ACP Internist Blog

Monday, October 16, 2017

ZIP codes of medical destiny

When the PURE diet study papers roiled headlines around the world recently, I wrote an admittedly lengthy analysis. I didn't feel I had much choice; the publications encompassed three distinct research papers, reams of data, and a whole lot of what proved to be mostly misguided interpretation of the findings by the media, and the investigators themselves. Getting the story sorted out reliably involved some heavy lifting, and considerable verbiage.

But, in the mix, was my succinct, summary judgment about the whole thing: poverty undermines reasonable eating. That, really, was the key message.

Officially, PURE stands for “Prospective Urban and Rural Epidemiology,” but I think “Poverty Undermines Reasonable Eating (and health, by the way)” would sum it up quite nicely. By way of brief reminder for those who already knew: The people in PURE who ate the most vegetables, fruits, and legumes had, by far, the lowest mortality rates. The people who ate the fewest vegetables, fruits, and legumes had by far the highest.

If you are thinking that simple assertion is a very odd place for headlines telling us that vegetables and fruits no longer do anything for health this week, I am with you entirely. How was that even possible?

Well, the PURE populations with the best diets also had the best of everything else: educations, jobs, homes, safe environments.

In contrast, there were populations included in the study from some of the poorest countries on earth, notably Bangladesh and Pakistan, where high intake of “carbohydrate” was associated with high mortality rates. But the blame here, rather blatantly, did not reside with a macronutrient, but with macroeconomics.

These were people dealing with poverty, all manner of deprivation, and getting by on little more than white rice; or, in the case of Zimbabwe, maize. We can all readily accept that a diet comprised almost entirely of just one food―any one food―because you have no other choices is a bad thing.

That would be true if the one food were broccoli, or butter; bacon or beans ― let alone white rice, or maize. The simple fact is, though, that rice and corn and wheat are among the least expensive, most readily available foods in subsistence populations, so when people are scraping by and trying not to starve, these ― and neither broccoli nor butter ― tend to be at hand. Thus, the utterly meaningless association between “carbohydrate” and mortality issuing from PURE. What is associated with mortality, and morbidity, for many reasons, is poverty, and its many henchmen: hunger, thirst, struggle, and a destitution of resources.

All of which is just a prelude to this week's study, perhaps not generating the headlines it should. An article just published in Annals of Internal Medicine reported health outcomes in nearly 110,000 people who had undergone cardiac risk assessment in the Cleveland Clinic Health System. The researchers applied the Pooled Cohort Equations Risk Model (PCERM) of the American College of Cardiology and American Heart Association and compared the predicted rate of cardiac events to actual occurrence.

The “punch line” in this case is just about as blunt as a literal punch to the gut: the model significantly under-predicted cardiac event rates “among patients from disadvantaged communities.” In other words, socioeconomic disadvantage- poverty and its baggage-caused heart attacks and deaths that otherwise should not have occurred.

This is, obviously, directly germane to the massive misrepresentation of the PURE papers that were yesterday's news. It is germane to tomorrow's public health news, too.

The message in the much-distorted reporting of PURE, hiding in plain sight, is that the social determinants of health―the basic circumstances of our lives and environments―prevail.

One of the great, and from my perspective distracting and fairly useless debates of modern public health is whether responsibility for the prevalent ills of modern society is more personal, or public. The debate is useless in that it tends to polarize an issue best situated in the middle.

Clearly, personal responsibility for health matters. No one else can exercise for you; no one else will put food in your mouth―but for rare and rather dire circumstances. At the end of the day, what you and I do with our feet, our forks, and our fingers (e.g., holding cigarettes) is up to us.

On the other hand, how preposterous to suggest that the playing field of opportunity for health is level. Some of us have every relevant advantage, with facilities readily available for exercise year round, indoors or out, and a choice among the most nutritious foods throughout the year. Others of us live in food deserts, where streets are unsafe to walk, where a recreational facility is a parking lot frequented by gang members, and where gym membership either doesn't exist, or is an unaffordable luxury and far lesser priority than protecting one's kids from ambient drugs and violence.

We have yet another reminder of the importance of such factors in a report on childhood obesity just released by the USDA. Obesity is far more common among children in overtly disadvantaged households.

Those admonishing all to make good behavioral choices may conveniently overlook that the choices any of us makes are ineluctably subordinate to the choices we have―and we simply don't all have the same choices. That the PURE analysis overlooked this was not only a failure of Epidemiology 101; it was a nearly paradoxical failure at the human level for a study intended to help us better understand the disparities between populations with and without every modern advantage.

In their seminal paper nearly a quarter century ago, McGinnis and Foege told us of the “actual” causes of premature death in the United States, attributing nearly 80 percent of the total to just three lifestyle behaviors: smoking, poor diet, and lack of physical activity. For those of us in lifestyle medicine, this has been a compelling mandate all the while. But we are obligated to recall that lifestyle behaviors are the choices we make; social determinants are the choices we have. We are obligated to recall that even causes have causes. We are obligated to recall that sometimes, the best and only defense of the human body resides with the body politic.

