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

Friday, September 19, 2014

Boom goes the dynamite

Oh yeah. Hot dang. All right. Groovy.

Boom goes the dynamite.

I had a very great day yesterday.

I saw 3 patients who had recent diagnoses of cancer. Yeah, those 2 statements seem to contradict. They don’t. Each person I saw gave me a clear view of how the practice I’ve been building over the past 18 months is making a difference. A big, big difference.

The first patient was a guy who is pretty far along in the treatment of his cancer. I sent him to a specialist about a year ago and he was diagnosed with a serious, but treatable form of cancer. While he’s happy with the overall outcome of his disease, he has lymphedema, which is making him very uncomfortable. Lymphedema causes swelling of soft tissue that is very difficult to treat, as it cuts off the normal drainage system for the fluid that is outside of blood vessels surrounding cells.

When he asked his specialists about this, they told him that nothing could be done. He expressed his frustration at the fact, so I did what every red-blooded person in 2014 would do: I Googled his problem. I immediately found a number of useful websites which talked about the exact problem he was facing, 1 of which was written by a physician who had dealt with his form of cancer (and has written a book chronicling his experience). While I read aloud from the website, he purchased the book from Amazon. I discovered that the pessimism of his specialists was not exactly right. In fact, I found out that there were important steps to take to prevent this problem from becoming permanent.

“Why didn’t my other doctors tell me this?” he asked.

I shrugged my shoulders. ”I guess they didn’t have the time to do it.” We had just spent about an hour together talking about his cancer experience and other non-medical things (computers, music). He nodded in agreement, acknowledging the reality the big advantage he has in my office: access to me.

The second patient, coincidentally, had the same kind of cancer. In fact, it was my experience with the first patient was just a few months before this second patient’s presentation that allowed me to quickly diagnose and treat his problem.

He had a peaceful expression as he sat across me in my office. ”This whole thing got me thinking differently about spiritual issues.” he explained. ”I just keep thinking about how many things worked out to get me diagnosed and treated. I noticed the lump and thought to myself: ‘I should make an appointment with Dr. Rob.’ and then you saw me the next day. Within a week I was diagnosed with cancer and things took off from there.”

I reminded him that before he got treatment, we had a discussion using secure messaging about “alternative” treatments for the cancer that were suggested by a family member. ”You remember when I told you about how Steve Jobs’ death was probably due to the time he spent going after alternative treatments before getting standard medical care?”

He nodded. ”Yeah, and I’m real glad I listened to you. Everyone has told me I’m doing amazingly well and have a good chance to be cured.” he told me. He looked away from me and took a deep breath. “I just wonder what would’ve happened if you weren’t in this office. I usually hate going to the doctor and put stuff off. I just wonder if things would’ve turned out like they did. It makes me feel like angels were around me.”

The third patient was a younger woman who was recently diagnosed with a very serious cancer. I saw her and her husband for the first time since the diagnosis. After tearful hugs and warm greetings, I asked how they were doing.

“Once we got over the initial shock of the diagnosis,” she explained, “we are doing much better.”

She had presented with symptoms not generally suggestive of cancer which persisted and grew worse. After going after the most likely causes, I got a secure message from the husband expressing his worry and asking me to do more to diagnose and treat her. After his message we immediately ordered the test that made the diagnosis. “She got really mad at me for doing that,” he said with a smile, “but I sure am glad that I did.”

She grudgingly agreed that he was right, and that (for once) a husband actually had an “I told you so” to hold over his wife. It’s usually the other way around. ”I would have waited much longer before doing that test. I’d probably have been nearly dead before making the diagnosis.” She paused and wiped away a tear. ”I’m just so glad you are our doctor.”

All 3 patients were significantly impacted by the different ways we do things in my new practice. Two of them may owe their lives to these differences. The main difference is the markedly better access my patients have to me. They don’t have a frustrating phone system to navigate, an army of office staff to convince, or a 2-hour wait to endure to get my time or attention. They needed my help, and they had easy access me when they most needed me.

One of the worst parts of the job of being a doctor is to diagnose people with cancer. At the same time, however, there is a sense of this being the highest honor paid to me as a person: I am the person who is there to help when the stakes are highest and the future looks darkest. I have the opportunity to be the right person at the right place at the right time. Bad stuff happens, and I will likely face many more sad yet meaningful days in the future where I am called on to stand beside people on the hardest days of their lives.

But yesterday made me happy. The hardest thing I’ve done in my life, giving up my old practice and starting something completely different, is succeeding. No, I’ve not yet earned enough to pay all of my bills (I am getting closer on that front). The success is measured in other ways: I’ve saved patients’ time, saved them lots of money, decreased their frustration, and restored some of their trust in doctors. This way of practicing medicine is not just different; it’s better.

Yesterday was the day when I saw its biggest success: My new practice saves lives.

