Tuesday, December 30, 2008

See you next year...

The ACP Internist staff, and thus this blog, will be taking the next few days off. Happy New Year, all, and we'll see you on January 5th.
Monday, December 29, 2008

Medical news of the obvious

Just in time for New Year's Eve, we bring you our "Sex, drugs and rock 'n' roll" edition of Medical News of the Obvious. (Actually, it's more like "sex, food and rock 'n' roll", but food is akin to a drug for some people, no?). Without further ado...

--Kids' meals at fast-food restaurants aren't very nutritious, according to researchers in Houston and Michigan. Also? They are high in fat and calories!

--Teenagers who pledge to remain abstinent until they marry aren't any less likely to have premarital intercourse than teens who don't pledge, a new study finds. Bet they are more likely to feel guilty about it, though...

--"Head banging" increases your risk of head and neck injuries, the BMJ reports. But the researchers have some tips for Metallica lovers to reduce their chances of injury: "Head bang to slower tempo songs by replacing heavy metal with adult oriented rock; only head bang to every second beat; or use personal protective equipment." In other words, listen to John Mayer instead of Ozzy, and be the one guy at the Motorhead concert who's wearing a helmet. Rock on!

Tuesday, December 23, 2008

Concierge practices reviewed as insurance

Maryland is proposing to regulate concierge medical practices as a type of insurance, prompting at least one internal medicine group to halt its plans to stop accepting private insurance, the Baltimore Sun reported.

Charter Internal Medicine of Columbia, Md., announced it will continue business as usual in a Dear Patient letter on its Web site. The group is made up of a College fellow and four members.

Concierge practitioners in other states have told ACP Internist the management method, in which doctors charge a flat fee to a limited panel in exchange for complete patient access, lets doctors practice medicine the way they see fit. But the method has even drawn fire from other doctors, who feel that limiting the number of patients harms healthcare access for the rest of the community. Maryland is the first time a state has stepped in to review the legality of concierge coverage.
Monday, December 22, 2008

Medical news of the obvious

In its best medical discoveries of 2008, NYU Langone Medical Center claims to have solved the problem of MRSA in the hospital. Before arriving for joint replacement or spinal surgery, patients are tested for staph. If they're infected, they get an antibiotic.

Meanwhile, researchers at the University of Missouri were shocked to discover that there are a number of adjectives used to describe intoxication and that gender differences exist in the use of these words. "Men tended to use heavy-intoxication words more than women, which were also relatively more forceful in their tone, such as 'hammered.' Women tended to use moderate intoxication words more than men, which were also relatively more euphemistic, such as 'tipsy.' This is similar to other gender differences in slang usage, for example, men 'sweat' and women 'glow,'" a researcher told the Washington Post. Here at ACP Internist, we prefer to gender-neutrally perspire while we're getting wasted.

This might be stretching it even more than usual, but we couldn't resist: Anyone who has ever owned a dog, then brought another animal (or an infant) into the home knows: Dogs can get jealous.
Friday, December 19, 2008

What's the big deal?

I'm mystified by the attention and press coverage that a new study in JAMA about dietary options for type 2 diabetics has attracted. The Canadian nutrition research found a very small difference in A1c levels resulting from two different diets (a .5% drop in patients who ate low-glycemic-index vs. a .18% decrease in those who ate a high-fiber diet). The results were less than overwhelming, but if these dietary changes are easy, maybe they're worth suggesting, right?

Good luck. The primary distinctions between the two diets are so miniscule that an obsessive-compulsive dieting teenager would have trouble keeping track, let alone your average overweight type 2 patient. To quote from the study, the first group was encouraged to eat "low-glycemic index breads (including pumpernickel, rye pita, and quinoa and flaxseed) and breakfast cereals (including Red River Cereal [hot cereal made of bulgur and flax], large flake oatmeal, oat bran, and Bran Buds [ready-to-eat cereal made of wheat bran and psyllium fiber])" while the other group ate "whole grain breads; whole grain breakfast cereals."

