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Friday, April 29, 2016

Is uterus transplantation ethical?

I am not a woman. I cannot contemplate the physical and emotional experience of carrying a pregnancy and birthing a child. I imagine that it is a singular experience that is as deep and awesome today as it has always been. We have all seen the explosion in reproductive technology with in vitro fertilization, surrogate mothers, fertility agents and other emerging techniques. This process, beyond the high costs, can create anguish for those who are on this journey.

I have felt in many instances that the ethical ramifications of some of these techniques are minimized or dismissed. Sadly, we often do stuff because we can, not because we should. Do we really think we can stop human cloning?

Recently, a woman in Cleveland had a cadaver uterus placed during an extremely demanding 9 hour operation on February 24, 2016. This was the first time this was performed in the United States. Only a handful of these operations have been performed worldwide. This woman, who has adopted children, was born without a uterus and yearned to carry a pregnancy. As this operation was part of a clinical trial, I assume that it was paid for out of grant funds. Shortly after surgery, a complication developed and the uterus was urgently removed.

Uterine transplants are not a 1-day affair. To prepare, the recipient's eggs are harvested and then embryos are created and frozen. Then, the complex process of finding a donor is triggered. The donor organ is harvested and must be transported to the recipient. Then, the all-day transplant surgery occurs. The patient is then kept on anti-rejection drugs. A year later, the embryos are implanted. Deliveries are performed by Caesarean sections. After the desired number of pregnancies, the uterus is removed so that the anti-rejection drugs can be withdrawn.

The cost of all this is unfathomable, assuming that no complications occur that would require additional care. It is certainly possible that a woman could go through the entire process and not carry a baby to term. Indeed, very few successful pregnancies have occurred worldwide.

I request that readers contemplate the following concerns regarding uterine transplant.
• Can society justify this massive cost for a procedure that is not necessary to save a life or cure a disease?
• Is it ethical to risk a healthy patient's life with highly complex surgery even if she consents to it?
• Is it ethical to maintain anti-rejection drugs, which have risks of severe complications, for years to preserve the transplanted uterus?
• Is there a right to pregnancy that the medical profession is obligated to satisfy regardless of the financial, emotional, and ethical costs?

If this technique gets perfected, then it might become possible to implant a uterus in a man. Then, perhaps, I will have the opportunity to experience the profound wonder that has eluded my gender since the beginning of time.

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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Monday, April 25, 2016

Patient-centered service

American health care has a customer service problem. No, customer service in the U.S. is terrible when it comes to healthcare. No, the customer service in the U.S. health care system is horrendous. No, health care has the worst customer service of any industry in the U.S.

There. That seems about right.

What makes me utter such a bold statement? Experience. I regularly hear the following from people when they come to my practice:
• “You are the first doctor who has listened to me.”
• “This office makes me feel comfortable.”
• “I didn't have to wait!”
• “Where's all the paperwork?”
• “Your office staff is so helpful. They really care about my needs.”
• “This is the first time I've been happy to come to the doctor.”
• “It's amazing to have a doctor who cares about how much things cost.”
• “You explain things to me.”
• “You actually return my calls.”

Each of these things is said as a sincere compliment, with a degree of wonder in their voices. People simply are not used to getting any customer service. By these compliments, I must assume that the majority of people's experience with a physician's practice is:
• They do not feel listened to by their doctor.
• Doctors' offices are uncomfortable.
• Visits usually involve long waits and extensive (and pointless) paperwork.
• Office staffs are usually unhelpful and don't act like they care about people's needs.
• People are never happy to go to the doctor's office.
• Doctors seldom pay attention to the cost of the care they give.
• “Care” from doctors is often poorly explained, and so patients often leave confused.
• Attempts at communication are seldom fruitful.

Add to this the ridiculous wait times, the unreasonable and confusing cost of care, and the plunging morale that people routinely face in medical practices, and you get a frightening picture of a system supposedly dedicated to helping people. What other industry has such a damning set of “normals.” Airlines? Cable TV companies? DMV offices? I have to confess, this makes my job much easier; it's a very low bar to cross. Basically, people are amazed that I don't totally suck. That makes me glad for me and my patients. That makes me really sad for most people.

The obvious question that arises from this is, how did the service that people expect to receive from their doctors get to be so terrible? Shouldn't professionals who dedicate their lives to helping others, even saving lives, be even remotely concerned about the way these people are treated?

As always, the answer lies more in the system itself than in the people working in that system. The simple truth is that in our system the patient is not the customer; the third-party payor is the customer. The product sold at hospitals and doctors' offices is not health care, it is CPT and ICD codes, for which they are paid proportionate to the number and severity of those codes. The patients, instead of being the customer, are the raw materials from which codes are extracted. This means that the best business practice for healthcare providers is to extract as many codes from the most patients in the shortest time possible. So the system rewards the exact things people don't want from their doctors.

You get what you pay for.

