Health & Care Review (8.25.17)
Screening for Depression on Google, Medical Drones in East Africa, Medical Marijuana evidence proves absent, and Telehealth has growing pains
Health: Depression is still under-diagnosed, under-treated, and a stigma both socially and professionally. We typically call hypertension the “silent killer” due to its long term contribution to cardiovascular disease without noticeable symptoms, but I’d add Depression (and a common risk factor, social isolation) as another killer that is silenced and suppressed far too often. People who now perform a Google search on a mobile device for “clinical depression” will see a link to the 9-question version of our most commonly used screening questionnaire (PHQ-9). I certainly welcome this effort to capture those outside of care who need it, but it’s not clear to me what happens if one screens positive (any link to further guidance, hotlines, a scheduling or telehealth platform to connect with a mental health professional?), why it’s only functional on a mobile device, and if search terms should be expanded beyond “clinical depression” alone.
Care: Medical drones from the company Zipline will be fully integrated into Tanzania’s healthcare system starting next January. In what will be the world’s largest drone delivery system, emergency supplies will be delivered on-demand in under 30 minutes throughout the country. Although the service is currently only able to perform one-way deliveries, the company intends to bring two-way service in the future (what’s really needed most). Doctors in The West are now looking to borrow this type of practice from an East African country in order to expand access to rural communities here in the US. For my techies: this is a great example of the importance of partnering with a healthcare system, government-based or otherwise, and using tech to improve rather than “disrupt” it (admittedly, not all systems are amenable to improvement the way we’d like). To the critics of tech solving real problems in healthcare: no, this is not a panacea, but enabling the delivery of emergency and urgent care where it’s practically nonexistent is a big deal. Let this develop further and be replicated many times over.
Health: A meta-analysis on Marijuana use for chronic pain and PTSD has found that evidence for its benefit is lacking. This is true, evidence is lacking, but I saw several doctors offer “I told you so” comments, as if this even comes close to confirming any of their preconceived bias suggesting weed doesn’t work. First, a meta-analysis that includes junk studies can only give you more junk (garbage in = garbage out), hence the lack of evidence. Second, Marijuana is still a Schedule 1 drug making it extremely difficult to study in any sort of rigorous, long term, prospective, and widely reproducible way. I don’t want to hear the “there’s no evidence = it doesn’t work” argument for medical MJ (or anything at that) until it’s been researched as much as Aspirin. After reading Stoned: A Doctor’s Case for Medical Marijuana , I hear voices of my professors repeating the scientific adage, “the absence of evidence is not the evidence of absence.” MJ is certainly not without risks (dependence and cognitive impairment come to mind), but we can’t come to any conclusions until high quality research is done, not reviews of observational and low quality studies to confirm what we already knew: evidence is LACKING, not conclusively negative.
Care: A 5 year telehealth study found that E-visit programs actually increased the number of in-person office visits by 6%, running counter to intended goals. The study authors add that there was minimal health benefit to such remote care programs. At the same time, we saw reports from The National Business Group on Health saying “ 56% of employers in 2018 plan to offer telehealth for behavioral health services as a covered benefit,” which is “ more than double the percentage of employers offering telehealth mental health services this year.” With respect to the study findings, I’m not surprised or discouraged by the increased number of office visits. Telehealth is relatively new and not something doctors have any formal training with, traditionally speaking. Like any new technology or model of care, there’s a learning curve in terms of best practices and use cases. Telehealth may not be for every patient or condition or complaint, and it will be important to study the variation in how doctors and patients are using it, but I would never expect it to actually improve a clinical outcome compared to a standard in-person visit. Rather, the goal is cost-effectiveness by providing the necessary quality of care without requiring a day off of work for the patient or requiring a high cost setting for something that can be dealt with remotely. As E-visits can be one tool among many interfaces with patients, which can now be augmented, honed, and targeted, don’t give up on this so soon. As Bernard Tyson (Kaiser CEO) recently said, “telehealth is going to be our future.”
Tips: STD tests online ; The FDA’s Digital Health Innovation Action Plan for entrepreneurs
Barry Breaux is a Board-certified Internal Medicine physician practicing and teaching at Stanford. His “Health & Care” posts consist of brief reactions to select pieces of healthcare news to address an understanding gap. Opinions are his own. Comments welcome, especially from fellow docs. @barry_breaux
