ACP Internist Blog


Friday, April 19, 2019

Be the one giving pushback

A piece of advice I would give to any younger physician, especially one who is just graduating residency, would be to expect a whirlwind ride into the realities of frontline medical practice. It's something that you are totally not prepared for in the controlled environment of education and residency training. A steep learning curve awaits you once you start practicing medicine. And one of the biggest things you will have to get used to, that you've likely been completely shielded from, is the difficult relationship that many physicians feel with their health care facility administrations. Realistically, there isn't a profession out there in which this conflict doesn't exist between the frontline “worker bees” and the administrative guys in suits. That's an inevitability in any large organization. I remember a colleague once telling me this when I was a medical resident, and I didn't really understand how true it would be.

Having worked in at least a dozen health care facilities since finishing residency, and even held administrative positions myself, I have seen at close quarters how things work in health care. There is something uniquely uneasy about administrative clashes that occur in medicine though, when clinical care comes up against pure business thinking.

Let me be clear, I don't think administrators, guys in suits, bean counters—or whatever else you wish to call them— are bad people. They have been trained to do a job, and are doing it. I have worked with some good ones, but also bad ones. Some, even including a few CEOs, I've been pretty shocked with their organizational and communication skills, that they've reached the heights which they have.

Working in clinical medicine, you see a full range of personalities within any physician group. I was actually having a conversation with a friend and colleague recently and we were talking about the experiences of the group, in one of the hospitals I've worked. That group is fortunate to include some very strong personalities who are also exceptional, experienced physicians. We came to the conclusion that the sole reason why that remained a good place to work, and administration had largely “laid off” them over the years, was because of these doctors (in other words, alpha personalities who gave very strong feedback and pushback whenever it was needed). They were the yin to the administration's yang.

I've seen similar situations in other hospitals. Those with strong physician voices (especially leaders within the group), were always the best places to practice medicine. The converse sadly, has also been true.

I worry when I see some of the newer generation of doctors coming through the system, that they've been trained and exposed to health care in a different way, without any independent physicians as role models (it was very different only 10 years ago when I finished residency).

So if I was to give advice to any young doctor right now, it would be to never feel afraid of giving pushback and standing up for what you believe. Be the best doctor possible, confident in your clinical skills, and a fierce advocate for your patients. Do not be intimidated by administrators. You have a skill set that is really needed and in-demand (your job is actually more secure than theirs is). This does not mean being rude, unreasonable or obstructive. It just means standing up for yourself, your specialty and your profession. Without that counterbalance, you (and your patients) will be eaten alive.

In life in general, nothing has ever been achieved by those who are compliant, submissive and mindlessly follow whatever is thrown at them from above. Strive to be the trailblazer and the man or woman who challenges authority when needed. The person who everyone knows not to mess with (or to be more crude, always give off the “Don't f&# with me vibe”). They are the people that hold the house together and you don't tread on. And they are probably the reason why if you work somewhere good with nice conditions, it became that way in the first place.

Suneel Dhand is an internal medicine physician, author and speaker. He is the founder of DocSpeak Communications and co-founder at DocsDox. He blogs at his self-titled site, where this post first appeared.
Thursday, April 18, 2019

Poop wars and the commercialization of fecal transplant

The New York Times is interested in fecal transplant. This is the euphemistic term for taking feces, poop, crap, sh*t, bowel contents from one person and putting it into another person. There are various procedures for doing this, from drying it and putting it into capsules to making it liquid and introducing it by enema, nasogastric tube, or colonoscopy. It is a remarkably effective treatment for a wide range of illnesses which appear to be related to an unhealthy gut biome (bacterial community.)

Politics:

The New York Times has published several articles about it in the last few years including one in which they introduce the politics of fecal transplant (also “fecal microbiota transplantation” or FMT). Apparently several companies have been working on ways to monetize human excrement for medical use. At the same time, doctors have been using do it yourself concoctions and a non-profit in Cambridge, Mass. has been packaging a fully screened selected-donor poop product which is commercially available now.

Why on earth would you do this?

