Friday, May 30, 2008

Get drug alerts, warnings and recalls fast

More than 100,000 doctors have registered to receive emails about safety alerts and drug recalls. Are you one of them?

The service is provided for free by the nonprofit iHealth Alliance, and you can sign up here.

The alerts are tailored to your specialty, and are limited mostly to the "Dear Doctor" letters that drug manufacturers send out about label changes, recalls and warnings.

According to the Wall Street Journal:

"After receiving email notifications, doctors will get updates by going to a Web site called the Health Care Notification Network, which will archive alerts for a year, and will record that the doctors have gone to the site to see the notices. The network will provide suggested language that doctors can forward to their patients....The network may also be used to send doctors information on major public-health emergencies or bioterrorism alerts. "

If you haven't already, you can also sign up for the FDA's MedWatch safety alert and recall emails. It's always good to cover your bases.

Also, your patients can be sent alerts about drugs they are taking by setting up an online personal-health record here.

Virtual exercise's real effects studied

The Robert Wood Johnson Foundation awarded $2 million to help strengthen the evidence base that video games improve players' health behaviors and outcomes.

Presumably, Grand Theft Auto isn't one of the games. This is the Robert Wood Johnson Foundation. Instead, 12 research groups across the country will get $200,000 apiece to explore how motion-based games may help stroke patients progress faster in physical therapy, or how people in substance abuse treatment can practice skills and behaviors in the virtual world to prevent real-world relapses.

The 12 grantees will study games that engage players from ages eight to 98 in physical activity, healthy lifestyle choices, prevention behaviors, chronic disease self-management and/or adherence to medical treatment plans. Researchers will gauge why certain game designs are compelling, fun and effective, and for which types of people. Using common sense, the teenagers will get Dance Dance Revolution; the seniors will get stationary bikes.

The grants were competitive. Twelve teams get to study video games while another 100 were sent back to vying for high score on Wii Fit instead.

The 12 grant recipients are online, as are instructions to get involved in the second $2 million round of grants in January 2009.

Robert Wood Johnson Foundation offers more information, including grant recipient profiles and interactive features, here.
Thursday, May 29, 2008

Strange bedfellows

As new evidence that the drive for universal coverage is gaining momentum, the Securities and Exchange Commission has sided with labor unions, priests, and American Indians in their efforts to make big business come out in favor of expanding health care access.

It made headlines last year when Wal-Mart joined with major labor unions to express their mutual concern about health coverage. But as this New York Times article reports, the allies on this issue have gotten even more diverse. The story quotes nuns and priests who have negotiated with corporations like GE to get corporate backing for at least the idea of universal coverage.

Particularly notable is who's not joining this motley crew, according to the story. United Health and big tobacco--is anyone surprised?

The actual project--putting proposals in support of the IoM's principles for health reform on shareholder ballots--is unlikely to have any practical impact. But, if the proposals pass, it would be another indicator of the widespread support for real health reform (i.e., if even people well-off enough to own stocks want change, maybe it's time that something will happen).
Wednesday, May 28, 2008

Information overload

This story*, about common pains like headache that could auger a more serious condition, raised an issue that's concerned me for some time.

There's so much information out there about various signs and symptoms of illness, and warnings about the perils of ignoring those signs, that it can be difficult to discern a clear message. A heart attack can present in myriad ways, from neck pain to a numb arm to tiredness to GI distress, and the signs are especially subtle for women. Are people really expected to run to the hospital every time they experience one of those symptoms? (I probably experience one of those at least three times a week, and I'm in a very unlikely demographic for heart attack.) And if people did, what havoc would that wreak on our already-overcrowded EDs?

I'm not sure of the solution. Certainly, any effort to inform people of warning signs and symptoms has to be maintained. I think it might help to ensure that messages to the public are as specific as possible, so people can differentiate indigestion from chest pain that's heart-related. It also may help to emphasize that having several of the telltale symptoms raises the alert level.

I know these ideas aren't perfect-- some heart attack and stroke signs really are subtle, and it's better to err on the safe side. I also realize that public health messages need to be simple, so that they can be remembered easily. But, personally, I'm apt to brush off indigestion or headaches because I don't want to be alarmist (or sit for hours in an ED), even though I know full well that these symptoms could indicate something worse. And I don't think I'm alone in that reaction.
What do you think, readers?

