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

Thursday, October 20, 2016

The awesome human factor

Recently I watched the movie Sully. It was the first time I'd ever watched a movie on its actual release date. Knowing what a legendary actor Tom Hanks is, and what a fascinating and near-tragic story unfolded on Jan. 15, 2009, I felt confident that my choice to venture out to the cinema on a beautiful Boston September evening, would be a good one. The movie sure didn't disappoint. Brilliantly directed and acted, the viewer learns about the series of events that unfolded after US Airways flight 1549 encountered a flock of Canada geese 3 minutes into the flight, causing catastrophic bilateral engine failure. Captain Chesley Sullenberger, who had a lifetime of aviation experience (and a keen interest in airline safety) heroically guided the stricken plane into the Hudson. Miraculously, everyone survived—and the rest is history.

The movie guides us in detail through the subsequent events, when the National Transportation Safety Board (NTSB) investigates what happened and whether Captain Sullenberger could have made it back to the airport safely instead of landing in the freezing Hudson River. I have read conflicting reports about whether the NTSB was as harsh in their initial assessment as the movie makes out, but as the story unfolded, the viewer was left with the feeling that it was the hero Captain Sully versus an uncompromising and mean-spirited safety review panel.

The aviation industry is rightly seen as a role model of extremely lofty safety standards, and many leaders in other industries have attempted to emulate their success. I have written previously about how lots of prominent health care leaders have also sought to do this, and how despite some good intentions, the comparison is a flimsy one.

One theme that comes up a lot in Sully, and is passionately defended by Captain Sullenberger, is the “human factor.” Hindsight is always 20-20, and everyone is always the wiser afterwards. This does not mean that we shouldn't investigate and analyze, but the problem with the so-called experts' initial analysis of Flight 1549, was that an engine-failure so soon after take-off was completely unprecedented, and nobody could confidently say how a human being would respond.

It turns out that the computer simulations that were used by the NTSB were incorrectly stating that a pilot could have made it back safely to a runway. In actuality however, only after a large number of attempts, did any simulator pilot make it back safely (and that was using the assumption that they knew immediately what had happened and what to do). Captain Sullenberger's defense of his own actions turned out to be right, and it was in fact only the human factor i.e. Captain Sully's actions, that saved the lives of all 155 people on board. Turns out no computer would have done that.

As the term “human factor” kept coming up in the movie, it got me thinking again about the health care comparison, and how it's really only that which puts the “care” into health care. In my capacity as a doctor, and all the other work I do in the entrepreneurial, writing and consulting realms—I meet so many people who are involved at the peripheries of healthcare. Technologists, start-up folk, “Big Data” people and yes, regulators and administrators—and there's 1 common theme that unites all of them. When you talk to most of them (and again, I hate to generalize, but for most of them it's true), they appear to have little understanding of the frontlines of medicine and the heroic work that goes on day in and day out. To them, medicine is all about numbers, outcomes and population health. The whole agenda appears to do everything possible to completely take out the “uncontrollable human factor.”

The problem with this perspective is that health care is different from any other industry, and this “helicopter view” doesn't quite make the cut. Caring for people is not like running a factory assembly line or operating a large automated machine. Whether we are talking about individual doctor-patient (or even nurse-patient) everyday interactions, or life and death situations such as a patient coding in the hospital—you cannot separate out the science from the human factor in an arena that is so full of very real human emotions. That's why anybody who takes an armchair general or Monday morning quarterback approach is doing the wrong thing. By all means investigate, be thorough, seek to improve, and hold to account any deviation from normal protocol, but never forget the very human side of medicine. The general standards of health care in the United States are already exceptionally high when compared to almost any other country, and the reality is that everyone is so highly trained that really serious mistakes are thankfully rare.

What everyone does in health care is heroic. Doctors, nurses, or any other professional who shows compassion and cares for the sick when they need help, are doing a noble thing. Using your skills to get people better may seem like “just a job” after a bit, but you are having your own Captain Sully moment every time you selflessly dedicate yourself to your patients' wellbeing.

Sitting talking to an elderly patient reminiscing about his Second World War experiences, spending an extra 5 minutes with a family who has had their whole world turned upside down, holding the hand of a dying grandmother who is expressing her biggest regret in life, or calmly facing the parents of a child who has been diagnosed with terminal illness. In health care, the human factor is everything.

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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Wednesday, October 19, 2016

Why I oppose home strep testing

Recently I read this tweet, “home strep test likely to reduce inconvenience, cost, strep complications, unneeded antibiotic and antibiotic resistance #medx”

I disagree, but the reasons are fairly complex.

In order to understand this problem, we have to define the possible test, its use, the likely misuse and both the intended and unintended consequences of such a test.

What makes a good home test? Users should have no difficulty collecting the test sample. The test performance must be straightforward and simple. The test should answer a question that has a dichotomous implication.

Clearly, even health care professionals receive criticism in obtaining tonsillar swabs. So that would make our current tests difficult to perform for many at home. Possibly one could use a spit test—again difficult to perform.

One could possibly develop a test that is almost foolproof to run. That does represent another challenge.

