Diagnose Cancer with Flash of a Light!

Traditionally, cancer is diagnosed by a surgical biopsy with pathology results taking days later. Supportive evidence for a cancer is also determined based on visualizing the lesion as well as radiological studies (CT, MRI, Ultrasound, etc).

However, there is a very exciting breakthrough technology that may be able to make a cancer determination under 1 second with only a flash of a light... meaning no biopsy with associated pain and scar to go along with it.

Called Verisante Aura, a probe emits a light that non-invasively analyzes a lesion by scanning 21 different cancer biomarkers at the cellular level using Raman spectroscopy.

Raman spectroscopy (RS) is a technology that involves shining a laser onto a material and interpreting the reflected light to learn more about its biochemical composition.  Healthy cells have a different reflected light "fingerprint" compared with diseased cells. Although this technology won the Nobel Prize in 1930, such RS units used to be huge and complicated machinery to operate. Fortunately, only recently has RS units been miniaturized and made robust enough to be idiot-proof to operate by Canadian researchers.

How accurate is it?

It has up to 99% accuracy leading to potential reduction in unnecessary biopsies by 50 to 100 per cent [link]. Given each scan is under 1 second, a complete body scan can also be accomplished in a single office visit. However, in order to obtain sensitivities between 95% and 99%, the specificities did range between 15% and 54% which is comparable to clinical examination and other optical-based methods.

The one caveat is that the probe needs to be able to shine a light directly on the suspicious lesion... meaning it is applicable only for lesions found on the skin and body cavities (mouth, colon, esophagus, etc)... not lesions under the skin (like a thyroid nodule). The lesion also needs to be larger than 3.5mm in size.

With such instant diagnostic accuracy, it would not only revolutionize in the diagnosis of cancer, but also in treatment! The big question mark for any surgeon is "did you get all the cancer out"? Well, with this probe, one could just scan the wound bed after excising the cancer and see if there's any residual cancer left behind that needs to be removed further. In essence, every surgeon can now perform a Mohs-like resection instantly and without need for pathology assistance with frozen sections.

Verisante Aura is currently approved for use in Canada, Europe, and Australia... but not yet available in the USA pending FDA approval.

Source:
Simply Amazing! Instantly Diagnose Melanoma with the Flash of a Light. Forbes 3/14/13

Reference:
Real-time Raman spectroscopy for in vivo skin cancer diagnosis. Cancer Res. 2012 May 15;72(10):2491-500. doi: 10.1158/0008-5472.CAN-11-4061. Epub 2012 Mar 20.

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Forbes Critical of Patient Satisfaction Ratings of Physicians

Forbes on January 2, 2013 published a story critical of Press Gainey and other companies that obtain patient satisfaction scores.

Please note that the following is a reprint of prior blog articles (2/19/12 and 6/8/12) written on this subject by Fauquier ENT.

Indeed, much has been made about improving patient satisfaction in the healthcare industry in the belief that greater patient satisfaction equates with better health. To this end, patients are routinely asked to complete a survey based on their impressions on the care they received at a medical office, hospital, and/or emergency room.

BUT... does greater patient satisfaction actually result in or is the result of better care???

According to a recent study... higher patient satisfaction actually resulted in:

• Greater inpatient hospitalization
• Higher overall healthcare utilization
• Higher prescription usage
• INCREASED RISK OF DEATH!

The one and only measured benefit of higher patient satisfaction scores was decreased ER use.

Why would there be an increased risk of death with higher patient satisfaction scores?

Well, if a doctor always does what the patient wants, that would tend to lead towards higher patient satisfaction... EVEN if it's the wrong thing to do.

For example... when a patient sees a doctor for a perceived sinus infection, it is not uncommon for a patient to expect to leave with an antibiotic.

Unfortunately, many sinus infections are actually viral URI for which antibiotics is the WRONG course of action.

Inappropriate antibiotics lead to drug-resistant infections which lead to deaths.

However, if a doctor resists a patient's desire for an antibiotic, that would lead to a decrease in patient satisfaction.

Such medical decisions do not apply to just antibiotics, but also tests, procedures, and hospital admissions.

This example and others may oversimplify a very complex issue, but it does suggest that one interpretation of higher patient satisfaction scores are that doctors and hospital systems may choose to do the wrong thing in order to get a better score.

And that gets into the problems with how the surveys are obtained in the first place...

