Friday, January 30, 2009

Where no one knows your name

Do your patients know your name? According to a new Archives study of inpatients at an academic center, probably not. When researchers asked hospital patients to name one of the physicians caring for them, 75% couldn't come up with anything. Of the 700 who had an answer, only 40% got at least one name (out of the attendings, hospitalists, interns and residents caring for them) correct.

Study authors suggested hanging photos of treating physicians in patient rooms to remedy the problem, or having everyone wear more obvious explanatory nametags. They don't discuss the aesthetic downsides of these solutions. After all, if patients don't even bother to learn your name, how likely is that they want to lie in bed staring at your face all day?

Perhaps supporting this argument, the study also found that patients who could name a physician were most likely to be dissatisfied with their care. If they're only learning your name so they can complain, maybe you'd be better off stuffing that nametag in your pocket.

More surgical procedures occurring outside of hospitals

More and more surgical procedures are being performed in freestanding ambulatory centers as opposed to hospitals, according to the recently released 2006 National Survey of Ambulatory Surgery by the CDC's National Center for Health Statistics. The rate of visits to freestanding ambulatory surgery centers increased by 300% between 1996 and 2006, while at the same time the rate of visits to hospitals remained virtually unchanged.

Other notable findings from the survey include:
  • Females had significantly more ambulatory surgery visits
    than men.
  • Although the majority of visits had only one (56.3%) or two (28.5%) procedures performed, 2.6% had five or more procedures performed.
  • Frequently performed procedures on ambulatory patients included endoscopy of large intestine, endoscopy of the small intestine, extraction of lens, injection of agent into spinal canal, and insertion of prosthetic lens.

There are many more interesting statistics in the CDC's Winter Quarterly Fact Sheet, which focuses on heart disease.

Thursday, January 29, 2009

TB and drugs: A double whammy

Nearly one-fifth of U.S. tuberculosis patients abuse drugs or alcohol, which is a problem in and of itself. But the substance abuse also makes it harder to treat the TB, according to a release from a new study in Archives of Internal Medicine.

TB patients are more likely to be substance abusers than to be recent immigrants, infected with HIV, homeless or working at a high-risk job, the study found. Substance abusers with TB, but without HIV, were almost twice as likely to have a contagious form of TV than non-abusers, and women substance abusers were more than twice as likely to fail treatment.

Why is this? Substance abusers may not get routine medical treatment, so they are less likely to be detected early. Since TB often spreads faster as the disease progresses, these undetected substance abusers would be more contagious, study authors said. And they may be harder to treat because of weakened immune systems.

Don't drink the water

ACP Internist's latest cover article describes the potential environmental impact of disposing of drugs down the drain and into the water supply. I ran into this problem after getting a bad series of eye, ear and sinus infections over the holidays.

I worked my way through all the antibiotics as prescribed, but those aren't the problem anyway, said Christian Daughton, PhD, Chief of the Environmental Chemistry Branch at the EPA's National Exposure Research Laboratory in Las Vegas. He told ACP Internist that antibiotics in drinking water occur only at parts-per-trillion range, which is probably a moot concern for creating bacterial resistance.

My main problem is all that leftover pseudoephedrine. I didn't mix well with the pills and didn't finish them. And, while I was looking through my medicine cabinet to throw them out, I found a family's worth of expired prescriptions and over-the-counter meds so old that I can't even remember buying them. If I dispose of them improperly, I'm making sure my neighbors don't get headaches, fevers, sore throats, cramps, coughs, stuffiness, gas, bloating or warts.

I'm supposed to mix it all with kitty litter, but I don't have a cat. If I did, I'd probably need more pseudoephedrine. I drink coffee and thought I'd found a conscience-free way of throwing them out with used grounds, but Dr. Daughton said, "The recommendation to mix drugs with kitty litter or coffee is not without controversy."

To top it all off, only one of the pill bottles is recyclable in my borough. It's not just me getting sick, it's the planet.

Work areas can be breeding ground for C-diff

A study in the February issue of the American Journal of Infection control found that the surfaces in hospital rooms are often contaminated with spores, even outside of Clostridium difficile infection isolation rooms. Of the 105 non-isolation rooms studied, researchers discovered that 17 (16%) were contaminated with toxin-producing C-diff.

