American College of Physicians: Internal Medicine — Doctors for Adults ®

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Friday, July 30, 2010

Should doctors be paid to communicate with patients?

This post by Steven Wilkins, MPH, appeared at Better Health.


I often hear from physicians that they would do a better job communicating with patients if they were adequately reimbursed for the time it took to do so. Given that certain types of physician-patient communications (patient education, care planning, etc.) can have quantifiable, therapeutic benefits for patients, I can see their point.

I have no problem with physicians asking to be adequately reimbursed for services they provide, as long as they are high quality and add value. For example, teaching chronic disease patients how to care for themselves at home takes time and is critical to effective patient self care. In this role, physicians are called upon to be a provider of necessary information as well as a coach to encourage and support patients.

But as evidence suggests, many physicians don't communicate effectively enough with patients, chronic or otherwise, to seem to merit additional reimbursement.

According to the evidence:
--Physicians typically spend less than minute of a 20-minute visit discussing treatment and planning with patients.
--Up to 50% of patients leave office visits not understanding what their physician told them to do.
--Physicians do not ask patients if they have any questions in more than 50% of outpatient visits.
--Physicians prescribing new medications do not always give dosage and frequency instructions to the patient.
--Physicians tended to underestimate their patient's desire for information in 65% of encounters and overestimated the patient's desire for information in only 6% of encounters.

If we are ever going to see significant improvement in patient medication adherence rates, greater levels of control of patient A1C levels and blood pressures, we are going to have to find new ways to pay physicians. But in so doing, physicians will have to be held as accountable for the quality of their patient communications as they are for the quality of their clinical care.

Before primary care physicians can expect to be reimbursed for the time they spend communicating with patients, three things must occur:
1) Quality standards must be established that define effective physician-patient communications.
2) Physicians and patients must be provided with training and tools to more effectively communicate with one another.
3) We will need to move beyond basic patient satisfaction surveys and develop more sophisticated approaches to measuring the quality of the physician-patient interaction.

References:
Kaplan, S. et al. "Assessing the Effects of Physician-Patient Interactions on the Outcomes of Chronic Disease." Medical Care, Vol. 27, No. 3. 1989.
Heisler, M. "Actively Engaging Patients in Treatment Decision Making and Monitoring as a Strategy to Improve Hypertension Outcomes in Diabetes Mellitus." Circulation. 2008.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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QD: News Every Day--'Don't know much biology ... '

Study painting, drama or the "soft" social sciences and you'll probably be a pretty good doctor anyway. Mt. Sinai School of Medicine has been doing it for years and compared students in a special liberal arts admissions program to its traditional pre-med students.

For years, Mt. Sinai has admitted students from Amherst, Brandeis, Princeton, Wesleyan, and Williams colleges based on a written application with personal essays, verbal and math SAT scores, high school and college transcripts, letters of recommendation, and personal interviews.

No MCAT is required.

Students need to take one year of biology and one year of chemistry and maintain (swallow hard) a B average. They later get an abbreviated course in organic chemistry and medical physics.

Researchers compared 85 students in this program to their traditionally-trained peers and reported results in Academic Medicine. The liberal arts students struggled more early on with the sciences, their gross anatomy coursework and the Step 1 exam. But by the end, they equaled their peers and were highly successful in university hospitals, and in psychiatry and pediatrics, often taking more prizes and awards at graduation.

Authors wrote, "Although students in this program have more academic difficulties in the preclinical years, they excel in the clinical/community setting and have greatly enriched the medical school environment. This program demonstrates that success in medical school does not depend on a traditional premed science curriculum."

Singer Sam Cooke would have been a great doctor. Just listen to all the pre-med subjects he knows nothing about.



In case you missed it ...
The Senate introduced a bi-partisan bill to reduce hospital readmissions by including lawyers on the health delivery team. The legislation would fund a pilot demonstration of providing legal help for patients in public health settings. Domestic violence, housing and Medicaid benefits were cited as three examples of how legal advice could prevent the same issues from cropping up over and over. (The Hill)

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New Pap smear guidelines: right care or rationed care?

This post by Davis Liu, MD, appeared at Better Health.


The American College of Obstetricians and Gynecologists (ACOG) recently reiterated their position that Pap smears should be performed on healthy women starting at age 21. This is different from the past which recommended screening for cervical cancer at either three years after the time a woman became sexually active or age 21, whichever occurred first.

How will the public respond to this change?

Over the past year there have been plenty of announcements from the medical profession regarding to the appropriateness of PSA screening for prostate cancer and the timing of mammogram screening for breast cancer. Understandably, some people may view these changes in recommendations as the rationing of American healthcare.

They should instead, however, welcome these advancements. Doctors are becoming even better at understanding which screening tests work and which ones don't.

Doctors have discovered that for cervical cancer, which is detected by Pap smears, a significant risk factor in infection from the human papilloma virus (HPV). HPV is the most common sexually-transmitted disease and aside from causing cervical cancer is also the cause of genital warts. Women under age 21 who are healthy and do not have a compromised immune system from HIV or organ transplant rarely develop cervical cancer from HPV infection.

Unlike the past, when women needed annual Pap smears, advances in screening with new liquid-based Pap smears as well as screening for HPV allows women to be checked for cervical cancer every other year. Women age 30 and older who have had three normal pap smears in a row can have Pap smears every two to three years with a Pap smear or every three years with a Pap test and HPV DNA screening.

If all doctors recommended these interventions, this would reduce the number of Pap smears needed by 50%. The newest cervical cancer screening method would be far better as it identified which women were at risk with better precision and information than the past. By doing fewer unnecessary Pap smears, doctors are now free to address other problems as well as begin to take on the millions of Americans who will have health insurance due to reform.

The question is will they do it? Will women accept the new changes in screening intervals?

Research shows it takes about 17 years before results of studies and guidelines become commonly practiced in the community. One study showed primary care doctors were not particularly good at screening for colon cancer though new guidelines have been around for a decade.

It's easy to blame doctors for being slow to change. It's easy to blame patients for being slow to change. Many of my patients still demand an annual pap smear even though HPV DNA testing is something my colleagues and I have practiced for years.

Solar system by Mads Boedker via FlickrThe fact is that change is hard unless of course you are new to something. As my five year old daughter proudly told me recently there are exactly EIGHT planets, not nine, in the solar system.

For the next generation of women, they will not need Pap smears until age 21. They can be safely screened every other year. There is a chance that none of them will ever develop cervical cancer as, since 2006, HPV vaccines exist for individuals age 9 to 26 that immunize them from the subtypes of HPV that cause cancer.

These women won't get upset. They won't get worried. They know this is the right care. This is not rationed care. That is, of course, until the next revision in the guidelines and recommendations.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Thursday, July 29, 2010

Crackdowns on painkillers may deny some legitimate uses

This post by ACP Member Kevin Pho, MD, originally appeared on MedPage Today's KevinMD.com.

