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

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Friday, October 29, 2010

Improving health literacy by healing the doctor-patient relationship

When it comes to understanding medical information, even the most sophisticated patient may not be "smarter than a fifth grader."

In one of the largest studies of the links between health literacy and poor health outcomes, involving 14,000 patients with type 2 diabetes, researchers at the University of California-San Francisco and Kaiser Permanente found that more than half the patients reported problems learning about their condition and 40% needed help reading medical materials. The patients with limited health literacy were 30-40% more likely to experience hypoglycemia--dangerously low blood sugar that can be caused if medications are not taken as instructed--than those with an adequate understanding of medical information.

Now, federal and state officials are pushing public health professionals, doctors and insurers to simplify the language they use to communicate with the public in patient handouts, medical forms, and health websites. More than two-thirds of the state Medicaid agencies call for health material to be written at a reading level between the fourth and sixth grades.

A new federal program called the Health Literacy Action Plan is promoting simplified language nationwide. And some health insurers, doctors' practices, and hospitals have begun using specialized software that scans documents looking for hard-to-understand words and phrases and suggests plain-English replacements.

More than just giving approachable information, I suggest that doctors have an opportunity to really make a difference in a patient's life by remembering the sacredness of the doctor-patient relationship, true HEALTH literacy. However, a recent study says that hospitalized patients don't even know who their doctor is. The doctor-patient relationship is sick.

Some possible explanations are:
--Patients are stressed while hospitalized and do not remember what is said;
--Many patients are heavily medicated and that affects ability to learn and remember;
--Doctors are too rushed and deliver information too quickly to be understood;
--Hospitalized patients have too many consultants and no one is identified as the "responsible physician;"
--The trend to get patients out of the hospital quickly short changes communication time;
--Nurses, consultants and hospitalists don't communicate well together and the patient gets a different message from each visit; and
--Poor outpatient communication with no physician reimbursement for emails, calls, etc.

There may be many other potential reasons. Everyone in medicine should take a pause to look at this study very carefully because it shows so much room for improvement.

CMS Administrator Dr. Don Berwick eloquently summarized the sacredness of the doctor-patient relationship in his recent Yale Medical School graduation speech:

Congratulations on your achievement today. When you put on your white coat, my dear friends, you become a doctor. You see, today you take a big step into power. With your white coat and your Latin, with your anatomy lesson and your stethoscope, you enter today a life of new and vast privilege. You may not notice your power at first. You will not always feel powerful or privileged--not when you are filling out endless billing forms and swallowing requirements and struggling through hard days of too many tasks.

But this will be true: In return for your years of learning and your dedication to a life of service and your willingness to take an oath to that duty, society will give you access and rights that it gives no one else. Society will allow you to hear secrets from frightened human beings that they are too scared to tell anyone else. Society will permit you to use drugs and instruments that can do great harm as well as great good, and that in the hands of others would be weapons. Society will give you special titles and spaces of privilege, as if you were priests. Society will let you build walls and write rules.

But now I will tell you a secret, a mystery. Those who suffer need you to be something more than a doctor. They need you to be a healer. And to become a healer, you must do something even more difficult than putting your white coat on. You must take your white coat off. You must recover, embrace, and treasure the memory of your shared, frail humanity--of the dignity in each and every soul. When you take off that white coat in the sacred presence of those for whom you will care--in the sacred presence of people just like you--when you take off that white coat, and, tower not over them, but join those you serve, you become a healer in a world of fear of fragmentation that has never needed healing more.


This post by Jennifer Shine Dyer, MD, appeared at Get 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--'Deliciously disgusting' sugar consumption

New York City's war on sugary soft drinks had to balance evidence-based medicine with a short, simple message that would go viral in the community. Going viral won, according to e-mails of internal discussions between the city's health commissioner, his staff, and the ad agency that crafted the campaign. The statement that soda would cause a person to gain 10 pounds a year is contingent upon many factors, argued the staff, but the desire to produce a media message with impact overruled the details. One nutritionist called the campaign "deliciously disgusting."

Chocolate may moderate HDL cholesterol in type 2 diabetics, according to the November issue of Diabetic Medicine. High polyphenol chocolate increased HDL cholesterol in diabetics without affecting weight, insulin resistance or glycemic control. Researchers enrolled 12 type 2 diabetics in a randomized, placebo-controlled double-blind crossover study to 45 g chocolate with or without a high polyphenol content for eight weeks and then crossed over after a four-week washout period. HDL cholesterol increased with high polyphenol chocolate (1.16+/-0.08 vs. 1.26+/-0.08 mmol/l, P=0.05) with a decrease in the total cholesterol: HDL ratio (4.4+/-0.4 vs. 4.1+/-0.4 mmol/l, P=0.04). No changes were seen with the low polyphenol chocolate.

With Halloween coming up, sugar will be on everyone's mind (and in everyone's stomachs.) To find out how many calories and how much fat that pile of Halloween candy totals, try this interactive module. (New York Times, Diabetic Medicine, ABC Chanel 7 News-Denver)

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When I really felt like a doctor

PalMD over at The White Coat Underground recently asked: "When did you really feel like a doctor?" Interesting question that I could answer in a number of ways.

While I didn't know it at the time, I felt like a doctor around 4 a.m. during my first night on call. I was an intern on the hematology ward at Texas Children's Hospital. I was fresh out of medical school, I had chosen a residency known for its mind-boggling volume, and the kids were really sick. I had hit a point where I simply couldn't keep up with what was in front of me. I stole away into the sixth-floor stairwell in the Children's Abercrombie building, put my face into my hands, and began to cry.

My first call night was a metaphor for my career. I had no idea at the time that the idea of simply keeping up would be a theme that would follow me through my training and into my day-to-day work.

While I can't remember the last time I cried at the hospital, I continue to struggle with input. I work to keep up with inbound information and professional social dialog. How I handle information or how I appear to handle it defines me as a physician. Harnessing this attention crash through technology will represent a major defining moment for the next generation of physicians.

This post by Bryan Vartabedian, MD, appeared at Get 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, October 28, 2010

An alarming advance in computerized monitoring

The hospital is never a quiet place. Walk through the wards on a typical day, and you'll hear a cacophony of alarms, bells and other tones coming from both computers and medical equipment.

American Medical News recently discussed so-called "alarm fatigue." They cite a study showing find that "16,934 alarms sounded in [a medical] unit during an 18-day period."

That's astounding, and for those who are wondering, that's about 40 alarms an hour.

It's not surprising that doctors become desensitized to these alarms, and that has potential to harm patients, as physicians may miss legitimate, emergent findings.

Alarm fatigue is also prevalent in electronic medical records. For instance, take drug interactions. Many EMRs aren't sophisticated enough to differentiate between drug interactions that are minor in nature, versus those that are absolute contraindications. The result is a plethora of alarms--not dissimilar to the Window Vista's flawed User Account Control option--which numbs the user due to sheer amount of alerts.

The answer, of course, is to tier alerts. Absolute emergencies should be different from those that are less important. Adding that simple layer of nuance can highlight more critical alerts, thus ensuring more doctors will pay attention to them.

