Friday, October 31, 2008

Our blog hits 1,000 readers a day

ACP Internist's blog reached 1,000 viewers in a day for the first time this week, a great milestone as we approach our six-month anniversary.

Our blog launched in early May, just before ACP hosted Internal Medicine 2008. The first post was a straw poll that didn't get much response (who was reading us then?) but our second post was Medical News of the Obvious, our review of research that examines every aspect of health care, whether it's needed or not.

At Internal Medicine 2008, the blog let us offer immediate coverage of the meeting, and conference coverage continues to be a blog staple to this day. Just last week, we covered meetings of the Medical Group Management Association, the American College of Chest Physicians and American College of Rheumatology. We cover the breaking news as it happens and some hilarious minutia when it doesn't.

Since then the blog has grown steadily, almost reaching 1,000 viewers per day by Labor Day, when readership dropped slightly--until now. We're increasing readership each week and expect to continue through guest contributors. In the near future, we're joining the Grand Rounds bloggers, who compile the best of the health care blogs each week.

We haven't given up on the straw polls, either. Our latest gives readers a chance to vote on the health care plans being offered by Senators John McCain and Barack Obama, and future polls will ask our readers to help us develop clinical topics and incorporate the results into our news coverage. Keep checking back as we do.

Don't let Halloween go to waist

With obesity and in particular childhood obesity in the news so much, parents are finding ways to cut back on Halloween candy excesses, including exchanging candy for money or toys.

It takes about 3,500 calories to produce a pound of weight gain. Exercising off 3,500 calories produces a pound of weight loss. But how much candy makes up 3,500 calories?

Kid's Health, the well-respected, ad-free resource, offers an easy and kid-enticing game to calculate how much candy makes up a day's worth of calories, which they estimated at 2,000 for kids ages 8-12. Eight big candy bars is all it takes to get a day's worth of calories. By the same measure, 13 would produce an extra pound of weight. Keep that in mind when checking over the Halloween loot.
Thursday, October 30, 2008

Primary care shortage dooms universal health care

Guest blogger Toni J. Brayer, FACP, of ACP Internist's Editorial Advisory Board, offers her comments on how the primary care shortage will doom attempts to reform health care. She writes:

Senator Obama wants to provide universal health care coverage to all Americans, but the physician shortage will stop it dead in its tracts. With less than 2% of medical students choosing primary care medicine as a specialty and the aging physician population that is ready to retire within the next five years, we have a crisis looming.

It is the primary care specialties who manage 80% of all health care needs of our population and who keep costs under control by knowing the patient and providing continuity and preventive care. As they retire or close their practices to new patients, there are no young physicians to take their place.

There is already a shortage of primary care physicians and physicians in some basic specialties like general surgery, neurology and rheumatology. Even large metropolitan areas are lacking in gerontologists, general internists and family physicians. Rural communities face challenges for primary care and specialty care.

Young physicians in training are turned off by the enormous unsatisfying paperwork and difficult practice environment of primary care. Our reimbursement system has disadvantaged these physicians for years and they are at the bottom end of the income scale, despite the fact that they are the basis for a healthy population.

Primary care doctors spend more time talking with patients and managing health care without expensive procedures and tests. The reimbursement for these cognitive services are not keeping up with the costs of running a practice and young doctors are walking away from this type of practice in favor of better lifestyles and more pay.

Even in medical strongholds like Boston, Mass., where there are several academic teaching hospitals and wonderful medical care, there is such a shortage of primary care physicians that doctors and nurses can't find a doctor to care for their own family. Finding a good primary care physician requires "knowing someone" who can open the door for you to be seen as a patient.

The proposal to provide insurance for the 45 million Americans who are presently uninsured will fall flat unless we address this critical issue of primary care and who is going to take care of people. Having insurance is not the same as having access to care.

Episodic, expensive, high-tech, specialty services have created a monetary health crisis that looms larger than the banking meltdown. It is time we look at the primary care crisis and begin finding solutions that will allow health care reform to succeed. Without considering the primary care piece, it is doomed to failure.

Some sobering news about wine

Adding to the good news about red wine, a new study in the November issue of Nutrition Research reports that red wine and other foods rich in the polyphenols found in grapes may help reduce LDL cholesterol, blood clotting, abnormal heart rhythms and blood vessel narrowing. "Supplementation with grape seed, grape skin or red wine products may be a useful adjunct to consider for a dietary approach in the prevention of cardiovascular diseases," the authors comment in a news release.

But you might want to put away the corkscrew after reading another new study that looked at the metal content of both red and white wines. The study, published in the open access Chemistry Central Journal, found that the vast majority of wines from 16 different countries contain hazardous levels of metal ions--potentially putting drinkers at risk for Parkinson's disease, chronic inflammatory disease and cancer. Using the Target Hazard Quotient (THQ)--a formula developed by the U.S. Environmental Protection Agency--as a basis for comparison, the researchers found that most wines far exceeded safe levels of metal--ranging from a low of 50 THQ to a high of 300 (a THQ over 1.0 is considered hazardous).

There were geographic differences, however, that might influence your next beverage purchase. Wines from Italy, Brazil and Argentina were on the low end of the THQ scale whereas Hungarian and Slovakian wines reached 300 THQ. Risk is based on consumption of one 250 ml glass of wine per day--researchers didn't get into how much the risks might increase as a result of binge drinking or mixing wine with other alcohol, or effects on the elderly, young or sick.
Wednesday, October 29, 2008

Best of convention hopping

After a whirlwind of conventions, it's time to head back to the office. But, before I go, a few non-clinical highlights:

Most unusual swag: It looks like a highlighter, but one end is a hand sanitizer spray, and the other is lip balm.