Patients requiring controlled substances to manage their pain have always been controversial to treat. Every time the subject is broached on KevinMD.com, the comments inevitably becomes a contentious discussion of "drug seeking behavior" versus treating legitimate pain.

It's a problem that doctors nationwide grapple with every day, and is addressed in a recent essay from the New York Times.

Michael Kahn is a Boston psychiatrist who recently asked residents how they would approach a patient who had asked for Xanax, a benzodiazepine often used to treat anxiety.

In the end, Dr. Kahn notes that, "The prevailing attitude was one of 'They'll have to pry that pill from my cold dead hands.' It made me wonder whether these budding psychiatrists might be working too hard to avoid being hoodwinked."

He then compares screening patients for drug seeking behavior with tests from other medical fields: "Surgeons are fooled when they open an acutely painful abdomen only to find a normal appendix: in the days before CT scans, it was said that if that didn't happen once in a while, you weren't operating often enough. When in doubt, it was safer (and wiser) to operate than to risk a rupture and peritonitis, even if the diagnosis was 'wrong.' Here was an error that wasn't an error, but rather a predictable side effect of balancing known risks with imperfect information."

Applying that to pain management, he suggests accepting a degree of false positives instead of missing patients with true pain: "I'd rather be taken for a sucker once in a while than know that my suspicion had denied someone legitimate help."

That's certainly the ideal, but the federal government isn't helping matters much. Recent high-profile crackdowns of more liberally prescribing physicians have scared doctors into a bunker-like mentality. Until there is better clarity from both law enforcement and pain specialists as to what constitutes appropriate pain management prescribing, it's likely that patients in true pain will continue to suffer.

This post originally appeared on MedPage Today's KevinMD.com, social media's leading physician voice. Voted best medical blog in 2008, and with over 33,000 subscribers and 23,000 Twitter followers, KevinMD.com is the web's definitive site for influential health commentary.

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QD: News Every Day--'Unusual' health utilization drop uncovered

Americans are using less health care than they used too. A weak economy, high unemployment and more high-deductable plans may all be to blame for an unusual pattern of lower utilization, as measured by insurers, labs, hospitals and physician billing services. Weak demand could accomplish one health reform goal of bending the cost curve. Or, it could bend the curve like a diving board, only to see costs bounce upward later. (Wall Street Journal)

Health care reform is encouraging Texas physicians to leave private practice for hospital-owned arrangements. The new law lets Medicare reward accountable care organizations in which doctors and facilities collaborate to improve care and reduce hospitalizations. And, the financial pressure on private physicians is tremendous right now. But while hospitals are gobbling up independent practices, not every doctor is lining up to affiliate. They worry about how much of the rewards they'll see, and they don’t want to be told how to practice medicine. (Los Angeles Times, ACP Internist)

Through a wine glass by dicktay2000 via FlickrDon't try this at home
Teetotalers have four times the risk of rheumatoid arthritis as people who drink more than 10 days a month, reports a study. Authors divided more than 1,000 adults into four categories, based on how frequently (but not how much) they drank. Arthritis was progressively less severe as frequency increased, with noticeable differences between abstainers and people who drink one to five times a month. More frequent drinking also lessened the severity of inflammation in joints, as measured by X-rays. Rheumatologist Guy Fiocco, FACP, said while it's known that alcohol suppresses the immune system, drinking is still not an advisable arthritis remedy. People who drink excessively have more cytokines, which lead to inflammation. (MSN)

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Wednesday, July 28, 2010

QD: News Every Day--a friend indeed

A study published in the July PLoS Medicine is getting a lot of press today for its conclusion that strong social networks are related to increased life span. The meta-analysis of 148 studies involving 308,849 people found that those with stronger relationships were 50% more likely to survive over 7.5 years of follow-up. What's more, the researchers reported that a lack of strong social ties is as bad, healthwise, as drinking or smoking and worse than not exercising or being obese. But although the association between strong social ties and improved longevity seems robust, other factors could be at play, and applying the findings in clinical practice could be difficult. And sorry, Facebook fanatics: Online "friendships" aren't thought to count as much as in-person ones do. (PLoS Medicine, New York Times, TIME, The Atlantic)

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Tuesday, July 27, 2010

QD: News Every Day--Telemedicine advances ease patient adoption

Ralph Terenzio, a patient with the Center for Connected Health, checks his blood pressure using remote monitoring equipment.Monitoring vital signs remotely saves time and money for everyone: patients, physicians, facilities and insurers. Heart failure is a particular target because its increasingly common, its easily triggered (by as little as too much salt on food, for example) it costs so much to manage in the hospital and it's so easily avoided. Remote monitoring equipment made even easier with wireless connections can take vital signs, and even ask standard questions every morning. The equipment puts patients in contact with nurses once they detect warning signs. That human touch is key. Case managers can screen out false alarms (avoiding alert fatigue) and can direct patients to the physician when needed. ACP Internist covered remote monitoring technology in its March issue. (Wall Street Journal, ACP Internist)

Ironically, the hospitals themselves are having trouble making the most of the technology they install, reports the American Hospital Association. The group changed its top 100 "Most Wired" hospital list to reflect new standards in infrastructure, administration, clinical quality and safety, and continuity of care in the ambulatory and physician community. 30% of hospitals on last year's list didn't make it back this year, and the list had to be pared down to 99 because that's all that met the criteria. One area of concern is electronic medical record use in affiliated (not owned) practices. 43% of practices affiliated with a "Most Wired" hospital use one, while 69% of owned practices do.

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Monday, July 26, 2010

A letter to patients with chronic illness

Author's Note: The following post, which recently appeared in my blog, has had a larger response from readers than any other I have written. The depth of emotion felt by people with chronic disease making comments that this stirred was remarkable. This is clearly an issue we physicians mishandle often. Chronic disease patients are the mainstay of internal medicine, but many of us don't quite understand what it's like to face this every day. I encourage you to go over and read the comments.

Dear Patients:

You have it very hard, much harder than most people understand. Having sat for 16 years listening to the stories, seeing the tiredness in your eyes, hearing you try to describe the indescribable, I have come to understand that I too can't understand what your lives are like. How do you answer the question, "how do you feel?" when you've forgotten what "normal" feels like? How do you deal with all of the people who think you are exaggerating your pain, your emotions, your fatigue? How do you decide when to believe them or when to trust your own body? How do you cope with living a life that won't let you forget about your frailty, your limits, your mortality?

I can't imagine.

But I do bring something to the table that you may not know. I do have information that you can't really understand because of your unique perspective, your battered world. There is something that you need to understand that, while it won't undo your pain, make your fatigue go away, or lift your emotions, it will help you. It's information without which you bring yourself more pain than you need suffer; it's a truth that is a key to getting the help you need much easier than you have in the past. It may not seem important, but trust me, it is.

You scare doctors.

