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

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Tuesday, August 4, 2015

5 simple ways we can give our patients a better experience

Being sick and hospitalized in a lonely and unfamiliar place is a terrifying time for our patients. It's an easy thing for doctors and nurses to forget as we go about our hectic days, when time goes by so quickly that we barely have time to stop and think. Whether you are practicing medicine in a large academic center or a small rural hospital, the feedback that patients give about their hospitalization is surprisingly similar. And as the world of medicine goes about trying to improve the health care experience (often with unnecessarily complicated and expensive solutions), it's worth remembering that the things that patients ask for are really very simple and straightforward. Here are 5 of them:
1. Allowing a restful sleep

This is often the first complaint doctors hear when they walk into a room first thing in the morning. It may be a noisy neighbor, excessive commotion outside, a beeping machine, or unnecessary vital sign checks (on an otherwise stable patient). Let's start first with everyone involved in healthcare acknowledging that nobody can possibly get better if they can't get a decent rest!
2. Give a clear plan every day

This needs to be communicated clearly to both patients and their families. There should never be any situation where it's already mid-afternoon and neither the patient nor the nurse know what the plan is for the day. Multidisciplinary rounds—where the doctor goes over the daily strategy with the nurses, case managers, and even the physical therapists and pharmacists—can really help, and are taking off across the country. Other strategies, such as a whiteboard at the end of the bed, are also a good idea.
3. Let's be clear about waiting times

This includes time waiting in the emergency room, when a doctor is likely to see you on any given day, and the timing of medical investigations. There can be few things worse than not being allowed to eat or drink anything (when you're already feeling unwell), and then being told that the test or procedure you're waiting for is scheduled at some unknown time of day—”could be any time between 8 and 5 p.m.!” Often, if it's late in the afternoon and you know in advance, a small breakfast may even have been allowed. At least knowing a rough time can really help a patient to psychologically prepare and not have the feeling of being left in limbo.
4. Listen to those small requests that can make your patient's day

In the overall setting of an acute illness, a patient asking for something like being able to take a shower or go for a walk outside may seem almost irrelevant. But remember that it may well make a patient's day if you let them do this. Taking a shower in particular can make some patients feel like a million dollars afterwards! As long as it's safe to do these things, they should be allowed and even encouraged.
5. Hospital food

The agenda items wouldn't be complete without mentioning this. The stuff of legendary jokes, hospital food really can be, well … quite, sick. While not suggesting we have to serve up gourmet five-star restaurant style food, we certainly can put a little more thought into some healthy, delicious and inexpensive menu options in our nation's hospitals.

And so the list goes on, also including many things that are likely to be more resource-intensive, such as hiring additional nurses, buying more efficient computer systems, and allowing time for a much more thorough discharge process to occur. These should be addressed over time as well, but leaders have to remember that with the health care experience, it's often the little things we can do for our patients that really count.

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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The new paradigm for high cholesterol

A recent FDA advisory panel recommended the approval of 2 new agents in a novel class of cholesterol lowering drugs known as PCSK-9 inhibitors. What makes this remarkable is that these drugs illustrate all the promise and pitfalls of modern pharmaceutical development.

First, a little science. The target of the new drugs, a protein named proprotein convertase subtilisin/kexin type 9 (PCSK-9), was discovered in 2001. Two years later, investigators reported that “gain-of-function” mutations in the gene that codes for PCSK-9 were associated with familial hypercholesterolemia and high rates of atherosclerotic vascular disease. Mutations of the gene that led to reductions in the function of PCSK-9 were associated with low LDL-cholesterol levels, and a lower incidence of vascular disease. That made the compelling case that PCSK-9 had a counter-regulatory function in LDL-cholesterol metabolism, so that interfering with its function would lead to lower cholesterol levels.

The pharmaceutical industry used this insight to design drugs based on monoclonal antibodies that specifically target PCSK-9. Early clinical trials found the agents to be safe and effective at lowering LDL-cholesterol levels, even in individuals who had persistently elevated levels on high dose statins. It was on the basis of these trials that the advisory panel recommended approval. Larger clinical trials are now underway to determine the impact of the drugs on clinical endpoints such as heart attack and death.

So what's not to like? On the face of it, this is the story of a remarkable achievement of rapidly turning a “bench” discovery into a “bedside” tool by utilizing modern molecular genetics.

Here's the rub. We are about to have a new genie released from the bottle. Because these agents are biologics, they must be administered by injection, and (like other biologics) they are likely to be very expensive. Among the as-yet unanswered questions are:

How do these agents “fit in” with statin treatment? Should they be reserved for patients who “fail” statin treatment, and if so, what exactly constitutes a statin failure? Does it get added to statins or replace it?

Should they be used only for patients with familial hypercholesterolemia? What about other high risk populations?

How much money are these drugs worth? The recent controversies over the pricing of anti-cancer drugs is soon to play out in the cardiovascular field.

All this boils down to the fact that we have a potentially wonderful new tool, but have no idea how best to use it or how much we should be willing to pay for it, or even if it improves clinical outcomes. This seems to me to be the problematic paradigm of new medical technology, and a significant driver of our ever-higher health care costs.