Rudest attendee: Raised his hand in the MIDDLE of a session and said, "I don't mean to be rude, but this is a little boring."

Strangest group psychology: the outsized appeal of free food. It's not as if any conference attendees would have trouble affording a couple of bucks for a snack. In fact, many of us are on expense accounts. But throw out a tray of muffins or a case of soda and we're stuffing our pockets like a horde of street urchins.

Weirdest souvenir: The ACR daily paper encouraged attendees to purchase a "Rodman Commemorative Gout Print." Your guess is as good as mine.

Strangest wardrobe: It may have related to the high percentage of foreign attendees, but spotted at ACR were a mullet, a pink fringed suit, and a study author's top so sparkly it could have blinded a cameraman.

Marketing gone wildest: In a montage promoting MGMA 2009, screen faded from e=mc2 to DEN=mc2, to DENVER. Hunh?

Most mysterious session title: Indian Hedgehog and Parathyroid Hormone-related Protein Regulate Articular Chondrocyte Differentiation.
Tuesday, October 28, 2008

Getting the gist

In my last ACR session (the convention continues through tomorrow, but our blog coverage finishes today), a psychiatrist spoke about explaining statistical risk to patients, a topic I've covered before.

One of her key points was that patients need to understand the gist, rather than the specifics, of risk. She used a clever example to make this point. Two patients are offered a surgical treatment that carries a 2% mortality risk. This risk is explained to them several weeks before the surgery, and then they are asked about it immediately beforehand. Patient A remembers the risk as 10%, while Patient B remembers a 0% risk. Even though Patient B's recollection is numerically closer to correct, it's less useful, because Patient A has correctly understood the gist that the surgery holds some mortality risk.

So what's the practical import? When talking to patients about risk, worry more about whether they seem to have gotten the general idea (aka the gist) rather than whether they can recite stats back to you verbatim.

Time for something besides medicine

This afternoon, I attended an ACR session on part-time medicine. A lot of the described advantages and disadvantages were ones you might have guessed (advantage: more free time, disadvantage: less money), but one speaker made some interesting points about the relative merits of working part-time vs. job sharing.

A lot of it comes down to overhead and benefits. Part-timers may be expected by their partners to continue covering an equal share of the overhead, but job-sharers may not be able to get full benefits. The speaker was a fan of job sharing, which she herself does, but she noted that finding a very compatible partner is of course a pre-requisite to making it work.

Both speakers said that it's usually better to cut back on the number of days you work rather than the number of hours, because a half-day will easily slide into a full day as patients and paperwork pile up. All in all, they made part-time work sound pretty lovely. Anyone want to be half of a medical reporter?

(Just kidding, unless you're willing to do half the work while I get all the salary.)

More reasons to quit smoking and lose weight

Smoking has already been shown to be a risk factor for rheumatoid arthritis. But a new study, presented this morning at ACR, expands the evidence against tobacco by finding that RA patients who quit smoking had significantly less disease activity than patients who continued to smoke. The research was based on a registry of 1,405 patients.

Being overweight, on the other hand, increases your risk for osteoarthritis. Swedish researchers compared BMI to likelihood of receiving a knee or hip replacement due to arthritis and they found that the more you weigh, the better the chance that you'll need a joint replaced. The finding held true even in the normal weight population, and when controlled for inflammatory and metabolic factors. The findings make it pretty clear that the greater joint load placed on the hips and knees of overweight people is responsible for the arthritis, said the study author. He recommended diet and exercise, although he wasn't terribly optimistic that patients would be leaping off their couches based on the study. "Maybe we need to work at this for 10 or 20 or 30 years," he said.

Old Blood = Bad Blood?

Transfusions with blood that is 29+ days old are twice as likely to lead to nosocomial infections-- including pneumonia, upper respiratory infections and sepsis-- as transfusions with newer blood, a new CHEST 2008 study found.

Researchers studied 422 ICU patients from July 2003-Sept. 2006. In addition to finding that older blood carried higher risk, they found that the more "old" blood a patient got, the greater the risk of infection.

Current standards allow blood to be stored for up to 42 days, and the oldest blood is usually used first, to avoid waste ("sort of like milk in a supermarket", quipped one reporter.)

Given that the U.S. isn't exactly flush with blood supplies, it's unclear how best to use this new information. Tightening standards could cause a shortage.

Study director David Gerber, DO, noted in a press conference that "there is a national tendency to transfuse liberally, " and said providers need to work towards using blood more cautiously.

For tips on tightening up on transfusions, see this article in October ACP Hospitalist.

Nicotine dependence: It's worse than you think

It's the best of times and worst of times for ending tobacco dependence, according to David Sachs, ACP Member, of the Palo Alto Center for Pulmonary Disease Prevention.

The best, because there are more tools than ever to help patients quit.
The worst, because most physicians have no idea how to treat patients effectively.

In part, that's because doctors don't know that nearly 75% of people seeking tobacco-dependent treatment are categorized as "highly" dependent-- meaning standard, OTC therapies won't work on them, Dr. Sachs said during a Chest 2008 press conference about a new study he authored. In the study, he and his colleagues analyzed pretreatment dependence severity from 1989-2006 and found severity increased 12% during that time, with those classified as "highly dependent" increasing 32%.

Doctors should measure dependence in their patients trying to quit. For treatment, they may need to increase drug doses and duration of use, try different drug combinations, and put more stress on minimizing withdrawal symptoms.

Dr. Sachs didn't have a pat answer for why dependence has increased in the last 15 years, so moderator Mark Rosen, FACP, speculated: "Can we attribute any of this (increase in dependence) to the stress of having Bush in the White House for the last eight years?"