No, I am not talking about the fear of disease, pain, or death. I am not talking about doctors being afraid of the limits of their knowledge. I am talking about your understanding of a fact that everyone else seems to miss, a fact that many doctors hide from: We are normal, fallible people who happen to doctor for a job. We are not special. In fact, many of us are very insecure, wanting to feel the affirmation of people who get better, hearing the praise of those we help. We want to cure disease, to save lives, to be the helping hand, the right person in the right place at the right time.

But chronic unsolvable disease stands square in our way. You don't get better, and it makes many of us frustrated, and it makes some of us mad at you. We don't want to face things we can't fix because it shows our limits. We want the miraculous, and you deny us that chance.

And since this is the perspective you have when you see doctors, your view of them is quite different. You see us getting frustrated. You see us when we feel like giving up. When we take care of you, we have to leave behind the illusion of control, of power over disease. We get angry, feel insecure, and want to move on to a patient who we can fix, save, or impress. You are the rock that proves how easily the ship can be sunk. So your view of doctors is quite different.

Then there is the fact that you also possess something that is usually our domain: knowledge. You know more about your disease than many of us do-- most of us do. Your MS, rheumatoid arthritis, end-stage kidney disease, Cushing's disease, bipolar disorder, chronic pain disorder, brittle diabetes, or disabling psychiatric disorder--your defining pain--is something most of us don't regularly encounter. It's something most of us try to avoid. So you possess deep understanding of something that many doctors don't possess. Even doctors who specialize in your disorder don't share the kind of knowledge you can only get through living with a disease. It's like a parent's knowledge of their child versus that of a pediatrician. They may have breadth of knowledge, but you have depth of knowledge that no doctor can possess.

So when you approach a doctor, especially one you've never met before, you come with a knowledge of your disease that they don't have, and a knowledge of the doctor's limitations that few other patients have. You see why you scare doctors? It's not your fault that you do, but ignoring this fact will limit the help you can only get from them. I know this because, just like you know your disease better than any doctor, I know what being a doctor feels like more than any patient could ever understand. You encounter doctors intermittently (more than you wish, perhaps); I live as a doctor continuously.

So let me be so bold as to give you advice on dealing with doctors. There are some things you can do to make things easier, and others that can sabotage any hope of a good relationship:
--Don't come on too strong. Yes, you have to advocate for yourself, but remember that doctors are used to being in control. All of the other patients come into the room with immediate respect, but your understanding has torn down the doctor-god illusion. That's a good thing in the long-run, but few doctors want to be greeted with that reality from the start. Your goal with any doctor is to build a partnership of trust that goes both ways, and coming on too strong at the start can hurt your chances of ever having that.
--Show respect. I say this one carefully, because there are certainly some doctors who don't treat patients with respect, especially ones like you with chronic disease. These doctors should be avoided. But most of us are not like that; we really want to help people and try to treat them well. But we have worked very hard to earn our position; it was not bestowed by fiat or family tree. Just as you want to be listened to, so do we.
--Keep your eggs in only a few baskets. Find a good primary care doctor and a couple of specialists you trust. Don't expect a new doctor to figure things out quickly. It takes me years of repeated visits to really understand many of my chronic disease patients. The best care happens when a doctor understands the patient and the when the patient understands the doctor. This can only happen over time. Heck, I struggle even seeing the chronically sick patients for other doctors in my practice. There is something very powerful in having understanding built over time.
--Use the ER only when absolutely needed. Emergency room physicians will always struggle with you. Just expect that. Their job is to decide if you need to be hospitalized, if you need emergency treatment, or if you can go home. They might not fix your pain, and certainly won't try to fully understand you. That's not their job. They went into their specialty to fix problems quickly and move on, not manage chronic disease. The same goes for any doctor you see for a short time: they will try to get done with you as quickly as possible.
--Don't avoid doctors. One of the most frustrating things for me is when a complicated patient comes in after a long absence with a huge list of problems they want me to address. I can't work that way, and I don't think many doctors can. Each visit should address only a few problems at a time, otherwise things get confused and more mistakes are made. It's OK to keep a list of your own problems so things don't get left out. I actually like getting those lists, as long as people don't expect me to handle all of the problems. It helps me to prioritize with them.
--Don't put up with the jerks. Unless you have no choice (in the ER, for example), you should keep looking until you find the right doctor(s) for you. Some docs are not cut out for chronic disease, while some of us like the long-term relationship. Don't feel you have to put up with docs who don't listen or minimize your problems. At the minimum, you should be able to find a doctor who doesn't totally suck.
--Forgive us. Sometimes I forget about important things in my patients' lives. Sometimes I don't know you've had surgery or that your sister comes to see me as well. Sometimes I avoid people because I don't want to admit my limitations. Be patient with me. I usually know when I've messed up, and if you know me well I don't mind being reminded. Well, maybe I mind it a little.

You know better than anyone that we docs are just people--with all the stupidity, inconsistency, and fallibility that goes with that--who happen to doctor for a living. I hope this helps, and I really hope you get the help you need. It does suck that you have your problem; I just hope this perhaps decreases that suckishness a little bit.

Sincerely,
Dr. Rob

Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes). He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

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QD: News Every Day--Patient-centered pilots need a PR makeover

While the patient-centered medical home may be a good idea, it needs a better name. It sounds like a hospice, reports surgeon and columnist Pauline Chen, MD. She outlines the initial experiences of practices making the transition to the new practice model.

One problem uncovered by pilot projects is that doctors in transition to the practice model have to spend inordinate amounts of time of things other than patients. And while the patients want and welcome the changes, they face a learning curve too, as they move from seeing just the doctor to working with a team of providers for their care.

Physicians suggested using resources from a collaborative group set up to help offices make the transition, the Patient-Centered Primary Care Collaborative. (New York Times)

Genomics
In a follow-up to last week's post, the maker of one direct-to-consumer genetics test has fired back at the Government Accountability Office's critical report of industry practices and results. While the GAO said the saliva-based gene tests are unreliable, test-maker 23andMe tossed a gob of its own at the agency, claiming it failed to analyze scientific information on its scientific merits, lumped credible companies in with all the rest and also failed to provide a copy of the report to companies before its release. (They may be spitting in the wind on that last point. The GAO works for Congress, not private industry.)

23andMe also pointed out that the GAO report hinged on the wide differences in results offered by each test, even though each one was conducted on the same test subject. Here, they talk about some of the difficulties of interpreting evidence-based medicine:

"Instead of constructively adding to these efforts, GAO has instead implied that because results differ between companies, they are simply wrong. Their report fails to provide all relevant information, and perpetuates the misunderstandings of genetics in particular and science in general that 23andMe has since the very beginning been dedicated to changing.

"It should be noted that the problem of different risk predictions from different sources is not unique to the direct-to-consumer genetic testing industry. Take for example, these two tools (here and here) available to the public to calculate risk for cardiovascular disease. Both are clinically valid, yet they give different answers. It should be noted that development of both of these two tools was at least partially funded by the federal government."

