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

Friday, January 20, 2017

Why pick on those independent hero physicians?

Since finishing my residency several years ago, I've worked in almost every type of hospital up and down the East Coast, ranging from big urban academic medical centers to more rural community outposts. Although I primarily practice hospital medicine, working with both smaller private groups and being a hospital employee, I do empathize a lot with my independent practice colleagues and brethren. I almost certainly would have gone down the route of trying to open up my own practice had the conditions for doing so been more favorable (and had I also been able to better suppress my insatiable desire for travel and moving to different places while I'm still young and single!).

What's happened to so many private practice independent physicians over the last decade has been a great shame, because these doctors have been the traditional backbone of our health care system. They are extremely hard workers and labor tirelessly for their patients, typically in an admirably free-spirited and autonomous fashion. But now, due to a combination of regulations and policy directives—it's almost impossible now for these solo practice and smaller group physicians to exist. Without getting into all of the technical reasons why, it all boils down to changes in reimbursement models and policies that favor doctors working in larger health care corporations over small private practice.

Let's look at the type of doctor who has been affected the most. We'll call him Dr. Johnson. Dr. Johnson finished medical school in the early 1980s. He immediately started his own practice after residency and has been his own boss for the last 30 years. He's very popular in his community and loved by all his patients and their families. He is subspecialty board certified but also practices primary care. He embodies the principles of that good old-school physician (the best doctors around). He is a thoughtful problem-solver and enjoys spending time with his patients. But over the last few years it's got more and more difficult for him to keep his practice open. He's had to fulfil a huge number of “tickbox” criteria just to keep up with reimbursements, installed an expensive slow and clunky electronic medical record in his office (or faced stiff penalties if he didn't do so), and is now on the verge of facing an avalanche of even more central regulations. All these things have taken their toll on Dr. Johnson. He's a fine doctor who used to love spending time with his patients. Now he's forced to spend the majority of his day clicking and typing away in front of a screen. His practice was very successful and has already been eyed by a couple of local health care conglomerates—who want his patients. Dr. Johnson would have been happy to work forever (and his patients certainly wanted him too), but now retirement just seems so much more attractive to him. The employees who worked in his office are concerned, because they know how much their lives would change as controlled employees in just another large corporation, instead of the relaxed and friendly environment they currently work in (they'd probably rather just do something else than face this new reality).

So as Dr. Johnson retires from his illustrious and dedicated career, let's ask ourselves 3 questions:
1. Was Dr. Johnson ever the reason why our health care system had such high costs and suboptimal outcomes, and is there a better way to improve “quality” that engages rather than alienates Dr. Johnson?
2. If our health care system is going to have a “patient-centered” and “bottom up” philosophy, why hasn't anyone asked the patients what they thought of their popular independent physician Dr. Johnson?
3. Are we completely missing the other targets, when there are plenty of additional reasons why health care is so expensive—including big pharma and costly new interventions and treatments—all against a backdrop of an ageing population?

I simply fail to believe that losing physicians like Dr. Johnson and just accepting that as “collateral damage” is acceptable. There would have been far better ways to improve health care and cut costs rather than losing our independent doctors and replacing their practices with large health care organizations that actually have multiple additional layers of bureaucracy and expense.

We're barking up the wrong tree and should stop picking on the Dr. Johnsons of America.

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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Tuesday, January 17, 2017

What we know about diet, and why time is of the essence

As a year of particular assaults on everything anybody thinks they know about diet and health, including if not particularly the science underlying the Dietary Guidelines for Americans, winds down, it's inevitable to reflect on what anyone truly knows about diet, and how we know it. The merchants of doubt, profiting handsomely from the status quo and perpetual confusion, would have you think no one knows much of anything, so enjoy some Coke with those fries.

I disagree. We are, emphatically, not clueless about the basic care and feeding of Homo sapiens, and I think that would be vividly clear to all but for time. Time, it turns out, is of the essence.

To explain what I mean depends on a thought experiment, and I ask for your indulgence here; it's just a bit macabre.

Imagine that, heaven forbid, you or a loved one is the victim of a gunshot wound to the abdomen or chest, be it the product of a bullet gone astray, or one willfully targeted. There are far too many of both flying around our culture, but that's a topic for another day.

First responders show up promptly to find you crumpled on the ground, bleeding profusely, surrounded by hysterical family members. They do what they do, and rush you into an ambulance, family in tow, and speed off to the closest hospital, which fortunately for you, has a Level One trauma center.

They burst through the emergency department doors, with you on a gurney soaked in blood, rushing to the operating room, where a top notch surgical team is scrubbed and waiting.

But before they get there, you and this entire, frantic entourage are intercepted in the corridor by a raised hand from a calm, imposing figure in a white coat.

Just a minute,” he (it could be she) says. ”Why the hurry? I am Dr. Reni Gaid Jeanyus. I am here to point out the folly of this rush to judgment.