There is one piece of evidence that convinces me that the system is the corrupting force that wrecks customer service: me. I spent 18 years in that system and have now been outside of it for the past 3. Since working in a system where I am paid directly by my patients:
• I am always thinking about improving the experience my patients have in my office because they can always leave me.
• I am constantly trying to save them money. Part of this is to justify their “extra” payment to me, but much of it is simply because it is what they want. Making them happy keeps them coming back.
• I have centered my practice around communication and access because that is what my patients (my customers) value the most.
• My office is clean and comfortable. We routinely offer people coffee or tea. I often talk to patients in my office (they sit on a comfy couch), not in the exam room.
• I make it a point to explain things to people so they are comfortable and confident in the care I give. I tell people, “if I can't explain why you need to take any medication, don't take it.”
• I put a priority on getting to know new patients to understand their priorities.
• People almost never have to wait in my office (except when they come early).
• We always tell people the cost of what we are doing and of the medications we are prescribing. When people can't afford medications, we do whatever we can to bring the cost down. One of my nurses dedicates many hours to getting free medications from drug companies for low-income patients.

I do these things for 1 simple reason: my patients are my customers. The more customers I have, the better income my business gets. My patients won't stay my patients for long if my service gets anywhere near the norm for doctors' offices. There is a bonus, of course: it's the nice thing to do. My business model makes being nice an asset, not a liability.

I've read rants by doctors who rail against the idea of patients being customers. If the patient is the customer, they argue, then aren't we obligated to give them antibiotics or pain medications when they ask for them? Doesn't this obligate us to follow the oft-quoted maxim, the customer is always right? This, of course, is total horse hockey (for both regular business and healthcare). Good service is simply good business. But more than that, good service as a physician has a much bigger effect. This is what I've seen over the past 3 years:
1. Treating my patients with courtesy and respect make it far more likely that they will show the same to me. They seem to like me more.
2. That respect (and affection) makes it more likely they will listen to what I say.
3. This means that compliance with medications and other treatments is far higher than it ever was. I am able to hold off on antibiotics and handle pain medications much better.
4. People don't avoid coming to see me, and so I can catch problems earlier. This has had life-saving consequences on several occasions.
5. When I show respect for people's time and money, they are much more trusting of me. People open up to me more about things they don't say to others. They believe I really care, and my office doesn't contradict that fact.
6. Because I care about their lives, they have taken a much higher interest in my life. They encourage me to take days off, ask me about my family, and basically treat me as a person who they care about. Because they do. They value me because they believe I value them. This makes me much happier.
7. Good service also makes my staff much happier, as they are beloved by my patients and highly valued by me. This too improves the overall care people get in my office.

In short, good customer service makes being a good doctor much easier and much more enjoyable.

Of course, I've had people come to me hoping I'll be a Pez dispenser for Percocet or Zithromax. These folks are disappointed when I instead take the time to discuss the proper use of these medications. Some leave me. But many who have come with this intent in mind have been so surprised at being treated with caring and respect that they listen to what I say and continue in my practice.

The vast majority of people truly want a doctor they respect and actually like. This may come as a shock to many of my jaded colleagues who routinely face the ire of people stuck in waiting room purgatory, ignored or disbelieved by doctors, and treated as objects instead of people. They think that people are angry because they don't like doctors. They view the people on their schedule as, at best, the hungry masses they must placate and, at worst, as their adversaries they must conquer. Then they wonder why their patients are so unhappy?

The past 3 years has taught me otherwise. People want to like their doctors. We just haven't given them any reason to do so.

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Friday, April 22, 2016

Do heartburn medicines cause dementia?

Proton pump inhibitors, or PPIs, are among the most common drugs prescribed in the United States. They are extremely safe and highly effective for gastroesophageal reflux disease (GERD). Are there potential side-effects? Of course. Look up the side effects of any of your medicines and you will soon need an anxiety medicine to relieve you of side-effect stress. The side-effect lists of even our safest medicines are daunting.

PPIs are associated with a growing list of potential serious side-effects, at least according to the lay press. A few clicks on your computer, and you will find that these medicines can cause pneumonia, Clostridium difficile colitis, malabsorption of nutrients, bone fractures and anemia. The latest report to emerge links these drugs with dementia. In the past 2 weeks, I've been questioned about this repeatedly by my patients. One stopped her medication from fear that her heartburn medicine might be incinerating her neurons.

While no drug, including PPIs, is entirely safe, I have never seen a serious PPI side-effect, having prescribed them to thousands of patients. I'll bet that your gastroenterologist and internist can boast a similar track record. Doesn't that experience mean something?

The lay press, in my view, often covers medical science carelessly and without context. The science underlying the above listed PPI side-effects is extremely thin. Yet, the headlines describing them can sound authoritative and persuasive. Remember the adage of local TV news, if it bleeds it leads? Same concept.

Which of these 2 headlines or sound bites would be more likely to appear?

Nexium, superb heartburn fighter, may have questionable effect on bones, although results preliminary.

Nexium leads to hip fractures!