Sadly, it's not a straightforward solution: "Solving the problem requires long-term dedication. Hospitals and their care units must evaluate their needs and develop alarm management plans. Responsibilities should be delegated and staff should be able to tailor alarm defaults for particular units or patients, such as adjusting a monitor alarm for a long-distance runner with a lower heart rate than average."

But it's a problem that's worth tackling, as more clinics and hospitals become reliant on digital equipment.

This post by ACP Member Kevin Pho, MD, 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--It's wicked hard to find a doctor in Boston

Harvard will apply $30 million to fix the "toxic" culture of medical schools toward primary care--it's not "splashy" and it pays less than specialties. Anonymous donors gave the money to found a center for primary care, as well as increase faculty salaries, expand the primary care curriculum, and test new models of providing primary care. Also, the school is looking to hire a "renowned national leader in the field" to head the center.

Harvard's efforts come at a time when half of Massachusetts's doctors aren't accepting new patients. A Massachusetts Medical Society survey reported the wait time for new patients to see an internist is now 53 days. News reports recounted a woman with fever and pains scouring her insurance plan's list of providers, and being told their first openings were December. She wound up in the emergency room, which was able to refer her to a primary care physician. It seems that doctors are likely to be working for hospital-owned practices. (Boston Globe, Massachusetts Medical Society, WCVB-TV)

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Wednesday, October 27, 2010

What makes a good leader? EQ, not IQ

Think your high IQ and mad technical skills make you a great leader? Think again, said J.P. Pawliw-Fry, president of the Institute for Health and Human Potential, during the last keynote session at MGMA's annual conference.

Emotional intelligence is what sets a true leader apart; it is twice as important as IQ and technical skills combined, he said.

"You need a threshold of IQ and tech skills, but that's all. If you've got an IQ of 120, you can be a great leader," Dr. Pawliw-Fry said. "This can be hard to get across to doctors, who are used to being the smartest people in the room. You may be smart and technically astute, but not lead effectively."

Emotional intelligence is marked by the ability to be cool and resilient under pressure; admit your mistakes (which enables others to do likewise, so problems and weak areas within an organization can be openly addressed); listen to others without jumping to conclusions; and, when needed, have difficult conversations where people are held accountable.

That last piece means letting go of the need to have everyone like you. This just isn't possible when you're in charge. "Trying to get everyone to like you is a sign of mediocrity," Dr. Pawliw-Fry said.

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"Obvious" advice that everyone ignores

Having attended several sessions at MGMA's annual meeting this week on how to improve one's practice, I'm struck by how much of the advice seems obvious...but clearly isn't, because people aren't following it.

A session today on Improving Patient Experience recommended that staff be taught to speak politely to patients as they arrive for appointments, tell patients how long they can expect to wait for a doctor in the exam room, and say "Take Care" as patients leave the office after the appointment. Sounds simple, but I have to say, I've yet to experience all three of those during a single appointment (and often, I don't experience any of them).

Other "obvious" tips? Compliment your staff when they do well. If a patient compliments the staff, tell them. Call your waiting room a "reception area" and NOT a "waiting room" (I heard this one in three different sessions). Get patients to write down their questions on a card in advance of entering the exam room, to avoid "hand on the doorknob" moments. Make your staff aware of how you expect them to do their jobs, and then "round" on them once a month--with checklists-- to ensure they are doing it that way. And, of course, hire the right people to begin with.

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QD: News Every Day--Hypertension rates holding steady

About the same percentage of people in the U.S.--30%--had hypertension in 2007-2008 as in 1999-2000, according to data released today by the Centers for Disease Control and Prevention. The rates held study among men and women; all age groups; and whites, blacks and Mexican-Americans.




In addition, a greater percentage of U.S. adults with hypertension were aware of their condition (80.6% vs. 69.6%) and were successfully controlling it (48.4% vs. 30.3%). At the start of the study, 60.2% of patients with hypertension took medication for it; that percentage increased to 73.7% by 2007-2008.

Experts told the Associated Press that hypertension prevalence may be staying stable because obesity rates have been leveling off, and because more people could be fending off the disorder by exercising or by drinking less. However, Sarah Yoon, the report's lead author, pointed out that although percentages didn't increase over the course of the study, the overall number of adults with hypertension did, from approximately 59 million to over 66 million.

"It's nice to see we're making progress with awareness and control, but 30% of a big number is a very big number," Donald Lloyd-Jones, MD, an American Heart Association spokesman and associate professor of medicine and preventive medicine at Northwestern University Feinberg School of Medicine, told the AP. (CDC, Associated Press)

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Quick tips on implementing an EHR

Dr. Jay Anders, the CMO of EHR vendor MED3000, offered a few tips during an MGMA session on implementing an EHR successfully:

  • Make a clear communication pathway. Everyone needs to know what's going on, from the physicians to the receptionist.
  • Clearly identify the needs of every physician who is going to use the EHR. The needs of an internal medicine doctor aren't the same as a dermatologist. Make sure the EHR meets those needs.
  • Get a physician champion for the EHR who will be responsible for talking about the project to peers and answering questions, and be the first person to implement it. Pay that person for his or her time spent in championing duties.
  • Some people need more time than others. Don't let a resistant doctor stop the implementation. Develop a plan for dealing with resisters that includes how you'll respond to negative comments, how to implement other colleagues despite the resister, and how to sell the benefits of the EHR to the resister.
  • Expect the EHR implementation to be time-neutral. Most EHRs don't save time; their value is in improved patient care and documentation, which leads to better reimbursement.

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Tuesday, October 26, 2010

The SGR cut: is this the year it really happens?

Yes, the issue of the SGR cut comes up every year, and the cut always get postponed. But circumstances this year actually are different, said MGMA President and CEO Dr. William Jessee in a press briefing at MGMA's annual meeting.

For one, the 23.6% cut scheduled for Dec. 1 coincides with when the “Dear Doctor” letters about Medicare participation status go out, which hasn’t happened before. Second, the cut is set to occur during a lame duck Congress, whose outgoing members may have a devil-may-care attitude, he noted.

“Congress has been playing kick-the-can with the SGR for a long time,” Dr. Jessee said. “But anyone who thinks (Congress) can’t possibly let the cuts happen this year is smoking some kind of funny weed."

And if the cuts do go through, about half of medical practices say they will stop seeing new Medicare patients, while 28% say they will stop seeing any Medicare patients at all, a new MGMA survey has found. More than half will reduce clinical and administrative staff, and about 45% will put off buying an EHR system, the survey found.

Noting that a second, 6.5% cut is scheduled for Jan. 1, Dr. Jessee concluded: "The holidays are going to be an interesting year for those of us in healthcare."

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QD: News Every Day--Doctors unhappy with Medicare cuts, but can't agree how to fix them

More than two-thirds of doctors will cap the number of Medicare patients they accept if Congress doesn't prevent reimbursement cuts that will take effect Dec. 1. But while doctors don't like how Medicare's reimbursement rates get set, they don't agree on how to permanently fix it.

The Medical Group Management Association reported that 67.2% of medical practices are likely to limit their Medicare populations. Nearly half (49.5%) will stop seeing new Medicare patients and more than one-fourth (27.5%) will stop treating all Medicare patients.