“I am guessing you don't know about the literature debating whether this scalpel or that scalpel is best; it's intense! You may not have dived into the roiling controversies regarding the use of mosquito versus alligator forceps, to say nothing of the Rochester Pean versus the Rochester-Carmalt for hemostasis. And this is just the tip of a foggy iceberg. Clamps? Don't even get me started!”

Sensing the growing restlessness of your paramedic team, Dr. Reni (these types are, for some reason, always ‘Dr. First Name’ rather than ‘Dr. Last Name’) puts a restraining hand on your gurney. No one is going anywhere until the peroration is done.

As I was saying,” he says, “the debates are all but endless, and I- and perhaps ONLY I- know what they really mean! There is no proven value in trauma surgery at all.

“The whole thing is a scandal; a conspiracy, orchestrated by the tired old forces of the status quo. The Trauma Surgeon Mafia is in on it, of course; as is the Royal Order of OR Nurses. Naturally, The Surgical Scalpel Society and the International Corporation of Unnecessary Surgical Instruments have skin in the game. And, of course, all concerned are aided and abetted, as ever, by the Federal Authorities.

“I tell you it's shocking! Do you realize that there are NO randomized trials comparing the benefits of prompt trauma surgery to, say visualizing goat cheese? Or counting the hair follicles on your fourth toe? Or schmearing rutabaga marmalade on your nipples? None!

“Fortunately for you, though, I happen to have with me several jars of Dr. Reni's Rutabaga Marmalade- which, by the way, goes beautifully with that goat cheese- available for those actively hemorrhaging at the bargain price of $24.99 a jar. Credit cards are OK, but I prefer cash. Personal checks work, but only when signed in blood, and I'm not sure you have any left …

This scenario is, of course, absurd. Were there to be such a Dr. Reni, he would be intercepted by security, and escorted off the premises. If he did manage to trouble you and your family, you would promptly push past him to the operating room, and rightly so.

But why do we know that “alternatives” to trauma surgery are absurd? Are you drawing on your expert knowledge of the topic? Can you cite the relevant randomized, controlled trials? Can you refute the claims about debate over clamps, scalpels, and forceps? Isn't it possible that the conventional wisdom is all wrong, and visualizing goat cheese might have worked just fine?

The answer to all this is: duh. It's perfectly obvious that when people are shot and bleeding out, if expert hands don't do expert things to stop that bleeding and repair the macerated vital parts promptly and expertly, those people die. You, in that corridor, might well die in the time it took to hear this huckster's case.

As implied at the start, this is not about bullet holes or trauma surgery. My point here is that the only difference between this scenario and what we know about diet and health is time. Bullets kill us fast; diets kill us slowly. Tobacco kills slowly, too, by the way, and that fact has been exploited in the prevarications of Big Tobacco for decades.

If the timeline between what we eat and its diverse effects on health were as instantly vivid as the effects of a gunshot, there'd be no place for the agents of pseudo-doubt, pseudo-discord, and pseudo-confusion.

Don't get me wrong; there is legitimate doubt and discord, too. There is still a LOT to learn about a lot of details. Nobody really knows the optimal level of most micronutrients. Understanding of how best to personalize diets based on biometrics, anthropometrics, and genomics is still nascent. And, of course, there is no truly decisive, 100-year-long randomized trial involving tens of thousands to say what diet is “best” across an entire lifespan for longevity as well as vitality.

But as Dr. Reni would point out, there is no single, decisive randomized trial to prove that some particular sequence of particular surgical instruments is best for patching a hole in your chest, either. That's a poor argument for parking yourself in the corridor and bleeding, with or without marmalade. Arguments that divert you from the profound benefits of a diet comprised principally of minimally processed vegetables, fruits, whole grains, beans, lentils, nuts, seeds, and plain water for thirst are comparably unjustified.

Variations on the theme of good diets foster vitality and longevity, and fortuitously, redound to the benefit of the planet as well. Alternatives that do just the opposite prevail. This would all be perfectly clear to everyone were the causal pathway better matched to human perception.

The truth about broccoli, beans, and bratwurst is about as clear as the truth about bullets. It's just slower.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Monday, January 16, 2017

Prevention paradox

Every clinician knows that “framing,” how we present information to patients, has a big impact on decisions they make about their care. Even something as simple and apparently transparent as talking about “survival” versus “mortality” is important, with “a 90% chance of living” sounding a lot better than “a 10% chance of dying” even if both phrases convey the same estimate of risk.

Things get even more dicey when doctors start talking to patients about more subtle concepts like risk-reduction or number needed to treat. The clinical impact of a big relative risk reduction operating on a low absolute risk can be hard for doctors to explain and patients to understand.

The impact of that complexity was the subject of a recent editorial in Circulation. In it, Diprose and Verster speculate that doing a better job of explaining these things to patients, which certainly seems like a good idea, may paradoxically lead to worse population health outcomes. Here's how it could happen.

