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

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Friday, July 25, 2014

Are your medical priorities straight?

The world is asunder. As I write this, Iraq is sinking into a sectarian abyss. ISIS, a terrorist group, now controls a larger territory than many actual countries. Russia has swallowed Crimea and has her paw prints all over eastern Ukraine. China is claiming airspace and territories in Southeast Asia increasing tensions with Japan, Vietnam and the Philippines. The Israeli-Palestinian peace process is in another deep freeze. Terrorists in Sudan and Nigeria are kidnapping and murdering innocents with impunity. The Syrian regime has resulted in 160,000 deaths and has displaced over 6 million people. The Taliban continue to destabilize and terrorize in Afghanistan and Pakistan. Disease and hunger claim millions of lives in the developing world while other world regions have a surplus of food and medicine. We have an immigration crisis in this country that gets worse by the day. Several million Americans are still out of work.

Let’s not be distracted by these trifles. A looming apocalypse exists that dwarfs the above issues and demands our overriding attention: Should the Washington Redskins change their name?

Sometimes, folks have difficulty deciding what’s important.

Assigning rational priorities is an important professional and life skill. Collectively, we all waste an incalculable amount of time, energy and resources pursuing ventures that should be left for another day. All of us do this. Sometimes, we do so deliberately when a lower priority activity will deliver some pleasure or entertainment. In these instances, at least we are aware that we are dipping down on our priority list.

An important physician skill is to judge which medical issues and tests should have a priority status. Hmmm, a patient suffering a heart attack also has athlete’s foot. Which issue do I address first? We would recognize that a patient recovering from a severe pneumonia in an intensive care unit should not undergo a mammogram or a screening colonoscopy. Often, it is not so easy to determine the medical priorities and different physician specialists on the case may disagree on what should be the next step.

Here are a few hypothetical scenarios.

A surgeon insists that an operation is urgently required, but the cardiologist counters that stabilizing the patient’s congestive heart failure must be done first.

A gastroenterologist advises stopping a blood thinner as the patient has a bleeding ulcer, while the pulmonologist disagrees as the patient has a new pulmonary embolus and argues that the blood thinner cannot be interrupted.

A patient comes to his internist very anxious over 3 days of rectal bleeding. He wants a colonoscopy as soon as possible as his father had colon cancer. The physician advises instead evaluating the patient’s recent episodes of chest tightness, which the patient dismisses as anxiety.

Knowing how to do something well is not nearly as important as knowing if and when it should be done at all. Who wants to have his gallbladder flawlessly removed if it didn’t need to come out? You can substitute any surgery, medical procedure, diagnostic test or treatment in this example.

Medical knowledge is important. Technical procedural proficiency is necessary. Communication skills are a distinguishing asset. But, medical judgment is paramount.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who 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.

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Oh, what to do about that background hospital beeping?!

You enter a patient’s room, begin a conversation, and then hear it. It may be from your patient’s machine, or the next bed; from the intravenous infusion or the telemetry monitor.

“Beep, beep, beep!”

What do you do? Do you:

A. Look into the situation yourself and work out what’s wrong?

B. Try to silence the alarm immediately?

C. Call the nurse to look into it?

D. Just let the machine keep beeping for now and carry on your conversation?

Which one you usually do probably depends on the clinical situation and what type of machine the alert is coming from. Obviously an emergency telemetry monitor alarm will provoke an immediate response. However, all hospital medicine doctors will be familiar with the above everyday scenario. More often than not, it’s a simple issue with the IV machine, such as an occluded line or an alert that the infusion has finished.

Interestingly, on occasions where people have shadowed me at work—from both clinical and non-clinical backgrounds—I’ve often heard them remark about all the background noise we hear from the machines on the floors. They also frequently ask me what certain alerts mean, and I must admit I’m not always sure without looking in detail at the machines! The volumes and types of alarms can make hospitals very noisy and confusing places. You wouldn’t have the same situation say on an airplane, hearing alerts that aren’t immediately understood and addressed by the pilot or cabin crew. Quite simply, there are far too many background alarms in the hospital environment. In fact, this phenomenon of “alarm fatigue” probably affects hospital medicine doctors more than any other specialty, because we spend the most time on the hospital floors.

And even though most of us have just accepted it as the norm of being in a hospital environment, the issue is finally getting the attention it deserves. The data is truly alarming (no pun intended). One national survey from earlier this year showed that 19 of 20 hospitals ranked alarm fatigue as a top patient safety concern. Statistics frequently cite the number of alarms at up to several hundred per day for some patients. There have even been some well-documented cases in the media of harm resulting to patients when alerts are ignored. As a result of this increased awareness, the Joint Commission recently rated the problem as a National Patient Safety Goal and is requiring hospitals to take steps to address the issue.

It’s easy sometimes for physicians to think about the alarm as a “nurses problem,” but it really isn’t. The issue requires high level thought, because who decides what is or isn’t a necessary alert and is it right that the nurse is typically responsible for adjusting the alarm settings?

Aside from the safety issue, there’s also another elephant in the room. How often have you walked in to see a patient and heard them immediately complain about the fact that their machine has been beeping for a long time and it’s been bothering them? The nurse may have understandably been busy with something else and not gotten to it yet. It can be a big barrier to patient satisfaction and allowing our patients to get a decent rest.