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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Monday, August 3, 2015

Learning theory vs learning approach

I had the privilege of giving a grand rounds presentation recently on the topic of lifelong learning in health care. In the presentation, I discussed how adults learn within medicine, and reviewed literature on “adult learning theory.” Malcolm Knowles wrote extensively on the topic of Adult Learning, creating “principles of adult learning“ also coining the phrase “andragogy” (as opposed to “pedagogy”).

Others have questioned the concept of Adult Learning Theory, and have evidence to suggest that having 1 learning style is a misnomer. In fact, an article suggests that, at the undergraduate medical education level, we should consider a focus on learning approach rather than teaching to a specific learning style. Learners may not learn optimally with their self-proposed best learning style, and it is hard to say that a learner can learn with only one particular style. See here for a great review of this.

So what should educators do, given this dichotomy? Should we focus on the content and a delivery style that “meets the needs of today's learners”? Should it be about teaching the content to the learners, and nothing more?

In clinical medicine, where I spend most of my time, I do think it is critically important to focus on not just the content, but also the context in which that content is delivered. Learning environment, sometimes referred to as learning climate, is critical to making the learning process successful. It is the backbone upon which is built the process where ideal learning can take place. Given the IOM description of the Learning Healthcare System, this is essential. After all, where there is a healthy learning environment, there is an opportunity for all to learn with and from each other in order to provide the best care of the patients for whom we are privileged to care.

Alexander M. Djuricich, MD, FACP, is Associate Dean for Continuing Medical Education and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis. This post originally appeared at Mired in MedEd, where he blogs about medical education.

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Unvaccinated boy in Spain dies of diphtheria

I love writing about vaccine-preventable diseases. I've written about measles, polio, and whooping cough. That's because vaccines have become victims of their own success. Less than 100 years after some of these vaccines were first used, they have led to the disappearance in the developed world of some of the most devastating infectious diseases. This extraordinary success has led to complacency or outright skepticism about vaccines among people whose grandparents knew the horrors of infectious diseases and rightly saw vaccines as godsends.

A child with diphtheria with the characteristic swollen neck. Image credit: CDC Public Health Image Library #5325


I've never seen a single case of tetanus or polio or measles, and I hope it stays that way. But it's much more difficult for typical parents who have also never seen a case to understand the misery that these diseases caused not very long ago. Add to that some beautiful but idiotic celebrities who stoke fear about vaccine safety and a fraudulent study linking vaccines to autism and the result is a small but growing cadre of parents who refuse vaccines for their children.

Unfortunately, this summer diphtheria is in the spotlight.

Diphtheria is caused by a bacterium. It is transmitted from person to person through respiratory droplets by coughing and sneezing. A person can also contract diphtheria by handling an object, like a toy, that has been contaminated with the bacteria. It typically causes weakness, sore throat, fever, and enlarged lymph nodes in the neck. Two to 3 days later a thick coating builds up on the throat or nose, making it hard to breathe or swallow. The bacteria produce a toxin that is absorbed into the blood stream and can damage the heart, kidneys, and nerves. Diphtheria is treatable with antibiotics, but even with treatment 5% to 10% of patients die. Before antibiotics the disease was fatal in up to half of cases.

In 1921 there were 206,000 cases of diphtheria in the US, causing 1,520 deaths. When vaccination began in the 1920s case numbers quickly plummeted and there has not been a death in the U.S. due to diphtheria for many years. There are scattered cases occasionally but between 2004 and 2008 no cases were recorded in the U.S.

Well, it's time to celebrate, get complacent, and flirt with dangerous anti-vaccine propaganda!

In June, a 6-year-old boy contracted diphtheria in Spain and died. This was not someone who didn't have access to health care. His parents had refused having him vaccinated. He was the first death due to diphtheria in Spain in 29 years. South Africa is currently facing an outbreak that has sickened 15 and killed 4.

Every day we make use of technology that would have been miraculous just a generation ago. It's hard to remember that. I use Bluetooth to pair my smartphone to my car. I get turn-by-turn spoken directions using maps on Google's servers. A flock of satellites allow my phone to figure out its location. It's hard to keep track of the staggering number of technological breakthroughs at my command. It's easy to believe that this is the natural order of things. It's almost impossible to remember that the achievements that we rely on daily are the incremental accumulated work of generations, and that they could just as easily be undone.

Vaccine-preventable diseases are making a comeback because we're forgetting what the world looked like without vaccines. If we don't remind ourselves from the history books, we'll be reminded by the news.

Learn more:

Diphtheria reported in Spain, 1st case in 3 decades (Outbreak News Today)

Boy Dies of Diphtheria in Spain, Parents Rejected Vaccine (AP)

South Africa diphtheria update: 15 cases and 4 deaths (Outbreak News Today)

About Diphtheria (Centers for Disease Control and Prevention)

Diphtheria vaccination (Centers for Disease Control and Prevention)

Measles Makes a Comeback (my post in 2014)

Polio Outbreak in Syria (my post in 2013)

Study Linking Vaccines to Autism not Just Wrong, Intentionally Fraudulent (my post in 2011 about the retraction of a fraudulent study)

California's Whooping Cough Epidemic (my post in 2010 about pertussis)

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. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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