They cite several sources that suggest that as patients gain a better understanding of the modest impact of most preventive measures (e.g. statins for primary prevention), they are less inclined to accept the prescribed therapy. This is presumably based on their weighing the small benefit against the disutility of taking medications that may produce side effects or just having to take a pill that makes them feel like a “sick person.”

The rub is that if lower utilization were to become widespread in the population, then measures of population health would decline. This is because even modest improvements in disease incidence in a large population can lead to a large number of averted adverse events. Of course, those population measures don't account for the side effects and general reluctance to taking pills, which is why things look different at the individual and population level.

I feel strongly that a clinician's primary responsibility is to the patient in front of him, not to the population as a whole, so I don't see an easy way out of this

Do you?

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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Friday, January 13, 2017

Government employed physician—no thanks

Every health care system in the world is facing its fair share of challenges. Ageing populations, the exponential increase in chronic diseases such as heart disease and diabetes, expensive new treatments—all at a time when most countries desperately need to curtail rising health care costs to save their economies. At the two extremes we have fully public-funded (socialized) medicine versus entirely free-market (private) health care delivery systems. I've written previously about my own experiences working in a number of different environments including the UK, Australia and US—three countries with vastly different systems, and how the ideal probably resides somewhere in-between the two extremes. I don't think that a fully centralized system such as the United Kingdom's National Health Service (NHS) is something that any country should ever be aspiring to. As fair as it sounds—completely free health care at the point use—patients unfortunately don't always get the choice or service that they need in a top-heavy bureaucratic set up.

Looking at things from the physician's point of view, there are also many profound differences when it comes to working in these different health care systems. I took the decision over a decade ago to come to the United States to do my residency training, and wasn't too sure whether I would stay in the country afterwards. I was young, a foreign adventure beckoned, and I had no idea what would await me as I started my residency in Baltimore. All these years later, I'm very glad I took that decision to come here. One of the first things that struck me when I started working here, was just how free-spirited and independent-minded doctors in America appeared to be, compared to the (also very hard-working) doctors I had just left behind in the UK. They were more in control of their own destiny and weren't constantly lobbying the government for their next $1,000 pay raise. As much as health care and the medical profession may be changing, I still think that America's doctors have it very good compared to most other countries. That isn't to say that we shouldn't stand up and fight for the autonomy and working conditions we still desire, but merely to put things in perspective. Given the chance, if you reduced the barriers for entry (e.g. taking the USMLEs, doing residency training again), doctors from probably every single country in the world would come to this country in a heartbeat to practice medicine.

Let's consider the current situation in the United Kingdom. It made news here several months ago when thousands of “junior” doctors were striking. Unlike the US, “junior” in the UK also includes some very senior physicians who may still be below Attending level (in a country where it takes a lot longer to complete a medical residency). I've discussed the strike in more detail here, and what lessons U.S. doctors can draw from it.

I still have many physician friends in the UK at various levels of seniority, and not to put too fine a point on it—the vast majority of them are quite miserable in their profession. Much more so than any job dissatisfaction that exists here in the US. Over there, the government controls absolutely everything, and a random health minister with absolutely no experience in health care can make cut throat decisions and enforce mandates that have an immediate and dramatic effect on the frontlines. The loss of control and autonomy that results from a completely centralized health care system is staggering. In the United States, despite our well-publicized problems, doctors still enjoy a much greater choice of working conditions and contracts. There are a variety of different ways any physician can work and types health care organization they can work in. In the UK: there's only one. The NHS bureaucrats control how many Attending physician posts are created, and doctors are completely beholden to their decisions. The private sector is tiny. During training, doctors frequently have to keep moving every 6 months to different towns as they complete their residencies, a process that can easily last a decade. Pay scales are published online, and are generally the same wherever you go, plus or minus maybe a few thousand pounds according to how many “antisocial hours” you work. Interestingly, because of the quirks of this government pay-scale, the salary for a senior Registrar (equivalent to a final year resident) could actually be higher than an Attending!

If you ever look at social media patterns of physicians in the UK (and I say this not to belittle them, but merely to state a point), you will notice a very government-employee type European attitude, filled with highly left-leaning statements, articles, and resolves to fight for better pay and conditions via striking and other organized union action. I'm quite middle of the road when it comes to politics, but there is definitely a very palpable difference in physicians' attitudes on both sides of the Atlantic—a result of what naturally happens when one becomes a “government worker”.

A final huge and important difference between physicians in a public versus a more private free-enterprise system, is that those from the latter are generally much more creative, innovative and entrepreneurial. Working for the government can indeed be a total ambition-killer.

A close physician friend of mine in the UK summarized it really well recently when he said to me that having a sole-employer in any profession is “always bad news”. I agree profoundly. That's why I have no intention of ever being a full-time government employed physician again in a completely centralized health care system.

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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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