* This is not a source of news I would recommend; I only reference it because it inspired the post.
Tuesday, May 27, 2008

Power of placebos

The New York Times reported today that a Maryland woman has started a company to sell placebo pills to the public, basically so that parents can pretend to medicate their kids. It raises all sorts of interesting questions. For one, are today's kids so heavily medicated that a pretend pill will do more to heal them than a kiss from Mom?

Experts who commented on the idea expressed concern that a) the pills wouldn't work because the situations would not be double-blinded (i.e., the parents know they're fake) and b) it's wrong for parents to lie to their kids.

The second criticism seems pretty ridiculous to me. With all the things that parents lie to their kids about (from Santa Claus to illegal drug use), how significant is a single pill? And, if as a society, we're really concerned about the dishonesty of placebo distribution, shouldn't we be looking more critically at their use in medicine and research? This Slate article on the subject isn't new, but it raised some questions in my mind about the use and value of placebos that have stuck with me since I read it.
Monday, May 26, 2008

Medical News of the Obvious

Why is it always the studies about young adults and drinking that are the most absurd?

Exhibit A:

STUDY FINDS 21ST BIRTHDAY BINGE DRINKING EXTREMELY COMMON, reports the American Psychological Association. From the press release:

"'This study provides the first empirical evidence that 21st birthday drinking is a pervasive custom in which binge drinking is the norm', said Patricia C. Rutledge, PhD, the study's lead author."

But wait! Let's not get too hasty, the release cautions:

"These findings may not apply to all college-age students in the United States. The data in this study were obtained from a single Midwestern university and most of the participants were white."

...The next item, from the AP via the Washington Post's online health section, sets the tone right out the gates with a stop-the-presses headline:
It goes on to say that a victim has a better chance of surviving being trapped under rubble if s/he isn't seriously hurt, is in good overall health, and if the weather isn't extreme. Oh, and also: infants and the elderly are especially vulnerable in this situation.

Huh. Who woulda thunk.
Friday, May 23, 2008

Free patient brochure on warfarin

The AHRQ today released a new patient brochure, "Your Guide to Coumadin/Warfarin Therapy," which explains what patients should expect and watch out for while undergoing therapy with the drug. Warfarin is second only to insulin in sending people to the ED for adverse events, the AHRQ says.

You can download the brochure via the link above, or order free copies by calling the AHRQ Publications Clearinghouse at (800) 358-9295, or by sending an e-mail to

Hypertensive patients should check BP at home

Hypertensive patients should take regular blood pressure readings at home, according to a new scientific statement by the American Heart Association, the American Society of Hypertension, and the Preventive Cardiovascular Nurses Association.

Patients whose readings are high in the doctor's office should take home measurements at least 12 times a week; this will help physicians make treatment decisions. Patients should also bring their monitors to the office to make sure the devices work and they are doing the readings correctly. Arm-cuff devices are preferred over other kinds, like wrist devices, the statement said.

Medical News of the Obvious moves to Mondays

We'll now be publishing Medical News of the Obvious at the end of the day on Mondays, so we can stay timely but also make sure we don't break any embargoes. Stay tuned!
Wednesday, May 21, 2008

Patient interaction tips

Here at ACP Internist headquarters, we're frantically reviewing our notes from Internal Medicine 2008 to decide what's the most useful and interesting info to include in our July issue. But some things, while worth sharing, just don't fit neatly into a story. So here you go...

From the session "Improving Patient Satisfaction and Health Outcomes": When you first enter the exam room, do you say "How are you?" to patients. That may not be the best idea, as it confuses patients about whether they should answer you conversationally, "Fine" or clinically, "I've had this rash for a week now."

From the "Update in Neurology": To determine if a patient has dementia, there's an easier, more effective technique than the mini-mental exam. Just ask the patient or a family member what the patient is interested in, and engage him or her in a conversation on that topic. If they can't keep up with the conversation, there's something wrong. (e.g. A basketball fan from New York should know how the Knicks are doing and a French chef should be able to tell you how to make bernaise sauce.)
Tuesday, May 20, 2008

Monkeys: They're just like us

New research suggests that low-status rhesus monkeys eat fatty "junk" food as a coping strategy, today's New York Times reports:

"The lower status monkeys can get as much food as they want but seem to have less of a desire to eat, perhaps because of the higher level of stress hormones in their brain. The anxiety of constantly toadying to their social superiors seems to curb their appetite, researchers suspect, at least when their regular high-fiber, low-fat chow is on the menu.

