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Friday, May 29, 2009

Superbug threat lurks in sewer

The threat of antibiotic resistance is attributed mainly to the overprescribing and overuse of antibiotics, but a new study explores a new, often-overlooked, danger: sewage sludge.

The study, by the Swedish National Veterinary Institute and the Finnish Food Safety Authority and published in the journal Acta Veterinaria Scandinavica, analyzes vancomycin-resistant enterococci (VRE) found in sewage sludge from a waste-water treatment plan. Researchers performed the unenviable task of collecting sludge from the plant weekly for four months and found that 79% of the 77 samples tested positive for drug-resistant superbugs. The danger, the researchers noted, is that VRE may pass on resistant genes to other bacteria.

Since sewage sludge is often used as fertilizer, its use threatens to spread antimicrobial resistance throughout the animal and human food chains, researchers warned. More efficient hygienic treatment of sewage sludge, they concluded, must become another weapon in the public health arsenal against superbugs.

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Thursday, May 28, 2009

Doctors discuss the consequences of misleading medical news

Doctors have to spend a lot of time correcting patients' misimpressions of medical research based on mainstream media reporting, readers told ACP Internist in a survey.

Mainstream media coverage of medical news overstate results and include too few details, according to ACP Internist's poll, "Your Thoughts Exactly: Media reporting of medical research."

According to the poll results, all respondents voted that mainstream media reports of medical studies were exaggerated "extremely," "very much" or "moderately." There were no responses of "somewhat" or "not at all."

When asked to rate the level of detail of medical stories in the mainstream media, all but one respondent thought there was "somewhat" or "way too little" detail in coverage.

The poll is based on a study in Annals of Internal Medicine that concluded the public relations departments of academic medical centers overstate results or don't include important caveats when pitching study results to the media. Authors questioned if this was being passed through to mainstream media reports, which patients then carry into their visits with physicians.

In the daily grind of medical practice, doctors reported a "time drain" of calming patients who'd seen a news report, or deflecting false hopes and over-expectations from others.

One poll respondent summed it up perfectly: "Medical news is almost always distorted, and leads to false hopes and expectations from patients. However, it's part of my daily job to provide patients with accurate and useful information about their medical conditions."

Also, another respondent chastised the media for the lack of distinction made between test tube studies and phase 3 clinical trials, and also the lack of explanation that discoveries about the mechanisms of diseases do not immediately translate into treatments that can be made available.

"Dramatic results are not often carefully noted to be preliminary and unreproduced," another respondent said. "This leads patients to believe findings are ... established. This often requires time to properly balance the whole of the existing (or non-existing) data. Patients don't get the language of 'may be' that is usually reported in the media."

"Fortunately, patients trust their doctor more than the media," one concluded.

Perhaps the best way to overcome poor medical reporting is to do it yourself. One doctor successfully reports medical knowledge to his patients by appearing on TV as a medical commentator.

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Wednesday, May 27, 2009

Watch out, bad doctors.

The interest group Public Citizen is launching a new campaign to get hospitals to step up their reporting of physician wrongdoing. Under a federal law, hospitals are required to submit to a database the names of any physicians who have lost their admitting privileges for more than 30 days. However the database has gotten very few reports; more than half of hospitals have never submitted a single name.

So either physicians have been being very, very good, or the hospitals are covering up their wrongdoing. Public Citizen suspects the latter and is urging the Obama administration to crack down on the failure to report. Doc are also on the hook: the organization's press release specifically calls them out for "lax peer review, including a culture among doctors of not wanting to 'snitch' on a colleague."

That's right; snitching isn't just for elementary schoolers and TV characters anymore. Let's hope that the next steps don't involve hair-pulling or cootie-catching.

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Tuesday, May 26, 2009

Who's referring who?

There's an interesting column in the New York Times today about the business of physician referrals. The physician author worries about the financial incentives generated by the dynamic in which specialists rely on primary care physicians to keep their schedules full.

Here in Philadelphia, at least, that concern seems almost laughable. Studies have established (and we have discussed) the long wait times to see a doctor here. And in the time it has taken me to write this post, I've been sitting on hold with a dermatologist's office--the same office that I've been calling for two months to try to schedule an appointment. At least with some specialties, the dynamic has so reversed itself that patients look to their internists to help them jump the queue to get in to see a specialist.