But the real problem is the rationale for the test. The underlying assumption of the strep test does not pass muster. Advocates would argue that patients either have group A strep pharyngitis (and thus deserve antibiotics) or not (and thus do not deserve antibiotics). This assumption has flaws on both positive tests and negative tests.

All guidelines recommend not testing patients for group A strep unless they have a Centor score of 2 or greater. Currently many urgent care centers, emergency departments and retail clinics test everyone, regardless of the score. One would expect many to run a home test for any sore throat, therefore leading to continued overtesting. Most experts believe that treating the zeros and ones means that we are giving antibiotics to carriers.

The next false assumption is that the test is highly reliable. Our meta-analysis (as well as other expert estimations) shows that the sensitivity in practice settings is only around 80-85%. Thus, as high as 20% of patients with strep throat are missed with a rapid test.

But the biggest problem is that rapid strep tests oversimplify our approach to sore throats. In pre-adolescents we really do primarily worry about group A strep, but acute sore throats in adolescents and young adults have a wider differential diagnosis that group A strep only.

A home strep test would not diagnose group C Streptococcus or Fusobacterium necrophorum pharyngitis. It would not help diagnosis infectious mononucleosis. A home strep test could give a false sense of not having a dangerous diagnosis. Acute pharyngitis can turn into worsening pharyngitis.

Admittedly, many physicians do not consider the entire differential diagnosis of acute sore throats or even understand when the patient does not have an acute sore throat. Will patients know when to seek medical care if they have a negative strep test?

Many patients and physicians seem to embrace the phrase “just a sore throat”. I fear that a home strep test would reinforce that phrase.

I have written before about long tail problems. Most sore throats are self-limited, but sore throats can portend great morbidity and even mortality. I fear dumbing down sore throat presentations. We need physicians who understand the complete differential diagnosis of sore throats. We need physicians who understand the “red flags” that alert us that it is not “just a sore throat” but rather something more complicated. (infectious mono, early HIV, peritonsillar abscess, Lemierre syndrome, Still's disease, leukemia, etc.)

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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Tuesday, October 18, 2016

Nursing staffing levels threaten patient care

On the day that I penned this post, I rounded at our community hospital. My first patient was in the step-down unit, which houses patients who are too ill for the regular hospital floor. I spoke to the nurse in order to be briefed on my patient's status. I learned that this nurse was assigned 6 patients to care for, an absurd patient volume for a step-down unit. “Why so many patients?” I asked. She explained that some nurses called off work and the patients had to be spread around among the existing nurses.

This occurs every day in every hospital in the country. Nurses are routinely required to care for more patients than they should because there is a nursing shortage on a particular day. Why do hospital administrators allow this to happen? If any are reading this post, I invite your response. Enlighten us. When a nurse is overburdened, how do you think this affects quality of care and nursing morale?

I suppose it saves a few bucks on payroll, but this strikes me as very short term gain that risks medical and financial consequences. Providing high quality medical care can't be a rushed effort. If a nurse's job description increases by 30%, do you think the quality of care and patient/family satisfaction won't decline? Don't administrators fear the risk of medical errors from overworked nurses? Would any of them like to be patients under these circumstances?

Nurses have confided to me for years how demoralized they are that no one speaks for them. Instead of watching their backs, they often feel that they are stabbed in the back.

I do not have warm feelings for labor unions and I support right to work initiatives. But, when I see what nurses endure and the lack of support that they receive, I would support them if they moved to organize.

If a third grade teacher is ill, we expect a substitute teacher to be called in. The third graders are not simply herded into another classroom expecting 1 teacher to handle a double load.

Many of us today are asked to do more with less. Teachers, law enforcement, businessmen and government program administrators know this well. At some point, you aren't cutting fat anymore, but are slicing into bone. We are not taking proper care of those who have dedicated their lives to care for us. Who will heal the healers?

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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Goodbye triclosan and triclocarban

Back when I was an infectious disease fellow, I completed a national survey (along with Anthony Harris) of the availability of tricolsan and triclocarban containing antibacterial soaps. At the time, the industry wouldn't release the use or sales data we needed to estimate a population risk from these chemicals. We found that 76% of liquid soaps and 29% of bar soaps sold to consumers contained these agents. Fifteen years ago we concluded: “with limited documented benefits and experimental laboratory evidence suggesting possible adverse effects on the emergence of antimicrobial resistance, consumer antibacterial use of this magnitude should be questioned.”

Well, patience is a virtue. Today, the FDA issued a rule banning triclosan, triclocarban and 17 other agents in hand soaps and body washes. The ban does not apply to antibacterial soaps used in health care settings. In a press release, the FDA stated:

“there isn't enough science to show that over-the-counter (OTC) antibacterial soaps are better at preventing illness than washing with plain soap and water. To date, the benefits of using antibacterial hand soap haven't been proven. In addition, the wide use of these products over a long time has raised the question of potential negative effects on your health.”

It's nice to see positive change happen in your lifetime. It's also nice not to have to read a soap's ingredients before washing our hands.

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). This post originally appeared at the blog Controversies in Hospital Infection Prevention.

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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 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.

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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