But suppose you tempted them with the equivalent of chocolate and potato chips and ice cream? Mark Wilson, a neuroscientist at Emory University, and a team tried that experiment at Yerkes by installing feeders with a constant supply of banana-flavored pellets-- not exactly Dove bars, but they had enough sugar and fat to appeal even to human palates. (In the interest of science, I sampled a few pellets.)

Once these foods were available, the low-status monkeys promptly developed an appetite. They began eating significantly more calories than their social superiors. While the dominant monkeys dabbled in the sweet, fatty pellets just during the daytime, the subordinate monkeys kept scarfing them down after dark. "

...I can't decide if this is sad or cute. Maybe a bit of both.

On a (barely) related note, I once interviewed a guy who decided to eat only monkey chow for a solid week. He kept a blog and a video diary of the experiment. (Warning: both blog and videos may contain explicit language.)
Monday, May 19, 2008

Cooler than disease detectives?

"CDC Disease Detective" always sounded like a really cool job. Now the NIH is giving the CDC a run for its money with its "Undiagnosed Diseases Program," which will focus on baffling medical cases.

The program will draw on more than 25 senior attending physicians at NIH-- with specialties ranging from immunology, cardiology, genetics and dentistry-- in evaluating each patient. As many as 100 patients a year will be evaluated. More info is available here.

"We have developed a stringent referral process to ensure this program deals with those cases that have truly confounded medical experts," Dr. William Gahl, clinical director at the National Human Genome Research Institute (NHGRI), part of the NIH. "Our focus is strictly on conditions that have not been diagnosed."

To be considered for the program, a patient must be referred by a physician and provide all medical records and diagnostic test results requested by NIH. The lucky winners will then be asked to undergo additional evaluation during a visit to the NIH Clinical Center that may take up to a week.

Worst bedside manner ever

One would think that life as dermatologist would be sweet enough (limited hours, good reimbursement) that you would be able to be pleasant to your patients. Apparently not. I just had a routine skin check with the most aggressively unsociable academic dermatologist imaginable. He walked in to the room with his magnifying headgear already on, never introduced himself, spoke only in unintelligible grunts (which were translated by the resident), was physically rough in the exam, and recommended a follow-up visit (with no explanation) on his way out the door.

It depresses me not only that such doctors are in practice, but especially that they are demonstrating their behavior for medical students and residents. Thankfully, my resident clearly knew better than to model his attending's example, but who knows who else he has taught?

I'm sure none of our blog readers have such abysmal bedside manner, but in case it needed repeating, I just wanted to reaffirm that all of us patients truly do appreciate it when you take the time to talk, explain yourself, and generally treat us like people rather than specimens.
Saturday, May 17, 2008

And the award goes to...

Guess who wins the Exhibit Hall booth award for Most Unexpectedly Popular?
No, it's not the booth with the massage chairs, or the free granola bars, or the mini footballs.

It's the Viagra booth. The poor sales rep could barely keep up with the demand for swag. One attendee gleefully told the rep, while grabbing a fistful of Viagra pens, "I come here a couple times a day!"

Session snapshot

Another great session from Dr. Paauw this morning on evaluation and treatment of common symptoms. The extremely condensed lessons:

-Not much works for acute persistent cough. A dose of honey is as good as anything, especially since there is a pretty significant placebo effect in treating cough.

- Migraines are common and underdiagnosed. Often they are mistaken for sinus headaches.

-Patient history is your best tool in sorting out the reasons for dizziness.

More to come in an upcoming issue of Internist....

Schedule your day by handout (really!)

I have found that, when undecided about a session, it's worthwhile to check out the handout, and boy, am I glad I did that today. Based on the title and the course description, "Ethical Challenges: Confronting Dual Loyalties When Seeing Patients on Behalf of a Third Party" sounded like a snoozefest.

In fact, it was a fascinating discussion of the ethical conflicts faced by military physicians who treat detainees at places like Guantanamo Bay. There was role-playing, lots of audience participation with interesting anecdotes from other military docs in the session, and analysis of how the dilemmas faced by these physicians have parallels in civilian medicine.

Sadly, there was a very small audience, probably because no one clicked through the dry course description ("What are the confidentiality/disclosure/consent implications in third party evaluation circumstances?") to get to the juicy handout. A lesson for next year...
Friday, May 16, 2008

Session Snapshot

Douglas Paauw, FACP, led a great session on drug interactions and side effects today. Here are a few of the pearls he cast our way:

-Always ask patients if they are taking a blood thinner before putting them on antibiotics; the combo could yield serious adverse reactions.