Boom. Dynamite. Boom.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

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Physicians lose right of free speech

I’m all for free speech and I’m very hostile to censorship. The response to ugly speech is not censorship, but is rebuttal speech. Of course, there’s a lot of speech out there that should never be uttered. Indecent and rude speech is constitutionally protected, but is usually a poor choice. We have the right to make speech that is wrong.

I relish my free speech in the office with patients. I am interested in their interests and occupations and sometimes even find time to discuss their medical concerns. I am cautious about having a political discussion with them, but patients often want my thoughts and advice on various aspects of medical politics, and I am willing to share my views with them. I don’t think they fear that politics or any other issue under discussion will affect their care. It won’t.

A Federal Appeal Court recently decided in a Florida case that physicians could be sanctioned if they asked patients if they owned firearms if it was not medically necessary to do so. Entering this information into the medical record could also result professional discipline. The court was considering such gun inquiries to be “treatment” and not constitutionally protected speech.

I am on the record in this blog more than once that I do not think we should look to the courts to make policy. Their task is simply to rule on the legality of a particularly claim. In other words, we should not criticize a legal decision simply because we do not like the outcome. Nevertheless, this decision is simply beyond wacky and could create a theater of the absurd in every physician’s office

Could the following examples of physician inquires be prohibited?
• A psychiatrist cannot ask about cigarette smoking as this is not relevant to the patient’s depression.
• An internist cannot ask what the patient’s hobbies are as this is not germane to the medical encounter.
• A gastroenterologist asks his patient who is a chef for a recipe and risks professional sanction for crossing a red line.
• A surgeon asks a patient’s opinion about the town’s new basketball coach and hopes that this patient is not a planted mole recording the conversation.

So for those physicians who practice in the 11th Circuit, no gun inquires unless you can demonstrate with clear evidence that it has direct medical relevance. The court left open for now asking patients about sling shots, fly fishing and skeet shooting, but medical practitioners are advised to consult with their attorneys regularly.

Apparently, idiotic judicial decisions can still be the law of the land.

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, September 18, 2014

Sodium studies, with a grain of salt

Another week, another roiling debate about nutrition. In the immortal words of Iago the parrot, I’m going to have a heart attack and die from that surprise.

Actually, heart attacks are directly germane to this topic; strokes even more so. The particular goal of guidelines addressing salt (or sodium) intake is to prevent ambient high blood pressure, a major contributor to cardiovascular disease and the leading cause of stroke. There are numerous other health effects of sodium intake as well, including an influence on bone density, but blood pressure tends to grab the spotlight.

And spotlight it is at the moment. Recent studies have reached almost shockingly divergent conclusions about the pros and cons of sodium restriction. Compounding matters, the studies in question appeared in the very same issue of the New England Journal of Medicine, published on Aug. 14.

Two articles, by the same large, international group of researchers called the “PURE investigators,” standing for “Prospective Urban Rural Epidemiology“ study, challenged the current emphasis on restricting sodium. Or at least, that’s what the related headlines say. One of these studies looked at variation in sodium excretion in urine and its association with blood pressure; the other looked at the same measure and its association with all-cause mortality and cardiovascular disease.

For both of these studies, the authors used a database of morning urine specimens from over 100,000 people in 18 countries to estimate 24-hour sodium and potassium excretion, and from those estimated values, to extrapolate daily intake of sodium and potassium. We may leave the methods at that, other than noting that as estimates are predicated on estimates, the error bars get pretty wide, pretty fast.

As noted, the inevitably hyperbolic headlines attached to these studies suggest they found that we should abandon salt restriction, and pour it on. But here are what the authors concluded in their own words. In the first of the studies, they stated: “In this study, the association of estimated intake of sodium and potassium, as determined from measurements of excretion of these cations, with blood pressure was nonlinear and was most pronounced in persons consuming high-sodium diets, persons with hypertension, and older persons.”

If you think that’s a long way from “pour it on,” well, I agree. Essentially, the researchers found that excess sodium was most likely to raise blood pressure in older people, and those already prone to high blood pressure. And, high sodium intake was most important when sodium intake was ... high. Well, alrighty then.

Moving on. The second study concluded with this: “In this study in which sodium intake was estimated on the basis of measured urinary excretion, an estimated sodium intake between 3 grams per day and 6 grams per day was associated with a lower risk of death and cardiovascular events than was either a higher or lower estimated level of intake.”

Superficially, that translates to: we can eat too much salt, and we can eat too little. That we have long known, since sodium is an essential nutrient. Too little can result in a life-threatening condition called hyponatremia. The study may have raised questions about how much is too much, since the 3-gram threshold is higher than current recommendations, although not higher than prevailing intake. But we have to be careful not to over-interpret that isolated finding. What does it mean if your intake of sodium is lower than average for the population of which you are a member? It means you are different. That might be good, but it could readily be bad. Being “different” might mean not fitting in with prevailing norms for any number of reasons, from poor health to social isolation. A lower daily intake of salt could result merely from a lower daily intake of food. Where any of these factors is operative, they might account for variations in both blood pressure, and mortality, quite independently of sodium.