And what do both these dietary plans have in common? Carbs!

There are some potential significant differences hidden in the details of the diets (the low GI list included nuts, while the high-fiber people ate potatoes). Might that have been responsible for the differential in A1cs? We'll never know, because the effects were buried under the details of the cereal aisle.

It's a pet peeve of mine how little attention the relationship between carbs and blood sugar gets in diabetes care recommendations. It's one thing to suggest that obese patients cut the fat, but having people obsess over bread varieties instead of just eating their sandwiches open-faced? Frustrating.
Thursday, December 18, 2008

To email or not to email

In a response to an ACP Internist article about patient web portals, we recently asked InternistWeekly subscribers whether they communicate with patients online. The results showed that our readers (or at least those who responded to the survey) are ahead of the curve with patient email: 38% said they communicate with patients online, and another 19% are interested in the idea. The remaining 43% said "No, and I'd like to keep it that way."

As a follow-up, the survey asked why the respondents do or don't use online communication. Not surprisingly, the answers revealed time, technology and money to be the biggest hurdles to implementation. Many readers saw no reason to mess with the status quo and add potential complications with HIPPA, encrypted email or malpractice risk. "The phone works fine and actually talking to a patient is far preferable to email," a commenter said. Or as one succinct doc put it, "Think it would double my workload."

Another saw a wide range of risks inherent in emailing: "Increases risk of misunderstanding and potentially increases liability. Increases tendency to carry out 'telephone' medicine with the lack of hands on, visual, and intuitive clues to the real underlying problem. It is time-consuming in aggregate and adds to an already overloaded schedule. There is no evidence that engaging in this type of communication will improve medical care or decision making, reduce liability, reduce workloads or increase income."

The physicians who do use email would likely disagree with that reader. Several mentioned that they limit their online communication to brief messages, like sending test results or setting up appointments. Listed benefits were the ease of communication, avoidance of phone tag, and savings on postage. And then there was the most unusual reason for using email: "It also intimidates enough people to not pursue silly things." Perhaps a selling point that EMR vendors will want to add to their pitches.

Want to add your two cents? Click Here to take survey
Tuesday, December 16, 2008

Medical news of the obvious

Lots of promotional press releases cross our desks at ACP Internist. When they're too weird to pass up, we'll post them here. It's like Annals of Internal Medicine's Personae, but without the cash prize.

This one came from a system promising whiter teeth. Obviously, it didn't convince the staff to try it.
Monday, December 15, 2008

Colonoscopy prep harder on women

Colonoscopies are especially important for women, because they're more likely to have polyps or lesions deeper in the colon. But the bowel prep, the part most essential to a thorough screening, is harder for women.

Harvard Women's Health Watch (pay-per-view subscription, $3.95) reported that women are more likely to be constipated, so it may be more difficult to clear the bowel. Women are also more likely than men to have irritable bowel syndrome, which can cause gas, bloating and abdominal pain or spasm.

Harvard Women's Health Watch suggests giving patients the following advice to help women with bowel prep:
  • Read prep instructions well before the procedure date. Some food and drugs must be stopped a week before;
  • Arrange the time and privacy ahead of well before beginning the prep;
  • Add Crystal Light or Kool-Aid (not red, blue or purple) to the foul-tasting prep solution. Drink it chilled; drink it through a straw far back on your tongue; or hold a lemon slice under the nose while drinking it; and
  • Water can get boring, so keep a variety of clear liquids on hand to drink.

ACP Internist highlights ways to make colonoscopy screening easier on patients, including video interviews, as well as reviews expert opinions on two guidelines on colon screening methods released in 2008.

Is it always about the primary care shortage?