There's a lot of talk about the shortage of primary care, but what's with the shortage of specialist appointments?

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Monday, May 25, 2009

Medical news of the obvious

Dreading the end of the holiday weekend? You'd probably never have guessed but the problem may be that your work is not meaningful to you, a new study reports. The survey, published in the latest Archives of Internal Medicine, found that academic physicians who get to spend at least one day per week doing something meaningful (isn't that a depressing standard?) are less likely to burn out. In other shocking news, submitting preauthorizations to Medicare didn't top the docs' list of meaningful activity. They preferred patient care by an overwhelming margin, followed by research, education and admin. An accompanying editorial concluded that physician employers should try to ensure that there's good "career fit" between docs and their jobs. Sounds like a major employment opportunity for all those physicians who find insurance paperwork deeply meaningful.

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Thursday, May 21, 2009

How to annoy a reporter

I spent the past two days at ACP's Leadership Day and full coverage of the event will appear in the July issue of ACP Internist. You can also read more on the ACP Advocate blog. But there will be a few things missing from the story, because the congressional staff and presidential advisors who spoke to attendees insisted on being "off the record." Of course, politicians live in fear of the press, and they know how easily blogs and youtube can shoot a misspoken word around the globe. But somehow I thought the result of that would be that they thought before they spoke, not that they would forbid the 400 people hearing their speech from repeating what they said. So, sadly, frustratingly, I can't tell you details, but take my word for it that the Democrats are really fired up about making health care reform happen now. And, if you want the inside scoop, I guess you'll just have to come to DC yourself next year.

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Press release puffery

Time points out that press release on a recent biological discovery created a media flurry that outpaced the actual event. And outpacing this discovery is tough, since it involved a 47-million-year-old fossil that provides a missing link in primate evolution.

Time chided the press releases, calling them a "master class in ballyhoo." Internists had recently chimed in with the same challenge to academic medical centers, whose press releases influence how the mainstream press reports medical research.

In Annals of Internal Medicine, researchers reviewed press releases from 20 academic medical centers, whose press departments had issued an average of a nearly a release each week.

Among press releases analyzed in detail, 87 (44%) promoted animal or laboratory research. Of the 87, 64 (74%) explicitly claimed relevance to human health, even though two-thirds of animal studies fail to translate into successful human treatments. Furthermore, releases omitted study size, failed to quantify results, reported on uncontrolled interventions or samples less than 30 participants, used surrogate primary outcomes or unpublished data, or lacked relevant cautions that tempered the findings. Few promoted randomized trials or meta-analyses.

Annals researchers suggested academic medical centers issue fewer releases about preliminary research, especially unpublished scientific meeting presentations, to avoid the confusion being passed along to the mainstream media. We took note of this at ACP Internist, and are asking our readers to tell us what they think. Tell us in our current poll, "Your Thoughts Exactly: Media reporting of medical research."

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Wednesday, May 20, 2009

Another reason to skip the soda: Potassium depletion

Supporters of the recent Senate Finance Committee proposal to tax sugary drinks may want to arm themselves with the findings of a new study on soda drinking. The study, published online May 13 by the International Journal of Clinical Practice, presents some alarming case studies of cola-induced hypokalaemia brought on by chronic consumption of up to 10 liters per day of sugar-sweetened cola.

The study's findings suggest that "potassium deletion should be added to the long list of soft drink-related health problems," (obesity, type 2 diabetes, dental decay and metabolic syndromes, to name a few), said a related editorial. To illustrate, the editorialist relates a case from his own files in which a 51-year-old man with COPD, hypertension and idiopathic gastroparesis developed persistent hypokalaemia, generalized weakness and loose stools. After running through a number of possible causes, the doctor hit upon the problem when the patient arrived in his office with a two-liter bottle of Pepsi in tow; upon further questioning, the patient estimated his total daily consumption at 4 liters. He agreed to keep his intake to two liters, and saw his potassium gradually rise back into the normal range.

