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

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Thursday, October 23, 2014

Ebola: The questions keep coming

The progression of the Ebola epidemic, particularly the recent episodes of transmission to health care workers who wore appropriate personal protective equipment, raises interesting questions. Certainly we need to continue to work on learning everything we can about the best approach to personal protective equipment and minimizing the risk of transmission during the process of care. But it’s also time to rethink some of the rituals surrounding care that have persisted in hospitals for decades.

Academic medical centers by their very nature increase the number of interactions with patients. Trainees at all levels need to interview and examine patients, and participate in their care to acquire necessary skills. While the benefits to the trainee are obvious, in some cases the patients benefit as well, via the therapeutic effects of another empathetic ear or the uncovering of a critical clue by the careful history of a novice interviewer. However, with a disease like Ebola, which can be transmitted in the health care setting, has no post-exposure prophylaxis, no effective treatment, and a high mortality rate, a strict approach to limiting the number of individuals in the physical proximity of the infected patient is appropriate as recommended by CDC.

Limiting contact typically means that in addition to students, other trainees such as residents and fellows also do not enter the room. But perhaps this needs to be taken a step further. Perhaps there should be one “examining” physician whose documented exam is used by consultants in their evaluations so as to limit room entry. In many cases, an additional exam probably doesn’t add much value, and is often performed because it’s expected or to maximize billing. Even before Ebola, as hospital epidemiologists we’ve asked ourselves the simple question: does every person on the care team need to examine every patient every day? Every encounter adds some level of risk for transmitting pathogens in the health care setting, but with Ebola the implications of transmission are taken to a whole new level. Fortunately, given technologies such as Skype, the ability to interview patients should not be impacted.

Ebola also pushes us to reconsider therapies that have a reasonably high probability of futility but increase risk to health care workers. In the case of the Dallas patient, who underwent endotracheal intubation and hemodialysis, we are left to question whether these procedures played some role in infection of the critical care nurse. Should CPR, which would seem to involve a very high degree of risk to bedside providers, not be performed? The ethical issues associated with withholding these procedures typically associated with “routine” critical care need to be explored since the risk-benefit calculus is markedly shifted by the level of risk to health care workers.

Lastly, should health care workers be compelled to work with Ebola infected patients? Do they have the right to opt out? Should those who volunteer receive hazard duty pay? Should there be a compensation fund for families in the event a health care worker contracts Ebola disease occupationally and dies? How do we handle the issue of pregnant health care workers? In the long run, how do we design the hospital of the future to maximize safety of the patient and provider?

These initial questions demonstrate that the Ebola crisis is challenging us in many ways and will likely continue to do so for quite some time. But perhaps we’ll emerge from this with a more thoughtful approach to patient care that improves safety without sacrificing quality.

Michael B. Edmond, MD, FACP, is the Chief Quality Officer at the University of Iowa Hospitals and Clinics. This post originally appeared at the blog Controversies in Hospital Infection Prevention.

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Which medical specialty should medical students choose?

A medical student recently asked my advice on her decision to pursue a career in dermatology. It was about 25 years ago when my own parents encouraged me to pursue this specialty. What was their deal? Perhaps, they anticipated future developments in the field and were hoping for free Botox treatments? As readers know, I rejected the rarefied world of pustules and itchy skin rashes for the glamor of hemorrhoids, diarrhea and vomit.

My parents were making a lifestyle recommendation. Dermatologists are doctors who sleep through the night. Spying one in a hospital is a rarer sighting than spotting a liberal Democrat at a Michelle Bachmann rally (unless a planted heckler). Nocturnal acne medical emergencies are uncommon. And anyone who has had cosmetic work done understands painfully that this is a cash business.

Here’s where some readers or dermophiles will accuse me of skin envy. Not true. Some dermatologists may be a tad thin-skinned over this assertion, but facts are facts. These docs have a soft lifestyle and earn much more money than most physicians do. Sure, these guys and gals see some serious stuff, but the nature of their specialty is less intense and frenetic than that of other colleagues.