There's an interesting article in the LA Times about a young doctor who had to give up her independent primary care office to go to work in a big, corporate practice. But it's hard to tell what conclusions to draw from her story. The article itself ties her problems to the infamous primary care shortage. The Wall St. Journal blog argues that the problem is that small practices don't work as a business model. And from my reading of the story, it seems to me that her problem was the opposite of what we think of the primary care crisis: she had a shortage of patients, maybe due to the economic crisis. Here at ACP, we were just talking this morning about the potential impact of the recession on physicians. Fewer primary care visits but more hospitalizations (because patients are skimping on chronic care)? More patients who come in for care but can't pay their bills? Is anyone seeing this out there yet?
Friday, December 12, 2008

Careful what you say...and how you say it

Patients get more anxious when you use the medical terms for conditions and diseases than the lay terms, a new study in PLoS Medicine finds.

When study subjects were given the medical term for a condition-- like "erectile dysfunction"-- the condition was perceived as being more severe, more apt to be a disease, and more rare, than when they were given a layperson's label--like impotence, a press release said.

Here's the thing: the effect was only seen with terms that have been "medicalized" in the last ten years, like "hyperhidrosis" for excessive sweatiness. Medical terms that have been around for awhile, like "hypertension", didn't make patients more nervous.

If a patient thinks her disease is more serious if you say "GERD" than "heartburn," it may affect how seriously she takes care of her health in relation to that condition, one of the authors said. So choose your words wisely.
Thursday, December 11, 2008

Ritalin for everyone

This Nature article, in which a group of scientists and ethicists come out in favor of allowing healthy people to take cognitive-enhancing drugs, has gotten a lot of news coverage, but it's definitely still worthwhile to read it for yourself.

The authors go pretty far out on some theoretical limbs--making the case that brain-stimulating drugs are no different than sleep or education and suggesting that someday it could be mandatory for surgeons to take the pills if they were proven to improve outcomes. But they build a compelling argument (and a lot of curiousity--would this blog post be vastly more intelligent if I had popped an Adderall beforehand?).

The article also puts a lot of responsibility on physicians, noting that they are already pushed by some healthy patients to prescribe the drugs (anyone want to comment on their experiences with that?). And, in the end, the experts want docs, or their representative organizations, to decide this tricky issue:

"It would therefore be helpful if physicians as a profession gave serious consideration to the ethics of appropriate prescribing of cognitive enhancers, and consulted widely as to how to strike the balance of limits for patient benefit and protection in a liberal democracy."
Wednesday, December 10, 2008

Alternative medicine use holds steady at more than 1 in 3 Americans

Approximately 38% of adults use some form of complementary and alternative medicine (CAM), a level that has held steady for the past five years, according to the National Institutes of Health Survey (NHIS).

Overall CAM use has remained relatively steady, from 36% in 2002 to 38% in 2007. However, use of specific therapies has varied.

The most commonly used by adults were:
--nonvitamin, nonmineral, natural products (17.7%), most commonly fish oil/omega 3/DHA, glucosamine, echinacea, flaxseed and ginseng,
--deep breathing (12.7%),
--meditation (9.4%),
--chiropractic or osteopathic manipulation (8.6%),
--massage (8.3%), and
--yoga (6.1%).

Adults used CAM most often to treat pain (back, neck or joint), arthritis and other musculoskeletal conditions. Use for head or chest colds decreased from 9.5% in 2002 to 2.0% in 2007.

Americans' use of CAM for health care reinforces the need for rigorous research to study the safety and effectiveness of these therapies, said National Center for Complementary and Alternative Medicine Director Josephine P. Briggs, MD. The data also point out the need for patients and health care providers to openly discuss CAM use to ensure safe and coordinated care.

As reported by ACP Internist in November 2007, "The challenge for internists is to keep up with the latest evidence so they are not caught off guard when patients announce they have been taking St. John's wort for depression, for example, or treating their low back pain with acupuncture." The issue also outlined easy ways for internists to open the lines of communication.

Click on More below for complete results and charts.

Survey results are based on data from more than 23,300 interviews with American adults and more than 9,400 interviews with adults on behalf a child in their household.