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Friday, July 23, 2010

QD: News Every Day--OTC gene tests are usually wrong

Rarely does a government report make for thrilling reading, but the subhead of this one was eye-catching: Direct to Consumer Genetic Tests:
Misleading Test Results are Further Complicated by Deceptive Marketing and Other Questionable Practices
. The title could have added "And they're expensive, too." The FDA has already been working on regulating genetic tests as medical devices, varying from their hands-off policy for lab tests. ACP Internist's genomics columnist, Greg Feero, MD, PhD, outlined how doctors can prepare for patients who use these tests and present results for interpretation. (Government Accountability Office, Reuters, ACP Internist)

Normally, one would sit down to digest a report of this scope, but as it turns out, that's not advisable either. Women and men who are sedentary for six hours during their leisure time are 40% and 20% more likely to die sooner than those who spend less than three hours sedentary. Exercise, diet and obesity weren't factors, reported an American Cancer Society study of more than 123,000 people for 13 years. (CNN)

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Thursday, July 22, 2010

QD: News Every Day--Patients don't mind long waits if kept abreast of how long it will be

Patients don't mind waiting in the ER as long as they're kept apprised of the time, an industry survey revealed. This is a good thing, since ER waits have risen nationally to an average of four hours and seven minutes this year.

Press Ganey Associates, Inc., has conducted the survey annually and says that ER wait times are four more minutes than last year, or a half hour more than the first survey in 2002. The company collected data on 1.5 million patients treated at 1,893 hospitals in 2009.

Despite longer wait times, patient satisfaction with U.S. hospital emergency departments stayed about the same in 2009. Communication was the key, as patients who waited more than four hours, but received "good" or "very good" information about delays were just as satisfied as patients who spent less than one hour in the emergency department.

Industry interaction
As a follow-up to yesterday's post on Harvard cracking down on physician-industry ties for its 11,000 faculty members, NPR points out that the rules have loopholes, albeit small ones. Faculty can still partner for speeches, research and consulting, but the intent is measured now. They can still accept meals and travel stipends, but they have to be integral to the work involved. Gifts are still forbidden, but CME courses can be industry-sponsored, just not single-sponsored. (ACP Internist, NPR)

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Wednesday, July 21, 2010

QD: News Every Day--Avastin may lose breast cancer approval

An FDA advisory committee yesterday voted 12-1 to revoke Avastin's accelerated approval for breast cancer, saying the drug's initial results weren't borne out by further studies. Its approvals for other cancers haven't been affected. The panel concluded side effects and risks, including fatigue, abnormal white blood counts and high blood pressure, outweighed benefits. (HealthDay)

Drug industry interactions
Harvard Medical School will enact new conflict-of-interest rules that will prohibit faculty from giving promotional talks for or accepting gifts, travel or meals from drug and device makers.

Rules also limit income from consulting or joining corporate boards, and will require online, public reporting of payments more than $5,000.

Also, Harvard's annual primary medicine conference, Pri-Med, will move the industry-supported portion of the program offsite, and marketing will be further restricted (advertisements had been allowed in bathrooms, for example.) A Harvard official said the new rules are meant to keep doctors from becoming or appearing as industry marketing agents. (The Boston Globe)

In case you missed it ...
The newly restored painting The Gross Clinic returns to public view this weekend in Philadelphia.

Thomas Eakins famous oil-on-canvas image depicts the upper lecture room of Jefferson's Medical Hall, a surgical amphitheater where Samuel D. Gross teaches the procedure for removing a segment of diseased bone from the left thigh of the patient who suffers from osteomyelitis.

The 135-year-old depiction of surgery and medical education was owned by Jefferson Medical College (which paid $200 for it in 1878), which was going to sell it to the National Gallery of Art in Washington for $68 million. Philadelphians objected and the Philadelphia Museum of Art and Pennsylvania Academy of Fine Arts bought it January 2007. Restorers then corrected previous attempts to brighten the 8-foot by 6-foot painting's dark hues, which had instead obscured details.

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Tuesday, July 20, 2010

The canary and the primary care physician

This post by Alan Dappen, MD, appeared at Better Health.


Why do you cage me? by tanakawho via FlickrThe vexing problem with "truth" when it comes to health care is to understand its limits. Let's start with two popular notions. The first, canaries are harbingers for detecting chemical leaks. The second, primary care specialists claim higher salaries for their work will prevent their extinction. Both claims sound plausible, but then come the conditions, the nuances, the variables and empirical testing and observation--the so called threads of truth.

Notion 1, The Canaries: In 1972 my brother passed through the military's basic training and was Vietnam bound until a perfect score on a standardized test, his Phi Beta Kappa and a chemistry degree from college rerouted his destiny to a remote patch of the Utah desert. Instead of being a foot soldier, he gave back to his country in a chemical warfare lab.

As the story goes (the lab was highly classified, luckily I was not there to be a primary witness), 1/10th of a drop of a nerve agent just on the skin could kill a person in less than a minute. Understandably, the lab employed the services of many caged canaries for testing possible leaks of the nerve gas. This became a time-honored safety measure.

One day a lab tech took the established belief and subjected it to empirical testing. The results rocked "the-canary-in-a-nerve-gas-lab" notion to its core. In reality, the lethal dose needed to kill 50% of the canaries was much higher than it was for humans. Instead of humans scurrying out of the lab to safety, the conclusion of the study predicted that in the event of a nerve gas leak, canaries would be chirping away in their cages senselessly while a roomful of humans lay lifeless on the lab floor.

The brass, confronted with the cold hard facts, summarily dismissed the canaries.

Next, let's consider Notion 2: Money Can Revive Primary Care, which is built on the belief that throwing more money at a problem can fix it.

I start anecdotally with my cohort of family practice residency friends who are now in their late 50s. Of the eight doctors I keep up with, three no longer see patients. One is retired, one quit medicine 15 years ago and one serves as an administrator. Another three work part time in patient care ranging from one to three days a week. Only two of us remain in clinical medicine full time.

Observational data suggests that enough money is to be made to either retire early or to work part-time. The comment I hear most often from this very dynamic and intelligent group? "I'm so done with medicine. I've moved on with my life."

Next, 90% of primary doctors work for someone else (e.g. Kaiser, Group Health, hospital systems, the Veterans Association, private companies, health management groups). Even "private practices" is a misnomer since insurance companies control and out-compete the doctor for the patient. Patients no longer employ doctors but hire intermediaries to protect them from predatory and unpredictable health care costs. Not surprisingly, the middle man who pays the doctor cares little about physician morale, work hours or paying one penny more than they have to acquire a doc. We are nothing but replaceable units.

Also, nurse practitioners are rapidly being seen as the new primary care workforce because it is believed that they are easier and cheaper to train and their emerging numbers will create a supply and demand curve that can easily stamp out any mirage of a doctor magically being offered more money just because MDs are "special" or deserve it.

