ACP Internist Blog


Monday, September 17, 2018

Getting there

I had the opportunity last week to participate in a day-long meeting sponsored by the Heart Rhythm Society. The goal was to help HRS develop recommendations for physicians and industry on providing patients access to information generated by wearable and implantable cardiac electronic devices. The organizers invited me to provide the viewpoint of an educated patient.

I can't say how HRS will ultimately craft the guidance (and I am not involved in writing it), but the discussion was lively, and I came away with a number of impressions.

First, device manufacturers understand that they must move to afford patient access to the data their products are generating, but they are limited in how quickly they can do so by a number of factors, including the slow pace of technical iteration created by close regulatory oversight, the uncertainty of what data patients want and how to present it, and concerns about getting out ahead of electrophysiologists (their traditional customers) on this issue. Nevertheless, I was impressed that there seemed to be unanimity of opinion among the manufacturers that patients should have access to the same data that doctors see.

Second, I learned that defining which data patients or their doctors get to see is more complicated than I thought. For example, a pacemaker may have proprietary software for arrhythmia detection. Does the “device data” include the algorithm, the data-set of recorded R-R intervals and QRS morphologies, or just the output of heart rate and rhythm? While there is a need for more discussion, definition and consensus around these issues, I was pleased again to see that most everybody agreed that patients should see whatever their doctors are seeing.

Last, the regulatory environment has not kept up with changes in technology and demands for more data transparency. A representative of a home monitoring technology pointed out that sharing “machine readings” of rhythm abnormalities with patients would subject his company to a much higher level of regulatory scrutiny than it now has to comply with as a purveyor of information to physicians, who are assumed capable of independently interpreting the findings.

All in all, I left encouraged that we are getting closer to the goal of “data about patients should be the patients' data.”

What do you think?

Ira S. Nash, MD, FACP, is the senior vice president and executive director of Northwell Health Physician Partners, and a professor of cardiology and professor of occupational medicine, epidemiology, and prevention at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. 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. He then held a number of senior positions at Mount Sinai Medical Center prior to joining Northwell Health. He is married with two daughters and enjoys cars, reading biographies, and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.
Friday, September 14, 2018

TSA and the Quiet Skies Program: a lesson for doctors?

Consider these behaviors. A newborn calf nurses from his mother. A robin places a worm into the gaping mouths of her offspring. Cats know how to hunt.

These behaviors are examples of instinct. The creatures do not even understand why they engage in these acts. They are inborn behaviors.

Humans have instincts also. Unlike most professional standards and qualifications, instincts cannot be easily quantified or tested. But, under certain circumstances, they are invaluable assets.

We learned last week that the Transportation Security Administration (TSA) has been pursuing a program called Quiet Skies, when passengers who have met certain criteria are monitored for various behaviors that might suggest that closer scrutiny is warranted. I am making no comment here on the merits of the program, but I am supportive of TSA using instincts of air marshals as a tool to evaluate threats. Some have criticized this as an infringement on passengers who are not under actual suspicion or been charged with a crime. But, if we strip instinct and suspicion from the armamentarium of our security services, then what is it exactly that makes these folks actual professionals? Do we want “box checkers” or real pros?

Of course, most of the time suspicions will not be borne out. This does not mean, however, that the tool is invalid or that the target should feel victimized. Before, we cry “discrimination!”, let's consider what the stakes are here. This is not an improper search of your car trunk; it's blowing up an airplane.

I related to this issue since seasoned physicians rely so often on our instincts and sixth senses about our patients. Every physician has said or thought throughout his career, “something is not right here,” even if all of the objective data seem to line up. I think patients understand this and want their doctors to use their intangible skills along with their stethoscopes. Frankly, it is these skills, in my view, that are amply present in our very best physicians.

While you can't teach these skills, doctors over time do develop them. While younger physicians have much to teach us experienced practitioners, we have a few things to offer them, at least that's what my instincts tell me.

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.

On teaching clinical reasoning, all about case conferences

When we studied ward attending rounds, the thought process represented the top attribute that learners valued. Learners can learn facts from textbooks, but using those facts requires experience and role modeling.

I have given many lectures on clinical reasoning and I have attended many lectures on clinical reasoning. These lectures can entertain, but one lecture does little to help our colleagues and our learners.

We must structure case conferences as a primary way to teach and learn. Lectures may help occasionally, but often the information in a lecture leaves our memory quite rapidly. But a case discussion gives the story bones on which to attach the meat!

Many years ago I had GI distress and hives after a seafood lunch. For years I thought I had developed a scallop allergy. Then I heard a similar case presented with a diagnosis of scombroid. That one case made my diagnosis, and has helped me make several more diagnoses.