Drugs to keep an eye on

As we reported in ACP Internist Weekly today, a record number of deaths and serious injuries from prescription drugs were reported to the FDA in the first quarter of 2008, according to the non-profit Institute for Safe Medication Practices (ISMP).

I thought it might be interesting to show the ISMP's chart of the top ten drugs in terms of adverse events and deaths. So here we go:

Drugs, ranked by reported # of serious adverse events:

VARENICLINE: 1001 events

Drugs, ranked by reported # of deaths:

OXYCODONE: 185 deaths
Monday, October 27, 2008

New uses for old drugs

There's something pleasingly efficient about research that finds new applications for existing therapies. A few such studies were presented today at the ACR meeting.

Hydroxychloroquine, an antimalaria medication, appears to be an effective treatment for both lupus and rheumatoid arthritis. In the lupus study, the drug protected against kidney damage, a common complication of lupus. The arthritis study, an observational trial, added to the evidence base for hydroxycloroquine by finding that it reduced the likelihood that RA patients would develop diabetes. Researchers suggested the drug--which is generic and costs less than $60 a month--might also be good for lipids and platelets.

Finally, a new study found that Cialis can increase blood flow to other parts of the body besides the one for which it was intended. In a trial of 25 patients (mostly women), the drug effectively treated secondary Raynaud's phenomenon, a condition which causes fingers to turn white and blue when exposed to cold. Guess now you can "be ready" to go build a snowman.

Good news, bad news

From ACR today:

The good news is that a new study found that TNF-antagonists do not increase the risk of cancer for patients with rheumatoid arthritis. The Spanish study looked at a database that included 14,001 person years and found very similar incidences of cancer in TNF-taking and control patients.

The bad news is that, even though rheumatologic patients are often at a higher risk of developing zoster infections, immunosuppressive therapies can prevent them from getting the vaccine. According to CDC recommendations, the zoster vaccine should be avoided in patients who are on high-dose corticosteroids or TNF-alpha-blockers. It can be given once patients have been off the drugs for at least a month, said this morning's presenter.

The patient who ruins your day

At ACR yesterday, Dennis Boyle, MD, led an entertaining, interactive session on dealing with difficult patients. In addition to clips from Cool Hand Luke, he offered some perspective on the visits that no one wants to have.

First, recognize that you bring your own issues to the encounter, which will affect how you respond to the patient. Dr. Boyle described how he used to complain about his problem patients to a psychiatrist friend until the shrink asked, "Did you realize that all your difficult patients remind you of your mother?"

More seriously, he reminded attendees that most angry patients are actually more afraid or sad than angry, and that open-ended questions ("Tell me why...") should be used to get their story. It's also important to actually listen to them when they're talking, and use reflective listening ("It sounds like...") to make patients feel understood, to control rambling stories, and to help you remember details for later charting.

Conference News: Chest 2008

Hot off the presses from beautiful central Philly, where the Chest 2008 conference is underway:

  • Statins may reduce VTE in patients with solid organ tumors. A new study of hospitalized cancer patients found that 8% of those who received statins developed VTE compared with 21% of patients who didn't. Study author Danai Khemasuwan, ACP Member, noted that a cause and effect relationship can't be inferred since the study was done by reviewing medical records, but hopes an RCT will confirm the results. Moderator David Gutterman, MD, said it makes sense that statins might improve the venous side of circulations, since it's already known they improve endothelial function. The author hopes to do an RCT next that will compare different kinds of statins, as well as different dosage levels.
  • Biphosphonates may increase the risk for serious atrial fibrillation. A meta-analysis of 16,322 patients found that 1-2% of those who took alendronate or zoledronic acid for osteoporosis experienced serious AF (i.e. hospitalization or death)-- an approximately 66% greater risk than patients taking placebo, author Jennifer Miranda, MD, said. There were only 3 studies in the analysis, however, and none assessed whether the patients had other risks for CV disease. Dr. Miranda said it's her understanding that FDA wants to conduct more trials to look at the CV effects of biphosphonates.
  • Most providers have scant knowledge of how to help smokers quit. A survey of 600 providers, including doctors, NPs, social workers and PAs, found less than 6% knew the AHRQ treatment guidelines for tobacco dependence. Only 16% of prescribers and 8% of nonprescribers knew which drugs were OTC vs. prescription, and the majority failed to recognize contraindications. Now that Medicare reimburses up to 8 visits/year for counseling people on quitting smoking, providers should take the opportunity to learn how to do this. One good first step, said the author: refer patients to 1-800-QUIT-NOW, a national quit line.

Medical News of the Obvious

We're running a little low this week, but here's what we've got:

Adults who eat rapidly or until they're full are more likely to be overweight, a study in BMJ reports. Just tell your heavier patients to slow down and chew. Problem solved.

Doctors are more likely to prescribe drugs to their patients-- in this case clopidogrel (Plavix) to stent patients-- when they have fewer hoops (like prior authorization) to jump through, the NEJM reports.
Sunday, October 26, 2008

Very different conferences

Attending two conferences in a row can be confusing, but I'm pretty sure the rheumatology session I just attended came out of a MGMA attendee's nightmare.

The purpose of the session was to convince rheumatology health professionals (who are co-meeting with the ACR) to refer their arthritis patients to occupational, vocational and physical therapy if they report any effects of their illness on work performance. The speakers made important points about how early interventions and workplace accomodations can lower overall costs by reducing absenteeism and disability payments.

But I think it's no coincidence that 3 of the 4 presenters were from countries with socialized medicine (England, Canada and the Netherlands). For example, the British speaker described the accomodations required for an office clerk with rheumatoid arthritis, which included a flat-screen computer, a customized ergonomic chair, speech-recognition software and construction of a ramp.