Wherever these first two studies left us, we couldn’t stay there long, because the third study followed immediately after to shake things up some more. This one, by a different group of investigators, obtained data about sodium intake and cardiovascular death for over 70 percent of the global population of adults. What’s good for the goose is good for the gander, so here is what these researchers concluded: “In this modeling study, 1.65 million deaths from cardiovascular causes that occurred in 2010 were attributed to sodium consumption above a reference level of 2.0 g per day.”

They went on to note that excess sodium intake was responsible for one in ten of all deaths from cardiovascular disease around the globe. Associated headlines either indicated that our salt intake is, indeed, too high; or more bluntly, that too much salt is killing us.

A pretty confusing batch of papers to say the least, and that, too, has made headlines.

Here’s where I think it all shakes out.

There is no doubt it’s possible to consume too little sodium, and there is no doubt it’s possible to consume too much.

Not everyone is equally sensitive to sodium excess, and in general, it matters more as we age, and to those of us prone to high blood pressure.

A lower intake of sodium than prevails in a given population might indicate other important differences in behavior, health, or social integration. The current studies account for these imperfectly.

The studies purportedly raising questions about the importance of sodium restriction are actually only challenging the optimal threshold, suggesting it should perhaps be 3 grams daily rather than the current World Health Organization recommendation of 2 grams daily.

Missing from all headlines is this important tidbit: More than twice as many adults have a sodium intake above 6 grams daily as have an intake below 3 grams daily; and nearly 7 times as many have an intake above 4 grams, as have an intake below 3 grams.

This, in my view, leads to key point one: it is theoretically possible to consume too little sodium, but whether the relevant cut-point is set high or low, the vast majority of adults living in the real world consume too much. All three studies actually agreed on this point.

So, yes, I presume if you fill a house with water, it might cause drowning. But I’m not sure that theoretical concern is of great practical value when putting out a fire.

The second key point, certainly for those of us in the U.S., is this: More than 75% of the sodium we consume comes from processed foods. This figures in the manipulation of recipes to maximize our calorie intake.

The implications are rather clear. Any shift from a diet of more to less processed foods will result inevitably in a decrease in sodium intake. That shift is advisable because of the decisive health benefits associated with it, and regardless of the specific contributions of sodium reduction to that benefit. A typical American diet tends to be too high in sodium whether the higher or lower cut-point is invoked. But its more important liability is likely the fact that it is a typical American diet, in which a third or more of calories routinely come from “junk.” There is no debate about the value of eating food in place of junk.

As ever, competing headlines propagating confusion are partly a result of the legitimate nuances associated with the incremental advance of scientific understanding, and partly the machinations of media profiting from hyperbole and intrigue. But we can bypass the potential confusion altogether if we take it all with the proverbial grain of salt.

Whether the topic du jour is sodium, or fructose; wheat or meat; gluten or saturated fat, we are subject to the impasse of perpetual confusion if we fixate sequentially on each successive study of each particular nutrient. If instead we embrace what we reliably know about healthful eating in general, sodium intake will tend to fall in the sweet spot, along with the intake of all other nutrients. In other words, we could reliably defend ourselves against hyperbole and headlines, malnutrition and misinformation alike, with wholesome foods, in sensible combinations.

Tune in next week when that news ... will be exactly the same.

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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Wednesday, September 17, 2014

Physician drug testing

The New York Times reported on a ballot initiative in California that would mandate random routine drug and alcohol testing of physicians, and targeted testing after major adverse patient events. The full text of the proposal is available here.

Proponents of the measure (Proposition 46) highlight the danger posed by impaired physicians and the ubiquity of drug testing for other professionals such as airline pilots and public safety officers. They also endorse the other “patient safety measures” included in the proposition, including mandating that providers check a controlled substance database similar to the New York State I-STOP database before prescribing. Their arguments are summarized here.

Predictably, the California Medical Association opposes the measure, mostly they say because it would also raise the current cap on “pain and suffering” payments in malpractice suits, and lead to higher malpractice insurance costs. Interestingly, the CMA website opposing the proposition doesn’t mention the drug testing provision.

My first reaction when I read about the drug testing initiative was one of sadness. What a shame that we have failed to maintain the public trust in our profession. But I was also reminded of a case I was involved in years ago in which a physician’s careless act led to a patient’s death. I have long regretted that I failed to insist that the physician be tested for drugs or alcohol at the time. If the death had been caused by a plane crash or a bus accident, we would all expect such testing to take place, and its omission would never be tolerated by the National Transportation Safety Board.

The mission statement of the CMA is: “Promoting the science and art of medicine, the care and well-being of patients, the protection of the public health and the betterment of the medical profession.” Seems to me that if they really mean it, they ought to be in favor of drug testing.

What do you think?

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. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. 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.

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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.

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.

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.

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.

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).

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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