MGMA also reported:
--76.6% will likely delay buying new clinical equipment and/or facilities,
--60.5% will likely reduce administrative support staff,
--54.0% will likely reduce clinical staff, and
--45.3% will likely delay buying electronic health record systems.

Physicians face a 23.6% cut on Dec. 1 and another 6.5% on Jan. 1, or a cumulative 30.1%. If this sounds familiar, it was just in June when Congress failed to prevent cuts from occurring. Although they retroactively paid physicians in full, the consequences included:
--29.5% of practices began reducing the number of appointments for new Medicare patients,
--37.3% delayed buying electronic health record systems,
--31.7% cut administrative staff, and
--27.5% cut clinical staff.

While doctors are reacting now to potential cuts in December, they don't agree how to permanently fix Medicare reimbursement.

Researchers reported survey results ranking several reimbursement reform proposals. Researchers mailed 6,000 surveys to doctors randomly chosen from the American Medical Associations Physician Masterfile. The questionnaire asked doctors to rank rewarding quality with financial incentives, bundling payments for episodes of care, shifting payments from procedures to management and counseling services, increasing pay to generalists, and offsetting increased pay to generalists with a reduction in pay for other specialties. Results appeared in the Archives of Internal Medicine.

Incentives were the most frequently supported reform option (49.1%), followed by shifting payments (41.6%) and bundling (17.2%). Generalists more often supported shifting payments than did specialists. While there was broad support to increase generalists' pay, only 39.1% of physicians supported a proposal to offset the increase with a 3% reduction in specialist reimbursement.

The driving factor was not at all surprising. It's practically common sense. Researchers wrote in their conclusion, "Overall, physicians seem to be opposed to reforms that risk lowering their incomes." A 30% cumulative pay cut for 2011 qualifies as exactly that.

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Making nice

Over the summer, a couple of news stories stood out to me as examples of lemons and lemonade. First, the prix du citron:

Tony Hayward of BP, after his company's oil rig 'malfunctioned' and poured millions of barrels of oil into the Gulf of Mexico. He had a few choice doozies. You probably remember: "The Gulf of Mexico is a very big ocean. The amount of volume of oil and dispersant we are putting into it is tiny in relation to the total water volume."

Free lemonade by Rochelle et al via FlickrNow technically, he was correct. But emotionally, he couldn't have been more wrong. His comment made him appear like a callous and unsympathetic weasel.

A bit later, when the heat from the spill and the negative media attention were at their height, he was quoted as saying: "There's no one who wants this thing over more than I do. I'd like my life back."

Oh, really? Listen bub, nobody whose life has been affected by the oil leak wants to hear about your needs. Can you say TONE DEAF?

A few days later, when spotted watching his yacht in a race, it was clear the man himself had become too toxic to stay at the helm of BP.

Example #2: Another summer media kerfuffle, a kind of strange one, that showed a way of making lemonade out of a real stinkbomb lemon.

Remember Shirley Sherrod, the career USDA employee who became ensnared in an out-of-context webinoma (I just made that up: a cancerous internet situation)? Two minutes of 30-plus minute speech were taken out of context in a way that made her appear racist. The public outcry led to her firing before anyone had a chance to review the evidence and learn the full story.

After learning that they had been snookered by the slanted portrayal of Sherrod, federal officials backtracked from their criticism and offered her a promotion, handling outreach and advocacy and addressing issues of race both in and outside the agency.

From my vantage point, even beyond getting her job back, it was President Obama's phone call to her that really started to turn the sour sweet. They spoke for seven minutes, and Obama didn't specifically apologize. But he expressed empathy, and asked her to continue her work on behalf of the agency and the federal government.

This was a classic example of "making nice." Using the ol' telephone to reach out and work through a problem or redress a concern.

I'd love to hear your stories of people doing you wrong and then making it right. Or doing you wrong and just leaving it that way. How did it make you feel? What would you have liked to hear?

In medical care, there's growing evidence that making nice is a win-win. Patients win because when they feel wronged, someone is validating their concerns and offering those simple little words: "I'm sorry." The evidence shows that it saves money on the hospital's side: Less anger means fewer lawsuits and claims of damages.

Nothing wrong with a win-win in my book.

This post by John H. Schumann, FACP, originally appeared at GlassHospital. Dr. 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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Monday, October 25, 2010

QD: News Every Day--Nurse anesthetists gaining ground for unsupervised practice

New Jersey's state health department is considering a rule that would allow nurse anesthetists to work without a doctor's supervision, as long as there's a plan to reach one in case of an emergency.

New Jersey would join the 30 states that allow nurse anesthetists to work without direct supervision.

On the other end of the country, a California court upheld the state's decision to opt out of a Medicare requirement that doctors be present while a nurse anesthetist works in order to be reimbursed. The Centers for Medicare and Medicaid services have allowed states to opt out of that requirement since 2001.

Since then, there has been no evidence of increased inpatient deaths or complications, researchers reported in the August 2010 issue of Health Affairs. Earlier this month, the Institute of Medicine reported that nurses should have a larger role in medical care, including anesthesiology.

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Friday, October 22, 2010

Why comparing the performance of doctors is trouble

Who do you think is likely to be a better doctor: A board-certified graduate of one of the top medical schools in America, or a non-certified doctor trained in a foreign country?

If your answer is "I have absolutely no idea," then you're probably spending a lot of time looking at the "report cards" that pass for measures of health care quality. And you're probably confused.

Researchers in Pittsburgh studied 124 process-based quality measures in 30 clinical areas. These process measures are the state-of-the-art ways in which government and private insurers are checking up on the quality of medical care. They include things like making sure patients with heart problems are prescribed aspirin, and that women get Pap smears. The researchers compared these measures against other, simpler measures, like medical education, board certification, malpractice claim payments, and disciplinary actions.

The result? You couldn't tell the differences among doctors.

From the Archives of Internal Medicine:

For example, the average board-certified, U.S.-trained female physician scored only 5.9% better on performance measures than a noncertified, foreign trained male doctor. There were no statistically significant quality differences when comparing physicians who made malpractice claim payments versus those with no such record. Doctors who graduated from medical schools ranked in the top 10 by
U.S. News and World Report scored no better on the quality measures than physicians who did not.

Surprisingly, the Pittsburgh researchers saw this as good news. The problem, in their view, wasn't that the quality metrics don't make sense ... it's that things like being highly educated and well-trained don't actually matter that much. I'm serious. According to the co-author of the study:

You can feel secure in the fact that some of these varied demographic characteristics that are used to judge one physician from another don't matter much in the end.

Well, okay then.

If it sounds familiar, it's because the same thing is going on with hospital quality measures. Using the government's quality measures, you can't tell the difference between a major academic medical center and a local community hospital.

So what's going on here?

As well-intentioned as these quality measures may be, they veer so drastically from experience that doctors are starting to ignore and resent them. Danielle Ofri, FACP, writing in the New England Journal of Medicine says these measures:

"... purport[] to make a statement about comparative quality whose objectivity is a fallacy…By and large it serves only to demoralize doctors. It offers patients a seductively scientific metric of doctors' performance-- but can easily lead them astray ... Doctors who actually practice medicine--as opposed to those who develop many of these benchmarks-- know that these statistics cannot possibly capture the totality of what it means to take good care of your patients. They merely measure what is easy to measure.