In terms of dealing with the alarm fatigue problem, there are a number of potential solutions. Some institutions such as Boston Medical Center have successfully led initiatives by changing the settings of alert systems, such as those related to non-emergent bradycardia. In the future, different machines could even be designed, quieter for non-urgent alerts, or utilizing built-in systems that automatically page the nurse instead with certain issues such as an occluded IV line. The final option is to just keep the status quo, accepting that hospitals are places that must always have background alarms because of the nature of the work.

There’s no easy answer, but do give it some more thought next time you’re with a patient and hear that beeping …

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, July 24, 2014

Guidelines should rarely become rules

The blog FiveThirtyEight has this wonderful provocative article, ”Patients Can Face Grave Risks When Doctors Stick to the Rules Too Much.”

The subsequent comments have debates over the value of guidelines. Guidelines are like a box of chocolate, you never know what you are going to get. Many clinical questions yield “competing guidelines.” We all know the controversies over breast cancer screening and prostate cancer screening. Recently BP targets and lipid management have become controversial. Pharyngitis (a personal research interest) has multiple varied guidelines.

In the movie Pirates of the Caribbean, this classic exchange makes the point:

Elizabeth: Wait! You have to take me to shore. According to the Code of the Order of the Brethren …

Barbossa: First, your return to shore was not part of our negotiations nor our agreement so I must do nothing. And secondly, you must be a pirate for the pirate’s code to apply and you’re not. And thirdly, the code is more what you’d call “guidelines” than actual rules. Welcome aboard the Black Pearl, Miss Turner.

What is the problem? As one of my heroes said many times, everything in medicine requires context. We have differing opinions on the importance of that context.

Given that I have studied the pharyngitis problem for many years, let me use that as my example.

You are a primary care physician seeing an adolescent with pharyngitis. You have 2 concerns, helping the patient feel better and decreasing the probability of complications, either suppurative or non-suppurative.

Now imagine you are an infectious disease expert. You rarely see pharyngitis patients, but you are worried constantly about antibiotic resistance. Your concern centers on the “overuse” of antibiotics.

You can imagine how these two incarnations of you would view the problem differently. The first you is patient focused; the second you takes a public health viewpoint. Who is correct?

Actually, neither is correct and neither is wrong. The two versions of you have differing context.

Since both views have validity if one agrees with the context, developing a context free rule based on one of these guidelines would constitute a potential error.

The danger of rules (I hope you are reading performance measurement here) comes when they discount context. Some rules have resulted in patient harm.

When insurance companies judge, and even reward, physicians for meeting rule targets, some physicians will overlook context.

This Medscape article about hypoglycemia in the elderly raises important issues about HbA1c targets. Hypoglycemia a Greater Threat Than Hyperglycemia in Elderly.

Performance measures are rampant, primarily because the “suits” believe that we can use them to measure quality. I am proud that the ACP performance measurement committee carefully evaluates many measures. Often these proposed measures get a thumbs down. ACP Performance Measure Recommendations

We need a more widespread accountability on performance measures. The ACP committee careful evaluates the context of proposed measures. Why do other organizations not adopt this enlightened approach?

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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QD: News Every Day--Drugs that raise HDL didn't reduce cardio events, mortality

Niacin, fibrates, and cholesterol ester transfer protein (CTEP) inhibitors may have raised HDL levels, but they showed no effect on all-cause mortality, coronary heart disease mortality, non-fatal myocardial infarction, and stroke, a meta-analysis concluded.

Researchers reviewed 39 randomized trials of more than 117,000 patients receiving drugs that raise HDL levels. The meta-analysis appeared at BMJ.

No significant effects were seen for:
• all-cause mortality: niacin (odds ratio [OR], 1.03; 95% CI, 0.92 to 1.15, P=0.59), fibrates (OR, 0.98; 95% CI, 0.89 to 1.08, P=0.66), or CETP inhibitors (OR, 1.16; 95% CI, 0.93 to 1.44, P=0.19);
• coronary heart disease mortality; niacin (OR, 0.93; 95% CI, 0.76 to 1.12, P=0.44), fibrates (OR, 0.92; 95% CI, 0.81 to 1.04, P=0.19), or CETP inhibitors (OR, 1.00; 95% CI, 0.80 to 1.24, P=0.99);
• stroke: niacin (OR, 0.96; 95% CI, 0.75 to 1.22, P=0.72), fibrates (OR, 1.01; 95% CI, 0.90 to 1.13, P=0.84), or CETP inhibitors (OR, 1.14; 95% CI, 0.90 to 1.45, P=0.29).

Before the statin era, niacin was associated with a significant reduction in non-fatal myocardial infarction (OR, 0.69; 95% CI, 0.56 to 0.85, P=0.0004) compared to having no effect in patients taking statins (OR, 0.96; 95% CI, 0.85 to 1.09, P=0.52) (P=0.007 for difference).

There was a similar trend for fibrates and non-fatal myocardial infarction for patients before the statin era (OR, 0.78; 95% CI, 0.71 to 0.86, P<0.001) and after (OR, 0.83; 95% CI, 0.69 to 1.01, P=0.07) (P=0.58 for difference).

The authors wrote, “Although observational studies might suggest a simplistic hypothesis for high density lipoprotein cholesterol, that increasing the levels pharmacologically would generally reduce cardiovascular events, in the current era of widespread use of statins in dyslipidemia, substantial trials of these 3 agents do not support this concept.”

The study follows another report that niacin did not significantly reduce vascular events and did cause a variety of serious side effects for high-risk patients.

In case you missed it …

The Guardian brings us “Great moments in science (if Twitter had existed).”

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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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