-Older patients on many drugs are the most likely to have trouble with warfarin interactions.

-If your patient is on warfarin, tell him/her not to take any herbal medicine that starts with a "G" (eg, gingko, ginger, garlic, glucosamine, ginseng).

-Research suggests the following drugs may be bad for the bones: corticosteroids, heparin, SSRIs, thiazolidinediones, PPIs.

-St. John's Wort has many potential interactions, including: lower cyclosporin levels, decreased efficacy of oral contraceptives and warfarin, reduced statin levels.

-Statins cause muscle pain/weakness in 10%-15% of patients, so use the lowest possible dose.

-SSRIs carry a probable increased risk of UGI bleed and sexual dysfunction, are an oft-overlooked cause of hyponatremia, and may decrease bone mass.

Session on the presidential candidates' platforms

More details in the July edition of the Campaign Trail column, but just to give you a quick glimpse of the session with reps from the three campaigns...

The large room had a full house, with attendees standing along the walls, and more questions than fit into the allotted time.

Line that drew the heartiest applause: a Republican internist expressing his thoughts on McCain's health care plan, "He's got to do better than that."

Heartiest laughter: Whitney Addington, who represented the Obama campaign, on his role as former College president (with credit to Hal Sox), "You're like a corpse at a wake. You are always expected to be there, but rarely called on to speak."

News of the obviously weird

This week's review of new research found it to be disappointingly useful, with potential to actually advance the field of medicine. So, in lieu of our usual analysis of obvious news, we offer you some highlights of the weirdest health-related news of the week, all courtesy of the Washington Post. The headlines speak for themselves...

Baby subpoenaed for unpaid chiropractor bill
Pair say they attacked each other with frying pan
9-year-old girl's twin is found inside her stomach
Woman accused of faking cancer to avoid work

The disadvantages of going early

During a very informative but otherwise pretty dry 7 a.m. session on hepatitis this morning, presenter Anna Lok made a couple of quite funny comments. But her early morning audience was far too groggy to react. So, in the hopes that her jokes will get the response that they deserve, here is a selection of them:

On what level is of alcohol consumption is appropriately moderate: "It varies. It's less than however much the doctor drinks."

An imaginary conversation between the immune system of someone born with hepatitis and the virus itself: "Hey, you've been in my body for a long time. Are you my friend?"

On how some adults contract the Hepatitis B: "If you were silly and had a one night stand with someone..."
Thursday, May 15, 2008

All I know of medicine I learned at the movies

It sounded like the most light-hearted and superficial of sessions. Little did I guess how the entertainment industry's portrayals of docs would inspire heavy doses of self-reflection on the meaning of medicine among panelists and attendees. Topics ranged from the inexplicable appeal of House ("At least you know he's paying attention," said panelist Faith Fitzgerald) to the unfortunate realism of a patient laughing hysterically when a doctor provided his home phone number in As Good As It Gets.

There were of course the usual laments about insurance companies, workforce shortages and tort lawyers, but many bigger, unanswerable issues were raised. ("What do we do to recover a sense of integrity?" asked one panelist.)

One particularly interesting issue raised by the session was racial discrimination in medicine. In a film clip, Sidney Poitier played a black physician who was spit upon by the white mother of a patient. One contemporary parallel, which the group discussion touched upon but didn't delve too much into, was discrimination against IMGs. Session moderator Michael LaCombe asked IMGs in the audience how many felt discriminated against and almost none raised their hands. He was surprised, as was I, since just yesterday I heard a U.S. Congressman bemoan the shortage of "Caucasian" doctors. And it's certainly not unusual to hear dismay within medicine about the trend of IM residency slots being filled by IMGs instead of U.S. grads.

The general attitude at the session seemed to be that these issues of discrimination in medicine are on their way out, but I wonder. Is the American attitude toward IMGs (both among physicians and in the general public) the modern-day equivalent of the racism faced by Sidney Poitier's character in "No Way Out"?

Session snapshot

The 8:15 a.m. "TIA and Stroke" session was jam-packed, with some of the more limber attendees sitting cross-legged on the floor. Dr. Nina Solenski went through two mock patient scenarios in detail, from first presentation of symptoms to discharge and follow-up. She maintained 100% professionalism despite the fact that two fire alarm strobes were flashing directly behind her during most of her talk.

Check out the handout for this-- and any other-- session here. You can also order a recording.

