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Friday, October 31, 2014

What would a straightforward referendum on nationalized health care look like in America?

The independence referendum in Scotland got me thinking. I must admit I was glued to the news over the last few days of campaigning. For those of you not following closely, it seemed as if the No camp had a comfortable lead right up until the last week, when the opinion polls suddenly showed the Yes camp pulling ahead. This rattled the establishment. The prospect of my country of birth splitting up rather saddened me as well, and I was fixated on the TV watching BBC world news late into the night as the constituency vote counts came in.

The result in the end was a fairly comfortable No vote. The Union remains intact. In the preceding week, a lot of people in my hospital asked me what I thought of the vote. I had a feeling that the No vote would prevail, if anything because when it comes to a big change, absent an economic catastrophe, people are usually quite conservatively inclined when they reach the ballot box (conservative as in keeping the status quo).

As someone who works in health care, a field where there is a lot of contentious debate at the moment, the Scottish vote also got me wondering what would happen if there was a straight referendum put to the American people about adopting socialized medicine? I found the thought intriguing. I can see both sides of a potential debate having very passionate opinions, as is the case with right versus left politics in general. Leaving aside any discussion on how it uniquely affects doctors and hospitals, I envision the two sides hinging their broad philosophical arguments on the following:

Vote: “Should the United States have a fully socialized, universal single-payer health care system?”

The Yes camp (probably coinciding with left wing politics):
• Every other Western industrialized nation has some form of socialized medicine;
• Older people generally like Medicare, so why not extend it to everyone?
• Health care should be a right and not a privilege;
• The free market does not work for health care; and
• It is the best way to control costs.

The No camp (coinciding with the right):
• Socialized medicine will restrict choice and personal freedom (it is a form of government control over a vital part of our lives);
• Socialized medicine takes away peoples’ own responsibility for their health;
• Socialized anything is very un-American;
• The free market always delivers the highest standards and best customer service; and
• The government does the worst job at controlling costs.

For the Yes camp, the assumption that Americans would want a European-style socialized health care system neglects the realization that the collective American culture and psyche is inherently very different from those countries. For the No camp, the assumption that the government cannot be trusted to deliver health care may not resonate with everyone. In a federal country as heterogeneous as the United States, the debate would be highly variable by region. I’m not even sure the federal government would have the legal authority to poll the American people in this way. Whatever the truth of the matter, it’d be a fascinating referendum. And I don’t think either side could take the result for granted.

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. This post originally appeared at his blog.

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Thursday, October 30, 2014

Curbside consultation and hallway conversations

“Curbside consultation” is an interesting term in medicine. There has been an increasing interest in this term in the recent medical literature, specifically as it relates to patient care in medicine. I myself have often pondered how much one learns from curbside consults. I know that some specialists may frown upon them because of the potential for some to document recommendations in the chart without a “formal” consultation. As a primary care physician, I enjoy the camaraderie associated with a curbside consult, and in turn, try to help my colleagues out when they ask me a quick question.

The other day, I was on the way from my administrative office to my clinical office where I see patients. Just outside the parking lot, I saw a colleague I had been meaning to call but just hadn’t gotten around to actually contacting. In a five-minute conversation, I was able to get so much more helpful information about the topic at hand, and helped my colleague in understanding a concept with which he was not familiar. For the record, this actual conversation took place on the sidewalk, right next to the curb. If there was anything that was truly “curbside”, this was it!

I wonder how much one can actually “learn” from a curbside consult? In my example described above, I can honestly say that the “worth” of that curbside consult is much more than that of a one-hour “lecture” on the same topic by an expert. I’d be willing to say that my colleague felt the same.

The same concept can be applied to “hallway conversations” at regional and national meetings: the energy disseminated from a brief conversation with a colleague is itself a wonderful opportunity for learning for all (including disseminating to others who may not be a part of the conversation). So the next question becomes this: “If it is so helpful, how do we value curbside consults/hallway conversations?” I don’t know the answer, but it is certainly worth exploring. Yet one more thing ripe for future study!

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

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Bedside ultrasound can diagnose kidney stones

I have been following the progress of bedside ultrasound (using ultrasound as a diagnostic tool during physical exam of patients) as it gets a foothold in standard medical practice. It has been part of my practice for almost 3 years now, during which time I have been repeatedly amazed by how helpful it is for guiding my clinical decisions. There is good research showing how useful it is for all sorts of applications, from heart problems to intestinal obstruction, but it is still slow to catch on.

An article came out just recently in the New England Journal of Medicine, which has a large circulation and should make a bit of a splash. This multi-center study looked at the option of having patients (excluding the very obese, pregnant and critically ill) with abdominal and flank pain suspected of having kidney stones evaluated first by emergency physicians with ultrasound of the kidneys and bladder before considering getting a CT scan. Normally a patient with suspected kidney stones (crampy pain in the back or abdomen, blood in the urine, suggestive history) will be referred for an abdominal and pelvic CT scan, which costs more than $3,000 and carries a significant amount of radiation exposure.

In perfect circumstances performing the test and getting the results takes an hour, but it can end up taking several hours due to the usual delays. Sometimes patients with kidney stone type symptoms are referred by the emergency physician for an ultrasound by the radiology department, which takes about the same amount of time as the CT which takes the same amount of time, but costs a bit less and delivers no ionizing radiation. CT scans have beautiful pictures and can often find the kidney stone, if it’s in there, and not finding the stone is strongly suggestive that the diagnosis of what is causing the pain must be sought elsewhere. Ultrasound can show if the kidney is blocked by showing lack of flow into the bladder or buildup of fluid in the kidney (hydronephrosis) but rarely actually visualizes the stone. This information, however, is adequate to make the diagnosis in most cases, when combined with a good clinical history, physical exam and lab tests.