Many professions push back when it is suggested that they are afforded unique and soft perks that most of us don’t have. Teachers, for example, never state out loud that having every federal holiday off, enjoying school vacations every few months and having 10 weeks off in the summer are unbelievable soft padding that no one else has. We know you work hard under difficult circumstances and we respect you and your profession. But just admit that you have some unbelievable professional cushions. This won’t diminish your self-worth or contributions to society.

Many medical interns and residents don’t consider lifestyle when they are making their career choice, and they should. Obstetrics is thrilling when you are 30 years old. Fifteen years later when you are overworked, tired and have your own kids, it may be slightly less thrilling to bring new life into this peaceful world in the middle of the night on a regular basis.

For me, leaving my own bed at an ungodly hour to haul out to the hospital is an unwelcome activity. I do not relish being awakened with phone calls or having to attend to an individual in the emergency room when the rest of Cleveland is soundly snoring. While gastroenterology is a more taxing specialty than the skin gig, it is still uncommon for me to have leave for the hospital during the black of night. Since we are in the era of medical hospitalists who are on staff around the clock, there is only a rare need for me to make a personal appearance. On most nights, my scope rests securely in its holster.

Do I think that medical students should consider lifestyle as they are contemplating their future? Absolutely. Indeed, the emerging culture of the medical profession has morphed from the prior culture when doctors worked 24/7 and interns were proudly on-call every other night. Medical doctors today are increasingly employed by institutions, work shifts and delegate the hassles of hospital life to hospitalists. Doctors are self-prescribing R & R.

Leisure, relaxation, avocations and personal time for reflection are not evil pursuits. They are the fuel that cultivates and sustains our humanity. Who wouldn’t welcome a little more humanity in the medical profession?

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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Wednesday, October 22, 2014

Medicare follies, or, the Annual Wellness Visit

Over the last few years, Medicare, the government insurance program for the elderly, has added a few benefits, one of them being a yearly doctor visit. This “Annual Wellness Visit“ is a great source of confusion around the office. Patients come in for a yearly wellness visit thinking that they are here for a “full physical.” They are not. The Annual Wellness Visit is something much more complicated and much less useful.

No one seems to agree on exactly how to run an AWV, but the basics are this: the patient fills out a questionnaire on their health; the doctor notes the patient’s basic data: age, blood pressure, body-mass index, etc. The patient is then assessed for their risk of falling, depression, and alcoholism, and their ability to take care of their basic needs. Their medications and other doctors are reviewed. After the visit they are supposed to receive a written plan detailing any prevention recommendations, such as mammograms, weight loss, etc.

Importantly, the AWV does not include a physical exam. I am not supposed to listen to your heart, feel your belly, or talk about your newly-diagnosed cancer. You have to make another appointment for that.

This sort of foolishness could only have been dreamed up by someone who doesn’t see patients. The AWV might as well be done at a self-serve computer station.

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog at Forbes. His blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.

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Tuesday, October 21, 2014

Clinical practice guidelines, autism, and ordering of tests

I gave a presentation to the Institute of Medicine (IOM) on the topic of emerging technology in medical education (more specifically, on graduate and continuing education in the health professions). The overall theme of the IOM Roundtable discussion was to examine practical approaches to improving genetics education in these groups. I am a primary care physician, and by no means an expert in genetics or genomics. My involvement in the meeting centered around using emerging technology within education of health care professionals.

It was a fantastic one-day conference, and I had the opportunity to meet some very wonderful people; not only fellow educators but also true experts in the field of genetics and genomics education. The discussions included how genetic providers can best partner with primary care physicians on ordering of tests that will help patients. We also talked about primary care physicians referring appropriate patients to geneticists for further evaluation. One of my take home points was that I should be considering genetic conditions more often than I am. Consider that objective achieved, IOM!

So I recently received this advertisement card in the mail, by Quest Diagnostics. On one side “Their future is in your hands.” On the other, a pitch to use the ClariSure brand of chromosomal microarray analysis.

I have never ordered one of these tests. I probably need to refer more patients to a genetics clinic, for sure, and not just for patients in whom I am entertaining a diagnosis of autism.