So what is FMT good for? I would point you to a blog I wrote a few years ago and a lovely page of evidence from OpenBiome, the nonprofit poop processing organization near Boston. It is clear that Clostridium difficile (C. diff) diarrhea, which is a scourge of hospitals due to widespread use of antibiotics, can be successfully treated with FMT. In fact the cures are nearly universal, quick and gratifying. Nevertheless, doctors use expensive oral antibiotics with far lower efficacy, often for months before considering fecal transplant because it has not yet become standard of care. People often die of C. diff without being offered FMT. There are also studies showing that metabolic syndrome, the altered physiology that accompanies obesity, improves significantly. This is likely to be associated with weight loss. Imagine something harmless that might replace obesity surgery or ineffective diets or the many complications of weight problems. Also inflammatory bowel disease, such as Crohn's disease or ulcerative colitis, usually treated with surgery and toxic medication which is often ineffective, has responded remarkably well to FMT. Even graft vs host disease, a devastating multi-system disease that affects some patients after successful bone marrow transplant, responds to this.

What:

A healthy poo consists of an unknown number and variety of cooperatively interacting bacterial, viral and fungal species. With changes in sanitation, diet, widespread use of antibiotics and Caesarian birth in countries like ours, the spectrum of organisms in our bowels has changed, and in some cases appears to have too few of the bacteria that can make us healthy and resilient. There is even good evidence that the multicellular critters that we call parasites contribute to robust health.

How:

It is possible to successfully transplant a new biome using stool from a healthy donor instilled either as an enema or through a deeply placed nasogastric tube. I see the procedure most often done by gastroenterologists via a colonoscopy. I don't know how much they charge for the whole routine, but a colonoscopy on its own is several thousand dollars. The stool is usually screened for pathogens with standard tests and the donor is checked for the usual diseases that we look for when a person donates blood to a blood bank such as HIV, syphilis, and hepatitis variants. A healthy spouse is a good candidate, as would be a child or sibling.

Home fecal transplants have become popular and make physicians very uncomfortable, since it is unlikely that a do-it-yourselfer will screen the feces donor before using his or her stool. I wonder, though, if it isn't quite a bit safer than we think, since the vast majority of people will have nothing that we screen for. Of course, I can think of several scenarios which might be disastrous, such as pressuring cousin Joe who doesn't want to admit to IV drug abuse or sexual promiscuity into donating a sample to his childless and partnerless relative.

Also I have wondered why we insist on using a colonoscopy to introduce stool into the colon when a simple enema has been shown to be effective in many trials. We don't have evidence to show that we need to put a patient at the risk or expense of a colonoscopy just to get this procedure done. I suspect this is because compensation for a procedure such as this, which is messy and not entirely simple, is next to non-existent unless the doctor is able to bill for a colonoscopy.

A story:

The most gratifying fecal transplant that I was around for was a simple in-office enema from a familiar and squeaky clean donor, mixed with saline in a cheap blender. The recipient was an elderly but previously very vigorous woman with a persistent case of C. diff that had completely undermined her life and health. She had tried multiple courses of antibiotics over several months, lost her appetite and was mostly home bound. She was completely cured within days, which is not an uncommon outcome.

Why not?

So. If FMT is so great, why aren't we doing it? Mainly because it's messy and kind of gross and a crap shoot (snort) with regard to outcome. By this I mean that if getting someone else's stool is good for all kinds of things, it could also have unexpected consequences. Not every infection can be screened for and there are cases of infectious diarrhea being passed from donor to recipient. What about metabolic syndrome? Will a change of biome make a thin person fat? We would prefer to “do no harm.” Also so far nobody has really told us that this is OK to do on our own. The FDA has been looking at classifying stool as a drug in this context since 2013 and there was even a set of guidelines released that were very difficult to follow. So this lifesaving treatment is a big stretch for us.

Politics take 2:

Back to poop wars. Three companies, Vedanta Biosciences, Seres, and Rebiotix have been working for years on poop products that will be effective and patentable. They have joined together to form the Microbiome Therapeutics Innovation Group and are lobbying for the right to sell their products as drugs, which would likely raise the price of the procedure and knock a non-profit like OpenBiome out of the picture. Critics argue that this will reduce innovation in the field and make what could be a very cheap and effective therapy so expensive that it will no longer be available to many patients. The idea of poop as a drug with a brand name and a hefty price tag is irritating in the extreme and yet another example of how healthcare can be so insanely expensive. But I'm not sure it's wrong. Here's why.

Why drug companies should get to take over:

It has been excruciatingly painful to see patients suffer and die of diseases that can be effectively treated by fecal transplant when there is abundant evidence that it works. Why, you may reasonably ask, do I let them suffer when it is within my power to give them this procedure? By the time a patient is sick enough with these diseases that it is clear that standard treatment doesn't work, there are usually multiple doctors involved, and the fact that it isn't standard of care means that someone on the team will be uncomfortable with this approach and it won't happen. So FMT needs to become standard treatment.