In the UK, she explained, the government will cover a signficant chunk of the modification costs. In the US, I thought, the manager of that office would be cringing even at the recommendation to buy an electric stapler.

Drugs, drugs, and...tai chi?

At most conferences, a press badge causes other attendees to avoid you if anything. But here at the American College of Rheumatology meeting, drug reps are drawn to my press ribbon like flies to honey. And they were in full swarm at a press conference this afternoon.

Early data on several experimental rheumatologic therapies was presented, including an injection for treatment-resistant gout and a new painkiller for knee osteoarthritis, as well as two potential competitors to Fosamax (in case Sally Field's commercials haven't already made it clear, there seems to be some money to made here). One of the drugs is a twice-yearly biologic and the other reduces glucocorticoid-induced fracture risk.

None of the drugs have been FDA-approved yet, though, so it should be a while before the drug reps are chasing you down the hall to discuss them.

The press conference did offer one non-drug therapy for knee osteoarthrtis--the ancient Chinese art of tai chi. Patients who did tai chi for 12 weeks had better function, balance and quality of life scores than those who did conventional stretching and wellness education. The researcher did warn that the tai chi exercises should be modified for OA patients because as typically done, tai chi can actually cause a lot of knee injuries. There's always a catch.
Friday, October 24, 2008

Physicians using antibiotics, sedatives as placebos

Internists and rheumatologists are using antibiotics and sedatives for their placebo effect, researchers reported.

Before 1960, sugar pills were common and ethical. Then advances in pharmaceuticals and in informed consent cast placebos in a negative light. But internists are using them, so researchers looked at internists and rheumatologists use of placebos, figuring they dealt with "debilitating chronic clinical conditions that are notoriously difficult to manage."

Researchers collected 679 responses split nearly evenly bewteen internist and rheumatologists. About half prescribe placebos, using saline (3%), sugar pills (2%), over the counter analgesics (41%), vitamins (38%) antibiotics (13%) and sedatives (13%). Nearly half said they use placebos monthly.

The researchers concluded, "Recommending relatively innocuous treatments such as vitamins or over the counter analgesics to promote positive expectations might not raise serious concerns about detrimental effects to patients' welfare. Prescribing antibiotics and sedatives when they are not medically indicated, however, could have potentially important adverse consequences for both patients and public health."

How are you using placebos in your practice?
Thursday, October 23, 2008

Good Samaritans help (when it's needed)

Physicians can find themselves offering care in emergencies outside their medical practice, as happened this morning in front of the American College of Physicians' offices in Philadelphia. A bystander had a medical emergency outside our doors and an ACP physician responded.

Physicians don't always think about the duties and liabilities of offering help as a bystander during a moment of crisis. They offer what aid is needed. Most states extend liability protection to medically licensed caregivers who try to help; states that spell this out in plain English include Mississippi and Missouri although they are far from the only two.

As it turns out, most EMTs prefer not to have the help of a bystander, even one who is a doctor, said the ACP physician who rushed outside to offer help. EMTs can and should handle emergencies, and in this case, police and EMTs were already working on the patient's airway. Even in situations where the physician has started life support, once the EMTs arrive the doctor should relinquish control to the EMTs. And in this case, since ACP's offices are next door to Philadelphia's police headquarters, the situation was already in hand.

But the issue of offering emergency aid may be different after a mass crisis. Doctors have considered the impact of offering free-lance aid after the World Trade Center attack on Sept. 11 and Hurricane Katrina, or they are considering what the response should be to flu pandemics. The Georgetown Law Journal has a dense article on the pandemic question, and starting on page 34 it offers a state-by-state overview of Good Samaritan laws.
Wednesday, October 22, 2008

Cast Your Health Care Ballot

With Election Day approaching and so many casting early ballots, ACP Internist is asking its readers whose health care plan they favor -- Sen. John McCain or Sen. Barack Obama -- and whether health care reforms will influence your vote. Need help deciding? ACP has a toolkit that analyzes the candidate's plans.

Click here to vote. Results will appear in an upcoming issue of ACP InternistWeekly. (This poll is not considered scientific and does not constitute an endorsement by the American College of Physicians.)

I'd rather have spam, thanks

We've got e-cards for birthdays, holidays and fall foliage trips. We've got an automated phone service for informing a person s/he has bad breath.

But did you know there is a free e-card service for anonymously informing one's partner(s) about an STD?

inSPOT, which has been around for several years and just got a write-up in PLoS Medicine, lets a user pick from one of six card designs, and insert the email addresses of up to six partners at a time. The user can choose a "pre-filled STD message" from a drop down menu of STDS (which includes gonorrhea, chlamydia, crabs and scabies, hep A, molloscum, shigella, syphilis, NGU, but not herpes or AIDS for some reason)-- or just leave it general and tell the person it's an STD. When a recipient clicks on the card, he or she is linked to a page with info on the disease/s.

One of the cards features a bare-chested man with a blurry neon bar scene in the background and the words:

"It's not what you brought to the party, it's what you left with. I left with (fill in STD name here). You might have too. Get checked."

Another one shows a photo of a little card that says "I'm so sorry". There are six cards in all, with varying degrees of contriteness and lightness. For certain cities and states, there is also an interactive map on the Web site which tells the various locations where one can get tested.

Over 750 people visit the site daily, the PLoS article says.
Tuesday, October 21, 2008

Visiting the dark side at MGMA

Learning about the business of medicine can be fun, even inspiring. I'm looking forward to writing up MGMA sessions on reducing no shows and improving the wait room experience for upcoming issues of ACP Internist.