The study also looked at surfaces in hospital work areas and equipment such as oximetry devices and electrocardiogram machines. They found that 23% were contaminated, including 31% in physician work areas, 10% in nurse work areas, and 21% on portable pieces of equipment.

Commenting on his blog, Kevin MD said the study reinforces the importance of old-fashioned soap-and-water handwashing. "Alcohol-based sanitizers aren't effective in killing the spores."
Tuesday, January 27, 2009

A company that makes Enron look good

I just listened to an FDA/CDC conference call about the salmonella outbreak. It turns out that Peanut Corporation of America, the company which supplied the tainted peanut butter and paste, detected salmonella in its own plant twelve times in 2007 and 2008 ...and shipped out its product anyway. Then the company failed to take mitigating steps to make sure it didn't happen again.

Whoever was in charge of that little operation should be glad he or she doesn't live in China.

CDC/FDA also said to expect more recalls as they continue to link the supplier to various products (A big job: FDA said it has already visited nearly 1,000 firms which got supplies from PCA). The illness toll to date: 501 sick, 108 hospitalized, and 8 dead. Twenty-one percent of the sick cases were in kids age five and under.

Full report from the investigation on FDA's Web site tomorrow.

The rights and wrongs of child plastic surgery

I've always been horrified by babies who even have their ears pierced, so I expected to be self-righteously certain about the cases in the new Hastings Center Report on cosmetic procedures for children (mostly subscription-only, unfortunately). In fact, it raised a lot of fascinating, unanswerable questions. For example, if many Asians choose to have blepharoplasty to widen their eyes, is it more wrong for a white adoptive father to elect the surgery for his adopted Asian daughter?

Or what's the right course of action when a young child identifies with the opposite gender, or even more complicated, has ambiguous genitalia? Medical intervention could likely make life easier for them, but not if their gender identification changed at a later date.

The issue also revisits the case of Ashley, the profoundly disabled girl whose parents requested surgery and therapy to prevent her from going through puberty. Although this is cited as "most controversial case" in the field, it actually seems the easiest to answer. The writing experts all seemed to agree, too, that no argument about messing with nature or Ashley's sovereignty could outweigh the expected positive effects on her and her parents' well-being.

Makes deciding whether to let your 17-year-old get a nose job seem easy.

Dr. Gupta doesn't poll well as potential Surgeon General

Most readers who took ACP Internist's most recent Web poll feature, "Your Thoughts Exactly," voted against Sanjay Gupta, MD, as a potential choice for Surgeon General by about a 2-1 margin. (The results aren't scientific and only reflect the opinions of poll respondents.)

Respondents mainly objected to Dr. Gupta's lack of experience in public health and health policy, or said they felt that he's biased toward pharma and insurance interests or toward specialty medicine over primary care.

Asked what they thought should be the Surgeon General's next priorities, respondents said they want more attention paid to obesity and all its negative health impacts, smoking cessation and universal access to health care.

Complete results and a sample of comments are available at ACP InternistWeekly. ACP Internist's next poll, "Your thoughts exactly: using placebos," is now online.
Monday, January 26, 2009

Medical news of the obvious

Food that's advertised in magazines tends to be unhealthy, a new study from the UK finds. It seems the glossies are filled with enticements to buy chocolates and pre-packaged meals loaded with preservatives, instead of tempting missives from the Carrot Farmers of England or the National Broccoli Foundation. But hey, the title of one of the 30 mags they studied is "Nuts," so maybe there is some subversive healthy messaging going on, after all.

Putting babies and small children in car seats, rather than letting them float around the car, greatly reduces the chances they'll die, a new study found. Study author Thomas Rice of UC-Berkeley, speaking in the Washington Post, clarifies for us that car seats are necessary because infants are fragile: "The higher effectiveness of safety seats among infants is likely due to their overall fragility," Rice is quoted as saying. Hear that, moms?
Friday, January 23, 2009

Let's talk about HIPAA (but not on your cell)

The sign in my pharmacy reads: "To comply with HIPAA regulations, we will gladly help you when you are finished with your cell phone conversation." I've seen similar signs in doctors' offices over the years.

HIPAA was meant to regulate health privacy, not common manners. HIPAA is being used as a bogeyman in this case. This makes HIPAA even harder for health care workers to understand, and they're already paranoid about not triggering a violation.

