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

Wednesday, February 10, 2016

On maintaining weight loss

Alex Hutchinson, who writes a wonderful column in Runner's World called “Sweat Science,” provided a very interesting column that relates to weight loss maintenance. We know that exercise can help with weight loss, but that you must also eat more carefully. This column, the Jute Diet, explains why exercise makes weight maintenance easier.

“What you see is that, above a certain level of physical activity, caloric intake increases linearly and weight is stable. For these workers, the body's ‘balance’ mechanism is functioning, and those who burn more calories also consume proportionately more calories.

But below a certain level of physical activity, the appetite balance breaks down. Caloric intake rises again, and these workers are the ones who gain weight. The researchers call this ‘the sedentary zone,’ and suggest that the regulation of food intake breaks down in this zone because ‘in his hundreds of years of evolution, man did not have any opportunity for sedentary life except very recently.’”

“To me, this picture helps reconcile some of the conflicting findings of diet and exercise studies. People who exercise a lot tend to see a direct connection between how much they exercise, how much they eat, and how much they weight (in line with studies that have repeatedly found that the more you exercise, the more accurate your appetite is at estimating how much you need to eat). They're on the right-hand side of these graphs. For people who don't exercise a lot, on the other hand, diet, exercise and weight are decoupled.”

I really do not think a great deal about my diet these days, but I do exercise almost every day. It appears that my exercise is helping me with maintenance. Since maintenance is traditionally difficult, this information is pure gold.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.

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Tuesday, February 9, 2016

Should patients consult Dr. Google?

You see your gastroenterologist with long standing stomach pain. You have undergone a reasonable evaluation and all the endoscopic bodily invasions and imaging studies of your abdomen have been normal. Repeated lab work provides no clue explaining your distress. You have been twice to the emergency room and were sent home with prescriptions that didn't work. You are frustrated and so is your gastro guy. You are convinced that there is a diagnosis that has been missed and you have the Google search to prove it.

Every physician has had patients who come into the office with reams of paper from an internet search. Usually, this approach uses a net that is just slightly over-sized for the task at hand. It would be like using a butterfly net to catch a paramecium.

Plug a few symptoms into a search engine, and then be prepared to take a year or so to review the results. Pick a symptom, any symptom.

Whistleblower Search Suggestions
• causes of stomach pain
• causes of fatigue
• causes of fever
• causes of joint pains
• causes of dizziness

The above searches might crash your computer and I hope I will not be legally vulnerable should this occur.

The internet is a powerful medical tool. Most physicians, including me, rely upon it. It contains an encyclopedic reference on all knowledge, but hasn't yet been able to rival living, breathing human healers with respect to medical judgment. Of course, artificial intelligence will surely enter the medical arena in our own lifetimes. Technology will continue to “byte” into the medical profession, bringing great rewards and many costs to society. While we can argue over technology's merits and drawbacks, its victory is inevitable.

I counsel patients daily that we physicians cannot eliminate all diagnostic doubt. There is no CAT scan, laboratory study, physical exam or professional opinion that is 100% certain of anything. All of us want reassurance that we are well. Every physician has been asked throughout his career by worried patients, “are you sure I don't have cancer?” Seasoned physicians are very careful with our speech and choose words carefully. We rarely speak in absolute terms.

We can't exclude every diagnosis, but like lawyers, we strive to surpass a reasonable doubt threshold. How much uncertainty are you willing to accept? How much doubt will your doctor tolerate?

Of course, this varies with the circumstance. We are likely to push harder to explain rectal bleeding and weight loss in a 60-year-old man than we would in an 18-year-old college freshman with stomach aches.

The hypothetical patient at the beginning of this post wants more work done. Assume the physician has already excluded 85% of the common causes of stomach pain. How much more medical work and money is worth reach the 90% level? 95%? If we use the patient's Google search as a road map, then the diagnostic journey is likely to be an endless excursion into the abyss.

When we search Google to find a restaurant, a vacation site, a plumber or a movie review, most of us well click on a few hits, even though there may be hundreds or thousands of search results. We can't spend our lives swirling and spinning in a search engine, even if it means we did not hire the best plumber. We make a reasonable effort and then we make a decision.

While I admit that the stakes are higher with one's health than with a clogged toilet, patients need to be wary of an avalanche of medical information that spews forth unfiltered noise and static.

I'm not suggesting that if you have an unexplained symptom that you simply accept it. Of course, one reason your symptom might be unexplained is because a diagnosis has been missed. There is a role for a second opinion or pursuing additional medical studies. But, not every symptom can or should be explained. Every case is different. Knowing when to pull the trigger or to hold your fire—the essence of medical judgment—is not something I would consult Dr. Google on. I'd talk to a real doctor instead.

If you feel I've missed the mark on this post, go for a second opinion. Google is just a click away.

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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Randomized trials and how we know what we know

I suppose I might be more expert in randomized controlled trials if I had ever had the actual opportunity to fetch a pail of water without 1 when my foot caught on fire, as I've said I would do. I can't say I'm sorry that hasn't happened.

I feel qualified to opine on the topic just the same. I have designed, conducted, and published dozens of such trials. I have written 2 textbooks about them, too, 1 addressing details of methodology, the other addressing both that, and its application to clinical decisions. I know a thing or 2 about randomized trials.

So here's the punch line: I know a thing or 2 without a need for randomized trials, too.

There is a fantasy taking over the world of nutrition, especially acute in the aftermath of the contentious Dietary Guidelines release, that nobody really knows anything. The arguments are made at times by seemingly expert people, although we often find they are either not the experts they pretend to be, or are badly conflicted. Or, sometimes, both.