But this afternoon, a couple of sessions wavered in the delicate balance between profit and clinical motives. First, a hospital exec who was trying to up his patient satisfaction scores explained how his organization told their docs to improve patient contact by thinking about "how you would do things differently if you valued the person in front of you." Implication being that the average patient previously had no value?

Then I went to a session on a topic that always riles our high-minded readers: medical spas and retail medicine. (I didn't mean to be there. The "Day in the Life of an EMR Physician" session was unexpectedly cancelled.) And it was painful.

The speaker (a lawyer) started off by talking about the impending primary care shortage. Which seems to me like an argument against spa medicine, since we might need those few docs who are left for real clinical care, but I suppose it's also a market opportunity. Anyway, apparently these spas are offering everything for which patients will open their wallets, from massage and Botox to hormone replacement therapy. Wait, isn't HRT a medical therapy that you should provide to patients based on the (substantial, hotly debated) evidence rather than the price they will pay? (I didn't get to ask.)

After a brief discussion of all those pesky regulations that medical boards and government regulators impose on the fortune-making possibilities of medicine, we moved on to retail clinics. The speaker predicted that more physicians will be getting offers to supervise in-store clinics that are staffed by NPs and PAs. The bad news is, legal constraints mean they might actually have to do work, like reviewing charts. "It's not just show up at WalMart every two weeks and pick up a paycheck," he said.

I know, physicians need to be paid, and medicine is still a capitalist enterprise (although after banking, who knows what's next). But after my foray into the biz of medicine, I'm ready to hop back over to clinical side of the wall.

The requisite motivational lecture

This morning at MGMA, expert/consultant Quint Studer gave the group some tips on how to improve performance of their medical groups. His top recommendation was to fire your bad employees.

A few less obvious tips:

  • He suggests using pre-visit phone calls to reduce no-shows. The interesting twist--while you've got them on the phone, ask for credit card payment of the copay. Saves time during check-in and gives them more to lose by noshowing.
  • Studer's designed a little brochure called a "patient visit guide" that is intended to improve compliance and satisfaction. Patients write down their chief complaint on it, then nurses fill in vital stats, and docs add follow-up (particularly medication) instructions. Patients then take it home, and have a clear idea of what happened during the visit. There's supposed to be an online version of the form on Studer's web site, but I haven't found it. Will do some more investigation.
UPDATE: A link to the form has been posted. Thanks, Anonymous and gscarbo, for pointing that out. I think he said these resources would be available for a couple of weeks, so if you want the form, hurry up and get it.

Millennials: demanding what all workers want?

It's only been a few years since the so-called Millennials (born 1980-2001) entered the workforce but their 'boomer' bosses are already pegging them as spoiled brats with inflated views of their own importance. Not surpisingly, that's causing tension in the workplace, according to an article in Tuesday's Wall Street Journal based on "The Trophy Kids Grow Up: How the Millennial Generation Is Shaking Up the Workplace," by WSJ contributor Ron Alsop. (ACP Internist has covered this issue from a medical perspective).

Aslop goes on to make some perceptive observations about how Millennials' proclivities are playing out in the workplace (jumping from job-to-job, expecting instant promotions, sending brash emails to the CEO) as well as possible sources of their elevated self-esteem (coddling by the boomers who are now their bosses). But in the end, what the Millennials want doesn't seem all that outrageous and in fact it's a bit sad that extending a few basic courtesies is viewed as "adapting" to unreasonable expectations. Tips for bosses include:
  • Show new hires how their work makes a difference and why it's of value to the company.
  • Listen to young employees' opinions, and give them some say in decisions.
  • Detail the career opportunities available to millennials if they'll just stick around awhile.
Isn't this how we'd all like to be treated?
Monday, October 20, 2008

What the managers are thinking

I (and the rest of the press pool) had lunch with MGMA president and CEO William F. Jessee, MD, today and he offered some thoughts on current events.

Already, the effects of the economic meltdown are starting to be felt among MGMA member practices, who are reporting recent decreases in patient volumes. There are also expectations that uninsured populations will go up along with the unemployment rate. In addition, practices are now holding off on big capital expenditures, Dr. Jessee said. That's bad news for the MGMA conference, for one, since you can't walk the exhibit hall without tripping on an EHR vendor. "I'm curious to see how our conference will look next year," said Dr. Jessee.

The MGMA is challenging the next president to concentrate some of his administration's health reform energy on payment reform. "Neither of the candidates is addressing the core issue," said Dr. Jessee. Key points that he would like to see addressed: universal coverage (the MGMA has not taken a stand on single vs. multiple payer); changing reimbursement to reward physicians for keeping patients healthy; aligning incentives so that physicians, hospitals and payers can work together instead of against each other; and reducing administrative waste.

Toward that last goal, the MGMA is starting a big push for standardized patient ID cards. Right now, they're doing research to show that insurance cards with magnetic stripes or bar codes that have basic patient and payer info encoded in them would save time and money for everyone involved. The next step is getting payers on board with the idea. A small step toward simplifying the administrative nightmare that is modern healthcare. Says Jessee, "We pitched this one because it's so simple even a legislator can understand it."

One more ill-advised session title

I'll be blogging from the annual meeting of the American College of Rheumatology next week, and for the most part, their session titles are depressingly matter-of-fact. "Translating Rheumoatoid Arthritis Treatment Guidelines into Quality Measures" and that sort of thing.

Some of them are intimidatingly specific: "Elevated Production of Interleukin 1β (IL-1β) and Tumor Necrosis Factor α (TNF-α) by Perpheral Blood Mononuclear Cells (PBMC) is Associated With Increased Hip Fracture Risk in Elders: The Framingham Osteoporosis Study."

But only this one caught my eye for sheer weirdness of imagery: "Preserving the Beans and Other Points in the Evaluation and Management of Chronic Kidney Disease." Yum.