And so if the goal of these measures is to improve the quality of care, they're missing the mark. Doctors will tell you that the biggest challenge they face in delivering quality care is the fact that they have to see 40 patients a day, spending 15 minutes with each one. Checklists and report cards continue the systematic devaluation of the thinking, reflecting and deciding aspects of medicine. So instead, why not start with what really matters: The time doctors spend with their patients. If you ask Dr. Ofri, "What would definitely improve the quality of your patients' care?," she will tell you: "An hour-long visit instead of 15 minutes."

This post by Evan Falchuk, JD, appeared at Get 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--Worst-case scenario projects one-third of adults will have diabetes by 2050

As much as a third of the U.S. population could have diabetes by 2050, much of it related to poor lifestyle, the Centers for Disease Control and Prevention reported in the journal Population Health Metrics.

The authors laid out projected growth this way: New cases will increase from about eight cases per 1,000 in 2008 to about 15 in 2050. Assuming low incidence and relatively high diabetes mortality, total diabetes prevalence of diagnosed and undiagnosed cases is projected to increase from 14% in 2010 to 21% of adults by 2050.

The worst-case scenario is that recent increases in diabetes incidence continue and diabetes mortality is relatively low, driving prevalence to 33% by 2050. A middle-ground scenario projects a prevalence of 25% to 28% by 2050.

The newer, bleaker figures are based on newer census figures that account for an aging population, rising minority and immigrant populations that are at higher risk, as well as for the prevalence of pre-diabetes in the U.S. population. About one in four Americans have pre-diabetes, although only one in 20 know it. Also, the good news that fewer people are dying from diabetes is also the bad news, since this factors into the higher prevalence as well.

The CDC estimates the current cost of diabetes at $174 billion annually, which could double in the next 20 years, the American Diabetes Association's chief medical officer told USA Today.

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The miners' tale: A story of health care delivered

Last week it seemed half the world was captivated by the story of the Chilean miners. The 33 men--mainly middle-aged and of modest means--zoomed up in high-tech capsules from the deep, would-be tomb where they'd been waiting for 69 days underground in the southern Atacama, not far from the industrial, northern Chilean city of Copiapo.

The amazing and nearly-too-good-to-be true news was that a top-notch team of engineers, doctors including the NASA/Johnson Space Center Deputy Chief Medical Officer, nurses, psychologists and others pulled off this fantastic rescue by which each and every one of these real men were delivered to Camp Hope (Esperanza) a tent city swelling with media and enthusiastic politicians, clergy, miners' families and, presumably, support staff--cooks, washers and others who helped people there cope with the situation.

It's inconceivable that any human with a heart would not be gladdened upon learning of the miners' safe arrival--all more-or-less in good shape, no less--on firm ground.

A rabbi said this of the affair: "We too-often take this world for granted; but after their ordeal in the darkness, the Chilean men kissed the earth and thanked god for simply returning them to what they'd had before--a place filled with sunlight, air, loved ones, friends, food, music and, well, everything they had and have again. So there's a religious message here, if you're open to that."

At the same time, an atheist would see clear evidence in this fantastic episode for the power of humans and science, technology and coordinating resources.

The medical issues are rich, including: risk of fatigue and dehydration in an inescapable, 90-degree, hot and humid environment; vitamin deficiency and possible eye damage upon exiting, from lack of sunlight; lung problems from metal dust exposure; infections like pneumonia, potentially shared in a small communal space or gut-related, if hygiene is poor and human waste is not stashed properly; emotional downers--like fear and depression--may affect men who don't articulate those sorts of concerns.

Some environmentally-minded thinkers point out that this true tale isn't representative, reducing the story like this: "For every miner who was rescued before the cameras this week, more than 400 others will die this year." Indeed, the International Federation of Chemical, Energy, Mine and General Workers' Unions, estimates that, worldwide, approximately 12,000 miners will lose their lives this year while on the job. They're right, I know--mining is a risky, under-regulated occupation.

Nonetheless, I'm thrilled by this remarkable story, at two levels: first, that the "patients" are all right, and second--what's even more awesome--is that people around the world cared so much about the miners' well-being.

I've been wondering what if the outcome hadn't been so successful. The news coverage would have been less intense, and the President of Chile would have had more difficulty maintaining his political position, and maybe there'd be more regulation of copper-mining in the future. Still, it would have been OK, good and maybe great, I think--even without the happy ending--that the engineers and international top-docs with their expertise, and miners' families and lovers' with their food and good cheer, did everything they could. The outcome matters, but so does the effort, in itself.

If we don't as much as offer care to humans who need it, there's little chance they'll get better. This news is about health care, delivered.

So the next, logical question is this: Can we take this up to another level by providing high-quality, coordinated care to every group of 33 patients with a guarded prognosis, and do whatever it takes to make them well using existent technology and medicines?

This story is a fantasy, as much as it's real.

This post originally appeared at Medical Lessons, written by Elaine Schattner, ACP Member, a nonpracticing hematologist and oncologist who teaches at Weill Cornell Medical College, where she is a Clinical Associate Professor of Medicine. She 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.

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Thursday, October 21, 2010

High-dose flu vaccine for older adults

Dr. Novella has recently written about this year's seasonal flu vaccine and Dr. Crislip has reviewed the evidence for flu vaccine efficacy. There's one little wrinkle that they didn't address, one that I'm more attuned to because I'm older than they are.

I got my Medicare card last summer, so I am now officially one of the "elderly." A recent review by Goodwin et al. showed that the antibody response to flu vaccines is significantly lower in the elderly. They called for a more immunogenic vaccine formulation for that age group. My age group. One manufacturer has responded.

Fluzone High-Dose vaccine contains 60 mcg of hemagglutinin antigen from each strain, compared to 15 mcg in the standard dose vaccine. This high-dose preparation has been tested in three clinical studies (here, here, and here) of 4,453 healthy people aged 65 years and older. In each of these studies the high-dose vaccine produced significantly higher antibody levels than the standard dose vaccine. There was a dose-related increase in minor local side effects (arm pain, redness and swelling at the injection site), but no increase in serious adverse effects. Most recipients had minimal or no adverse effects.

We don't yet have data to prove that the increase in antibody titers will result in fewer clinical influenza illnesses and complications, but it seems logical that it would. A study comparing the effectiveness of Fluzone High-Dose to Fluzone is expected to be completed in 2012. The high-dose vaccine is more expensive, but Medicare pays for it.

The Medical Letter recently covered the 2010-2011 flu vaccines and did not recommend (or advise against) the high-dose formulation for older patients, because the clinical efficacy data are not yet available. Neither the CDC nor the ACIP has been willing to express a preference for one vaccine over another at this time. I asked our own infectious disease expert, Dr. Crislip, and he recommends the high-dose in view of its improved immunogenicity and biological plausibility.

I'm 65 and my husband is older: We opted for the high-dose vaccine. Not everyone will agree, but shouldn't older patients be given the facts and the option?