In addition, health care, even after "reform," is bankrupting America more than any other sector of our economy. Primary care physicians' incomes already approach 95% of all American's incomes. The tolerance to pay more money for physicians' crocodile tears will be but deaf and blind pleadings upon the public and our bosses.

Lastly, the equation between happiness and money in numerous studies show repeatedly that physicians can't buy more happiness with more money. They already sit well along the threshold of money where the happiness curve flattens and no longer responds to money. More money will mean hedging for fewer hours or quitting faster if nothing changes the morale and conviction of the current primary care workforce. Certainly my cohort of residency friends exemplifies this finding.

In sum, a prediction: The brass, confronted with the cold hard facts, will refuse physician pay raises and hire nurse practitioners and physician assistants instead. Canaries will not save chemical warfare workers. More money will not save the endangered primary care physicians. Canaries have enough purpose flying, singing and looking beautiful. The struggling primary physician movement might want to go back to the basics or their mission and take control of their own destiny. There are a plethora of physician collectors who are willing to pay just enough to keep you in a cage. There are also a few primary care physicians out there who have taken flight and have refused to give up hope that others will follow and focus on mission, not money.


This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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QD: News Every Day--Doctors allege insurers unfairly profiling them based on spending

Medical groups say that insurers are unfairly profiling doctors based on inaccurate utilization assessments. The American Medical Association and dozens of medical groups are asking insurers to improve the accuracy, reliability and transparency of physician ratings.

The medical groups already published a study of aggregated claims data of 13,700 Massachusetts physicians treating 1.1 million adults enrolled in four Massachusetts commercial health plans in 2004 and 2005. The study found that a two-tiered rating based on costs would incorrectly classify an estimated 22% of doctors.

When internal medicine was broken out as a specialty, the overall misclassification rate was 25%. Internists whose cost profiles were in the lower 25% of all profiles were designated as "lower cost." 41% of internists were misclassified as lower cost when they shouldn't have been; 14% who should have been, weren't.

Insurers responded that their efforts are fair, and that they are already working on further improvements. (American Medical Association, Rand, Wall Street Journal)

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Stress, burnout are thinning primary care's ranks

This post by ACP Member Kevin Pho, MD, originally appeared on MedPage Today's KevinMD.com.


Do doctors take care of themselves? Sometimes, patients may better follow the advice of physicians that are not obese and don't smoke. That was a question asked in a post last year, entitled, When fat doctors talk to obese patients. According to studies, as reported in the Wall Street Journal, it's a mixed bag: "Physicians as a group are leaner, fitter and live longer than average Americans. Male physicians keep their cholesterol and blood pressure lower. Women doctors are more likely to use hormone-replacement therapy than their patients. Doctors are also less likely to have their own primary care physician--and more apt to abuse prescription drugs."

Clearly, there's room for improvement. One aspect that's often under-reported is the amount of stress that physicians face. It's no secret that burnout among doctors is rising, in part due to the frustrations of practicing medicine compounded by an uncertain health reform environment.

And that's becoming evident with these distressing numbers: "Surgeons surveyed by the American College of Surgeons in 2008 found that only 36% felt their work schedule left enough time for personal and family life, and only 51% would recommend their children pursue a similar career. It's long been known that while physicians have about the same rate of depression as the rest of the population (affecting roughly 14% of male doctors, and 20% of female doctors), physicians are more likely to commit suicide."

Burnout starts early in residency training, and only worsens once physicians graduate. Addressing this head-on, and finding ways to recognize and treat physician stress, will not only help overburdened clinicians, but the patients they treat as well.

This post originally appeared on MedPage Today's KevinMD.com, social media's leading physician voice. Voted best medical blog in 2008, and with over 30,000 subscribers and 22,000 Twitter followers, KevinMD.com is the web's definitive site for influential health commentary.

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Monday, July 19, 2010

How insurance companies help kill primary care

Most doctors have a love/hate (and mainly hate) relationship with health insurance companies. We struggle with their confusing and complex coding rules in an effort to be reimbursed for our care of patients. When patients leave the office, they may think that a bill is sent to their insurance company and payment follows. More often than not it rarely happens that way.

I am staring at an explanation of benefits (EOB) from Blue Shield of California for a patient I saw for a physical exam and Pap test. This patient had recently been hospitalized with a life threatening throat infection and abscess and saw me for needed follow up. I spent about 45 minutes with the patient, reviewing the events leading to hospitalization, coordinating the medications, as well as addressing the routine screening and examination of a middle aged woman with some chronic health problems.

I billed Blue Shield for a 99215 (comprehensive physical) and a G0101 for the Pap test exam and processing. Blue Shield has reimbursed me $25.55 and states the patient owes another $25.56 as a copay. The EOB says they will pay zero ($0) for the exam because "This procedure is included with the payment for the primary procedure."

Yes, they have decided the $51.11 for the Pap test is payment in full for the entire visit. This is called "bundling" the payment and they have chosen to bundle at the smaller amount. The 99000 code for handling of the specimen is denied as "These services are not eligible for separate reimbursement."

Thanks, Blue Shield (annual revenue $9.7 billion). That is one reason only 2% of medical students are going into primary care internal medicine.

Toni Brayer, FACP
Toni Brayer, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

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QD: News Every Day--Medicare payment change hurt care coordination

Eliminating Medicare consultation codes hurt subspecialists' incomes, and also led them to cut back on reports to primary care referring physicians, according to a new survey released by the American Medical Association and dozens of medical societies.

Subspecialists offset revenue losses through cost-cutting measures, including:
--30% cut services to Medicare patients or are contemplating other measures,
--20% have already eliminated or reduced appointments for new Medicare patients,
--39% will defer new equipment purchases,
--34% are cutting staff, including physicians,
--6% stopped providing primary care physicians with a written report, while nearly another 19% plan to stop providing them.

Furthermore:
--95% of infectious disease specialists reported less income, forcing them to lay off staff, reduce time with patients and report less to primary care referring physicians,
--79% of clinical endocrinologists are decreasing the number of Medicare patients or reducing reporting to primary care physicians,
--11% of oncologists plan to close satellite offices, often in remote locations, 14% plan to retire and 30% will eliminate staff.

The AMA and medical specialty societies suggested ways to make the policy more equitable. ACP's position is here.

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Friday, July 16, 2010

QD: News Every Day--federal government targets Medicare fraud

The federal government announced a crackdown on Medicare fraud today, indicting 94 people in five cities. Doctors, nurses, patients, and others in Miami, New York City, Detroit, Houston and Baton Rouge, La., are suspected of such crimes as charging Medicare for nonexistent treatments and buying or selling access to Medicare numbers, USA Today reported. The false claims involved total more than $251 million, the government said. (U.S. Department of Justice, USA Today)

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The best-laid (follow-up) plans

This post by John H. Schumann, FACP, appeared at GlassHospital.

My friend's 92 year-old grandmother goes to see her eye doctor.

"Everything looks great," he reassures her.