The editorial also cites the intriguing case of a 44-year-old ostrich farmer who returned from a kangaroo-hunting trip in the Australian outback with profound muscle weakness and respiratory distress that required intubation and mechanical ventilation. It turned out that his serum potassium level plummeted when he upped his Coca-Cola intake to 10 liters (from his usual 4 liters daily) to combat his thirst on the hunt (From the study, "Coca Cola and kangaroos," Lancet, 2004; 364: 1190).

The editorial warns against relegating these cases as "outliers," citing some rather unsettling statistics. Worldwide consumption of soft drinks was almost 83 liters per person in 2007, with the U.S. level even higher at an estimated 212 liters per person. While healthy adults often can tolerate low potassium levels, not so for patients with heart problems, the editorial points out, and even moderate chronic cola consumption has been associated with chronic kidney disease.

The statistics should be a wake-up call for internists, especially considering the steady rise of obesity and type 2 diabetes. Most people know that sugary drinks are unhealthy, but public health initiatives have focused largely on children and teens. However, the editorialist urges, internists need to start asking their adult patients about soft drink consumption, along with questions about alcohol, cigarette and drug use.

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Tuesday, May 19, 2009

Internists, FPs alike trying to help their patients through the recession

The economy is prompting internists and family physicians to increase charity care, discount fees and offer free screenings, according to a survey by the American Academy of Family Physicians.

ACP Internist reported its own poll results earlier in May asking internists how they handled patients who couldn't afford to pay. ACP members reported they most commonly offered free care or reduced payments (66.7%), offered free samples for prescriptions (61.1%) or referred to community clinics (34.7%).

Nearly 90% of the AAFP crowd reported their patients expressed concerns over their ability to pay, 58% had seen more appointment cancellations and 60% had seen more health problems caused by patients forgoing needed preventive care such as such as pap smears, mammograms and colonoscopies, or failing to return for follow-up visits or refills.

Also:

  • 66% were discounting fees, increasing charity care, providing free screenings, and moving patients to generics;
  • 54% have seen fewer total patients since the recession began in January 2008;
  • 73% saw more uninsured patients;
  • 64% of respondents reported a decrease in the number of employer-sponsored/privately insured patients; and
  • 87% saw more patients with major stress symptoms since the beginning of the recession.

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Monday, May 18, 2009

Evidence for the PCMH

An article in today's Philly Inquirer offered an update on the patient-centered medical home pilot that we recently covered in ACP Internist. A year into the Pennsylvania program, the percentage of participating diabetics with their "blood sugar under control" (the article doesn't specify what measure) increased from 33% to 44%. Sounds pretty good.

However, there does seem to be debate about whether practicing in a PCMH is fun or not. Two quotes from the article:
"It has been fun to create a system where there is a real strong interdisciplinary approach to managing diabetes," said the executive director of one practice.
"I can't say we are having a lot of fun," said a doc from another practice.

Lucky they decided against calling it the fun-centered medical home.

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Medical news of the obvious

Kids and parents get on each others' nerves, a new study out of the University of Michigan finds.
Specifically, adult children and parents annoy one another, according to a news release about the study. One of the biggest sources of tension? Unsolicited advice.

Teens do the opposite of what adults want them to. An adage proven once again in a new study that looked at whether more visible standard labels on alcoholic beverages would influence teens' drinking choices (participants were college students in New South Wales, Australia, where the legal drinking age is 18). The Australian alcohol industry presumably was hoping for a positive influence but the teens reported that the new labels were a big help in their quest to purchase "the strongest drinks for the lowest cost."

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Friday, May 15, 2009

Playing Operation

The SGIM session I attended this afternoon made it clear that patient simulators (whether they're mannequins, body parts or actors) are not just for fun. Medical students and residents should be required to use them and then tested on their skills, the speakers said. And they presented data to show how remarkably effective the simulators are.

But still...one of the simulations they mentioned cracked me up. The student/resident is presented with a woman (actually an actress) who needs a pelvic exam. The student makes all the proper conversation with the woman and then lifts her gown. And underneath they find...a fake pelvis (aka a part task trainer)! I know the students are probably told about the setup ahead of time, but I can't stop snickering at the image of a wide-eyed med student who's just unveiled plastic genitals on a live woman.