This post by Harriet Hall, MD, appeared at Get 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--Teen pregnancy decline has probably bottomed out

Teen pregnancy rates have declined, but likely bottomed out, according to a report by the Centers for Disease Control and Prevention.

Teen births dropped by a third between 1990 to 2005, but rose again in 2006 and 2007. The latest figures for 2008 show a decline of 2.4%, to 41.5 pregnancies per 1,000 teenagers. Experts told My Health News Daily/MSNBC the dropping rates have bottomed out, and that new strategies are needed to deglamorize teen pregnancy.

Teen birth rates were consistently highest in states across the South and Southwest, and lowest in the Northeast and upper Midwest. In 2008, state-specific teenage birth rates varied widely, from less than 25.0 per 1,000 15-19 year olds (Connecticut, Massachusetts, New Hampshire, and Vermont), to more than 60.0 per 1,000 (Arkansas, Mississippi, New Mexico, Oklahoma, and Texas).

Mathews TJ, Sutton PD, Hamilton BE, Ventura SJ. State disparities in teenage birth rates in the United States. NCHS data brief, no 46. Hyattsville, MD: National Center for Health Statistics. 2010.Historically, birth rates have been higher for Hispanic and non-Hispanic black teenagers than for non-Hispanic white teenagers. Thus, states with large proportions of Hispanic or non-Hispanic black teenagers would be expected to have higher overall teenage birth rates.

But there were exceptions, CDC experts noted. Birth rates for non-Hispanic white, non-Hispanic black, and Hispanic teenagers are all uniformly higher in the Southeast and lower in the Northeast and California. Birth rates for non-Hispanic white, non-Hispanic black, and Hispanic teenagers in California, New York, and New Jersey are among the 10 lowest state-specific rates for each of these population groups.

States in the upper Midwest exhibit a different pattern. Rates for non-Hispanic black teenagers in the upper Midwest are uniquely among the 10 highest rates of all states. In contrast, in the same upper Midwestern states, birth rates for non-Hispanic white teenagers are generally significantly lower than the overall U.S.

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Wednesday, October 20, 2010

QD: News Every Day--Chemotherapy, reimbursement and the law of unintended consequences

A private insurer has launched its first pilot into bundled payments for chemotherapy, offering to pay oncologists a lump sum for each patient’s total course of chemotherapy for breast, lung and colon cancer. The payment is based on regimens drawn up by the doctors themselves--based on what the insurer was paying the doctors under the old rules--plus a case management fee.

The goal is to encourage doctors to use standard chemotherapy regimens instead of more expensive and sometimes unproven regimens that garner more reimbursement.

Photo by Rhoda Baer/National Cancer InstituteThe pilot project involved oncologists in five practices located across the country will compare patient outcomes such as emergency room visits, side effects and outcomes for each type of cancer. Results will be evaluated annually, and if successful will be applied not only to more oncologists, but to other fields such as rheumatology.

All eyes are on the new reimbursement method, as insurers, oncologists and cancer-advocacy groups from all parts of the health care spectrum balance the issues of reimbursement, rising health care costs and evidence-based medicine.

But can payers influence physician prescribing habits? Earlier this year, ACP InternistWeekly reported that doctors adapted to cuts in Medicare reimbursement by changing which drugs they used to treat lung cancer patients. Following changes in Medicare reimbursement in 2005, doctors switched from drugs that experienced the largest losses in their profit margin, carboplatin and paclitaxel, to one that didn't, docetaxel. The lump sum incentive would fix that one aspect, but the law of unintended consequences still presents itself, time and time again. (Kaiser Health News, New York Times, ACP InternistWeekly)

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Doctor, patient, friend: Blurring the boundaries

"I would be careful," a fellow physician cautioned, as I told of my plans to attend a patient's birthday party. In my 12 years of clinical practice I have lived in the community in which I practice, less than two miles from my office. I encounter patients daily in the supermarket, at soccer games, swim meets and school events. I have had conversations with patients at parties, on the street and while half-dressed in the locker room. With my foray into social networking, beginning with participation in Facebook in 2008, I have "friended" my patients in cyberspace. As such, I have allowed patients to know details of my personal life and beliefs. They inquire about my family and are aware of my hobbies and interests. Perhaps against my better judgment, we have talked politics and health reform. But what are the appropriate boundaries?

Clearly the doctor-patient relationship is a highly privileged one, in which private and confidential information is exchanged. The communication that occurs within this context is subject to unique rules, ethical, and legal boundaries, as described by the Health Insurance Portability and Accountability Act (HIPAA). Patients share information with their doctors that they would not share with a friend, a neighbor, a fellow school committee member or another soccer parent. Should a doctor back away from a blurring of these boundaries?

Online social networking has introduced new aspects to this old question. Dr. Sachin Jain expresses it well in a New England Journal of Medicine Perspective piece: "The anxiety I felt about crossing boundaries is an old problem in clinical medicine, but it has taken a different shape as it has migrated to this new medium." Whether or not physicians should engage in relationships with patients within the context of sites such as Facebook or Twitter is a matter of ongoing discussion.

One blogger, Dr. Bryan Vartabedian, suggested that physicians might take the following precautionary measures to avoid trouble:

1. Have an offline discussion with patients who contact you via social networking regarding the confidentiality and privacy issues inherent in communicating in this manner.
2. Discuss with patients the need to document doctor-patient communication in the medical record.
3. Develop a personal social media policy to govern your interactions with patients via the internet and social networking sites.

These measures seem prudent to me.

Others have advocated that physician-users of Facebook have two pages, one personal and one professional. Those same physicians might hesitate to have coffee or dinner with a patient. Clearly Facebook and Twitter are never appropriate sites for discussing the details of an individual's health or other information that could possibly be privileged and identifiable. Patients need to be aware that tweets show up on Google searches. Does this mean I shouldn't enjoy seeing pictures of a patient and her family, or getting to know her better through her status updates, sense of humor, likes and dislikes? In contrast, I believe that through this type of sharing the doctor-patient bond can be strengthened and trust enhanced. My view is that allowing some blending of doctor-patient-friend roles is likely to enhance the individualized advice that I am able to give my patients about their health problems.

With proposed changes to our primary care delivery model, "the patient-centered medical home," we are looking at using electronic systems to care for populations of patients in part to compensate for inadequate numbers of primary care physicians. The proposed model would enlist care teams, including a single physician, to provide care for up to 5,000 patients (most primary care physicians currently care for two to three thousand). A system of automatic reminders, feedback on quality indicators, and decision support tools would ensure high quality care in this idealized model. But what happens to the doctor-patient relationship? So I say, let's not be so stymied by legalism that we are afraid to befriend our patients.

Juliet K. Mavromatis, FACP, is a primary care physician in Atlanta, Ga. Previous to her primary care practice, she served on the general internal medicine faculty of Emory University, where she practiced clinical medicine and taught internal medicine residents for 12 years, and led initiatives to improve the quality of care for patients with diabetes. This work fostered an interest in innovative models of primary care delivery. Her blog, DrDialogue, acts as a conversation about health topics for patients and health professionals. This post originally appeared there.