But this phrase right on the pretty glossy paper caught my attention: “Chromosomal Microarray Analysis is recommended as a first tier test for autism spectrum disorders and developmental delay by ACMG” (the American College of Medical Genetics). Wow, I thought! That could be considered a pretty bold statement. Remember, this was sent to me, a primary care doctor, who sees patients with autism, screens pediatric patients at well child visits for it, and refers where appropriate. The statement above does NOT say “for diagnosis”, “when/if referring to genetics”, or anything like that. It says “recommended as a first tier test for autism ….” How should a pediatrician reading this pamphlet sent directly to them interpret that?

I pulled the ACMG guidelines, entitled “Clinical genetics evaluation in identifying the etiology of autism spectrum disorders: 2013 guideline revisions“. In that guideline, Table 4 is titled the following: “Template for the clinical genetic diagnostic evaluation of autism spectrum disorder”. Indeed, chromosomal microarray is listed as a first-tier test. But let’s go back to the title of Table 4 and read it more carefully: “… for the clinical genetic diagnostic evaluation of autism spectrum disorder”. It does NOT say “for pediatricians and primary care providers” anywhere in this table. I don’t really know too many primary care pediatricians who are ordering this test, but maybe I am insulated. I am not a clinical geneticist. So why is this pamphlet being sent to me, a pediatrician?

When I am not sure about something, I like to “go to the literature”. So I looked for guidelines or a policy by the group with which I affiliate as a pediatrician: the American Academy of Pediatrics (AAP). I do not recall the AAP recommending chromosomal microarray testing the last time I looked. The AAP does indeed recommend Screening for Autism, in a guideline from 2007: “Identification and evaluation of children with autism spectrum disorders”, with a simplified algorithm found here, on page 2). Basically, routine screening in every patient at 18 months for autism spectrum disorders is what pediatricians should be doing. There is even a code for screening (It’s 96110, for anyone interested!) I know this algorithm well.

We are actively working to improve screening for autism in the state of Indiana, and colleagues at my institution have some preliminary data that demonstrate a lowering of the mean age of diagnosis of autism in certain communities by quite a bit (the lower the age, the earlier the patient can be referred to an autism specialist). Maybe in the future, ordering of a chromosomal microarray analysis will be part of a general pediatrician’s armamentarium, but I’m not sure it is right now.

Is it just me, or should I be bothered by this pamphlet which I received from Quest Diagnostics? Again, the wording on the pamphlet sent to me, a primary care doctor, at my home address, recommends “chromosomal microarray analysis is recommended as a first-tier test ….” I struggle with the wording, which omits “by clinical genetics.” I am not saying that geneticists should not order this test; they probably should. I am saying that sending this pamphlet to pediatricians, who see scores of patients who may have positive screening tests for autism, seems a bit bold.

Pediatricians should refer patients they are concerned may have autism spectrum disorders to a specialist. Their concern may arise from a gestalt, or from a formal screening test, such as the M-CHAT-Revised. If this screening test (which costs only time to complete) is positive, a referral to a specialist and a community early intervention service resource is indicated. One such specialist is a clinical geneticist; another might be a behavioral/developmental pediatrician or a child neurologist. In addition, each state has its own individual process for early intervention service referral.

People wonder why the costs of health care are so ridiculously high. I agree with this sentiment: costs are too high! I do believe that we should be referring patients and interacting more with our genetics colleagues about patients with whom we might be considering certain diagnoses, such as autism spectrum disorders. But I wonder if general pediatricians are the right audience for such an advertisement for a specific diagnostic test. I certainly can see this pamphlet sent to the offices of clinical geneticists.

I think the point of the IOM meeting recently was to improve the education of primary care physicians. IOM: consider your goal achieved, with this primary care doc (me), at least. I wonder how many of my primary care colleagues are now ordering this chromosomal microarray test in patients who have a positive (abnormal) screening test, versus just referring. Something tells me that chromosomal microarray analysis is not a cheap test either. But that’s a discussion for a future blog.

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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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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