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More about the benjamins.

Yesterday's discussion at SGIM centered on health care costs, and assumed that some kind of reform is coming, but both Bob Brook and Albert Siu avoided the issue of whether the new system should be single- or multi-payer. That contentious topic was the focus of this morning's plenary session. Richard Epstein, a law professor, and Steffie Woolhandler, MD, founder of Physicians for a National Health Program, each presented their views and then responded to questions from the audience. Their conclusions were pretty stark. Dr. Woolhandler, who comes from Massachusetts argued (and presented evidence) that the mandated coverage plan that her state has enacted and Obama is considering only makes health care worse and less accessible. She sees single-payer as the only possible solution. Meanwhile, Prof. Epstein said that single-payer would be a costly, bureaucratic disaster and that the only solution is an entirely free-market health care system. The poor and uninsured can get their lower quality health care from Wal-Mart, just as they do other goods and services, he said. As you might guess, that was not a popular suggestion with the audience.

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Thursday, May 14, 2009

Fixing the house of medicine from the inside

As promised, the story of how Bob Brook wants doctors to spend less, in addition to eating less. At the SGIM opening session this morning, he called on physicians to improve the quality and lower the cost of their care, before making demands for insurance and payment reform. He suggested that the Journal of General Internal Medicine only publish research that works toward lowering costs (by, for example, testing out a new, less expensive alternative to an accepted treatment). He also recommend that physicians threaten their hospital CEOs with a job action unless they start working to increase the value of care provided at their facilities.

His ideas sounded pretty revolutionary until the keynote lecturer on geriatrics, Albert Siu, MD, made some similar arguments. He also called on general internal medicine to prove its value in caring for chronically ill patients. His point was that PCMH-like models would never be fully supported until primary care proved its value. Although he also said that payment system had to be reformed in order to show the value, so it seemed like a slightly circular argument.

Both lectures included the sort of digs on more procedural specialties that you would never hear at, um, other internal medicine meetings. These SGIM folks are not afraid to say how they think health care spending should be redistributed. But they also placed some of the blame on primary care, for not providing "excellent, affordable, humane care," as Bob Brook put it. Sounds like a challenge.

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A light breakfast

Regular readers of this blog know that our conference coverage usually serves as an opportunity not only to pick up clinical knowledge, but also to conduct some zoological observations of physicians in their natural habitat.

Along these lines, I'm pleased to report that attendees at the Society of General Internal Medicine's annual meeting practice the healthy eating that they preach. At this morning's buffet, piles of muffins and danishes sat untouched while people formed a LINE at the fruit table!

Those docs were probably glad of their restraint when keynote speaker Robert H. Brook, MD, took the stage. As a solution to the obesity epidemic, he advocated decreasing the availability of the food supply. For example, for his office at RAND, Dr. Brook has pushed for the elimination of all food outside the cafeteria and replacing buffets with calorie-limited servings.

He had similarly harsh prescriptions for practitioners of general internal medicine--think procedures and meds instead of snack food. More on that in my next post.

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Readable Rx labels: Clear but not compelling

Confusing prescription labels and poor patient adherence to medication are concurrent yet complementary problems. Fixing the former would seem to lead to improvements in the latter. That's what researchers hypothosized in a recent study that assessed the impact of Target pharmacies' easier-to-read labeling, introduced in 2005, on adherence to chronic medications.

But after analyzing 23,745 Target users (clear labeling) and 162,368 matched non-Target pharmacy users (presumably near-incomprehensible gibberish), researchers found no difference in adherence between the two groups. The new labels seemed popular enough, if the small increase in Target users is any indication, but they had no influence on behavior. The study was published in the Journal of General Internal Medicine.

Undaunted, researchers optimistically concluded that, "while adherence may not be improved with better labeling, evaluation of the effect of labeling on safety and adverse effects is needed."

Will that research reveal that patients are less likely to adhere precisely because they finally understand all the fine print they couldn't be bothered to read before? Stay tuned.