Consistent with results from the 2002 data, in 2007 CAM use among adults was greater among:
--women (42.8%, compared to men 33.5%)
--those aged 30-69 (30-39 years: 39.6%, 40-49 years: 40.1%, 50-59 years: 44.1%, 60-69 years: 41.0%)
--those with higher levels of education (masters, doctorate or professional: 55.4%)
--those who were not poor (poor: 28.9%, near poor: 30.9%, not poor: 43.3%)
--those living in the West (44.6%)
--those who have quit smoking (48.1%)

NCCAM also tracked children for the first time. Overall, CAM use among children is nearly 12%, or about 1 in 9 children. Children are five times more likely to use CAM if a parent or other relative uses CAM. CAM therapies were used most often for back or neck pain, head or chest colds, anxiety or stress, other musculoskeletal problems, and Attention Deficit/Hyperactivity Disorder (ADD/ADHD).

Tuesday, December 9, 2008

Wrong agency, buddy

It seems the FDA knows it's got enough on its plate. Yesterday the agency decided not to get into the business of approving firearms, the AP reports.

A New Jersey man tried to get approval for an easy-to-use "Palm Pistol" for folks with disabling conditions who might find it hard to pull a trigger. He registered the palm-sized gun-- which discharges at the press of a button-- with the FDA as a medical device last week, the AP said.

The FDA wisely pulled the plug on the idea yesterday, which the inventor reportedly chalked up to "political pressure" (and not the fact that guns are nowhere near an "F" or a "D").
Monday, December 8, 2008

Medical news of the obvious

There was a bumper crop of obvious research this week, so we'll keep it snappy. Some of the highlights:

Employees who are sexually harrassed have lower job satisfaction.

Couch potatoes are fat.

The internet has scams.

Talking on your cell phone in the car is bad.

Banning soda at school doesn't solve the child obesity crisis.

People in clinical trials like to know the results when the study's over.

Middle-aged men like to chase after younger women.

A little holiday fun from the CDC!

Sometimes it's hard to find the right card for a special occasion. Perhaps you want to congratulate a friend on their compliance with epilepsy therapy or suggest that a loved one get tested for syphillis. The CDC has got just what you need on their new health-e-card web site. Who doesn't want a greeting card that includes the diagnostic criteria for ADHD or steps for preventing traumatic brain injury in the elderly? You can urge your friends and family to share the road, fear climate change, quit smoking or get a colonoscopy (Jimmy Smits may have traded some sex appeal for karma by posing for that card). Not sure about the practical uses of this site--although there is a nice, plain appointment reminder ecard--but it has already provided me and my unsuspecting recipients with hours of email entertainment.
Sunday, December 7, 2008

Consumer-driven health care - FAIL

How can you expect the patient to make good health care purchasing decisions if they can't find out the price of a service?

My patient has a $3500 deductible before insurance will pay anything. She is young and mainly needs preventive care so she is paying out of pocket for everything until she hits $3500 (which certainly didn't happen this year).

She was charged $308 for a blood test for Vit D level. Yes $308 for one test. (Vit D found to be abnormally low so supplements were prescribed by me.)

$308 is no small hunk of change for a working woman. In fact, it is an outrageous charge for a simple blood test. She needs a follow-up test to see if her levels are improving and she has been calling around to other labs to price compare.

SHE CANNOT GET A PRICE QUOTE! I am serious. The labs are annoyed at the question and said they need a "client number" and a "request from a physician" and they will not give her a price estimate so she can be a "good consumer of health care". Without transparency in pricing, we can't expect patients to make good purchasing decisions.


Toni Brayer, MD, FACP
Friday, December 5, 2008

Want more patients? Charm the ones you've got.

There are hundreds of health care rating schemes out there that aim to help consumers pick a doctor or hospital. Trouble is, people don't use them.

A new study by the Center for Studying Health System Change finds that, rather than use price/quality information to pick a physician, most Americans ask their friends and family, or take referrals from their current physician. The study found:

  • About half of health consumers use word of mouth to find a new primary care doc, while about 38% use doctor recommendations and 35% use health plan information.