If the concern is that someone may disclose protected health information over a cell phone, follow the "elevator rule" and don't talk in open areas about private information. But if the concern is speeding service for all by making sure people aren't standing at the front desk gabbing, say that instead.

ACP's practice management staff say HIPAA is a frequent source of confusion, and they offer plenty of HIPAA compliance information. They're glad to help our members understand the rules, too ... as soon as you complete your cell phone call.

Abuse by caregivers may be cry for help

About half of 220 family caregivers surveyed in a recent study reported abusive behavior towards a relative with dementia, according to a study published in the British Medical Journal. Only a very small number of respondents reported physical abuse, the authors noted, but about one-third admitted to "signficant" abuse defined as frequently insulting or swearing at their elderly charges. Occasionally screaming or yelling was considered less-serious abuse.

The findings shouldn't villify the caregivers, the authors suggest, but draw attention to the difficulties faced by family or friends attempting to care for an elderly person at home, with little support. The study, which was conducted in the UK, indicates that government policies to prevent elder abuse won't do much good unless the problems faced by family caregivers also are addressed.

Physicians can be reluctant to ask family caregivers about abuse but if they bring up the issue they may find that the caregivers are anxious to talk, researchers commented. A physician's concern can be the impetus needed to prompt a caregiver already worried about his or her abusive behavior to ask for help.
Thursday, January 22, 2009

Clean and green

Maybe you've already been convinced by our Green Medicine series (here and here) that making your medical practice environmentally friendly is worth the effort. If not, your nurses might start lobbying for greening, too, based on the results of a new study in Occupational and Environmental Medicine.

In a study which included more than 900 Texas nurses, those who regularly cleaned medical instruments were 67% more likely to have newly diagnosed asthma and those who worked with solvents and glues were 51% more likely to report asthma symptoms. Time to throw out that glutaraldehyde, or at least get your nurse a mask, the authors suggested to the Washington Post.

In other green medical news, the Teleosis Institute is offering a new toolkit to help you set up a medication take-back program (the subject of an upcoming article in ACP Internist). Ordering is online, but it does cost $95.
Monday, January 19, 2009

Medical news of the obvious

People are more suggestible under laughing gas. This won't hurt a bit... ha, ha, nudge, wink...Researchers at the University College London found that being sedated with nitrous oxide (aka laughing gas) makes people more likely to listen when their drill-wielding dentist tells them to relax.

Problem teens become problem adults. At risk behaviors include disobedience, lying, lack of punctuality, restlessness, truancy, daydreaming in class and poor response to discipline--in other words, adolescence itself. The data came from the UK's Medical Research Council.

Parents should limit the amount of TV children watch before the age of two, according to a review published in the January issue of Acta Paediatrica by a child expert from the Seattle Children's Research Institute and the University of Washington. DVDs aimed at infants are also concerning researchers report. Toss the Baby Einstein!

Glaucoma impairs reading. We're not sure how it connects to the well-known relationship between glaucoma and vision problems, but a new study found that glaucoma patients could not read aloud as quickly as their unaffected peers. By the way, researchers noted, reading speed may also relate to cognitive ability and education.
Thursday, January 15, 2009

Meet the new drug...same as the old drug.

The NEJM has an article out today which dispels the notion that atypical antipsychotics have a lower cardiac risk than typical antipsychotics. Traditionally, the atypicals have been considered safer.

The rate of sudden cardiac death for people taking atypical antipsychotics was more than twice that of non-users-- actually a little higher than the rate for those taking typical antipsychotics. And the greater the dose, the greater the risk.

I'm wondering how relevant this study is to primary care internists. I know that, in addition to being used for schizophrenia, antipsychotics are often prescribed as adjunct therapy to offset the side effects of other psychiatric drugs, but I don't know if this is mostly a practice of psychiatrists, or if primary care doctors do this as well. Anyone care to weigh in on how this information about antipsychotics might be useful to internists?

A story that's not going to sell EMRs

I've been to conference sessions where the Veterans Administration was held up as a sort of gold standard for electronic medical records--they've had them longer and used them more than most docs and hospitals. Now it turns out that the VA might not be such a shining example, after all.