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Tuesday, October 19, 2010

The checklist and future culture of medicine

Like many New Yorkers, I learned about the checklist in a magazine. I remember thinking, in late 2007, that maybe I'd seen something on the subject in The New England Journal. Indeed, a year earlier Dr. Peter Pronovost and colleagues reported on a simple, inexpensive strategy to save lives in a now-landmark article, "An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU." Still, I'd missed the paper. Or at least I'd overlooked the significance.

Fortunately I had the opportunity to hear Pronovost, a still-youngish professor at Johns Hopkins and recent MacArthur award recipient, speak at last spring's annual meeting of the Association of Health Care Journalists in Chicago. After hearing his talk, I couldn't wait to read more.

The checklist refers to five steps doctors can take to reduce the likelihood of patients getting serious infections from catheters placed in the ICU. One problem with Pronovost's quintet is that it's, well, unexciting. In his book Safe Patients, Smart Hospitals he reveals what a person shouldn't forget before inserting an intravenous (IV) tube through a vein to the heart's entryway:

1. Wash hands with something like soap before the procedure;
2. Set up a clean work area by covering the patient with a sterile drape and donning a gown, cap, mask and sterile gloves;
3. Insert the catheter in a place other than the patient's groin, if possible;
4. Wipe down the patient's skin with antiseptic fluid, chlorhexidine;
5. Remove catheters that are no longer needed.

Pronovost, an intensive care specialist who holds an MD and a PhD in Public Health, first tested the checklist on his home turf, the surgical ICU at the Johns Hopkins Hospital in Baltimore, Md., in 2001. At the start, he distributed the list and asked ICU staff nurses to mark physicians' compliance. It turned out the doctors skipped at least one step in over a third of central catheter placements. Next, he upped the list's power by talking to Hopkins administrators. Nurses, they said, could call out a physician if they didn't stick to the rules.

"This was revolutionary," said Atul Gawande in the New Yorker.

What's the big deal, you may wonder. It's this: First, in the usual culture of medical practice, doctors don't follow orders but give orders. And second, what's implicit in the checklist is that physicians--even at one of the world's most renowned medical facilities--are fallible to such a degree that their work can improve, and measurably so, by using something as ordinary as a checklist. It's humbling.

"We don't use checklists in health care because we still have this myth of perfection," Pronovost said at the journalism conference.

In the year after Pronovost's team implemented the checklist at Johns Hopkins, the rate of central catheter infections there dropped from 11% to zero. As for how much good this did, the estimate runs at 43 infections spared, eight deaths avoided and $2 million saved in one year at that hospital alone. The work expanded, soon to cover ICUs in most hospitals in the state of Michigan. There, after a lot of fuss, administrative hurdles and number crunching of results for some 375,757 catheter-days worth of infection data, the incidence of central line-associated bacterial infections snapped from 2.7, on average, for every 1,000 days a patient was in a Michigan ICU with at least one central line, down to 0 (zero!).

These numbers are supported by impressive stats, with P values falling below 0.002 in the original study. Estimates for the Keystone Initiative render some 1,000 lives saved and $175 million in hospital costs reduced in a single year in Michigan. What's more, all of this was accomplished without the use of expensive technology or additional ICU staffing.

This is a win/win intervention with huge implications. Every day some 90,000 people receive care in ICUs in North America. The annual incidence of catheter-related blood infections is 80,000 per year in the U.S.; the cost of treating each line infection runs around $45,000. In the U.S., we might save over $3 billion in expenses per year.

So why aren't more hospitals and states adopting these and other, similar measures? Gawande addresses this, to some extent, in the New Yorker piece and in his book, The Checklist Manifesto. "There are hundreds, perhaps thousands, of things doctors do that are at least as dangerous and prone to human failure as putting central lines into ICU patients," he writes. "All have steps that are worth putting on a checklist and testing in routine care. The question still unanswered is whether medical culture will embrace the opportunity."

Poka-yoke, a Japanese term for rendering a repetitive process mistake-proof, may be familiar to business students and corporate executives. This concept, that simple strategies can reduce errors in highly complex works, is not the kind of thing most doctors pick up in med school. Rather, it remains foreign.

Pronovost is unusual because he examines health care delivery, in itself, rather than attempting an innovative cure for cancer or surgical method. His work just isn't sexy enough to sell. I suspect that's the reason he came to the health care journalism conference in Chicago and gave such an impassioned talk about the checklist, so that a few of us might help get the word out.

Things change, after all, and sometimes they do get better.

This post originally appeared at Medical Lessons, written by Elaine Schattner, ACP Member, a non-practicing hematologist and oncologist who teaches at Weill Cornell Medical College, where she is a Clinical Associate Professor of Medicine. She 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.

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QD: News Every Day--Prescriptions on the rise, so look out for the side effects

88% of Americans 60 or older take at least one prescription drug and more than two-thirds of this age group take five or more, according to a report by the National Center for Health Statistics. Spending for prescription drugs totaled $234.1 billion in 2008, more than double what was spent in 1999.

The National Center for Health Statistics excerpted elements of its National Health and Nutrition Examination Surveys to prepare the report.

Gu Q, Dillon CF, Burt VL. Prescription drug use continues to increase: U.S. prescription drug data for 2007-2008. NCHS data brief, no 42. Hyattsville, MD: National Center for Health Statistics. 2010.Other key findings include:
--Over the last 10 years, the percentage of Americans who took at least one prescription drug in the past month increased from 44% to 48%. The use of two or more drugs increased from 25% to 31%. The use of five or more drugs increased from 6% to 11%.
--Those who were without a regular place for health care, health insurance or prescription drug benefit used fewer prescription drugs.
--The most commonly used types of drugs included: asthma medicines for children, central nervous system stimulants for adolescents, antidepressants for middle-aged adults, and cholesterol-lowering drugs for older Americans.

But, no drug is without consequences, and those very popular cholesterol medications may have serious side effects such as memory loss.

And if one of those prescription drugs happens to be an opioid, the American Society of Interventional Pain Physicians has called for increased training for prescribers.

According to a recent report from the Centers for Disease Control and Prevention, deaths caused by opioid analgesics more than tripled between 1999 and 2006. More than 40,000 Americans die each year of prescription overdose, and in some states opioids cause more deaths among young people than motor vehicle accidents.

ASIPP has issued prescribing guidelines.

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Public health should be apolitical

You can be for freedom. You can be for smaller government that intrudes less. You can be for lower taxes. You can be for most anything, but if you're interested in improving the sagging health of American citizens, get on Michael Bloomberg's wheel.

As reported in the Wall Street Journal, New York City Mayor Michael Bloomberg has asked the U.S. Department of Agriculture to bar city residents from using food stamps to buy sugary soft drinks. It turns out that last year $135 million in food stamp money was used for the consumption of these obesity-fostering beverages in NYC alone.

Mr. Bloomberg is morphing into a real-world public health super star. Previously, he was a pioneer in banning smoking in restaurants and bars. They said it could not be done, or that it wouldn't work. Well, the naysayers were dead wrong. Now public smoking bans are commonplace and, backed by objective data, are accepted as having prevented thousands of heart attacks.

More recently, Mr. Bloomberg has championed a ban on the use of inflammatory and artery-toxic trans fats in city restaurants. Although trans fats bans have found traction harder to come by, my guess is that similarly favorable data will be forthcoming.