If drug companies make a product that stands up to safety and effectiveness standards, packages it hygienically and markets it with a snappy name and simple instructions, FMT will become standard of care. First it will just be for C. diff that hasn't responded to antibiotics, but drug companies will want to sell more of it and will do research to prove that it is good for at least all of the indications I know about, and probably a few more. That research will sell drugs and will save lives. It will probably mean that a simple in-office FMT with a blender and a friend's stool will be specifically disapproved, but the home procedure will be universally available as long as there are enema kits and blenders, ideally with adequate screening. Eventually the preparations of Vedanta, Rebiotix, and Seres will go off patent and by that time the procedure will be something we try before exposing people to antibiotics or immune suppressant medication or surgery.

If the FDA makes a decision that offers exclusivity to these three for-profit companies, I do hope that the significant contributions of a group like OpenBiome are recognized and compensated. They have been a major contributor to making fecal transplant easier and more acceptable and have probably pioneered some of the procedures that the other entities will be using. OpenBiome's product is not cheap either, costing just shy of $1,500 for a preparation that can be instilled by colonoscopy or nasogastric tube and nearly $2,000 for capsules with dried feces. I expect that the commercial versions will be more than double that price.

Janice Boughton, MD, FACP, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.
Monday, April 15, 2019

The role of podcasts in medical education

Obviously I am very biased, hosting a podcast now for eight months, and being a guest on two other popular podcasts – The Curbsiders and The Clinical Problem Solvers. Given my obvious conflict of interest, here are my thoughts on the contribution that podcasts are making for students, residents and practicing internists.

Two or three years ago some students asked me if there were any good podcasts to listen to while on their medicine clerkship. Soon thereafter, two things happened: The Curbsiders started their podcast and Annals of Internal Medicine asked me to develop a podcast. I had a growing love of podcasts as an accompaniment on long drives. When the Curbsiders asked me to appear on episode #16 of their new podcast in October 2016, I jumped at the chance and started my love affair with medical podcasts.

Now when I make rounds for 1/2 months or full months, I regularly recommend podcasts to the learners. Now that we have released 16 episodes of Annals on Call, I frequently get comments from colleagues and learners about individual episodes. This week at an Update in Hospital Medicine done at our noon conference, podcast episodes were quoted. Earlier this year the CMRs asked me to give Grand Rounds on social media. The response from house-staff and faculty was outstanding.

Why so much excitement about podcasts? I think it follows from the classic way we learn. Storytelling is likely the oldest form of education. We learn best from stories. This concept holds particular in medical education. Patients are our best teachers. The best is taking the history ourselves and then following the process of diagnosis and teaching. Next best is learning from someone else telling us a compelling story about a patient.

I do not think we can overestimate the value of clinical stories to expand our medical diagnostic and therapeutic abilities. As a resident, I loved and tried to never miss Morning Report. I love hearing cases presented at a conference and discussed in depth. That knowledge sticks so much better than reading an article, unless the article helps me understand my patient.

In addition to the two podcasts above, I particularly love The Clinical Problem Solvers, because each week they provide a highly selected Morning Report case to solve. They focus on the thought process and schema for evaluating a problem (syncope, eosinophilia, chest pain, etc.).

Other IM podcasts that I frequent include Core IM and Bedside Rounds. I get different things from each podcast, but most of all I get continued learning. Even at age 70, I want to continue to learn more so that I can do a better job teaching and caring for patients.

Podcasts increase learning and (in my humble opinion) the joy of medicine. As internists, we love solving our patients' puzzles. We all want to be Sherlock Holmes. This gets us closer. And I love that our students and residents are enthusiastic devourers of this teaching.

db is the nickname for Robert M. Centor, MD, MACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and the former Regional Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds regularly at the Birmingham VA and Huntsville Hospital. His current titles are Professor-Emeritus and Chair-Emeritus of the ACP Board of Regents. This post originally appeared at his blog, db's Medical Rants.
Monday, April 8, 2019

The little girl who didn't cry wolf

Your chest was hurting. This was your chief complaint. “Like pressure,” you'd said. Then you shook your head and closed your eyes. Your hand pushed into the center of your chest for emphasis.