An investigation by Congress and the AP just revealed that software glitches in the VA's EMR have resulted in health records being associated with the wrong patient and several medication errors, including overuse of heparin. First, it's scary that this happened. Second, it's scary that the VA kept it quiet. And the third scary thing is the VA's response. A quote from a VA official (via the AP): "VA believes that veterans are active partners in their health care, and encourages patients to always follow up with their health care teams to ensure that their treatment options meet their understanding and their health care needs." So the responsibility is on the patients to make sure that the hospital's computers aren't malfunctioning? Come on.

The real question, though, is how many other EMRs have similar glitches. Obviously plenty of mistakes happen on paper, too, but can anything match the myriad ways computers can screw things up without anyone noticing?
Wednesday, January 14, 2009

For when you're bored with YouTube

The surgeon general (the old one that is, not Sanjay Gupta) has a cool new Web tool that could be of real use to physicians and patients. The site helps users construct a family health history which can be printed out or integrated into electronic medical records. You fill in everything you know and then email relatives to complete the missing parts (at which point they can "reindex" the tree to map their own health info, if they want). It takes only about 20 minutes and the results can be "amazingly positive," the acting SG told Yahoo news.

As in, now you can gather useful health information but avoid the embarrassment of interrupting Christmas dinner to ask Grandma for the results of her last Pap smear.

It's science fiction week at Grand Rounds

Grand Rounds , a collection of weekly posts from the medical blogosphere (including an ACP Internist contribution), is now up at In Sickness and In Health. The host's organizing theme is science fiction movies. Check it out for an entertaining read.
Tuesday, January 13, 2009

Sleep it off--avoiding the common cold

A study from researchers in Pittsburgh caught my attention for two reasons. First, the conclusion of the study: more and better sleep reduces the odds of getting a cold.

Researchers interviewed 153 healthy volunteers for 14 days about how many hours they slept and their sleep efficiency (the percentage of time in laying bed compared to the time actually asleep). Then volunteers then took nasal drops containing a rhinovirus and were followed for colds.

Volunteers averaging less than 7 hours of sleep a night were 2.94 times more likely to catch a cold than those with 8 hours or more. Those with 92% efficiency were 5.50 times more likely to get a cold than those with 98% or more efficiency.

That's astounding by itself. Less relevant but still prevalent in my mind is that 153 people volunteered to catch a cold. They got $800 for their time and trouble. I just got over a nasty cold and would pay that much to not get another one.

Add brown recluse spiders to your list of things not to worry about

A Missouri University entomologist warns of brown recluse spiders moving indoors in the winter, leading to more bites as they hide in cluttered spaces, including clothes in closets. But how common is it?
Photo by Richard Houseman
First, the bad news. Brown recluse spiders do move indoors when it turns cold. They find undisturbed storage areas such as attics and basements, filing cabinets and closets. They do bite, and the bites can cause necrosis, permanent scarring and death.

But Wikipedia and several other Web sites temper this alarmist warning. Brown recluse spiders only bite when you press against them. Some bites may cause no reaction. The worst consequences are rare. And, the brown recluse's range is limited to the south central Midwest.

And no one seems to agree on how common brown recluse spider bites are. Missouri University (the same entomologist) issued a similar but more tempered press release two years ago that contained this tidbit: "An MU-based study done in the 1970s concluded that about 80 percent of Missouri homes harbored brown recluse spiders. Some homes can have thousands with residents never suffering a bite." So arachnophobia is most of the problem.

Primary care tops locum tenens requests

The front page of today's Wall Street Journal has a story on the rising demand for temp surgeons in the face of a nationwide shortage. But while demand for surgeons is growing more quickly than for other specialities, most locum tenens requests are, by far, for primary care docs, notes the WSJ's health blog. According to a survey by national locum tenens company Staff Care, primary care accounted for 41.5% of total staff-days requested by clients in 2007, followed by anesthesiologists/CRNAs (20%), behavioral health specialists (17.6%), radiologists (11.6%) and surgeons (7.7%).

Many private practice internists are being forced to make changes in the face of declining reimbursements and the current recession. Are docs who may not have considered locum tenens in the past now giving it more serious thought?

The patient-centered medical home--at home

Sometimes medicine is cyclical. Leeches went thoroughly out of style, and then it turned out that bleeding patients really was the best treatment for conditions like hemachromatosis.