The Problem With Surveys

What if I told you 100% patient satisfaction scores were due to a survey of only two people... that I personally picked?

Welcome to the big bad world of patient satisfaction scores.

Often (well... pretty much all the time), I come across an article, bulletin posting, or meeting where patient satisfaction scores are announced... but no background information to back it up. HOW many people completed the survey? HOW were the people selected? WHO administered the survey?

HOW many people completed the survey?

The number of patients who actually completed the survey is very important. Mainly, because of the variance that may occur month-to-month as well as ease in manipulating the results.

Let's assume only TWO people completed the survey. The first month, both give me a thumbs up giving me a score of 100%.

However, the following month, another TWO people completed the survey, but only one gave me a thumbs up giving me a score of 50%.

NEWSFLASH!!! "Patient satisfaction scores plummeted 50% over a 1 month period of time!"

In order for meaningful interpretation of patient satisfaction scores, enough survey results MUST be obtained, especially when comparing scores across time.

HOW were the people selected?

Let's pick on the emergency room...

If I wanted to "pad" my results, I would tend to provide surveys to patients who had simple problems and who were seen quickly.

Child with an earache? Let's seem them immediately in Fast-Track ER. [Look in the ear! There's an ear infection.] Here's some antibiotics. Can you also complete this survey?

As opposed to...

55 year old narcotic-addicted patient with fibromyalgia demanding a prescription for 500 percocet pills for his chest pain. I would probably not want this patient to fill out the survey. Neither would the patient as he would probably toss it.

Granted these are extremes, but if performance bonuses are provided to departments with the best patient satisfaction scores and the ER staff were the ones providing the surveys, one can easily manipulate the results in their favor.

WHO administered the survey?

As mentioned above, survey results can be manipulated depending on who provides or gives the survey, ESPECIALLY if money is involved based on the results of the survey.

In order for survey results to be meaningful, a third uninvolved party should be the one to administer the test.

Survey Fatigue

Now even if the survey was done dispassionately and adequate number of surveys were completed, there's still the problem of survey fatigue...

What's that?

I don't know about you all, but I get about 3-4 letters per week and at least one phone call per day asking me to complete a survey on my car, toothbrush, tater tots... etc. You name it... there's a survey for it now.

Now add how many questions are asked... Hopefully one so it's quick.

But also HOW the questions are asked (yes/no versus a scale of 1-10).

As a person completing a survey, if I had my way, there would only be one question that is a yes/no question.

The more questions there are and if they are scaled rather than yes/no, the less likely I'm going to do it.

Now add if you are sick and in pain... How likely are you going to actually complete a 50 question survey on a scale of 1-10???

Probably not...

In fact, it's probably only going to be healthy individuals who tend to give better scores giving a skewed result.

Also, given the survey fatigue I and I bet most people have, it will be a rushed completion without much thought given. The default being five stars all the way down (I may not even bother to read the questions).

A decent way to look for survey fatigue is to have 2 randomly buried questions where rather than 5 stars being the best, 1 star is the best. Surveys where everything is 4 or 5 stars INCLUDING the reversed scale questions should be thrown out.

Summary

If surveys are accurately administered with statistical power and used in such a way that financial incentives are not so tightly linked to the outcomes, than potentially all stand to benefit.

However, performed the way they are currently, whether good or bad, patient satisfaction scores can be VERY misleading if not completely wrong...

I should also add that whenever money is involved, NO test is going to be 100% accurate due to cheating that is bound to happen one way or another... even if cheating occurs by providing healthcare not due to medical reasons.

I predict that this problem is going to get MUCH worse because health insurances will soon base how much reimbursement hospitals and physicians get based on patient satisfaction scores. We are talking about millions and millions of dollars.

Just read about the "no-child left behind" from the Bush era where student test scores influenced teacher pay leading to teachers allowing cheating on tests.


Sources:
Why Rating Your Doctor Is Bad For Your Health. Forbes 1/2/13

Greater Patient Satisfaction At Expense of Better Care? Fauquier ENT 2/19/12

100% Patient Satisfaction Scores. Fauquier ENT 6/8/12

Patient satisfaction: When a doctor’s judgment risks a poor rating. JAMA 11/26/12

Reference:
The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality. Arch Intern Med. Published online February 13, 2012. doi:10.1001/archinternmed.2011.1662

Patient Satisfaction and Patient-Centered Care: Necessary but Not Equal. The Journal of the American Medical Association, July 11 (jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2012.7381)

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