"When should I come back?" she wants to know.

"Two years."

Now that's positive thinking.

* * * * *

This funny story raises an interesting question. When should you go back to see the doctor? Turns out like a lot of things in medicine, it's a bit of hocus pocus mixed with tradition. Perhaps with a tiny pinch of scientific evidence thrown in.

If you have no chronic medical problems (e.g. diabetes, high blood pressure, etc.), do you see your doctor once a year?

Should you?

There's debate about the value of annual physicals. I fall clearly into the middle of the road, "Get 'em if you want 'em" camp--but I don't think they're at all mandatory. In my experience, however, there is some clear psychological benefit to people of a certain mindset: Getting an annual physical makes them dutifully able to check something off their list and perhaps allay anxiety for another year.

Ironically, it's usually the healthiest people (i.e. those least in need of medical care) who report for annual physicals. Hmmmm, maybe there's some correlation there.

The extremes of the annual physicals question [from the doctors' camp] are:

  1. Absolutely. It's a great chance to catch up with your patients and discuss new health issues that arise, take advantage of evolving medical science, and achieve age-appropriate preventive care. [Don't call it 'preventative' care.]
  2. Since there's no medical evidence for the annual physical itself (and under current health care financing, it's poorly reimbursed), scrap the idea.

As far as patient viewpoints, there are also two camps:

  1. It's a must. I swear by it, and could tell you about my uncle/cousin/brother/neighbor/fill in the blank who had some horrible thing discovered at his/her annual physical.
  2. I only go to the doctor when something is a tad amiss. "If it ain't broke, don't fix it."

Most experts agree that scientific evidence in favor of physicals is downright skimpy. Nevertheless, research shows that about two-thirds of surveyed adults think there's value in an annual physical with a doctor. This makes it seem as though it's a habit that will die hard. And advocates of behavior change suggest using the annual visit as a means of improving health through diet and exercise--since there's so little time to do that at other visits.

There are a few key evidence-based age appropriate vaccinations and screening tests that are recommended by multiple authorities. To learn about those, you can read about them, or use my colleague Dr. Nundy's online checklist.

Of course, you can always visit the doctor, too. Just don't be put off if we tell you to come back "when you feel like it."



John Henning Schumann is a general internist in Chicago's south side, and an educator at the University of Chicago, where he trains residents and medical students in both internal medicine and medical ethics. He is also faculty co-chair of the university’s human rights program. His blog, GlassHospital, 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 that inhabit them.

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Thursday, July 15, 2010

QD: News Every Day--Avandia can stay, panel says, but with caveats

An FDA advisory panel voted yesterday that Avandia can remain on the market, but recommended further warnings associated with its use. The panel was divided, the New York Times reported, with 12 of 33 members saying the drug should be removed from the market, 10 voting to restrict sales and strengthen the warning label, 7 recommending only strengthening the warning label, and 3 voting for no change. One panel member abstained. (New York Times)

The White House yesterday announced which preventive services would be available at no charge to patients under the new health care legislation. Adult patients who choose a health plan after September 23 will receive mammograms, diabetes screening, and tobacco cessation counseling, among other services, at no increased cost, but insurers have said patients will eventually pay in the form of higher premiums, the Wall Street Journal reported. (Wall Street Journal)

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Wednesday, July 14, 2010

QD: News Every Day--ruling expected today on Avandia

An FDA advisory panel is expected to vote today on whether Avandia should remain on the market. Testimony yesterday offered conflicting evidence, with some FDA experts supporting and others questioning the drug's safety, the Washington Post reported.

The New York Times' public health reporter is live-blogging the FDA panel discussion here. (Washington Post, New York Times)

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Tuesday, July 13, 2010

QD: News Every Day--"meaningful use" defined

CMS issued its much anticipated final rule today on "meaningful use" of electronic health records, laying out what physicians need to do to qualify for federal bonus payments. The Department of Health and Human Services said in a press release that as much as $27 billion in incentive payments could be made over a 10-year period, and that eligible clinicians could earn up to $44,000 through Medicare and $63,750 through Medicaid. To earn bonus payments, clinicians must meet 15 requirements as well as choose an additional 5 of 10 measures on which to report, the New York Times said, a significant change from the draft version of the rule, which would have required physicians to report on 25 fixed measures. Clinicians must also use electronic prescribing for 40% of their prescriptions to qualify for bonus payments, down from 75% in the draft rule, the Times reported. David Blumenthal, FACP, the national coordinator for health information technology, and Marilyn Tavenner, the principal deputy administrator of CMS, co-authored a paper published online today by the New England Journal of Medicine summarizing the final rule. (Office of the Federal Register, Department of Health and Human Services, New York Times, New England Journal of Medicine)

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Monday, July 12, 2010

QD: News Every Day--new research on Alzheimer's disease

Data presented at the International Conference on Alzheimer's Disease in Honolulu this week indicated that exercise and adequate vitamin D levels could help reduce risk for the disorder. Framingham Heart Study researchers found that risk for dementia was halved in "moderate to heavy exercisers" compared with more sedentary people, while researchers on a separate study found that vitamin D deficiency can greatly increase risk for mental impairment.

Another study found that injecting the compound florbetapir into the brain of patients with dementia and then performing a PET scan could help pinpoint the size and location of plaques. Researchers also reported that tea consumption was linked to a slower rate of cognitive decline in older adults without cognitive impairment, but there was no dose response and more studies will need to be done to determine a definitive link. (CBS News, Wall Street Journal, Medscape)

In case you missed it...
The New York Times recently posted a last interview with pioneering gerontologist Robert Butler, MD, who died last week of leukemia at the age of 83.

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Friday, July 9, 2010

A different kind of action movie

Feeling sorry for yourself after a long, hot week of cranky patients and insurance hassles? Maybe a glimpse of someone else's practice will make you feel better. Especially if that doctor is alone in war-torn Africa, treating vast numbers of patients without sufficient equipment and supplies.

The new film "Living in Emergency: Stories of Doctors Without Borders" is not a fun summer flick, but it is a fascinating portrait of the work done by Medecins Sans Frontieres/Doctors Without Borders. The film follows several volunteers (some new, some veteran) through their stints practicing in dramatically underserved and sometimes dangerous areas.

Although the film does seem to be intended to garner support for MSF, it gives a surprisingly nuanced picture of the organization and its members, revealing their flaws (lots of arguments and cigarettes) as well as their heroics. You might want to leave the popcorn and the kids at home, though, as some of the clinical footage is a little grisly.

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Doctor sues patients for lousy online ratings

This post by Toni Brayer, FACP, appeared at Everything Health.


I must say I think Dr. Kimberly Henry, cosmetic surgeon, has made a big professional mistake. She has filed a lawsuit to stop online reviewers from badmouthing her on the Internet. She is seeking injunctions against at least 12 reviewers from sites such as Yelp.com and DoctorScorecard.com. Dr. Henry claims libel and defamation, invasion of privacy and interference with prospective economic advantage and is seeking $1 million in general damages and $1 million in special damages, etc., etc., etc.