Now an internist writing in the New York Times is arguing that house calls--rather than hospitalization--are the most cost-effective and high-quality means of care for many patients. Keeping patients at home protects them from hospital-acquired infections, dementia, bedsores (not to mention simplifying discharge!), Dr. Jack Resnick says. But he has a list of complaints about how the system makes home care more difficult that it needs to be and he admits that running from door to door is tough on docs.

So is it worth it? Would you trade hospital rounds for a drive around town?
Monday, January 12, 2009

Medical news of the obvious

Eating "on the go" encourages consumption of unhealthy food, a new study finds. IE, fast food isn't good for you. Other groundbreakers in the study include that young people like eating together, but often feel too busy to sit down and eat.

In other food news, if you want to maintain or lose weight as you get older, you have to eat less, people! Because your metabolism slows down, you see. The lead author offered several helpful tips for eating less, including "put less food on your plate." Here's my helpful tip: Put less food in your mouth.

And here's a study result that is not obvious, but fishy: The babies of women who eat apples during pregnancy are less likely to have asthma. Sounds plausible, until you realize the lead researcher's names is Dr. Appleyard....

(We joke. But let's just say we're not surprised Dr. A chose the apple as the "fruit of her labors".)
Friday, January 9, 2009

A good sort of giveaway

Not to be outdone by Wegman's and Giant, Walgreen's is wrapping up its year-long "Take Care Health Tour", for which it dispatched a fleet of med-equipped RVs to provide free health screenings around the nation. When the tour is all finished by this spring, it will have provided on-the-spot blood pressure, BMI, total cholesterol, glucose levels, bone density and waist circumference screenings in 300 cities.

Hard to argue with that, though one hopes there's been some effort to target less priveleged areas, and to direct folks to local clinics where they can get low-cost follow-up. Either way, this is one "giveaway" I can get behind. But maybe I'm missing something-- is there a downside, here? Feel free to weigh in..
Wednesday, January 7, 2009

Let them eat drugs!

I understand that retail stores are under pressure to entice customers amid a faltering economy. But I'm not sure Wegman's and Giant are sending a great public health message by offering free generic antibiotics to patients for the next few months (source: Baltimore Sun). Might this encourage doctors to prescribe them more freely, or patients to pressure doctors for prescriptions, at a time when they are already overused?

Maybe the grocery store chains should have picked a different drug. Statins, perhaps?
Monday, January 5, 2009

Medical News of the Obvious

This week in Medical News of the Obvious, sex, drugs and...puppies? To wit:

Teens talk about having sex, using drugs and drinking alcohol on their MySpace profiles! The researchers who "discovered" this also created a profile of a "Dr. Meg," and sent messages to the teens who talked about sex/substances to tell them their profiles contained "risky information." Guess what? Many of the teens removed the info from their profile. Because nothing is more creepy...I mean, helpful and effective...than the idea of a stranger mining your profile for news about your sex life.

Meanwhile, people who are at high risk of driving drunk are most deterred by the belief that they are likely to get arrested or pulled over, not by drunk driving laws themselves. So laws aren't useful unless you enforce them. Got it.

You know how animals can cheer up the elderly and the ill? Well, puppies make college students happy, too! "Even younger, healthier young adults can benefit from living with our four-legged friends," the lead author said in a press release. Young and old: we're not so different, after all!

And speaking of the elderly, an AP report finds that the best-rated nursing homes in Massachusetts are usually located in the wealthiest areas. Next on the AP Investigations Team schedule: Is school district quality related to median income? Stay tuned...

103-year old aunt imparts secrets of longevity

Clif Cleaveland, MACP, writes in the ACP Tennessee Chapter's online journal, Grand Rounds in Literature, of an inspirational lunch he had recently with his still-spry 103-year-old aunt. After suffering a minor stroke earlier in 2008, 'Aunt Mary' gave up driving and checked into a retirement home, Dr. Cleaveland writes, but, aside from a few memory lapses, her "energy and socialibility" remain relatively unimpaired. Her longetivity speaks to a few simple truths, Dr. Cleaveland reflects:

"We do not need sophisticated, electronic devices for our entertainment and well-being. A library book or Scrabble, checkers, or chess board can provide endless hours of pollution-free engagement of the mind. Conversation, without interruption of cell-phone sonatas, is a precious, yet undervalued activity. A walk can refresh the mind, while toning the muscles. A sense of community dilutes personal stress or sorrow."