To the cynics and naysayers that feel government should not tell us how to live, I say: "Don't overthink this one." Being against government-sponsored soda consumption is a no-brainer. Public health should be apolitical.

All can surely agree that an advanced and kind society should have safety nets for those less endowed by nature and nurture. But we should also find common ground on the idea that the safety net shouldn't be dangerous to those it's supposed to help. No one is suggesting that soda be banned, rather just not state-supported.

I'm with Mr. Bloomberg, strongly. And being so isn't mean.

JMM

[Disclosure: I love Coke. An edited excerpt from the above post: "In the heat of the summer, immediately after a hard training ride or life force-sapping bike race, there are few more pleasurable ways to replete the hollowness of glycogen depletion than an ice-cold Coke."]

This post by John Mandrola, MD, appeared at Get 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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Monday, October 18, 2010

QD: News Every Day--Eight common HPV types tied to cervical cancer

Researchers have identified the six types of human papilloma virus (HPV) that cause 91% of global cervical cancer, and now suggest that research focus on these genotypes.

Researchers sampled histologically confirmed cases of invasive cervical cancer from a global population from 38 countries, the largest study ever conducted. Results were reported in The Lancet.

The study looked at 10,575 cases of invasive cervical cancer, of which 8,977 (85%) were linked to HPV. The most common types were 16, 18, 31, 33, 35, 45, 52, and 58, which in total were linked to 8,196 of 8,977 (91%; 95% confidence interval [CI], 90-92%) incidents of cervical cancer.

HPV types 16 and 18 were detected in 6,357 of 8,977 cases (71%; 95% CI, 70-72%) of invasive cervical cancer. HPV types 16, 18 and 45 were detected in 443 of 470 cases (94%; 95% CI, 92-96%) of cervical adenocarcinomas. Women with invasive cervical cancers related to HPV types 16, 18, or 45 presented at a younger mean age.

Researchers reported in The Lancet that "HPV types 16, 18, 31, 33, 35, 45, 52, and 58 should be given priority when the cross-protective effects of current vaccines are assessed, and for formulation of recommendations for the use of second-generation polyvalent HPV vaccines. Our results also suggest that type-specific high-risk HPV-DNA-based screening tests and protocols should focus on HPV types 16, 18, and 45."

Reuters reported that while wealthier nations have started HPV vaccination programs, more than 80% of cervical cancers occur in developing countries that would benefit from second-generation drugs.

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Friday, October 15, 2010

QD: News Every Day--Medical liability costs continue to rise

Hospitals and physicians should prepare for increasing liability costs, according to an analysis by a risk management firm. There are more claims made, growing 1% annually, and their severity is growing 4% annually.

Hospitals are expected to face more than 44,000 claims from incidents that occurred in 2009, according to the report, with anticipated costs exceeding $8.6 billion. Obstetrics and the emergency department comprise nearly one-fourth of claims, adding more than $1.4 billion and $1 billion respectively to overall liability costs. For accidents occurring in 2010, hospitals should expect to incur $204 per birth for liability costs associated with obstetrics claims and $6.30 per visit for emergency department claims.

Loss rates, which measure the total cost of medical malpractice claims per hospital bed, could grow 5% annually. In 2011, hospitals are expected to experience a rate of $3,280, a $150 increase from 2010’s expected rate of $3,130 and a $300 increase from 2009’s rate of $2,980.

Another change is that, from 2005 to 2009, the average number of employed physicians per hospital bed increased 12% annually. Claims costs will likely shift from physician liability to hospital liability.

Also, from 2000 to 2006, tort reforms, patient safety initiatives and sympathetic public attitudes helped reduce medical malpractice costs, the report noted. Today, tort reform is waning and existing tort reforms face serious legal challenges in several states.

"The uncertainties of health care reform and difficult economic times represent significant sources of risk for many hospital systems," said Erik Johnson, an actuary and author of the analysis, in a press release. "While many hospitals have grown accustomed to declining professional liability costs, the underlying claim frequency and severity cost drivers have entered a period of growth. Whether commercially insured or self-insured, hospitals and physicians should prepare for increases to their professional liability costs in the coming years."

The 2010 Hospital Professional Liability and Physician Liability Benchmark Analysis was conducted by Aon Risk Solutions, in conjunction with the American Society for Healthcare Risk Management. The analysis includes 119 hospital systems and more than 1,800 facilities representing 23% of the total U.S. hospital industry.

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Thursday, October 14, 2010

QD: News Every Day--Drop in vaccination rates linked to autism fears

The belief that vaccines are linked to autism is hurting kids by causing an alarming drop in vaccination rates, according to a report by the National Committee on Quality Assurance (NCQA). Vaccination rates declined by almost 4% among children covered by private insurance, while it actually improved among Medicaid enrollees for DTAP/DT, hepatitis B, HIB, MMR, IPV and pneumococcal conjugate.

NCQA's report also noted that medical societies and federal research agencies reported similar shifts in vaccination rates.

Graph courtesy of NCQAThat vaccines are linked to autism has been repeatedly debunked. The peer review paper that raised the connection in 1998 was withdrawn from The Lancet, the researcher was discredited on a long list of alleged misconducts, and he was eventually kicked off England's medical register.

Yet, the NCQA report speculates that the connection between vaccines and autism lingers in public awareness, driven first by media reports before the research was discredited, and since then by celebrity activists who perpetuate the misinformation despite the evidence. The report states, "If this downward trend in vaccination rates in commercial plans persists, an unusual phenomenon may occur. The comparatively well educated or 'high-information' members more typical of commercial plans may endanger their children’s health--and the public’s health--because of their greater access to and overvaluing of misinformation. Medicaid patients may become healthier."

Pediatric vaccines prevent 10.5 million diseases per birth cohort in the U.S. and are a cost-effective preventive measure, the report continues. For every dollar spent on immunizations, as much as $29 can be saved in direct and indirect costs.

As a side note, earlier this week the U.S. Supreme Court took up the issue, to consider whether autistic children can pursue claims through the 1986 National Childhood Vaccine Injury Act, which set up a "vaccine court" that acts as an alternative to litigation against vaccine makers.

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Patients as partners

The famous late 19th and early 20th century physician, Sir William Osler, said that "a physician who treats himself has a fool for a patient." How would he have felt about patients diagnosing and treating themselves? Would he have written in support of the Journal of Participatory Medicine or against it? I also wonder how he would have practiced medicine in the "information age" when many of our patients present with a diagnosis already made, right or wrong.

I recognize that bringing Dr. Osler into a discussion set in the information age is, perhaps, anachronistic. Yet I believe he still has something to teach the 21st century on the topic of patient participation. When he advised that "the first duty of the physician is to educate the masses not to take medicine," he offered one of the earliest lessons on a physician's role as educator.

He also said: "The great physician would treat the patient with the disease while the good physician would treat the disease." For me, this marches lock-step with the reality of today's patient as consumer and active participant in the doctor-patient relationship. Simply put, it is impossible to separate the patient from a pre-conceived and often well-researched opinion--correct or not. So to treat the "patient with the disease" requires me to think of my patient as an intellectual partner.