There is much many of us can do with lifestyle choices to impact our medical destiny. But sometimes the critical matter is neither a choice we can make, nor our lipid panel, nor our genetic code. Sometimes, it's our ZIP code.

Golden communication tips for doctors

It's something that's not taught anywhere near enough as it should be in medical school, but every practicing physician quickly realizes that communication is everything in health care. It's the foundation of the doctor-patient relationship, and what patients will judge you on. Sure, doctors are among the busiest professionals out there. We do an incredibly hectic job. But it's so imperative to remember the importance of that interaction with your patient, and to treasure those few minutes you have with them. It's essential not just for patient experience, but also your success as a physician. Here are some things you should always do, Doctor.

1. Knock
Before entering the room, always knock on the door as you walk in. Of course you are going to enter anyway, but knocking just displays a sense of politeness and consideration.

2. Greeting
Walk in calmly, confidently, and in a professional but friendly manner. Ideally shake hands. A nice firm handshake, but not as firm as you would in certain other situations such as a job interview. Often, the patient will extend their hand anyway when they see you walk in. Smile. Of course, a smile doesn't come naturally to everyone! But as far as social science is concerned, it generally displays a sense of openness and friendliness. Obviously, it may not be appropriate to smile if it's a bad clinical situation, but a measured smile may still be appropriate when you first meet. Using the patient's first or a more formal “Mr.” or “Mrs.” is a judgment call. Older people may prefer the more formal greeting.

3. Sit down
Always sit down with the patient. Research shows that when doctors sit down, patients perceive them to be in the room significantly longer than doctors who stand up (even though they were found to actually spend less time in the room than the doctors who stood up!). Patients have also been shown to be more satisfied with their care and expressed better understanding of their condition when their doctor sits down. Moreover, it's more comfortable for the physician as well, instead of towering over the patient and peering down.

4. Let the patient speak
Studies show that physicians interrupt their patients after an average of just over 20 seconds of speaking. Yes, that's right—20 seconds. Again, nobody doubts how busy you are and the need to focus, but give your patients a chance to speak! Next time, let them talk for just a little longer. Remember the famous saying: if speaking is silver, then listening is gold.

5. Other techniques
Maintain good eye-contact throughout your conversation, but not freakishly constant eye contact—which can be intimidating. Look away every so often like you would during a regular conversation. Lean in and use hand gestures as you explain things, to emphasize important points.

6. Involve the family always
Often, it's more important to talk to the family than the patient. This applies especially if the patient is elderly or disoriented. Don't move onto that next patient before pondering whether or not the family is in the loop. Give them a call from the bedside if you can. It may even save you a page or call later in the day!

7. Always ask open-ended questions
There's often more grey in medicine than black or white, and there's not always a “Yes” or “No” answer out there. A medical history is a story, not a robotic set of tick boxes. Open-ended questions typically start with words like “How”, “What”, “When”—or a phrase like “Tell me about that abdominal pain”. Closed-ended questions demand yes and no answers only, such as: “Do you have abdominal pain?” There is a way to balance these questions while staying focused and time efficient. Asking open-ended questions is also a way of promoting empathy and compassion in your discussion.

8. Avoid technical jargon
You are in the bubble of medicine, and it's easy to assume other people understand all the lingo. The reality is that they probably don't. Use as many layman's terms as possible. For example, avoid banding around words like “hemoglobin,” “hypotensive,” or “tachycardia” without putting some thought into whether the other person really comprehends what you are saying. Make things easy to understand. Instead of saying something like “your hemoglobin is low”, people may better visualize “your red cells are low”. Instead of “Your troponin level is elevated indicating myocardial ischemia,” it should be, “One of your heart blood tests is high that indicates strain or lack of oxygen to the heart.” If you want to get into more detail afterwards, you can. Use common sense and imagine you are talking to a family member who knows nothing about medicine. I'm always amazed whenever I overhear conversations between experienced doctors and their patients, and how many technical terms are used—even some that I would struggle to understand!

9. Always give a chance to ask questionsbr/>Make sure the patient understands everything you've told them. Never end a conversation without asking if they have any questions. Remember, this is their life on the line, so they should have questions! If there really isn't enough time, come back later.

10. Ending
Always finish your conversation on a positive note if possible. End with a statement of encouragement for the patient, such as: “You'll get through this just fine.” Words like that can mean a lot. Remember to always let them know how they can contact you again if they have any questions or concerns. Even though you may not be coming back to see them on that day, it's important the patient never gets the feeling that you are just “disappearing.” Also be considerate and leave the patient as you found them with things such as bed position and lighting.

So now that we've talked about 10 things that you should always do, here are three quick things that you shouldn't do:
1. Keep turning around and looking at the computer as you speak

This is highly annoying for the patient, who wants nothing more than a good old fashioned one-on-one conversation with their trusted doctor. It gives the impression that the doctor is distracted. Ideally, review information about the patient briefly before you walk into the room or they walk into the office, so that you are not meeting them completely “blind”.

