American College of Physicians: Internal Medicine — Doctors for Adults ®

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Friday, November 21, 2014

Unscrambling our eggs

I recently saw a patient in my clinic who made me think about the many other patients like him I’ve treated over the years. He had a rather dramatic family history of heart disease, and had himself undergone coronary bypass surgery before his 40th birthday. He had, of course, seen many doctors before me, including all those directly involved in his surgery. But nonetheless, he traveled a considerable distance to see me and get my advice.

We may reasonably leave out the particulars of pharmacotherapy, and merely state the obvious. Since he was very overweight, he needed to lose weight. Since he didn’t exercise, he needed to start. Since he didn’t eat especially well, he needed to eat far better. In other words: well, duh.

While both you and I might understand why someone already working very hard to eat well and be active might seek out expert guidance on how to do even better, I trust you see the anomaly in this case. Why would anyone need expert guidance to start using what essentially all of us already know about lifestyle as medicine? More fundamentally, with a compelling family history of heart disease, a host of very obvious risk factors, and even an entry-level understanding of the link between those risk factors and their potentially calamitous consequences, why wait until after bypass surgery to consider doing something about it all?

This patient, as noted, made me think of other patients like him; in particular, one whose story I tell, calling him by the pseudonym “Doug,” in the first chapter of Disease Proof. But this patient, and Doug, and all the others like them, made me think of Ebola. In their cases, it was a body in danger. With Ebola, it is the body politic. In both cases, a penchant for attempting to unscramble our eggs is on display.

As noted in a column by Dr. Steven Osofsky, executive director for wildlife health and health policy at the Wildlife Conservation Society, published yesterday by CNN, we know a lot about the origins of Ebola outbreaks, just as we know a lot about the origins of heart disease. Unlike virtually all of the Ebola coverage inundating us at present, half of which is telling us not to panic and the other half telling us why we should, Dr. Osofsky looks beyond the current outbreak to its root causes. There is a proud history of that very method in preventive medicine. Root causes tell you what you can and should fix not just now, but so that the current crop of bad news isn’t replicated any time soon. That’s the benefit of getting to the roots.

The roots of the Ebola outbreak reside not with the arcane biology of exotic viruses, but the mundane behavior of hungry people on an overcrowded planet. In parts of Africa where other food sources don’t meet the need of populations swelling ever more into wildlife areas, hungry people wind up catching and killing wild animals for food. Their choices can be rather indiscriminate, and include both bats and primates. Such exposures are how Ebola first infected humans. Much the same is true of HIV.

I won’t repeat here the insightful, clear recommendations Dr. Osofsky offers for addressing this problem at its origins; I commend his column to you for that. I will note, as he implies, that failure to learn from the follies of our history may well destine us all to endless repetition of them. There are many other animal viruses we have yet to encounter. In a world of business as usual, where bush meat is the only way to fill the bellies of hungry people in rural Africa, we will inevitably find them, in the worst way possible.

So, at the moment, it is Ebola. It was once the high waters of hurricane Katrina on the low ground of New Orleans. Or the mostly undefended stretches of Jersey Shore in the face of Super Storm Sandy.

It could also be the high temperatures of global warming. Or the high threat level on our color-coded scale of terrorism. It might just as readily be the low rainfall in California, and the desiccation of aquifers.

It might also be Doug’s many risk factors for heart disease; or your own.

The common theme? The risk of crisis portended by warning signs all too often neglected. In the case of wayward biomarkers such as cholesterol, only somebody is harmed by that neglect, although that’s small comfort if the somebody is you or anyone you love.

In the case of Ebola and Katrina, it is the body politic. In all such cases, bodily harm tends to ensue from willfully mindless neglect of the obvious.

That’s what we do, bodies and the body politic alike: wait for catastrophe, then scramble.

So it is that Ebola, a preventable catastrophe like so many before it, is upon us. Even as we address it, we should be considering the root causes, and directing resources there to prevent the next outbreak, potentially, of something even worse. At the roots, ounces of prevention will do. Once the next calamity germinates, even pounds of cure may not suffice.

The best treatment of any disease is its prevention. The best response to any crisis is its aversion.