One of the shibboleths with which this camp routinely differentiates itself is the contention that all reliable knowledge, in science, at least, results from randomized, controlled trials (RCTs). Implied, if not stated, is that RCTs are not just necessary and better, but presumably, infallible. The argument continues that such trials are glaringly absent in nutrition, and then finishes with the flourish: We therefore know nothing about nutrition. I can only guess how much Big Food loves this sequence.

It is, however, nonsense, from start to finish. We know plenty about the basic care and feeding of Homo sapiens, in part from excellent RCTs, but by no means limited to them.

For starters, RCTs do only a very specific job, although admittedly, they can do it uniquely well. They are designed to answer questions when there is considerable uncertainty about the best or right thing to do. In the absence of such uncertainty, RCTs quickly bog down in ethical problems. We have, for instance, no RCTs of treating gunshot wounds to the chest or abdomen, versus watching them bleed to see what happens. We have no RCTs of actual vs. sham emergency surgery in this circumstance, or comparisons of trauma surgery to Gregorian chants.

Similar reasoning extends well beyond the bounds of the emergency department. We have no RCTs of spraying water on a house fire vs. watching it burn to see which saves more of a family's possessions. We have no RCTs of spraying water vs. spraying gasoline.

These silly examples aren't as silly as they seem. They point out 2 serious flaws in the RCT fantasy: (1) for ethical reasons, you simply cannot always run a RCT, and (2), when you do run 1, the answer is only ever as good as the question.

Randomization, technically, is a methodologic defense against something called confounding, which is the influence of an overlooked variable. For instance, if one compares coffee drinkers to non-drinkers and finds more emphysema in the former group, it suggests that coffee might cause emphysema. If, however, coffee drinkers smoke far more often than non-drinkers, it would account for the finding without indicting coffee. Coffee is an innocent bystander. There are innumerable variations on this theme; randomization is a robust, albeit imperfect, defense against them.

Blinding, as in “double blind,” is a defense against bias. The idea is that if no one knows who is in which group, no one can contrive the results—intentionally, or otherwise—to correspond with expectations or hopes. However, it's rather difficult to blind people randomly assigned to, say, beef vs. broccoli. They tend to notice the difference. The technique is very useful, but not universally applicable. It is most important when the outcomes are least definitive, and most subjective. If, for instance, the outcome is survival rate, you can imagine the difficulty, not to mention legal problems, in contriving it.

Finally, controls, or as they are generally known, placebos, serve to distinguish specific from non-specific effects. If, for instance, you compare a pain pill to nothing, and pain gets better with the pill, it might be due to specific effects of the pill. However, it might be due, in part, to people getting “something” expecting to get better, and people getting “nothing” expecting no such luck. These expectations map to a complex physiologic response that can, itself, relieve pain and exert other effects. Placebos and control groups guard against mistaking the effects of expectation for the effects of a given treatment.

So, RCTs have decided strengths. But they have rather profound limitations, too. They tend to require rather large treatment effects in relatively short periods of time. If we are looking for effects over a lifetime, in a study of, say, longevity, and feel we need a RCT, then our RCT will need to last 100 years. Those aren't done very often.

The strict stipulation of inclusion and exclusion of RCTs makes them quite robust in one way, but very contrived in another. The result is that: what happens in a RCT may stay with the RCT. In other words, people who agree to participate and play by the trial rules may look too little like the rest of the world to tell us much of anything applicable to it. And as noted, ethics alone preclude RCTs in many circumstances.

Lastly, RCTs can get it wrong, badly wrong. This can happen because the trial is flawed in some way, or the question is misguided; or it can happen because the results are sound, but misinterpreted by scientists, the media, or a bit of both. I won't repeat the tale here, but colleagues and I discovered that what we thought we knew about hormone replacement at menopause based on observational trials was a bit wrong in one direction, while what we thought we learned from subsequent RCTs was at least as wrong in a different direction.

Just about everything currently passing for wisdom about RCTs and nutrition is wrong. The claim that we have no RCTs is wrong; we have many, and some quite dazzling. The claim that other forms of evidence are inevitably lesser is wrong; sometimes other data sources are all there is. Blue Zone populations have not been randomly assigned to live as they do, but how absurd to ignore their shining example for that reason. Results at the level of whole populations over a span of generations trump just about anything we could hope for in even the most lavish of RCTs. The idea that RCTs are themselves infallible is every bit as silly as the questions they are sometimes designed to answer.

And finally, and most importantly: You don't need me or anyone else to tell you that you know some things pretty darn well in the utter absence of evidence from randomized trials. Just ask yourself what you would do about it if your foot ever caught on fire.

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, February 8, 2016

'About as stupid as it gets'

I have to thank Eli Perencevich, MD, ACP Member, for rekindling my interest in the mandatory influenza vaccination controversy. I had resigned myself to it being water under the bridge and had not thought much about it until the last week. What I didn't realize is that another Cochrane review was published last year on influenza vaccination of healthy adults. This is very useful to our discussion, since most health care workers fall into the category of healthy adults. A free full-text version of the review can be found here.

This review examined 69 clinical trials involving 70,000 participants, 27 cohort studies with 8 million subjects, and 20 case control studies with 25,000 participants. The bottom line is that the parenteral vaccine was 60% efficacious in preventing influenza, which didn't seem surprising to me. However, the absolute difference in influenza infections between the vaccinated and unvaccinated groups was only 1.3%. That knocked my socks off! All of the energy and resources consumed and ill will created in trying to increase vaccination rates in health care workers, including firing people, for a vaccine that reduces infection by 1% is about as stupid as it gets.

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.

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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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