When adjectives attack

We go to a lot of medical conferences, and have noticed that some folks like to snazz up their session titles. The effort is valiant, but at times, overreaching. As such, we thought it apt to institute an occasional feature called "Ill-Advised Session Titles." Please feel free to submit your own from any conferences you attend.

IM '08 turns out to have a small selection. We found two:

"Irritable Bowel Syndrome: What's hot and what's not"

"Sailing out of the doldrums towards effectiveness and meaning"

Let us know if we missed any...

Beware of cops bearing bagpipes

Internal Medicine 2008 is in full swing here in D.C. It's also National Police Week, so between all the cops and docs, D.C. is pretty much the safest place on earth right now.

As an added bonus, there's a good chance you'll stumble across a bagpipe performance by kilt-clad cops. A few of us were treated to a pool-side recital on Tuesday night at our hotel, and there are scattered reports of spontaneous bagpipe activity in nearby bars. You are warned.

The latest news, ideas and trends in internal medicine

News delivery is no longer a one-way stream, from journalist to reader. The Internet has given readers the power to shape the content of news. ACP Internist wants to deliver information in the way readers want it, whether through our print and Web edition, ACP Internist, by our weekly clinical e-mailed update, ACP InternistWeekly, or our latest way, our blog.

Blogs are now an integral channel to deliver timely, researched information. It's also much more interactive, allowing immediate feedback from our readers. To deliver feedback, click on the comments link that follows each message. After a brief login and validation, you'll be able to react to our posts. And in the upcoming months, we'll add new features to the blog, such as discussions with ethics columnist Lachlan Forrow, FACP.

Our tagline is the latest news, ideas and trends in internal medicine. Let us know how we're doing. After all, it's your blog too.
Friday, May 9, 2008

Are you ready to play God?

Disaster planning has been a hot topic in medicine lately (see here and here for our coverage), but a group of physicians known as the Task Force for Mass Critical Care has taken the preparations to a whole new level. In a recent report, they offer specific suggestions on which patients should be left to die if an emergency were to cause a scarcity of critical care resources.

The full recommendations are available in Chest, but here are some of the key points: in addition to the more obvious categories such as cardiac arrest not responsive to electrical therapy, the first patients to lose care include people over 85, patients who have suffered severe trauma, and anyone with severe baseline cognitive impairment.

Obviously, such calculations are impossibly difficult to make, and that's why this group of government and academic leaders wants to save regular docs from having to decide. But it's interesting how far their choices stray from traditional disaster response (elderly get the first spots in the lifeboats) and current political correctness. So far in fact, that a law professor interviewed by the Washington Post noted that the recommendations would likely violate federal anti-discrimination laws which protect older and disabled Americans.

The report raises a lot of questions: Should likelihood of healthy survival be the criteria for deciding who receives care in a shortage? Are hard and fast rules the answer, or do these decisions need to be made on a case-by-case basis? And the dilemmas only get tougher from there. The authors of the recommendations noted that "the area most desperately in need of future study" is pediatric triage.

Medical News of the Obvious

Welcome to the first installment of our weekly Friday series Medical News of the Obvious, where the staff of Internist and Hospitalist bring their cubicle banter directly to your computer. If the subject or outcome of a study released in the last week inspired us to roll our eyes or emit a "Well, duh," chances are it will make it on the blog.

Suggestions and comments from readers are definitely welcome!

So, without further ado:

Many teen drivers don't think they're inexperienced, reports HealthDay, citing a study in the May issue of Pediatrics. Up next for the journal: "Many teens believe they know more than their parents."

Preference for alcohol in adolescence may lead to heavy drinking, according to scientists at Duke. But be warned: this was only a rat study, so we still can't be certain that liking something in your youth might actually lead to liking it more as an adult.

Sudden death of a parent may pose depression risks for children, surviving caregivers, according to the May Archives of Pediatric and Adolescent Medicine. This one speaks for itself.
Monday, May 5, 2008

Straw Poll

It's an election year in the nation's capital. Inspired by the political atmosphere, ACP Internist is conducting its own elections. Vote for your favorite among the presidential candidates' health plan.

First, bring yourself up to speed on what the candidates are proposing. ACP has analyzed the health care platforms of the leading candidates to help you cast a critical eye on their plans for reform.

After reading about their positions, vote for your favorite plan. We'll report on the results in an upcoming post.

The usual caveats and conditions apply. This straw poll isn't scientific. The results reflect only the opinions of individual ACP members. Result do not imply endorsement by ACP or represent ACP's opinion on the plans or candidates.