EHRs at 8 a.m.

I'm at the Medical Group Management Association's annual meeting this week, in not-so-sunny San Diego.

This morning, I started off by going to a lecture about the operations of the Certification Commission for Health Care Information Technolgy, the recognized certification body for electronic health records, which was founded by the Healthcare Information and Management Systems Society and HEY! DON'T FALL ASLEEP! I'M STILL TALKING HERE!

Anyway, I managed to stay awake for a few interesting facts. First, despite all the talk about how Stark exceptions will let hospitals give EHR systems to physicians, very few are actually doing that. Specifically, the MGMA rep said that he's never met anyone who got their EHR that way, and the CCHIT director suggested about 100 hospitals have actually done it. Biggest hurdle, according to the speakers: disputes over who controls the data in the records.

But, one entity that actually is encouraging EHR adoption: malpractice carriers. Both speakers said they've talked to liability insurers that are offering up to 5% off premiums if you have an EHR. (There's no proof yet that electronic records lower claims, but they do improve documentation.) Depending on the size of your premium, that discount might pay for a significant chunk of your EHR costs, the experts suggested.

And, a few of the mysteries of CCHIT certification were revealed. When you're looking at an EHR, the more recent the certification, the better, but don't rule out a system that's still 2008 certified in the spring of 2009, they said. The certification cycles run from August to August, so no one will have the current year's certification until the summer at the earliest. Also, certifications are good for two years, but vendors should state in their contracts that they will get renewal of their certifications when needed.

Looking into gaps in candidates' health records

New York Times columnist Lawrence K. Altman, MACP, has commented that the lack of medical information released by the presidential and vice presidential candidates concerns him greatly.

Sens. John McCain and Joe Biden have been treated for serious medical conditions(melanoma and brain aneurysm, respectively.) Sen. Barack Obama released a one-page letter about his excellent health (although he's having trouble quitting smoking) and Gov. Sarah Palin has not released any medical information. Dr. Altman covers their known ailments, and then muses on what hasn't been disclosed.

More concerning than the gaps, Dr. Altman writes, is the "retreat from the approach that most campaigns took over the last 10 elections" to fully disclose medical problems.

Other ACP members have shared their insights into how much presidents should disclose about their health. E. Connie Mariano, FACP, for nine years treated presidents and their families (and their pets; I guess there is no "First Vet"). She talked about her experiences at Internal Medicine 2008 and shared stories with ACP Internist here.

Medical news of the obvious

This edition focuses on Europe, a continent from which more inanity than usual was emanating this week.

First, it took a team of nine European specialists on the Scientific Committee on Emerging and Newly Identified Health Risks to conclude "Listening to personal music players at a high volume over a sustained period can lead to permanent hearing damage." Could you repeat that?

This second study may be less obvious than mysterious (as in, why on Earth did someone fund this research?). Researchers in the U.K. "analyzed 413 adult deaths from unintentional injuries that occurred in the county of Sussex, England, between 1485 and 1688," the Washington Post reported. They found that people frequently died from drowning, being hit by objects and falling, and that some of them were drunk at the time.

Who would have guessed? And who would have cared? (Aside from the families of these poor victims, of course. Our condolences of the loss of your great-great-great-great...great-grandfather.)

Ill-advised session titles

In perusing the online schedule for the Chest 2008 conference (Oct. 25-30 in Philly), I've discovered an atypical attention to alliteration. Here are the titles of three sessions in a row:

Peculiar Pleural Problems
Perplexing Pulmonary Pressures
Propitious Pleural Problems

"Propitious?" Holy 800 SAT Verbal!

Then the next day we have these:

Pulmonary Puzzlers
Miscellaneous Mish Mash
Capricious Cancer Cases

Followed by:

Extraordinary Endobrachial
Malevolent Mestastacies
Wild ILD
Freakish Fevers

Speaking of freakish, how about this title:

"Surgeons: 6, Mortality: 0".

I, for one, am intrigued.

Then we have those titles that fall into the category of overly-sweeping and grandiose. Like this one:

"Women and Tobacco: A lesson for mankind"

Finally, there is an event called "Asthma Bingo" in the exhibit hall, with the prize being a free CPAP machine. (just kidding. The prize is a laptop.) Instead of numbers, do they shout out allergens? ("B- Dander!" "G-Pollen!")

I can't wait to find out.
Friday, October 17, 2008

The Bee Gees saved your life tonight

Disco may be dead, but the Bee Gees' hit song "Stayin' Alive" has literally found new life. Research that will be presented during the American College of Emergency Physicians' scientific assembly in Chicago this month revealed that the song has almost the same number of beats per minute (103) as the AHA's recommended compressions per minute for CPR (100).

And it may be annoying you right now, but the way that beat gets stuck in your head also turns out to be a good thing. Having practiced CPR with the music helped medical students and physicians maintain the ideal rhythm, even weeks later without the benefit of headphones. "A number of pop songs have the right rhythm for CPR, but of course the meaning of 'Stayin' Alive' is pretty powerful when you are trying to save someone's life," one researcher pointed out.

But the funniest comment on the subject comes from a resident interviewed by the Associated Press: "I heard a rumor that 'Another One Bites the Dust' works also, but it didn't seem quite as appropriate."
Thursday, October 16, 2008

Texts teach anatomy of white males

It's a man's least on the shelves of medical libraries, according to researchers who reported that, "Images of white men predominate in western anatomy textbooks, which present them as a 'universal model' of the human being."