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Tuesday, May 12, 2009

Alfalfa sprout recall easily digested

Salmonella outbreaks typically make big public health news. Consider the furor surrounding the nationwide peanut butter recall earlier this year or the tainted tomato scare of 2008. But where is the hue and cry over the more recent multiple-state outbreak tied to eating contaminated alfalfa sprouts?

According to the CDC's May 7 Morbidity and Mortality Weekly Report, a total of 228 sprout-related salmonella cases have been reported in 13 states since Feb. 1. On April 26, the FDA and the CDC recommended that consumers not eat raw alfalfa sprouts until further notice and on May 1, the FDA notified sprout growers and retailers that the seed company identified as the source of the tainted sprouts was voluntarily withdrawing all affected seed lots from the market.

The FDA recommends thoroughly cooking your sprouts before eating, although that would seem to eliminate them as a crunchy salad topping. I'll opt for croutons over limp sprouts any day. Then again, now that tomatoes and peanut butter are back on shelves, pizza or a PB&J suddenly seem like sensible choices.

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Step away from the doughnut

Physicians--and everyone else in the world--know that diet and exercise are the pillars to weight loss. But a study presented Friday at the European Congress on Obesity suggests that diet is, by far, the main culprit when it comes to packing on pounds, and should be the focus of weight-loss efforts as well, Science Daily reports.

The rise of obesity in the U.S. since the 1970s can pretty much be blamed on eating more calories, the study found. In order to get back to those sleek '70s physiques, adults would need to cut about 500 calories a day from their diets, and children would need to cut about 350 calories a day.

The alternative is to add about 2 extra hours of walking time to your day (2.5 hours if you're a kid). Which doesn't seem very realistic. Exercise is, of course, wonderful for many reasons and should be maintained and promoted, the study authors said. But to really combat the obesity epidemic in the country, Americans have simply got to stop pigging out.

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Monday, May 11, 2009

Medical news of the obvious

  • People actually do better at sports when they are being encouraged (as opposed to, say, berated or ignored), a new study in the Journal of Sport Psychology finds. Not sure what this does for the stereotype of the tough-as-nails, it's-for-your-own-good-kid coach that has enlivened many a TV show and film, but it's bound to make some athletes happy.
  • Children who are exposed to "adult content" on TV have sex earlier than their peers who aren't exposed to such content, a new study found. Indeed, for every extra hour that 6- to 8-year-olds watched adult content, their likelihood of having sex increased by 33%. Yikes.
  • Drinking alcohol can cause your mind to wander, while making you less aware that your mind is wandering, a press release from the Association of Psychological Science informed us earlier this week. The study--which tested drinkers' ability to focus on reading War and Peace (a popular pasttime while getting hammered)-- "provides the first evidence that alcohol disrupts an individual's ability to realize his or her mind has wandered," the release says. Um, isn't this why we don't give the car keys to drunk folks, even when they insist they are fine to drive?
  • Speaking of driving, turns out that texting while driving is dangerous. Also dangerous? Reading War and Peace, eating a huge sloppy burrito, and sleeping while driving.

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Thursday, May 7, 2009

Pop Quiz: Women's Health

Pop quiz: What's the #1 medical condition that drives women to the doctor, hospital, clinic, etc?

Hypertension, according to the AHRQ, which reported today in a news release that about 25 million women were treated for hypertension in 2006.

In women age 65 years+, the other most common diseases which drove them to treatment were hyperlipidemia (7.1 million), osteoarthritis (5.9 million), heart disease (5.7 million), and COPD and asthma (5.5 million).

In women age 45-64 years, the next most common were: depression and other mental disorders (8.3 million), COPD and asthma (8.2 million), hyperlipidemia (6.5 million), and osteoarthritis (5.8 million).

And in women age 30-44 years, the next most common were: depression and other mental disorders (5 million), COPD or asthma (4.8 million), female genital disorders (4.2 million), and acute bronchitis (4 million).

The analysis, which comes from AHRQ's Medical Expenditure Panel Survey, includes data on treatment in doctors' offices, hospitals, ERs, hospital outpatient clinics, and by home health care providers.

