ACP Internist Blog

Monday, July 16, 2018

Work attire

I'm a creature of habit. My first activity every day is to read the New York Times. Depending on my schedule, some days I read more articles than others. This week I was away at a conference and found myself with some early morning extra time before the first meeting session, so I delved into the Arts section. I began to read the first article: ”Women of the Philharmonic Can Play It All. Just Not in Pants.“ It begins:
Women can wear pants at the Oscars, the Tony Awards and state dinners. They can wear pants while graduating from the Naval Academy, figure skating at the Olympics and running for president. They can wear them at just about any workplace in America.

But when the women of the New York Philharmonic walked on stage at David Geffen Hall recently to play Mozart and Tchaikovsky, they all wore floor-length black skirts or gowns. And they're required to: The Philharmonic, alone among the nation's 20 largest orchestras, does not allow women to wear pants for formal evening concerts.
The article goes on to discuss some of the unique problems that this dress code presents for musicians, such as the difficulties encountered when playing large stringed instruments, and one woman who plays the English horn recounted how the folds of her long dress got caught in the keys of her instrument during a critical passage.

I found the article interesting, but as an outsider to the music world simply thought that it's another example of how the frivolous often eclipses the big issues in life. Then I came to this quote from a female violinist, ”One thing is really clear: People in the orchestra want to remain dressy. It's important that we look like we care. That is sending a message. We put so much into the preparation of our programs that, yes, we need to look good as well.” At this point the light bulb turned on and all of the dots connected for me: here is the musical equivalent of the judgmental doctors who think that all doctors must wear white coats. And then I knew that the pathologic manifestations of professionalism are not limited to medicine.

Well at least in medicine our clothing police aren't sexist, I thought. But then I remembered that it was only three years ago that Mayo Clinic dropped its pantyhose requirement for women physicians. And in a recent essay, Roshini Pinto-Powell, the Associate Dean of Student Affairs at the Geisel School of Medicine at Dartmouth, writes about how professionalism forces nearly every woman interviewing for medical school or residency to follow rigid rules of dress that makes her look like a penguin. Maybe we aren't ahead of the New York Philharmonic after all.

You might think that in medicine we've overcome ageism and classism in our sartorial expectations. However, it's worth pointing out that the Department of Medicine at Johns Hopkins is just now dropping the requirement of short white coats for interns. In the video attached to this article about that in the Baltimore Sun, the Internal Medicine Chief Residents express their sorrow at the loss of the short coat. Really? In 2018? Yet almost everywhere medical students are still relegated to the short coat. How about we just get rid of them all given that hierarchy with its associated authority gradient in medicine makes it much less likely that a short-coated person will speak up when she sees a long-coated person about to make an error?

On a happy note, there are always positive deviants, and I want to point out two of them. In the musical world, there is Seiji Ozawa, who was the conductor of the Boston Symphony for three decades. Instead of wearing the customary white tie and tails, he boldly wore a white turtleneck and tails, a look that became his trademark. The other is Jorge Mario Bergolio. As he was about to step out onto the balcony in St. Peter's Square to be introduced to the world as Francis, he was handed the mozzetta, a short red velvet cape trimmed in ermine worn only by the pope. He declined this heirarchical symbol despite the professionalistic expectations of his peers in the College of Cardinals.

I remain convinced that we need to assess work attire using simple humanistic criteria. Your clothes should be clean, comfortable, functional, and safe. No need for white coats. No long gowns. No mozzetta. No penguin suits. And the only people that will care are those who remain blinded by professionalism.

Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on improving the quality and safety of health care, and sees patients in the inpatient and outpatient settings. This post originally appeared at the blog Controversies in Hospital Infection Prevention.
Friday, July 13, 2018

Teaching empathy in medicine, lessons from an IV drug abuser

We've all heard the excuse or explanation that “It's society's fault,” to explain someone's failure. We hear expressions like this often when an individual has committed a crime or simply failed to succeed. Personal accountability is diluted as we are told that this person came from an imperfect home, had no role models or ample education.

These arguments are often wielded by those who have been favored with society's blessings and advantages.

As readers here know, I am not politically liberal and regard myself as an independent who usually votes for Republican candidates. I did vote for Sen. Sherrod Brown, one of the most liberal members of the U.S. Senate, a fact that astonished friends and family, as I had concerns about the character of his opponent that I could not overcome. I am proud of this vote.