I asked what you were doing when it came on. You shrugged and insisted that it was nothing out of the usual. Then you scratched your shoulder vigorously. The suddenness of the gesture startled me.

“You okay?” I asked.

“Yeah,” you said. “I just be itching sometimes.”

I nodded. And then went back to the discussion.

Pressure like chest pain at rest that made you miserable enough to come to the emergency department. A little bit of shortness of breath. But not much. No numbness or tingling in your arms. You weren't exerting yourself in any way.

Nope.

And yeah. You USED to use crack. But not anymore. You were adamant.

“I fell to my knees,” you said. “I was so tired, Miss Manning. I fell to my needs and asked God please. Please take this stronghold away from me.”

I kept listening. Almost feeling like I didn't deserve to be on the other end of this testimony given my mood. My team was surrounding me during this conversation. They followed my lead, saying nothing.

You went on: “Then? Just like that. He took it away from me. I swear. It's been three whole months. THREE WHOLE MONTHS.” You repeated that last part.

“Wow,” I said. My ‘wow’ didn't sound wow-ish. It sounded mechanical and fake. My hand was rubbing the side of my neck. I was listening to you and watching you. Your eyes were dancing and your hands were animated. The laxity of your jaw as you spoke reminded me of the many heavy crack users I'd seen over the years and the patient years ago who pointed to Bobby Brown on the television and said, “That way he move his jaw like that? That's when you use a whole, whole bunch of crack.” So yeah. This was what I was thinking about. The whole time that you were talking about what God had taken away from you.

Sigh.

I didn't fully believe you. Not that I didn't think you believed what you were saying. But I was tired. Very tired this day. And I just needed something to just bark exactly like a dog and say, “Hello. My name is Fido.”

Sigh.

The third year medical student, however, was new to this. He'd heard your story and presented you to me as the last patient at the end of a busy day. And every drop of your Kool-Aid, he'd lapped it all up, gleefully reporting your newfound abstinence. “I believe her,” he said about you. His young face was emphatic and his greenish eyes glistening with advocacy and defiance. He repeated himself. “I believe her.”

I wanted to. But my bias against you was so strong. And I was tired. Like so, so tired. Not take-a-nap tired. But emotionally tired of watching how this sickening crack epidemic decimated my people and how it was all beginning to feel like a hopeless version of that movie Groundhog Day.

Uggh.

I remembered what I'd learned about ways to fight bias. Being aware of triggers like exhaustion and such. And so I held your hand and did the things we do for chest pain. I nodded my head and mumbled words of affirmation about God's intervention like “Won't He do it.”

Then I said sorry in my head right after that. To God for fronting and using his name in vain.

“We didn't check a urine drug screen,” the student said outside of your room. “I mean, we can. But I will be so disappointed if it's positive.”

I was tired. So I just dragged a breath of air and said, “Me, too. But check it.” Which he did.

Yeah.

Today when I came to see you, you looked so happy to see me. Your face was still full of light. The gladness in your eyes to see this black woman doctor was palpable. I could see it before I even turned the light on. “My doctor! Heeeeey Miss Manning!”

You reached for my hand. I grabbed it. “Hey sis,” I said softly. Then I sat down. My face was serious. And my eyes almost immediately welled up with tears.

“What?” you queried. Your eyes looked worried. About ME. “What?

I swallowed and gained my composure. “I owe you an apology.” Your eyes widened. “I … I just got back your urine drug screen. The student didn't want to get it. But I insisted.” You kept listening. “It was negative.”

The expression on your face was inexplicable. Then what you did next surprised me. You held open your arms and asked for a hug. I obliged you.

“You be wanting to believe, don't you? But you can't always believe.”

I nodded and sighed. “I do want to believe. I do.”

“It's okay. That's the thing about a stronghold. It make reality and fantasy look like one and the same. Bet you heard a whole bunch of folks cry wolf before.”

I tapped my foot and bit my lip so I wouldn't cry. “I am very proud of you. And so happy for you.”

“And I believe you,” you said. Then you squeezed my hand.

When I left your room, I went to a stairwell to cry. Mad with myself because every day I am preaching to my teams to believe that today could be the day. Here “today” was staring me in the face and my bias and exhaustion wouldn't let me believe it. Or at least try to believe it.

Sigh.

No. I don't have all this shit figured out. No, I do not. But you were right. I be wanting to believe. Damn, I do.

Yeah.

P.S. I told my medical student I was sorry, too.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.