Researchers looked at 16,329 images from 12 manuals currently recommended by universities in Europe, the U.S. and Canada, so it was no small sample. Nine of the 12 manuals used Caucausian images exclusively to illustrate anatomical concepts. So much for diversity.
Tuesday, October 14, 2008

Attack of the Cuban chickens

We haven't heard much lately about bird flu (maybe because the apparent collapse of our economy is enough for everyone to worry about), but a recent Associated Press article points out a new way in which Americans are not prepared for the possible pandemic.

Despite the hassle we've given the Indonesians over their refusal to share bird flu samples, the U.S. actually has a law on the books that would prevent (or at least delay) the sharing of vaccines with any of the Axis of Evil countries (including North Korea, which is in prime bird flu territory, and Cuba, which is just a bird flight away).

Not clear how much of a problem this is, since no one knows how long it would take to cut through the red tape if sharing were necessary. It's also unclear whether the regulation has any merit, since scientists quoted in the story say the chances of terrorists using vaccines to develop weaponized bird flu are extremely slim.

Just another thing to keep you up at night...
Monday, October 13, 2008

Medical news of the obvious

The days are getting shorter and colder, the leaves are turning, and researchers want to get their studies published before the holidays. You know what that means: It's harvest time for some really obvious news.

Like this: A new study reports city kids like to go to corner stores to buy unhealthy snacks and drinks on their way to and from school! And here we thought those gaggles of backpacked youth down the block were just popping in for some fruit and a new set of pencils.

Also, the tanking of the U.S.-- nay, the global!-- economy is, like, stressing people out, the Washington Post reports.

Don't let that stress lead you to take up smoking, though....the latest research is that smoking is bad for you! Archives of Internal Medicine reports that men who never smoke live longer and better lives than heavy smokers. "Health-related quality of life appears to deteriorate as the number of cigarettes smoked per day increases," explains a helpful news release.
Friday, October 10, 2008

A new, and somewhat puzzling, depression treatment

So the FDA just approved this new gadget that looks like a dentist chair, but in fact is a device to treat depression. The NeuroStar Transcranial Magnetic Stimulation device delivers a magnetic pulse to a specific part of your brain-- sort of like a much milder version of electroconvulsive therapy, and one that doesn't involve seizures.

The device is only indicated in patients who have tried one antidepressant. You may have tried that drug four different times at four different dosages, but you must have tried just that one drug.

The company-sponsored study didn't test the device against switching to another antidepressant, but only to placebo. (And it did twice as well as placebo.) One advantage the TMS offers is that it doesn't have the nasty side effects one can get with pills, like weight gain and loss of libido.

I do wonder, though, how many patients are going to decide, after failing to get any response from one antidepressant, that they want to strap themselves into a scary-looking chair and have their brains zapped, rather than just trying a different drug. Especially since the TMS treatment requires that you be awake when you get it, and the normal therapy course is 40 minutes every day for 4-6 weeks.

What do you say? Would you recommend this kind of treatment to patients?

Is honey the new red wine?

We've already heard (and re-heard) that red wine, olive oil, omega 3-rich fish and dark chocolate have healthful properties. Now it looks like honey is primed to have its place in the sun.

Cochrane Researchers have found that honey reduced the healing time of patients suffering from mild to moderate burn wounds. They reviewed 19 studies and found honey worked better on the burns than some gauze and film dressings. It also kills the bacteria that cause chronic sinusitis, another new study found.

Last year, a study found that a single dose of buckwheat honey resolved symptoms of upper respiratory tract infections in kids, while honey-flavored cough medicine didn't.

Of course, unlike the other foods, researchers here are focusing on honey's healing properties, rather than its potential preventive benefits. Either way, looks like we might want to start paying attention to that declining bee population...
Thursday, October 9, 2008

Government exercise guidelines

There are a lot of competing recommendations out there about how much exercise people need to stay fit. This week, the Dept. of Health and Human Services released what it hopes is the definitive word on the subject with its "Physical Activity Guidelines for Americans."

These are based on "the first thorough review of scientific research about physical activity and health in more than a decade," and crafted by 13 advisory committee members appointed by HHS Secretary Mike Leavitt.

Without further ado, some highlights:

For adults, 2.5 hours a week of moderately intense aerobic activities, like brisk walking or gardening, is enough to yield big benefits. The 2.5 hours can be spread out over the week, but you need at least 10 minutes at a time to get your heart rate up.

Vigorous aerobic activity like jogging or jumping rope buys time: adults need only 75 minutes/week to stay healthy. You know it's vigorous if you can only say a few words before having to catch your breath.

Adults should also do muscle strengthening activities (lifting weights, sit-ups, carrying heavy stuff) 2 days/week.

Older folks should do as much as they can to meet the adult guidelines, and also do balance exercises if they are at risk of falling.

Pregnant women should follow the adult guidelines, though vigorous exercisers should talk to their doctors about whether they need to modify any activities.

Kids and adolescents need an hour or more of moderate or vigorous exercise at least 3x/week. They should do muscle strengthening and bone-strengthening activities (eg: running and jumping rope) 3x/week.

These are minimum guidelines. More exercise than this is, of course, better.
Wednesday, October 8, 2008

Robbing Peter to pay Paul

John McCain has criticized Barack Obama's health care plan for its expense, and argued that his own proposal will be budget-neutral. A recent article in the Wall Street Journal gives a little insight into how he's going to accomplish that.

According to the article, the McCain plan will cut Medicare and Medicaid spending to the tune of $1.3 trillion over 10 years. The cuts will be achieved by eliminating Medicare fraud (a worthy goal), increasing premiums for wealthier seniors (not an idea that's likely to win Floridian votes), and "reforming payment policies to lower the overall cost of care," to quote the WSJ. That last part sounds most relevant to physicians, and distressingly ambiguous. Is it money for the patient-centered medical home or longer do-not-pay lists? Hard to tell from the platform on McCain's Web site, but it looks like maybe a little bit of both.
Tuesday, October 7, 2008

Step awayyy from the buffet

Most everyone has heard that if you want to lose weight, you should take smaller portions, put your fork down between bites, chew slowly, etc. etc. etc.