A 19-year-old female was sent to me to evaluate hepatitis C. She was unemployed. She had used intravenous needles years ago and resumed using them a few weeks before she saw me. Hepatitis C was not the immediate medical priority here.

I felt that I was facing an individual who inhabited an alternative universe from mine. While I am speculating, I surmise that she faced choices through her life that I never had to confront. What narrative, I wondered, could this young woman have had that would lead her to her present destination, where she would be self-injecting poison into her body? I am not relieving her of personal accountability for the decisions that she has made. Adverse circumstances do not guarantee failure. Indeed, we all know phenomenal people who have overcome incredible adversity and long odds to achieve and inspire. I wish that their methods were contagious. The woman before me, at least so far, was not one of these individuals.

Perhaps, she came into this world unwanted and unloved. She may not have had adults in her life to build her self-worth and to help guide her. Maybe, education was a closed pathway for her. What caliber peer group was available to take her in to soothe her rejection?

My point is that it's always easier to judge someone's failures from higher ground. Would many of us have reached higher ground if we weren't born with a ladder that was set up beside us to ascend?

I'm all for personal responsibility and accountability. I'm also making a case for empathy, a virtue that has not always been as strong as it should have been in my own life.

If our ladder breaks and we crash, how would we like to be treated?

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.

The danger of pronouncements in medicine

“Experts” mean to improve health. They have great intentions, but we all know what is paved with good intentions.

This week I twice checked my blood pressure on a machine at our grocery store. The first time my blood pressure with 134/82 and the machine told me I had an elevated blood pressure. The second time it was 124/78 and it told me that my blood pressure was elevated. I was very pleased with my blood pressure, and astonished. The machine justifies these interpretations because a group of “experts” wrote and published a guideline pronouncement that redefined almost everyone as either being hypertensive or at least elevated.

That same group championed a flawed risk calculator that greatly overestimates my risk of coronary artery disease. As soon as they release risk calculator (now touted for both statin use and hypertension treatment) Dr. Nissen wrote this opinion piece, “Risk Calculator for Cholesterol Appears Flawed.”

Annals of Internal Medicine includes a very complex, careful alternative to that risk calculator, “Clinical Implications of Revised Pooled Cohort Equations for Estimating Atherosclerotic Cardiovascular Disease Risk.”

The 2013 PCEs overestimated 10-year risk for atherosclerotic CVD by an average of 20% across risk groups. Misestimation of risk was particularly prominent among black adults, of whom 3.9 million (33% of eligible black persons) had extreme risk estimates (<70% or >250% those of white adults with otherwise-identical risk factor values). Updating these equations improved accuracy among all race and sex subgroups. Approximately 11.8 million U.S. adults previously labeled high-risk (10-year risk ≥7.5%) by the 2013 PCEs would be relabeled lower-risk by the updated equations.
The authors are incredibly polite in their discussion. I refuse to play the politeness game.

This example is only one in a series of many such overreaching pronouncements.

Why does this happen? We work in a world that champions evidence-based decision making. We believe that evidence exists without bias. But cognitive psychologists have taught us (just as they have taught economists) that data require interpretation. As Dr. Verghese recently said, “Medicine is messy and complicated, because humans are messy and complicated.” Yet our experts try to impose simple rules for patient care.

Confirmation bias leads many groups to focus on possible benefits and minimize likely risks. Labeling someone incorrectly as having hypertension or needing a statin is a major mistake. But yet the experts champion a flawed calculator and flawed targets. Obviously these pronouncements really aggravate me. And I do not believe that I am unique among rational physicians.

Please decrease these pronouncements. Save your guidelines and recommendations to situations that are very clear. Embrace the controversies and allow physicians to consider multiple patient considerations when making decisions with their patients.

If you are skeptical of my rant, just consider how many dueling guidelines we have. Guidelines have assumed almost religious fervor in some quarters, yet when panels disagree on the recommendations we are placed in an impossible situation.

Save the money and time spent on crafting these missives and explain why our decision making is appropriately messy. Embrace the messiness. We all know that the emperor has no clothes. Do not pretend otherwise.