  • Almost two-fifths used more than one source of info to pick a primary care doc.

  • Most patients rely solely on doctors' referrals when picking specialists and facilities for medical procedures.

  • Only 3%-11% of patients use online provider information. The higher end was for those choosing a new PCP; the lower end was for those undergoing procedures.

  • In the last year, 46 million people saw a new specialist. Nearly seven in 10 chose that specialist based on a referral from their PCP; six in 10 relied solely on the PCP in making that choice. One-fifth used a friend/family recommendation.

  • Younger patients with more education were more likely to use the Internet or health plan information to find a specialist, while those with chronic conditions and in poor health were more like to use their PCP's recommendation.

Internship years often trigger depression

Recent research involving medical students in Brazil suggests that professors should be alert to signs of suicidal thoughts during the internship years, when students appear mostly likely to suffer from depression.

In the study of 481 students, depression scores were highest in the "affective" (sadness, dissatisfaction, episodes of crying, irritability and social withdrawal) and "cognitive" (pessimism, sense of failure or guilt, expectation of punishment, dislike of self, suicidal ideation, indecisiveness and change in body image) clusters during the internship years. The latter symptoms, researchers noted, were likely linked to fear about entering the hospital environment. One thing that seemed to alleviate symptoms: having a physician parent who had already been through the internship process.

According to one of the researchers, “Frequently pre-internship students fear they ‘know nothing’, and are insecure about the physical examination of other people.”

The catch-22 of catching z's

A new Institute of Medicine report finds that medical residents are still--despite the institution of work-hour limits--not sleeping enough. It's a finding that almost anyone (except those grumpy old guys who also walked uphill both ways to their residencies) would agree with.

But the report also captures the damned-if-you-do, damned-if-you-don't nature of this problem. One of the IoM's major concerns about sleepy residents was that they conduct inadequate handoffs. Yet, one of the primary arguments against work-hour limits was that they would require more handoffs. So is the best way to reduce errors to reduce the number of handoffs or to increase them but hope that well-rested residents will mess them up less often? Already we're stuck, and we haven't even gotten into the whole money part of the problem.

Funny side note: The New York Times article about the IOM report uses a chart from a study of residents' sleep habits and self-reported errors. The chart shows the two factors to be inversely related--more sleep, fewer errors. But we have to wonder: isn't any resident who says he or she gets 7-8 hours of sleep obviously a liar? No wonder only 21% of them admit to having made an error.
Thursday, December 4, 2008

Is health care the new Hummer?

Rationing is in. First, we learned that we all need to cut back on our carbon output, then it was discretionary spending that had to be restricted. Now, some health care analysts are pointing out the painful truth that the only affordable, equitable way to provide health care may be to ration it.

Daniel Callahan of the Hastings Center has recently stirred controversy on the issue, with a New York Times blog post describing his rationing plan. Basically, he suggests that Medicare coverage for very expensive therapies (like open-heart surgery) be cut off once patients hit age 80. By the way, it seems important to note that Dr. Callahan himself is 78. "Our society can not, and should not, promise open-ended, progress-driven medical care that is indifferent to costs," he concluded.

Sound outlandish? Not to the Brits, who are already doing something along these lines. Another NYT article discusses NICE, the British government institute that decides whether a therapy is cost-effective enough to be covered. Their cut-point right now for life-extending cancer drugs is about $22,000 for per 6 months of life gained. The policy raises a whole heap of protest from pharma companies (who the article pretty well puts through the ringer) and patient advocates. Even so, numerous other countries are looking at the British example to deal with their ballooning health care costs, the NYT says.

"What price is life?" asks a woman in the article whose husband was denied an expensive drug. It's a tough question, but one which bureaucrats, health experts and politicians might soon have to answer. Is rationing the only solution?
Wednesday, December 3, 2008

Insurance insurance (no, that's not a typo)

Worried that the recession might lead you to lose your job and therefore your health insurance? Relax. UnitedHealth is here to ease your mind with a new policy that will ensure your right to buy insurance in the future if you get sick, the New York Times reports.