It turns out that the bedside ultrasound exam done by emergency room docs (in this study they were from multiple medical centers including University of California at San Francisco, Cook County and Rush Medical Centers in Chicago, Group Health in Seattle and many more high quality locations) is adequate in cases of abdominal or flank pain as a first evaluation to rule in or out kidney stones. It is much more focused than an ultrasound performed by the radiology department and it only takes about 5 minutes or less to perform. Since it is done by the physician examining the patient it is also a time to take more history and do more general observation, which is always a good thing. About 40% of the patients initially evaluated this way got an official radiology ultrasound or CT scan which were felt to be necessary by the ER physician to clarify what was going on.

About a million patients with kidney stones visit emergency rooms each year in the U.S. and more than 10 times that many visit ERs with symptoms that sound a bit like kidney stones and have to be evaluated for them. If all of them got bedside ultrasound as the initial evaluation of their kidneys, my back-of-the-envelope calculations suggest that multiple billions of dollars could be saved on imaging costs and lives could potentially be saved due to reduced radiation exposure. The study showed no significant increase in complications in the patient who first received bedside ultrasound. Actual cost savings were calculated, but not reported in the study (why?)

We can’t just start doing this because not all ER doctors are yet comfortable performing and interpreting bedside ultrasound of the kidneys and bladder. But they could be. It is not hard. Pretty much anybody could learn to do this in maybe an hour and could certainly be competent after doing 50 exams. The implications of this are bigger than the article points out. When ER physicians start doing regular bedside (or “point of care” as it’s sometimes termed) ultrasound they are going to get better at it. They will start to use ultrasound more and develop some pattern recognition skills that can’t be predicted which will likely lead to more accurate diagnoses of other diseases, and possibly less dependence on ionizing and expensive radiation in the form of CT scans.

Unfortunately CT scans for abdominal pain in the emergency room are an important source of revenue for both radiologists and hospitals, which puts a little kink in the clear path toward adopting bedside ultrasound as a diagnostic procedure of choice. It’s not clear what to do with this, because we could surely use the expertise of radiologists and radiology technicians in training physicians to be good bedside ultrasonographers and presently that would be a pretty big conflict of interest for them. Still, there is so much good stuff going on in the field of high tech ultrasound that is not in the scope of bedside ultrasound that radiologists and technicians could be kept gainfully occupied by doing things that other physicians can’t and shouldn’t do.

In the journal of the American Institute of Ultrasound in Medicine there were several articles about amazing and technically challenging imaging applications that non-radiologists might be wise not to try. There were articles about ultrasound of the midbrain to evaluate Parkinson’s disease, ultrasound of the liver to look at severity of cirrhosis, ultrasound of children with intestinal intussusception (telescoping of the bowel) to follow the success of noninvasive treatments and detailed prenatal evaluations for conditions I didn’t even know existed. Ultrasound to diagnose appendicitis has become nearly standard now, but is really hard to learn and ultrasonographers and radiologists do it well (some ER physicians do it well too, but it’s far from an entry level skill.)

Looking at the kidneys in 5 minutes in the ER is clearly fine for evaluating possible kidney stones. An abdominal ultrasound in the radiology department with their big powerful machine with the gorgeous images combined with the stunning command of anatomy of radiology professionals is a different and differently beneficial thing. This recent article may help move us as hospitalists, ER physicians and primary care providers toward doing more bedside ultrasound, which could be a very good thing. Perhaps more radiologists will find peace with that and can bring themselves to help teach other medical staff who need to learn how to do it.

Janice Boughton, MD, ACP Member, 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.

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Wednesday, October 29, 2014

Let's talk Ebola

Ebola is all the rage so it is time for EverythingHealth to “talk Ebola”. Unless you have been in a coma, you are aware that Ebola is sweeping through West Africa and there have been several identified cases in the United States. This is a big news story so anxiety and fear are being felt by anyone who picks up a paper, goes on the internet or watches TV. What does EverythingHealth say? First, calm down, everyone!

Here are some Ebola facts:
• There are actually 5 different Ebola viruses that cause hemorrhagic (bleeding) fever;
• Ebola is not very contagious because it is not airborne;
• Initial symptoms are fever, body ache, diarrhea, stomach pain and vomiting; and
• The incubation period is up to 21 days.

The average American is not going to be at risk for Ebola. Direct contact with body fluid is needed so standing in a room or an airplane with an Ebola victim will not cause infection. Gunshots kill more than 30,000 Americans a year. Now there is a risk for you to worry about!

Health care professionals, trash collectors and airline cleanup crews are the most at risk of exposure to Ebola virus. Those workers should keep abreast of current events and take precautions. Until the infection can be controlled in Africa, there is always the chance that a traveler will have silent disease. The best way the World can protect itself is to help Africa contain the infection. This does not mean closing airports. That would simply prevent needed help and cause the virus to spread across borders to other countries in Africa.

What can you do? First, get a flu shot. As winter approaches, influenza will be here and it causes some of the same early symptoms as Ebola. I worry about our Emergency Departments being crushed by people with flu symptoms who think they may have Ebola. Please make it easy on all of us and get a flu shot!

Second, send some money to your favorite relief organization. I recommend Partners in Health and International Medical Corp. I have personally worked with both of these organizations and they do wonderful relief work around the world.

This post originally appeared at Everything Health. Toni Brayer, MD, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

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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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