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, July 12, 2018

Humans, made to move it

Yesterday, my Apple Watch reprimanded me for failing to close my activity rings. I had a pretty good excuse, however: I was on a plane from New York to San Francisco. Besides, I had done my customary workout earlier in the day; I just wasn't wearing my watch at the time. There was some irony in it all as well, as my meeting at the other end of that flight was in Cupertino. My Apple Watch was admonishing me while I was flying it home.

Leaving aside my wearable's timing and temperament, I must concede that in general, it had a point. We need to move, routinely and often. That is the obvious implication of an important study just published in Nature Scientific Reports.

We have known for some time now that sitting is bad for us. The slightly exaggerated mantra that “sitting is the new smoking“ is something of a wellness meme. The popularity of everything from standing desks to work station treadmills has ensued.

The view apparently persists, however, that sitting is a worry for the sedentary, but less so for the active. This notion was captured facetiously in a cartoon I saw some years ago: a group was waiting for the elevator to an exercise class one flight up. The staircase was right behind them.

The new study shows that perception to be dangerously wrong. While the details of this paper get pretty dense pretty fast, the gist is clear enough. A total of 61 adults, some lean, some overweight, and some with diabetes, completed a comparison of a 4-day period of an assigned approach to exercise, to a 4-day period without exercise.

Two distinct approaches to activity were tested against the same control condition: sitting for 14 hours daily without any compensatory physical activity. In one, the participants sat for 13 instead of 14 hours, and did one hour of moderately intense exercise. In the other, there was no intense exercise, but there were 5 to 6 hours daily of light activity, standing, and walking. The authors helpfully designated these assignments “sit,” “sit less,” and “exercise.”

Assessing a wide array of cardiovascular risk biomarkers, the investigators saw distinct patterns. Measures associated with blood flow (i.e., endothelial function) improved markedly with a bout of intense exercise, but did not respond to sitting less. In contrast, measures of insulin sensitivity and blood lipids improved markedly with sitting less, while not changing appreciably in response to an hour of exercise.

All of these measures matter, predicting risk of diabetes, heart disease, stroke, and more. And, therefore, both approaches to physical activity matter, too. Should we exercise, or sit less? Yes. The authors conclude that their findings “suggest the need of both performing structured exercise as well as reducing sitting time on a daily basis.” I concur.

There are many reasons for the differential health effects of differing approaches to activity. Moderate to intense exercise increases cardiac output (the volume of blood pumped each minute), and acutely elevates blood flow. An effect on the endothelium, the inner lining of blood vessels, makes perfect sense. Exercise that elevates heart rate has a conditioning effect as well, enhancing fitness and aerobic capacity. Standing and walking don't tax the heart or blood vessels in the same way, but do improve blood return, and facilitate the actions of insulin by activating muscles throughout the day.

These complementary effects of exercise and routine motion make sense in the context of our adaptations. We Homo sapiens lack the impressive physical attributes of many other animals, speed, strength, agility, but our endurance is a case apart. We are high endurance animals, clearly adapted to a nomadic, foraging lifestyle, and the exertions attached to such daily effort in the service of survival. We are endowed with both fast and slow-twitch muscle fibers, suggesting our adaptions to both protracted motion at low levels of intensity, and shorter bouts of intense exertions as our daily travails demanded.

That we are more prone to thrive when our native adaptations are accommodated than when they are denied is all but self-evident, and that much more so when we reflect on species other than our own. Fish are notoriously prone to ill health out of water. Why? Simply because they are fish, adapted to extract oxygen from water, not air. There is nothing “toxic” about getting oxygen from air; we do just that. Doing so is toxic for fish because it does not conform to their adaptations.

Sitting and sedentariness are toxic to us high-endurance Homo sapiens for much the same reason. We are adapted to activity, constant and light, along with intermittent and intense. We have yet to enumerate all of the expressions, genetic, biochemical, hormonal, of those adaptations, but we know they are there, as reliably as genes for gills in every fish.

The mandate to move it for the sake of health encompasses both exercise, and simple motion throughout the day. We need both, and the benefits are complementary. Either is better than neither, but both is best. Move often and variably, gently and more intensely, as your routine and health permit.

Studies of this topic can be rather sophisticated, as this new one is. But the story is really quite simple. Homo sapiens without a robust daily dose of motion are rather like fish out of water.