Got that? They're not selling you insurance. They are selling you, a healthy person, the opportunity to buy insurance later, should hard times befall you and you get laid off, then stricken with illness. All for the low-low monthly cost of 20% of an individual policy premium. That's $50 a month for Richard A. Collins, the president of UnitedHealth's individual insurance unit.

Mr. Collins calls the policy a "hedge." (You know, sort of like credit default swaps.) It's a huge vote of confidence for heath insurance reform, no?

Sermo launches flu tracker

Sermo, the online social network for physicians, has launched its own flu tracking system that it says improves on those offered by the CDC, Google and Harvard Medical. Whereas other sites aggregate content from online searches and lab result reports, Sermo says its tracker is based on input from actual physicians and updated in real-time. After logging in, physicians can exchange geographically based clinical observations instantly.

According to Sermo, the site's analysis of each flu outbreak is based on:
Patient breakdown for vaccinated vs. not vaccinated
Age distribution - which age is most affected
Symptom breakdown - which symptoms are presenting more than others
Voracity of outbreak - how many per day/week/month, etc.

Physician members of Sermo (registration is free for MDs and DOs) can link directly to the flu tracker after signing in.

Obama should read the NEJM

There's no shortage of advice available to President-elect Obama on how to reform health care. If there's a health policy analyst out there who hasn't thrown her 2 cents in yet, I'd be surprised. But the experts writing in this week's New England Journal have an extra argument on their side: history. They analyze the last successful piece of federal health reform--the creation of Medicare.

In their account, the passage of the plan was in large part due to LBJ's political skills. We know Obama is talented in that department, but a couple of the authors' key suggestions may prove difficult for him to follow.

First, they say that to be successful, health care reform must be tackled immediately (if not sooner). Yet, it seems likely that dealing with the disaster that is the economy will take most of Obama's attention after inauguration. Can he really launch a huge, new spending plan when pleas for money are coming from every direction? (See governors' meeting taking place today.)

The authors also recommend letting Congress manage the specifics of reform. But Obama's already got problems with Congressional Democrats straying way off the health care reservation. (e.g., Sen. Baucus is now proposing to mess with employer-sponsored coverage--an idea that Obama campaigned hard against during the election.) Also, can what has come to be known as our do-nothing branch be trusted to get something effective passed on this issue?

There is one recommendation that it seems like it shouldn't be too hard for Obama to follow. LBJ got Medicare enacted because he didn't worry too much about the future costs, the authors say. (Explains a lot about the mess it is now.) And as AIG, Citi and the rest of the bunch can attest, if there were ever a time when it was publicly acceptable for the government to spend money it doesn't have, that time is now.
Tuesday, December 2, 2008

The power of the personal touch

Today's Wall Street Journal reports on a new study that found radiologists are more apt to make incidental findings when a head shot is included in a patient's file. The authors concluded that patient photos should be attached to patient files from now on-- a suggestion that others at the Radiological Society of North America (where the study is being presented) reportedly balked at. The "personal touch" provided by the photos would probably wear off over time, and including photos could lead to stereotyping and bias in interpreting results, the detractors said.
Instead of taking mug shots, prescribing clinicians should do a better job of filling out requests for scans by providing as much up-front information as possible for the radiologist, one doc said.
Monday, December 1, 2008

Ever wonder what people are saying about you on the web?

A new investigation conducted by Slate provides some interesting insight into online physician-rating systems. You know, those things that pop up when you Google a doc and then ask you to "click and pay here" to get all the dirt on him or her. So what's it all worth? Nothing, according to the article. The sites provide almost no information and even less that is useful. But, if you're a doctor with some spare websurfing time on your hands, you might want to try fixing your stats just in case, the author suggests.

Medical news of the obvious

We're too full of turkey and goodwill to attack the obvious news this week, so post your own findings or sit tight until next week. Happy holidays!