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Your Thoughts Exactly: Handling patients who can't afford to pay

With the economy uncertain and unemployment rising, ACP Internist readers reported they are facing patients in their offices who are ill, but unable to pay for health care. The situation has left many physicians with the unexpected dilemma of how to treat such patients while also trying to manage a practice. Or worse, patients may not seek health care at all, an option suspected by virtually all respondents in our latest poll, Your Thoughts Exactly: Caring for unemployed/uninsured patients.

Results were collected anonymously throughout April. The results are not scientific and do not reflect any ACP policy, and are reported for their news value only.

When faced with a patient who was unemployed, uninsured or otherwise unable to pay, physicians fell back on a few options:
When faced with a patient who was unemployed, uninsured or otherwise unable to pay, physicians fell back on a few options:
Options (respondents could choose more than one; n=73)

  • I've offered free care or reduced payments. 66.7%
  • I've offered free samples for prescriptions. 61.1%
  • I've referred them to community clinics. 34.7%
  • I've reduced or eliminated co-pays. 18.1%
  • I've deferred billing. 16.7%
  • I've had to refuse care to delinquent patients. 6.9%
  • I've let the front desk handle it. 6.9%

Among those who offered other options, hospitalists who responded are generally able to refer to their own facilities. One reported, "As a hospitalist I try to take care of them as I do the others ... but I have the devil's own time getting consultants to see them, and arranging outpatient follow-up is often difficult or impossible."

Another respondent said, "I have the luxury of practicing in an academic setting where most of these decisions are made for me. I would hate to be faced with the situation of not providing care due to inability to pay. I can say that since our institution has implemented a co-pay policy, attendance at our resident teaching clinics has fallen off dramatically. I see a future where residents graduate with even less ambulatory care experience than they're already getting."

Office-based practitioners are setting up payment plans, steering patients toward low-cost or no-cost generic options through their local chain pharmacy or grocery. A few have some sort of sliding scale for payments; others suggested downcoding services, even comprehensive exams, so the overall cost would be less.

"I provide them information on how to shop for their prescriptions, explain the excessive cost of needless over-the-counter products, attempt to keep the costs of tests and other health care to a minimum, refer to the physicians who will provide the same level of care and concern that I have whenever possible; I also refer to the state."

Many are referring to local support groups or working at free clinics--in one case the doctor opened a free clinic. Many physicians are doing more chronic care management by phone, which as one person said, "I have done it in previous recessions."

Nearly all (72 of 73 doctors, or 98.6%) said that they know or suspect their patients are skipping needed care, while the other respondent replied he or she wasn't sure. Among the patients suspected of skipping care, they were thought to be rationing medications or not coming back for follow-ups. "I suspect this is a much bigger problem than any physician actually knows about," one physician added.

One doctor suggested a way to prevent losing patients to follow-up: "Be sensitive to proud patients who do not want to admit they are having financial troubles."

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Wednesday, May 6, 2009

Need to see a doc? Take a number.

It's almost Medical News of the Obvious to those of us who have lived in big cities.

Merritt Hawkins released a survey today on the cities with the longest wait times to get a new patient appointment. Number one on the list of 15 metro areas? Boston, where it takes, on average, 70 days to see an Ob/Gyn, 63 days to see a family doctor, 54 days to see a dermatologist, 40 days to see an orthopedic surgeon, and 21 days to see a cardiologist.

Next on the list is Philadelphia (no surprise to yours truly), followed by L.A., Houston, Washington, D.C., San Diego, Minneapolis, Dallas, Miami, New York, Denver, Portland, Seattle, Detroit and Atlanta.

It's always been a little perplexing to me that it's so difficult to get appointments in Philadelphia, when there is such a large supply of medical schools and facilities. Boston is also chock-a-block with doctors, although, as the Merritt Hawkins release points out, there's been a surge in demand there since the state mandated coverage for all residents in 2006.

The survey also looked at Medicaid acceptance rates among medical offices, and found the overal rate for all 15 metro areas was 55%. It was highest in Minneapolis at 82%, and lowest in Dallas at 39%.