2. Make it obvious you are in a hurry
You probably are in a rush as a doctor, it's the nature of the job. But try to avoid any body language cues like standing up or motioning towards the door, that may give this away.

3. Make it sound like any problem is trivial
If a patient tells you about something that's really bothering them, don't just pass it off. Be careful with completely ignoring that “painful finger.” Address it, even briefly, and reassure them that you'll help get it fixed even though it's not the main acute medical problem.

Doctor, communication is truly everything in health care. Treasure those few minutes you have with your patient, which they may have been waiting hours or days for. Be fully present, engaged, and as good a doctor as you can be. Those moments of personal connection and helping people will probably also be the most meaningful moments of your day as well. It's why I went to medical school, and probably why you did too. Make the patient feel like the center of your world and show them how devoted you are to their complete well-being. Because as Maya Angelou said: ”People will forget what you said, people will forget what you did, but people will never forget how you made them feel.”

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.
Friday, October 13, 2017

Patients need more time with their physicians, and vice versa

One of my favorite songs of the 60s, Does Anyone Really Know what Time it is?, and the song has a great line “Does anyone really care?”

Both patients and physicians really care. My friends, neither physicians nor my patients, often tell me stories about brief visits. Occasionally I hear praise about a physician who really spent time and listened. My physician friends often lament that they do not spend enough time with patients, and research confirms that. A wonderful piece in The BMJ makes the point brilliantly, “Margaret McCartney: Why GPs are always running late“?

An intelligent, kind friend says to me, “My general practitioner is always running late—why?”

I try to explain that her GP is probably similar to me. Even arriving early and staying late, I still only have about 12 minutes for each patient. And I have to fit a lot into those 12 minutes.

As a colleague puts it, general practice is based on a lie—a lie that we can do this safely and well in 10 minutes. I reckon that acceptably safe practice would take double that, and excellent practice would need more again to ensure that everything's in place for proper, shared decision making.

No one goes into medicine for an easy life. But I'm haunted by a feeling of persistent failure. We need to know: what expectations can we realistically have of the time currently available to us—and how much more time and resources should we really have to do it well?

What happens when we try to see patients too quickly? We must take short cuts, take less careful history, cheat on the physical exam, try to avoid extra questions, order tests rather than spend more time interviewing, or obtain a consult to do what we might do with enough time.

This article comes from Great Britain and their wonderful National Health Service. It is slightly less bad in the U.S. Electronic health records have worsened the problem because charting takes much longer.

Many experts believe that inadequate time leads to diagnostic errors. Others (as the article suggests) note that shared decision making takes time, and too often we do not have adequate time to have those discussions.

We waste resources trying to cram too many patients into the physician's day. We cannot say this often enough. This is not a doctor issue; this is a patient issue. Patients suffer when we shorten their visits.

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.
Thursday, October 12, 2017

When the US opioid epidemic causes a Serratia outbreak

We are in the midst of an almost unprecedented opioid epidemic in the U.S. Last year (2016), overdoses caused 64,000 deaths, which was a 22% increase from the previous year, while fentanyl-associated deaths increased by 540% over the past three years. (I wanted to add a thousand exclamation points after the 540, but thought better of it)

Fifteen years ago, Belinda Ostrowsky reported a 26-patient outbreak of S. marcescens bacteremia in a surgical ICU that was ultimately linked to contamination of fentanyl by a respiratory therapist who had diverted the narcotic for their own use. (The Centers for Disease Control and Prevention has a nice webpage describing 30-years of health care acquired infections associated with drug diversion by health care workers)

Given the current opioid epidemic, we should expect an increase in hospital outbreaks associated with narcotic diversion. So, it is not surprising to read about a five-patient cluster of Serratia marcescens bacteremia linked to narcotic diversion by a PACU nurse just described in Infection Control & Hospital Epidemiology by Nasia Safdar and colleagues at University of Wisconsin. Even before the Serratia cluster was identified, a nurse found hydromorphone and morphine PCA syringes with the tamper-evident caps no longer intact and drug levels undetectable in a locked automated medication dispensing cabinet. The subsequent investigation eventually found 42 syringes had been tampered with and narcotics replaced with saline or lactate ringers before the nurse was fired. Unfortunately, even though the outbreak was clonal, the tampered syringes were destroyed before they could be cultured. However, four patients were epi-linked to the PACU nurse and the fifth patient was the nurse's father. (I resisted adding an exclamation point here too.)

There you have it, but if you want to read beyond the ICHE report, there is an interview of Dr. Safdar over at STAT. We certainly don't need more things to worry about with the current opioid epidemic, but we should all make sure we keep talking with our pharmacy colleagues about narcotic thefts and keeping our theft policies and prevention practices up to date.

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). This post originally appeared at the blog Controversies in Hospital Infection Prevention.