Alas, we, anybody and the body politic, alike, seem to harbor an aversion to just that approach. We are forewarned again and again, but never quite manage to be forearmed. We wait for the inevitable fall, then dash in madly to unscramble our eggs.

By all means, let’s do what we always do: call in the King’s horses and the King’s men, at the customary high cost in dollars and human potential. And why not, while we’re at it, go ahead and cross our fingers.

As for those good eggs lined up atop that wall over there, wavering in the wind, well, pay no attention to them. I’m sure they’ll be fine.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Thursday, November 20, 2014

Heroic

I got a call yesterday. It's not the kind of call most people get; it was a call from someone who is dying and wanted to talk with me.

“How are you doing?” I asked, not knowing exactly what to ask.

“Pretty lousy. They say my cancer is spreading and the oncologist told me there wasn't much more to do at this point.”

There were a few seconds of silence, and I was about to say something when the patient said, with voice cracking, “I just want to thank you for all you've done for me over the years. You've been a good doctor, someone I can talk to when I needed. Thank you for all you've done.”

“Thank you for letting me take care of you,” I answered, “It really is an honor when people trust me with their care.”

Another pause.

“Just let me know if I can help in any way” I said, again not knowing what to say. ”I assume they've set you up with hospice. You are facing that time that we all will face some day. It's just got to be weird when it's actually happening to you.”

“Yeah, doc,” the patient said. ”It's not something normal, that's for sure.”

I thought about that conversation for the rest of the day. Someone had felt strongly enough to call me and thank be before they died. I was a person on their list that they wanted to contact before death. That's amazing. It may not be the first time this has happened, but it was the first time I was acutely aware of its significance.

We talked for a while after the things I chronicled above, talking about family, plans for wrapping things up, about whether quitting smoking had brought on the cancer (I didn't debate the point), and about our shared experiences in my office. It was hard to say goodbye, as it could easily be my last conversation with the person.

This all got me thinking about a conversation I heard on sports radio about the definition of the word “heroic.” One of the hosts was complaining about the use of the word “hero” in conjunction with the amazing efforts of Madison Bumgarner in the World Series. Yes, it was amazing how he pitched 5 scoreless innings on 2 days of rest, but would you truly call his efforts heroic? ”Shouldn't we reserve the term for people who are true heroes,” the host asked, “like soldiers, firefighters, and doctors? This guy pitched in a game; he didn't save anyone's life or find a cure for cancer. It just bugs me when people call this heroic

The reference that caught me was his assumption that doctors were heroes. This is something that has been said to me before, after I discovered heart disease, found cancer early, or helped a person gain control of their difficult disease. I can't deny it: I have saved many people's lives, but I resist any suggestion that what I do is heroic.

It is my job to find cancer early, diagnose heart disease, and put people on the path to health. I am supposed to save people's lives. I would consider myself a poor doctor if I didn't do these things, just as a firefighter or soldier would deflect the title of “hero” for their doing their job as they should. Are there truly nobler jobs than others? If so, does having a noble job confer its nobility to the people who do it? I must say, I've known many doctors where the terms “hero” and “noble” would be far down on the list. Yet these people also save lives and help the helpless for a living.

I think there is something in us that makes us want to make heroes. This is part of the attraction of sport and other entertainment. We want to see people doing things that are amazing, superhuman, and heroic. As a child, I imagined me hitting the home run in the bottom of the 9th inning, or hitting the basket with no time left on the clock. I imagined the adulation and praise of my skill from the adoring masses. I dreamed of being a hero.

But then, is the fact that Bumgarner plays a game and doesn't save lives make his superhuman effort less heroic? I tend to think this is an unnecessary distinction. It is the effort that is heroic, not the outcome. It is the person being in the place that matters, when nobody else is able to do the task. It is when we are truly ourselves when we are the only people who can make a difference.

So, in some ways, the fact that this person wanted to call me before they died, that fact makes me feel heroic. This is not the heroism that attracts outside praise from the masses (I say ironically as I publish this on my blog). Really, I am not writing this to garner praise, but to say that we all can and should be heroes. Being heroic is to be who we are in the position we've been given. It isn't sexy, loud, or earth-shaking.