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Hacker demands ransom for patient records

The Web site Wikileaks reported this week that a computer hacker wiped out more than 8 million patient records stored on a secure site for the Virginia Prescription Monitoring Program (VPMP) and replaced the home page with a ransom note demanding $10 million for the records' return. The director of Virginia's Department of Health Professions declined to provide details but confirmed that a criminal investigation is underway, according to the Washington Post's Security Fix blog, which picked up on the story.

While details have yet to be confirmed, there is a message on the VPMP Web site that its systems are inaccessable until further notice. The site, which also contained 35.5 million prescriptions, is used by health officials to monitor prescription drug abuse. The incident follows another as-yet unsolved case from October 2008 when hackers demanded ransom for the return of computer files held by Express Scripts Inc.

Knowing that anonymous hackers can bypass the safeguards of a supposedly secure government Web site is fodder for those who argue against transferring patient information to electronic records. But neither does it make sense for patient records to be relegated to paper, the lone holdout in an online world. It's a virtual arms race as legitimate Web sites step up security only to be foiled by ingenious hackers. One can only hope that the techies working inside the system are as clever as those on the dark side.

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Grim reports on healthcare quality, equality

Two AHRQ reports issued today reveal a rather dismal state of affairs for American healthcare.

The 2008 National Healthcare Quality Report and 2008 National Healthcare Disparities Report suggest many Americans don't get recommended care, and that patient safety measures have gotten worse.

Some findings from the report:

  • 40% of recommended care isn't received by patients.
  • Only 40% of patients with diabetes received three recommended diabetic preventive exams in the past year, and this rate hasn't improved over time.
  • Only half of obese adults and children are given advice to exercise more and eat a healthy diet.
  • 70% of adults with mood, anxiety, or impulse disorders receive inadequate treatment or no treatment at all.
  • Patient safety measures have worsened by nearly 1% each year for the past 6 years.

Patient safety has declined, in part, due to a rise in infections acquired in healthcare settings, the AHRQ said in a press release. As such, HHS Secretary Kathleen Sebelius plans to make $50 million in grants available to states to fight healthcare-associated infections, it said.

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Tuesday, May 5, 2009

C'est la vie!

A new report from the Organization for Economic Cooperation and Development reveals that the French spend more time sleeping (8.5 hours a day on average) and eating (over two hours a day, nearly double the time spent by Americans or Canadians) than any of the OECD's 30 member countries. It's one of the more intriguing of the evolving social trends identified in the OECD's latest edition of "Society at a Glance."

Being well-rested and amply fed apparently confers some signficant health benefits as the French are also noted as having one of the longest average lifespans of the 30 countries--88.4 years on average for women, second only to the Japanese, and 77.3 for men, two years less than the hearty Swiss and Icelandic men. (With all that time spent in bed, it comes as little surprise that the French also have one of the highest fertility rates of countries studied.)

Other interesting findings from the report include that Norwegians have the most leisurely lifestyle, with just over a quarter of their time spent on leisure activities. By comparison, Mexicans spend the least amount of their time (16%) on leisurely pursuits. Unfortunately, most people seem to squander what free time they have watching TV, which accounts for nearly half of all leisure time in Mexico and Japan.

A telling statistic, considering the obesity epidemic, is the small amount of time devoted to exercise. Spain ranks highest, but hardly merits bragging rights with just 13% of leisure time spend on physical activities. The Turks may be the most well-adjusted, choosing to spend 35% of their free time entertaining friends.

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Monday, May 4, 2009

Outrageous medical claims promise to cure everything!

News media are often criticized for exaggerating science stories and deliberately sensationalizing the news. However, researchers argue that sensationalism may begin at the source--the press departments of academic research centers.

The accusation comes from Annals of Internal Medicine, in which researchers reviewed press releases from 20 medical centers. The centers' PR departments had issued an average of a nearly a release each week.

Among 200 randomly selected releases that were analyzed in detail, 87 (44%) promoted animal or laboratory research, of which 64 (74%) explicitly claimed relevance to human health. But the paper later points out that "Two-thirds of even highly cited animal studies fail to translate into successful human treatments."

