole offers lower pay than private coverage, will partially hold down physician spending growth. But a shortage of primary care physicians and registered nurses will counteract this trend by boosting doctors' and nurses' wages. In addition, a series of positive Medicare physician updates is scheduled to begin in 2014 under current law, said Andrea Sisko, a report co-author and an economist in CMS' Office of the Actuary.

Public health spending is expected to overtake private spending by 2016, largely from growth in public programs due to an aging population. In 2007, public spending accounted for 46.2% of total national health spending.

The ongoing recession looms large in the debate over long-term national health system reform, Sisko said. "Policymakers and the public will be faced with tough decisions regarding the future of the health care system."

The recession is not expected to affect Medicare spending dramatically in the short term, said Christopher Truffer, a CMS actuary and report co-author. But the shrinking economy could hasten the insolvency of the Medicare Part A trust fund -- which covers hospital, home health, skilled nursing and other care -- by reducing payroll tax revenues that support the fund. Previous CMS estimates said the fund would run into a deficit in 2019, but now that could happen as early as 2016, said CMS chief actuary Rick Foster.

An unhealthy debt

President Obama said health reform figures prominently in his economic agenda. "Over the longer run, putting America on a sustainable fiscal course will require addressing health care."

Obama made that remark on Feb. 23, when he convened a group of more than 100 policymakers -- administration officials, congressional leaders and a variety of stakeholders -- at the White House to begin discussing how to tackle the country's $12 trillion national debt and ongoing annual $1.3 trillion budget deficit. Obama said the country spends $250 billion a year in payments on the national debt -- about one of every 10 taxpayer dollars. That doesn't include the trillions obligated in future years to Medicare, Medicaid and Social Security.

The recession is shifting health care costs from the private to the public sector.

Although Obama approved the stimulus package, which helped increase the national debt, he opened the forum by pledging to cut the $1.3 trillion budget deficit in half by the end of his first term. "We cannot simply spend as we please and defer the consequences to the next budget, the next administration or the next generation."

Participants -- including AMA President Nancy H. Nielsen, MD, PhD -- broke into five groups chaired by White House staff to discuss health care, Social Security, the federal budget process, tax reform and the federal purchasing process.

According to press pool reports of the event, Dr. Nielsen said any savings from reform should be reinvested in the health system. She worried about the conflicting needs for investing in health care and for adopting federal budgets without running up deficit spending.

Dr. Nielsen also said the nation needs to reach consensus on whether health care is a right, a responsibility or a privilege. "We cannot pay for everything for everyone. We really have to have together a societal discussion. What is an individual's responsibility for their health, the choices they make, do they exercise, smoke?"

Although the participants appeared to agree that the health system must be reformed, the event was more notable for bringing key leaders together to talk, said AARP CEO Bill Novelli. "I went away feeling that it was a productive afternoon and that we have momentum here in terms of health care reform."

Obama said at the conclusion of the forum that dialogue will continue. "We need to build off this afternoon's conversation and work together to forge a consensus."

AMA Applauds Obama's Commitment to Health System Reform

Response to President Obama’s address to U.S. Congress

For immediate release:
Feb. 25, 2009

Statement Attributable to:
Nancy H. Nielsen, MD
President, American Medical Association

“America’s patients and physicians want meaningful progress on health system reform this year, and the American Medical Association applauds President Obama’s commitment to achieving that goal. 

“In these tough economic times, the need for health system reform that provides coverage and high quality, affordable health care for all Americans has never been more clear. We must strengthen the public-private mix of health insurance, and achieve greater value from the nation’s health care spending. President Obama’s call for greater investments in research, preventive care and electronic health records will help physicians keep patients healthy.  

“We pledge to work with President Obama and Congress to improve the health care system for all Americans.”