Being truly heroic is something solid, which comes from ourselves, not from the opinions of others. In a strange way, this patient, by calling me and letting me know how much I've done, did something heroic for me.

Thank you for being my hero.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

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Defeating the purpose

The Affordable Care Act. Obamacare.

No matter what you call it, the law has 2 main goals: Insure more (all?) Americans, and in doing so, lower the aggregate costs of health care in the U.S.

After year 1 of the Act’s main rollout, there is no doubt about the first goal—millions more Americans now have health insurance. Many have purchased it on the “exchanges,” whether they are state run (best example might be Kentucky) or run by the federal government (think “Healthcare.gov”). Millions more are now covered by Medicaid, the 1960s-era federal program (which also uses state matching funds) to insure the poor.

The jury is still out on whether the law will lower costs. In principle, insuring more people lessens costs by bringing more healthy people under the insurers’ umbrella, thereby spreading risk more effectively and using more (but smaller individual) premium payments to provide care to more individuals in a group market setting. More buying power, and more market efficiencies (see automation and digitalization of health care, as well as streamlining of processes) in theory lower the aggregate costs.

Another way in which insuring more people while costing less occurs is by providing insurance that people don’t use. When we don’t use our health plans, the overall spending in the system goes down. Obstacles to using health insurance include co-pays (the out-of-pocket portion of health costs that insurance doesn’t cover) and deductibles (an annual out-of-pocket amount that you must spend before your insurance kicks in).

In a solid analysis of this situation, the New York Times ran a front-page article demonstrating how the new plans use tiered deductibles, which have the net effect of dissuading people from using their insurance.

Remember that everyone has the right (in fact the responsibility, i.e. the mandate) under the law to purchase an affordable plan, tiered as platinum, gold, silver, or bronze. [This does not apply if you a) have insurance through your employer or b) you qualify for Medicaid.]

The platinum plans cost the most up front, but have the least in terms of deductibles and co-pays. Just the opposite for the bronze plans, the most “affordable,”—i.e. the ones with the lowest annual premiums. The problem with these is that it turns out the deductibles can be so high as to impede people’s use of the insurance. It’s in effect an insurmountable hurdle to using newly-gained health insurance.

Here’s an excerpt from the article to give you the idea: Mark Yuschak, 57, of Jackson, N.J., said he had a silver plan with an annual deductible of $3,000. He discovered its limits in March.

“My wife had an incident, a digestive disorder, and we had to go to the emergency room of a hospital in Freehold, N.J.,” Mr. Yuschak said. “We presented our insurance card and filled out all the forms. They told us, ‘You don’t have a co-payment, you’re free to go.’ “

Later, though, they received a bill “that could choke a horse,” Mr. Yuschak said—for more than $1,000. “Our insurance wouldn’t cover any of it because we had not met our deductible.”

How can we make this system work better?

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.

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Wednesday, November 19, 2014

Health insurance companies sometimes put money over care

From the New York Times article, “U.S. Finds Many Failures in Medicare Health Plans: In more than half of all audits, “beneficiaries and providers did not receive an adequate or accurate rationale for the denial” of coverage when insurers refused to provide or pay for care.
When making decisions, insurers often failed to consider clinical information provided by doctors and failed to inform patients of their appeal rights.
In 61% of audits, insurers “inappropriately rejected claims” for prescription drugs. Insurers enforced “unapproved quantity limits” and required patients to get permission before filling prescriptions when such “prior authorization” was not allowed.
Medicare plans frequently missed deadlines for making decisions about coverage of medical care, drugs and devices requested by doctors and patients.

Unfortunately this story does not surprise physicians and many patients. This report focuses on Medicare, but we would all believe that private insurance plans would have the same “track record”.

The profit motive is at work here. While I love capitalism, sometimes it has a dirty underside. In health care insurance, 1 way to improve profits is through rationing care. We would hope that the rationing has logic, but indeed it appears to not have logic.

One could easily make the case that these companies are committing malpractice. Their denials constitute a practice of medicine. When you practice medicine and deny need prescription drugs or testing that the physician has recommended, how can that process be anything but the practice of medicine.

This story is very important. It confirms the belief of almost every physician with whom I talk. This story is an outrage.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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