The scientific studies that link PPIs to bone disease or dementia are not high quality research studies. These studies are done on large populations of individuals and do not demonstrate any actual causative effects of the medicines. When you read the word associated, as in Nexium is associated with cognitive decline, you can accurately interpret that statement to mean there is no proof that Nexium causes dementia. Association is a weak link which has results from a weak study.

For the same reason, favorable results from similar studies should be viewed with great skepticism. Next year we may read that Nexium is associated with a reversal of male pattern baldness and enhanced libido. (If this hypothetical were to truly occur, then I hope that I can time my stock purchase just prior to the announcement.)

So, if heartburn patients have forgotten their keys somewhere, there is no need to flush your heartburn medicines down the toilet. You are not losing your mind, just your keys. Remember, much of what we read and hear in the lay press is associated with ignorance.

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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Thursday, April 21, 2016

Paleo meat meets modern reality

The Oldways Common Ground conference I was privileged to co-chair with Walter Willett last November had no shortage of riveting moments, as the recent posting of conference videos reminds me. But one really stood out.

Boyd Eaton is arguably the founding father of our modern understanding of, and preoccupation with, the Paleolithic diet. He shares credit with a very short list of others, among them his frequent co-author, Mel Konner. But there is no question that Boyd is on that short list. You can be confident that whoever provides you guidance on the Paleo diet concept gets their guidance from someone who gets their guidance from the work of Prof. Eaton. His work is all but universally recognized as part of the bedrock of our understanding.

What stood out, then, was Prof. Eaton's call for people to eat less meat. Not none, necessarily, although that's an option; but considerably less.

Let's be clear, Prof. Eaton is in no way “anti” meat. He readily acknowledges his own taste for it. He feels that all humans share that taste, whether they choose to indulge it or not, or even acknowledge it. And, he argues, rightly, that we are constitutionally, adaptationally, physiologically omnivorous.

But after allowing for all that, Prof. Eaton says, in essence: too bad! There are two basic reasons for his position, one the lesser, one the greater.

The lesser issue is the nature of the meat in question. That mammoth is no longer a choice is a given. Is modern meat like the meat our Stone Age ancestors ate?

The work of Prof. Eaton and his colleagues provides a very clear answer: not much. I have noted before that people routinely wave the “Paleo” banner as an excuse for eating pastrami, and that's baloney. Prof. Eaton agrees. For the rather dramatic nutritional and compositional differences between the modern meat that prevails, and the meat our Stone Age ancestors are thought to have eaten, I refer you to Dr. Eaton's original papers.

Those trying to have their side of beef and eat it, too, often talk about narrowing the gap between modern meat, and the kind of meat we “should” all eat. Pure meat. Ethically raised, free to range, well fed, organic, and all that. The trouble, of course, is that there simply isn't enough free range on the surface of the planet to raise enough animals that way to feed 8 billion quasi-carnivores. Mass production conspires against all of the very methods the “as long as it's pure” crowd espouses.

So, if you advise everyone to eat meat, but then add provisos about the purity of the meat, only one of two things can ensue. Either everyone ignores you, in which case your advice was rather pointless. Or people listen, in which case the demand for meat you've now fostered decimates the production methods you claim to favor. The production methods that supplant them give us meat nothing like that of our Stone Age ancestors.

The greater reason is, quite simply, the global human population and its impact on the planet. The Stone Age was home to scattered, isolated bands of Homo sapiens. There are now ever closer to 8 billion of us. Prof. Eaton states quite categorically that 8 billion Homo sapiens cannot have a meat-centric diet without ravaging the Earth; period.

This by no means makes our Paleolithic adaptations irrelevant; they still help define who we are, and inform what we need. Prof. Eaton's papers present estimated intake ranges for many nutrients, which may provide guidance toward optimal levels by clarifying native levels.

Dr. Eaton commented to me that the Paleo model advocates a higher protein diet than do many nutritionists, especially for children and teenagers, at least until full height is attained. There is lively debate in this area, in part because what was optimal for a physically demanding, 4-decade life span may or may not be so for a generally less strenuous but far longer life. Either way, Dr. Eaton goes on to say that we should get our protein, at whatever level, predominantly from plant sources now. (He noted in addition that the very well planned meals at the Oldways conference proved to him how delicious a plant-based, high protein meal could be.)

All too often, discourse on diet devolves into ideology when it should be bound to epidemiology. All too often, we approach dietary proclivities with nearly religious fervor, and fail to separate church and plate. All too often, some label like “Paleo” ignites fierce passions, and our imaginations, and we follow both into fantasy land. This is a reality check, from a uniquely qualified authority.

The modern reality is that we aren't in the Stone Age anymore. We can certainly learn from our Paleolithic experience, but we cannot replicate it in the 21st century, among our billions, and Tweet about it. When one of the world's foremost authorities speaks out on the implications of that, everyone waving the Paleo banner should set down their smartphone for a moment, and pause to listen.

This column was reviewed and approved by Dr. Eaton before publication. Both Dr. Eaton and Dr. Melvin Konner are members of the Council of Directors of the True Health Initiative.

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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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 Iowa City, IA, 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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