Now I don't know Dr. Henry, nor do I know of her plastic surgery technique. I don't know who the disgruntled patients are or if they are unfairly targeting her. What I do know is that the Internet is here to stay and there is no place to hide if you do not provide excellent customer service. I was curious and checked DoctorScorecard.com and there is a brand new complaint placed today, so I don't think this publicity is helping her. It will bring more angry patients out to comment, I'm afraid.

A similar case was filed last year by a dentist in San Francisco, Gelareh Rahbar, who filed a case against a patient who wrote a negative review on Yelp.com. The case was thrown out by the judge and Rahbar was ordered to pay $43,000 for the patient's legal fees. Anti-SLAPP (strategic lawsuits against public participation) laws provide some protection for online commentators as a preservation of free speech.

I wrote about medical rating sites back in 2007 and in 2008 and those posts have proven to be correct. (Reading my old posts is rather interesting and I agree with myself all over again!)

I know some physicians feel it is unfair that angry patients can say whatever they want and there is no rebuttal. But if a surgeon has that many disgruntled patients who would take the time to comment, there might just be a problem. And let's face it, those sites are anonymous and I know of doctors who post their own "good" ratings. It swings both ways.

I feel sorry for Dr. Kimberly Henry because no one likes criticism and public critique is especially hard to swallow. But bringing it even more public with a lawsuit (that may be hard to win!) is just throwing oil on the fire. Better to spend that time and effort satisfying patients and asking them to post great comments to counteract the bad.

Toni Brayer, FACP
Toni Brayer, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

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QD: News Every Day--Privacy, please

HIPAA regulations would apply to billing services, customer service contractors and others who provide services to physician offices under proposed new rules from the Department of Health and Human Services. The proposed rule expands the Health Insurance Portability and Accountability Act of 1996 by:
--expanding individuals’ rights to access their information and to restrict certain types of disclosures of protected health information to health plans,
--requiring business associates of HIPAA-covered entities to follow most of the same rules,
--setting new limitations on the use and disclosure of protected health information for marketing and fundraising, and
--prohibiting the sale of protected health information without patient authorization.

privacy.jpg by jcortell via FlickrThe rule is now open for public comment. The American Health Information Management Association already has chimed in, calling the move vital for patients to trust their electronic health records. David Blumenthal, FACP, HHS’ national coordinator for health information technology, said, "Giving more Americans the ability to access their health information wherever, whenever and in whatever form is a critical first step toward improving our health care system. Empowering Americans with real-time and secure access to the information they need to live healthier lives is paramount."

HHS also launched a privacy website to help the public easily access information about existing HHS privacy efforts and the policies supporting them. The agency is also looking more closely at entities that are not covered by HIPAA rules to learn how they handle personal health information and to determine whether more privacy and security protections are needed.

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Dr. Insurance Broker

This post by Westby Fisher, MD, appeared at Better Health.


Call it sweet, delicious vindication. It was clinic day yesterday. No longer had I completed my rant in this blog about UnitedHealthcare's program to require all cardiac elecrophysiologists to obtain a "notification number" before performing any pacemaker or defibrillator procedure, I discovered my letter from them dated June 3, 2010, on my desk stating that this requirement will begin September 1, 2010, for all Illinois electrophysiologists for "all electrophysiology procedures."

Not longer than an hour later I was seeing a 67-year-old patient in the clinic who asked me: "I just got my Medicare (Part A) card and must decide about which insurer I should use for Part B, C, D, E, and F," he said jokingly. "Since I have the medical problem and might need some care in the future, is there a company you would recommend?"

I sat stunned, relishing my ever-so-brief, influential role. I showed him UnitedHealthcare's letter.

"I'd avoid UnitedHealthcare," I found myself saying, "and any other frontman like AARP that peddles their supplemental insurance products and drains value from your policy."

My new role: Insurance broker.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Thursday, July 8, 2010

91% of physicians fear medical lawsuits

A new study published in the Archives of Internal Medicine shows that 91% of physicians practice defensive medicine to protect themselves from lawsuits. Out of fear of being sued, doctors in all specialties order more tests and procedures than necessary.

The researchers from Mount Sinai School of Medicine questioned 2,416 physicians from a variety of specialties. There were no differences found among geographic location, specialty or type of practice. Almost 93% of male doctors said they practice defensive medicine compared to 86.5% of female physicians. Even doctors in lower risk specialties like general internal medicine and pediatrics had similar fear of being pulled into a lawsuit.

This study reproduces what has been found before in other studies that show more than 20% of X-rays, CT scans, MRIs and ultrasounds are ordered for defensive purposes. Add to that 18% of all lab tests and 28% of all specialty referrals and you have some big bucks.

The solution to this waste is malpractice reform.

Some argue that "tort reform" would not lower medical costs. Others who oppose tort reform say that there is no such thing as an "unnecessary" test because that test could potentially diagnose a condition in someone. It is that type of opinion that is driving up the cost of health care and that type of opinion that makes clinical judgment impossible to defend. But this new study is one of a number that tells a different story. Can 90.7% of physicians be wrong? That percentage of doctors believes that better protections against malpractice lawsuits are needed to decrease the ordering of unnecessary medical tests.

Toni Brayer, FACP

Toni Brayer, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

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QD: News Every Day--You can't possibly forget to take your meds

Normally, the patient calls the pharmacy for a prescription. Now, the prescription is doing that by itself. GlowCaps, a prescription bottle cap made by Vitality, has assumed control for medication compliance.

The bottle cap fits prescription bottles, but has uses cell phone technology to tap into wireless networks. Once connected, the pill bottle does everything imaginable to remind patients to take their pills. There's lights--plenty of them. The bottle cap really does glow and make noise to remind patients. Plug-in units wirelessly connected to the bottle cap can be placed anywhere there's a wall socket. Oh, and it will call you, too, if you forget. The company calls this "Reminders Ramp from Subtle to Insistent." (Add "relentless" to that.)

Ultimately, GlowCaps tallies compliance and sends reports to caregivers and physicians. Not surprisingly, studies show that constant nagging to take one's medications works.

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Wednesday, July 7, 2010

How much do patients value a primary care visit?

This post by ACP Member Kevin Pho, MD, originally appeared on MedPage Today's KevinMD.com.

How much is a primary care appointment worth?

Not much, it appears.

Physicians in California decided to embark on an innovative idea, asking patients to simply pay them what they thought the visit was worth.

Here’s how it worked: On the day of the events, no insurance was accepted. Care was provided only to the uninsured, who were asked to pay what they could afford. Laboratory tests were provided at cost, and patients who needed additional services were referred to various public resources. Practices also handed out lists of generic medications available for reduced prices at large, discount pharmacies. Physicians who accept Medicare are not allowed to include Medicare beneficiaries in any pay-what-you-can program.