Among 95 releases about primary human research, 22 (23%) omitted study size and 32 (34%) failed to quantify results. Among all 113 releases about human research, few (17%) promoted randomized trials or meta-analyses. 44% of releases reported on uncontrolled interventions, samples of less than 30 participants, studies with surrogate primary outcomes or unpublished data. 58% of releases lacked relevant cautions that tempered the findings.

The researchers even chastised the exaggerated quote from researchers (although it didn't clarify whether they were making the statements or if the PR staff were somehow spinning quotes.) They concluded that academic press releases often promote research with uncertain relevance to human health without acknowledging important cautions or limitations.

Acknowledged. And mainstream journalists still shoulder some of the burden of knowing all these caveats so they can unspin the press releases to better report medical news.

One solution researchers offered was to issue fewer releases about preliminary research, especially unpublished scientific meeting presentations, to reduce the chance that journalists and the public are misled. Unpublished presentations can change substantially or fail to hold up under subsequent research, and 40% of meeting abstracts and 25% of abstracts that garner media attention are never published as full reports.

The newspaper staff here at ACP can take advantage of some key resources when we choose what to cover. We have clinicians who help with the editing process. Physicians on staff shared with us the same training they give to medical students about how to interpret research and write studies. We have ACP resources on writing and reporting medical statistics at our desks.

But probably our greatest resource has been the readers, who don't hesitate to contact us when they feel our coverage is askew. It's probably the main difference between writing for doctors and writing for the lay public. We have a check and balance in our audience, and the mainstream media doesn't.

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Researcher's disclosures plant seed of doubt

With conflict of interest issues so much in the news, one can't help but wonder about the integrity of certian studies. When researchers disclose ties to companies that stand to benefit from a study's conclusions, how can the results--however valid--not be tainted?

A case in point: An article in MedPage Today reports that research presented recently at the American Urological Association meeting in Chicago concluded that switching patients from brand-name to generic urologic drugs resulted in lower efficacy and more side effects.

The article dutifully points out that while generic drugs must be FDA approved as bioequivalent to the branded versions, the U.S. definition of bioequivalence encompasses a fairly wide range, from 80% to 125% of the active compound, thus opening the door to differences in efficacy.

The two small observational studies showed that control of lower urinary tract symptoms decreased by as much as 42.5% when patients were switched to a generic alpha-blocker or 5 alpha-reductase inhibitor (5ARI) from a brand-name drug.

Cause for concern? Maybe, but one can't help but wonder when the researcher, Steven A. Kaplan, M.D., of Weill Cornell Medical College, discloses relationships with several makers of the branded drugs used in the study (Detrol by Pfizer, Uroxatral by Sanofi, Vesicare by Astellas Pharma and Avodart by GSK). "Patients and their physicians need to be aware of the implications of switching to generic medications," Dr. Kaplan told MedPage.

We might add that it also pays to read the fine print.

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Medical news of the obvious

Overweight people are more likely to eat more and to opt for driving over walking, report researchers in the current issue of the International Journal of Epidemiology. The researchers tie their astute observations to environmental problems -- eating and driving more contributes to greenhouse gas emissions from food production and car exhaust. Furthermore, a lot of that food is wasted and thrown into landfills where it decomposes and emits methane or is burned and produces CO2. So, being overweight hurts the entire planet. How's that for a guilt trip?

Asthma sufferers should be cautious of swine flu, according to a "Quote us, too" press release from the American Academy of Allergy, Asthma & Immunology. Non-asthmatics have not been reported to be OK with getting the disease.

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Friday, May 1, 2009

Capitalizing on swine flu, part 2

Speaking of opportunistic use of swine/H1N1 flu, the FDA and FTC just released an alert to warn the public about fradulent products and Web sites which "claim to diagnose, prevent, mitigate, treat or cure the 2009 H1N1 influenza virus":

"These fraudulent products come in all varieties and could include dietary supplements or other food products, or products purporting to be drugs, devices or vaccines....

"The last thing any consumer needs right now is to be conned by someone selling fraudulent flu remedies," said FTC Chairman Jon Leibowitz. "The FTC will act swiftly against companies that resort to deceptive advertising."

If you run across such sites or products, you are kindly requested to contact the FDA/FTC here.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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