But researchers have found that a bevy of other behaviors may cause people to gorge, especially at buffets (which, really, Congress should just outlaw until we get over this obesity crisis).

To wit, researchers found that overweight diners sat 16 feet closer to the buffet than normal weight diners. They were also more likely to face the food, use larger plates, eat with forks instead of chopsticks, and serve themselves right away instead of browsing the food.

One assumes that counseling people NOT to do these things has a shot at stopping them from eating quite so much. Perhaps something to pass along to your portly patients who are planning a trip to a buffet-laden place like Vegas. Or a cruise.
Monday, October 6, 2008

Is JAMA psychic?

Just two days after JAMA ran an article that found long-term psychotherapy works better than short-term for the complex mentally ill, Congress passed (and Pres. Bush signed) a bill that would effectively require many insurers to cover longer-term treatments.

So does JAMA have some sort of psychic on its payroll? (NEJM has already informed us there are psychic cats that can predict when people will die; perhaps JAMA has a psychic hedgehog that predicts the outcome of legislation?)

In all seriousness, this mental health parity legislation-- which was attached to a big bailout bill you may have heard about-- was a long time coming. To be clear, it doesn't tell insurers they must cover mental illness. It just says that if they already offer mental health coverage, it has to be equal to that of other medical coverage. In other words, treat schizophrenia like you would heart disease.

For years, mentally ill patients have paid higher copays and deductibles, and had lower visit limits, than people with other kinds of illness. This makes it difficult for internists to do anything with these patients other than write them a prescription, because doctors know that a referral to psychotherapy means a limited number of sessions-- if any at all. (An issue we addressed in a story about parity last year.)

Medication is useful, but research has shown the best approach for certain disorders, such as severe depression, is medication plus therapy. And the Oct. 1 JAMA study shows it can take quite a bit of that therapy to make a dent in complex disorders like depression and anxiety.

Specifically, the study found that patients who had at least one year or 50 sessions of psychodynamic psychotherapy were better off than 96% patients who had shorter durations of other therapies, including cognitive-behavioral and behavioral therapies. (Psychodynamic therapy focuses on the patient-therapist relationship-- not the same as the Freudian stuff.)

Study author Falk Leichsenring told the Washington Post that the ideal number of sessions varies by patient, but that most patients with acute distress will do well with 25, while those with chronic distress need about 50, and those with personality disorders need about 200.

Until the parity legislation, most insurance plans covered 20-30 sessions per year, at best.

So what do you think? Will you be more likely to refer your mentally ill patients to therapy, once this law kicks in on Jan. 1, 2010 (for most plans)?

Medical news of the obvious

In a startling insight into the human psyche, researchers report that "patients with generalized social phobia respond differently than others to negative comments about themselves."

Meanwhile, the Journal of Sport & Exercise Psychology reports that listening to music while exercising increases endurance. And here we thought all those people with headsets at the gym were catching up on their financial news podcasts!

And...finally. Workers who take long bouts of sick leave (7+ days) are at a higher risk of death than their colleagues who don't take sick leave, BMJ reports.
(To be fair, they also found this: workers who were absent for circulatory diseases, surgical operations, and psychiatric diagnoses were more likely to die than those out for infections, respiratory illness, or injury absences.)
Friday, October 3, 2008

Say what you're thinking

There's never going to be a happy way to break bad news. But, as a recent column in the New York Times points out, physicians' efforts to perfectly stage their delivery may actually backfire and make things worse.

I can vouch for this. When I saw my primary care physician for an undiagnosed problem last year, she had a couple of my labs back, but a few more were still on the way. Without all the labs, she wouldn't speculate about a diagnosis. When she called a few days later with a diagnosis, she thought she was breaking bad news, but I was actually relieved because the silent, worried look with which she scruntinized the labs had convinced me that I was probably terminally ill.

So, to sum up, don't underestimate your patients' ability to read your poker face...or their hypochondria.
Thursday, October 2, 2008

What's the deal with medical tourism?

You've probably heard about the trend of Americans going abroad to save money on health care--it's been pretty popular in the media lately.

But a couple of recent articles in the Wall Street Journal raise interesting questions about this apparent trend. The first highlights a new pattern of employers encouraging workers to travel within the U.S. to get cheaper care, although they don't seem to have found any patients who have actually done that. The second article (which mysteriously cites the exact same employer as the first!) addresses the idea of employers going so far as to pay their workers to get treatment overseas.

A union rep quoted in the story has some dire predictions about what this scenario could mean for patients and docs. "You create a slippery slope where medical tourism starts out as an option, maybe even an attractive option, but over a short period of time I believe will become mandated."

What do you think? Is your job--like that of so many customer service reps--going to be outsourced to India? How much of a trend is medical tourism, really? Have any of your patients gone overseas for surgery or some other treatment?

Special thanks to reader Pat C. for pointing us to this topic. Also, we swear we recently saw an article about U.S. docs going overseas to provide cheap care to visiting American patients, but now we can't find the story anywhere. The first reader who sends us a link to that piece of irony wins a prize.
Wednesday, October 1, 2008

Kevin, MD piece on EMRs

Kevin, MD has a nice, succinct opinion piece in USA Today about why doctors resist using electronic medical records. He is also now a member of the newspaper's board of contributors, so you'll be seeing his opinions on medical issues every few months.

USA Today has the highest circulation of any newspaper in the nation, so if you want a shot at getting the word out to the general public about something, email your ideas to Kevin.