Although patients did value the visit, they grossly underestimated its cost. Of course, some paid nothing, others paid as much as $100 for the appointments that lasted from 10 minutes to 1 hour. The bottom line, however, was that none of the doctors were able to financially sustain such a practice for more than a single day.

And therein lies the disconnect between the actual cost of providing primary care and what patients perceive that number to be. Until we better bridge that gap, it’s unlikely that primary care will escape its financial woes anytime soon.

This post originally appeared on MedPage Today's KevinMD.com, social media's leading physician voice. Voted best medical blog in 2008, and with over 30,000 subscribers and 22,000 Twitter followers, KevinMD.com is the web's definitive site for influential health commentary.

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QD: News Every Day--Fewer people are dying from heart attacks, but why?

Heart attack mortality fell by nearly a half a percent last year at 4,500 hospitals that treat Medicare patients. And, facilities with the lowest and highest death rates saw similar declines, according to a new hospital report card by the U.S. Centers for Medicare and Medicaid Services (CMS).

Heart attack mortality fell from a national average of 16.6% last year to 16.2%, with a range among all facilities from 14.5% to 17.9%. CMS released the data as part of its hospital report card effort to spur better quality and outcomes through public reporting of recommended treatments. The agency added heart attack and heart failure mortality to the report card three years ago.

At issue now is what's driving the figures: public reporting of hospital data driving improvement, or faster door-to-balloon treatment times. Areas that do need to improve include lowering readmissions and getting people to the hospital faster when they have a heart attack. (USA Today)

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Tuesday, July 6, 2010

QD: News Every Day--Hospital jobs now half of physician recruiting requests

Hospital-employed physicians make up more than half of all physician recruitment efforts for the first time, reported one national search firm. Of the physician searches tracked in a new survey by Merritt Hawkins, 51% involved hospital employment, up from 45% last year and 23% four years ago.

Also, the firm reported in a survey (which has not yet been released), recruiting has fallen by 14% overall, as tight budgets and real estate pressure inhibit job-search activity.

Merritt Hawkins conducted 2,813 physician recruiting assignments nationwide from April 2009 through March 2010. Family practice continued to be the #1 search, followed by general internal medicine.

Pediatric recruitment has risen, being the seventh most requested assignment this year. In 2005-2006, pediatrics was not in the top 20. Another trend is a rising need for psychiatrists, for whom recruiting is growing faster than for any other medical specialty. The company fielded 179 requests for psychiatrists, up 47% from last year and 121% from three years ago. The same recession that is inhibiting recruiting budgets may be driving the need for mental health services, according to the firm.

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Monday, July 5, 2010

Medical news of the obvious

There's nothing obvious about this new formula for calculating women's peak heart rates. In fact, it sounds pretty useful. But the justification that one author offered was amusingly already-known.

"Women are not small men," she told HealthDay.

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Friday, July 2, 2010

QD: News Every Day--Do the words 'doctor's orders' mean anything anymore?

Why don't people believe their doctors anymore? Studies show that families of critical patients are likely to have more optimistic outlook on a loved one's chance of survival no matter how the doctor delivers the bad news. A study looked at doctors using qualitative phrases, such as "unlikely" chances of survival, compared to quantitative phrases, such as "10% chance" of surviving. Family members kept their hopes up either way.

Yesterday, we reported that patients didn't understand or accept evidence-based medicine. Now, they don't accept their doctor's best advice in end-of-life decisions. But all is not lost. Doctors can still successfully help patients at the end of life and their families through paperwork.

Documenting end-of-life treatment decisions as doctor's medical orders in nursing homes resulted in patients getting the care they wanted and fewer unwanted hospitalizations and interventions, according to a study of 1,711 patients.

The orders, documented as Physicians Orders for Life Sustaining Treatment (POLST), resulted in nursing home residents more often having orders about life-sustaining treatment preferences than residents who didn't (98.0% vs 16.1%, P<.001). Residents with POLST forms for comfort measures only were less likely to receive medical interventions than residents with full treatment orders (P=.004), traditional do-not-resuscitate orders (P<.001) or traditional full code orders (P<.001).

Researchers explained that POLST is more than just paperwork, but is the nexus for a system-wide understanding of patients' wishes that is kept with the patient instead of being filed away. ACP Hospitalist outlines how it works. (Reuters, ACP Internist, Journal of the American Geriatrics Society, Kaiser Health News, ACP Hospitalist)

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Thursday, July 1, 2010

QD: News Every Day--Helping patients understand evidence-based medicine

Doctors trying to help patients understand a course of treatment must teach them new terms such as "medical evidence," "quality guidelines" and "quality standards." Patients might not be willing to accept that language lesson.

A study in Health Affairs concluded that 41% of patients didn't ask questions or tell doctors about problems. The main barriers were that patients didn't know how to talk to doctors, or their physicians seemed rushed. Only 34% of patients recalled physicians discussing medical research in relation to care management.

But, physicians say, that's only half the problem. Sometimes, patients demand to see specialists when they don't really need to. Or, they don't accept it when evidence shows that highly desired treatments aren't the best ones for care. One reason may be that one in three patients believe that more expensive treatments work better than less expensive ones, according the the study in Health Affairs. Once the evidence is laid out, it can be a delicate negotiation to get patients to accept that. (American Medical News, Health Affairs, RangelMD, KevinMD)

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No shows hurt patient care, practice's bottom line

This post by ACP Member Kevin Pho, MD, originally appeared on MedPage Today's KevinMD.com.


No-shows are a problem for both doctors and patients. When a patient misses, or fails to schedule, a follow-up or specialist appointment they are not receiving the care recommended by their doctor.

And for physicians, when a patient no-shows, they're left with an empty appointment space, which can be fiscally damaging in a predominantly fee-for-service payment system.

The Wall Street Journal cites a study on the issue, which "tracked nearly 7,000 primary-care patients age 65 or older ... and discover[ed] that only 71% were ever scheduled for a needed follow-up appointment. Of those, 70% were actually seen at the specialist's office, meaning that just 50% received the treatment that their primary-care doctor intended them to have."

Scheduling an appointment with a specialist can be daunting for the older patient, who can be forgetful, anxious about the appointment, or have transportation issues. These reasons contribute to the fact that missed specialist referrals comprise the biggest source of medical errors.

Computer-based scheduling systems can help, along with automated reminder letters, e-mails or calls. Most small physician practices lack systems to track specialist referrals, which puts them at a disadvantage when compared with large, integrated practices that house both primary care doctors and specialists. Despite the cost of these systems, they should be strongly considered as we work to modernize our antiquated health IT system.

This post originally appeared on MedPage Today's KevinMD.com, social media's leading physician voice. Voted best medical blog in 2008, and with over 30,000 subscribers and 22,000 Twitter followers, KevinMD.com is the web's definitive site for influential health commentary.

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Contact ACP Internist

Send comments to ACP Internist staff at acpinternist@acponline.org.

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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