At our institution we address case conferences in several ways. The majority of our morning reports use case presentations with a clinician discussing the case as it unfolds. Residents often rate these conferences as the number two learning opportunity in residency (after daily rounds). At our Grand Rounds, while we often have pure lectures, we do have occasional CPCs that remain quite popular. Our GIM noon conference has both CPCs and CPS (clinical problem solving). We do CPS every month with 1 attending physician presenting patients to another attending physician. The discussion focuses on the thought process. Residents and students love this conference.

But for me the best conference is Tinsley conference (named after our hero, Tinsley Harrison, our Osler-like influence). At Tinsley, the chief residents choose the most interesting patients from our teaching service (also name after Dr. Harrison) and present it to a room full of students, residents and attending physicians. In this conference, faculty do most of the talking. We have many subspecialists who attend regularly. Thus, we have general internists and a variety of subspecialists helping to dissect the details of the presentation. I always learn a great deal.

We must model clinical reasoning. Patient stories provide the bones, and the discussion provides the meat. The meat sticks because it attaches to the bones. When done properly these conferences help us all improve as clinicians.

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.
Thursday, September 13, 2018

A major academic medical center removed historical physician portraits

In June, a story circulated online about how Brigham and Women's Hospital in Boston, one of the most famous academic medical centers in the United States and a major Harvard Medical School affiliated institution, decided that it would take down physician portraits that were hanging in a popular and historic lecture theater. The reason? Well, it was felt that the portraits were predominantly of white male physicians, who had been esteemed teachers and leaders of medicine over the decades. In today's environment of wanting to promote inclusiveness and diversity, it was felt that these pictures were “the wrong message to send”.

After this story was made public (you can read the Boston Globe article here), it was widely circulated online. I, myself, learned of the story when some physicians (also from major academic centers) started sharing the story on social media, predominantly feeling proud of Brigham's decision.

This story piqued my interest. As somebody who is a keen reader of history, and also a physician, it actually disappointed me on a few different levels that our collective psyche and culture is moving in this direction. Of course, as an ethnic minority and person of color myself, I am always going to be for anything that promotes a culture of diversity and mutual respect. But there's a right and a wrong way to go about progress, and the move that Brigham took, and the subsequent reaction of delight by so many educated people, surprised me a bit.

Over the years, since I was a student, I have always enjoyed walking through medical institutions and looking at the historical pictures. I find them both fascinating and also sometimes slightly amusing (especially the attire and solemn facial expressions!). I have never once felt intimidated or angry looking at a portrait, or felt like it hinders my own progress. On the contrary, I just smile at myself inside, and wonder what they would think now in today's great and highly diversified environment. My own attitude and response would be to celebrate today's more inclusive society by putting up new pictures (or statues) instead—but not tearing the old ones down. Heck, why not do something like put up a portrait of a distinguished modern-day woman physician of color, right next to them?

From a purely medical standpoint, these were fine physicians who made immense contributions to the field of medicine, many being called world pioneers in their respective fields. The education and progress of mankind has been a long and sometimes painful process. If you could find me evidence that these physicians were criminally flawed or controversial individuals, that's another matter. But if the reason for removing them is based purely on not wanting “old white males” hanging on the walls, with the concern that it sends the wrong message, that may be a deeply flawed way of thinking. These distinguished individuals helped build the institutions we have today, and that shouldn't be something to be ashamed about, or feel like it should be hidden away to suit our modern-day way of thinking. On the contrary, they should continue to be celebrated and revered, regardless of race or gender. Removing historical images and statues of people who have done nothing wrong, just because of concern about “sensitivities,” is in all actuality not too far off being the mirror image of how the Taliban thinks!

This also gets to a larger debate that we are currently grappling with in society. The history of most nations is difficult to look back upon. The trend, particularly for some of the younger generation, of wanting to judge history and historical characters by today's standards and demand “perfection.” Unfortunately, we won't find it in many places. Even America's biggest hero, Abraham Lincoln, when one reads what he actually wrote, had some very controversial and odd views on societal structure and race. What other big names like Thomas Jefferson and George Washington said and did is also well known. Such were the times until relatively recently.

This slope is a slippery one. The Pandora's box is giant. Not only would you end up having issues with almost every single older institution, and person in every country who lived more than several decades ago, but you waste an awful lot of time too. Far more productive to just celebrate today's progress and look forward instead.

Brigham, you may be a great hospital and school, but you made a disappointing call. As a temple of education, you should not be in the “let's delete history” camp. You should be all about acknowledging and educating, and then building bridges to a better future. You should also be familiar with the age-old adage: “Those who seek to erase their history, are bound to one day repeat it.”

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.