Growing up in the late 20th century, I am comfortable with technology and remember an elective course I took in my fourth year of medical school on "the future of medicine and computer science." The vision of the future shared by my instructors blew me away--after all, this was the first time I had even heard of the internet. Awe-inspired I found it difficult to stop talking about the new future with my fellow students, but despite my awe those instructors had no idea how far-reaching and pervasive the ready access to information would be for 21st century medicine.

For a clinician practicing medicine today to ignore the ready access to information and approach medicine in much the same way as Marcus Welby did on the black and white TVs of generations past would be a mistake. It is my experience that informed patients make happier and healthier patients. I always try to involve my patients as an intellectual partner, to do otherwise would require me to turn a blind eye to the reality of today.

Dr. Jerome Groopman, in his book How Doctors Think, strongly advised patients to become informed and assume an active role in the doctor-patient relationship. I agree completely and would like to share an example from yesterday's clinic schedule with a well-informed patient that serves as a good example of the type of patient I enjoy caring for.

A 22-year-old female was working to improve her tennis game and presented with three weeks of pain on the left side of her back. She intended to continue with tennis, regardless of her pain, and asked me to evaluate her pain and see if I had the same opinion as to diagnosis and treatment that she had reached from her research on the Internet.

Ten weeks earlier she had had surgery for a trigger finger and this forced her to change her grip on the tennis racket. It was her opinion that as a result of her changed grip she had overused other muscles in her back while swinging the tennis racket. I examined her and found localized pain over some left sided muscle groups only. The rest of the exam was unremarkable.

I agreed that physical therapy would be the best option for her and made the arrangements. I added scheduled anti-inflammatory medications to her treatment plan (something she had not done yet) and furthered her understanding of the involved muscle groups.

If I had treated her pain primarily I would have advised her to stop the activity until she was better and some may argue that her pain would dissipate quicker. Perhaps, but by treating her as a partner and considering her as a person first I was able to treat her in a way that gives due credit to her role as partner in the doctor-patient relationship and will allow us to build a relationship that will serve her health as she grows older and as her problems become more consequential.

Until next week, I remain yours in participatory primary care,
Steve Simmons, M.D.

This post by Steven Simmons, MD, appeared at Get 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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Wednesday, October 13, 2010

QD: News Every Day--Medicine pays well, but is it considered meaningful?

Doctors are the top six best-paid careers (based on median and top pay), with anesthesiologists being the best-paid, primary care being the sixth-best and nurse anesthetists the seventh best-paid, according to a survey by CNN/Money magazine and PayScale.com. But not one of the physician careers landed on the top lists for job growth or quality of life. The title of best job went to software architect and the second-best job went to physician assistant. Take heart, though. When asked about having the most meaningful work (based on the percentage who think their job makes the world a better place), the top spot went again to anesthesiologists, and second through ninth went to some kind of medical provider or health care administrator. Social workers rounded out the tenth spot. (CNN/Money)

One internist who considers his job meaningful is Stanford, Calif., educator Abraham Verghese, MACP, who is profiled for his work on the work-up, and how he diagnoses patients via the physical exam. Dr. Verghese learned his hands-on skills in the pre-scan era, in countries where such technology wasn't available even when it existed elsewhere. Dr. Verghese, Stanford's senior associate chair for the theory and practice of medicine, designed a course made of up of 25 techniques every doctor should know. (The 25 and their justifications are listed here.) (New York Times)

Embryonic stem cells could one day be a meaningful treatment, although they're still far off. Yet, the first patient has been treated in a phase 1 study. Researchers injected 2 million oligodendrocyte progenitor cells, which become oligodendrocytes that make myelin, into a partially paralyzed patient's spine one to two weeks after having suffered an injury between the third and 10th thoracic vertebrae. The patient is at the Shepherd Center, a spinal cord and brain injury rehabilitation center in Atlanta. (Washington Post)

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Tuesday, October 12, 2010

What I learned from asthma

As a kid I had allergies and asthma. Because of this, for several years, my mother wrote a note excusing me from the 600 meter run in elementary school. My father took me to weekly allergy shots. At times I had eczema on my forearms and eyes, and according to my allergist, whose notes I later read, I had moderate allergic shiners (also known as dark circles under my eyes). My allergies led to frequent nosebleeds, which got me sent to the nurse's office in school. Some nose bleeds were bad enough so that I was sent home from school. For years I was in and out of doctors' offices frequently, when my attacks were severe enough to require treatment with epinephrine injections to afford me some relief. Otherwise, I remained perpetually wired on a daily cocktail of theophylline, Dimetapp, and an occasional albuterol tablet. Despite all of this I tried hard not to be a complete dweeb.

I remember the doctors wanting to put me on oral steroids, which my parents refused. Maybe we were "difficult" patients. My parents were concerned about the long term toxicity of steroids, particularly the possibility of stunting my growth. Perhaps they thought I had a career ahead of me in professional basketball (I am now 5 foot 10 inches). We learned that I frequently would require a course of antibiotics after I became sick with a virus. As doctors became more cautious to avoid antibiotic overuse, our insight about this frequently met some resistance by those who were not familiar with me.

When I was thirteen I was admitted to Mott Children's Hospital in Ann Arbor, Michigan. I shared a room with two other girls, one from the Upper Peninsula of Michigan, who had some sort of intestinal issue that had required her to have multiple surgeries and hospitalizations. The girl in the bed across from me had anorexia. I remember overhearing intense discussions with her parents and being perplexed about all the talk of food. My illness seemed pretty minor in comparison.

Asthma therapy has changed a lot since the 70s and early 80s, but some of the experiences of being a patient and having a long term health condition remain the same. It was my good fortune to have had an illness that, for the most part, has resolved. Although, it still seems that I am allergic to most living things with fur, much to my children's dismay. After spending a year living in Brazil and going through a late puberty, in high school I stopped my allergy shots and discontinued most of my medication.

Asthma has played a minimal role in my adult life. Only occasionally do I use my albuterol inhaler before I run. However, having had this illness experience has taught me a few things about caring for patients, and likely contributed to my decision to become a doctor. As a child I remember feeling guilty about my allergies, as if somehow they were volitional, or that I was deliberately trying to get attention by inventing health issues that excused me from participating in various kids' activities. In retrospect, I am glad that my parents were "difficult" at times, refusing steroids and insisting on the antibiotics that they learned from experience would help make me well.

Here are some of the lessons that I learned:
1. People with chronic illness may feel guilty about the social effects of their illness.
2. People with chronic illness may feel that they are to blame for their illness.
3. Our current culture of personal responsibility may not be helping those with chronic illness with these perceptions, and may lead to increased depression and social isolation in those who have chronic illness.
4. Difficult patients should be listened to and usually bring up valid points.
5. Allergies are not volitional.
6. Patients with chronic illness frequently understand their health conditions better than doctors do.
7. Chronic illness care is more effective in the context of a long term collaborative relationship with one's personal physician.
8. Family pets are hard to get rid of.

Juliet K. Mavromatis, FACP, is a primary care physician in Atlanta, Ga. Previous to her primary care practice, she served on the general internal medicine faculty of Emory University, where she practiced clinical medicine and taught internal medicine residents for 12 years, and led initiatives to improve the quality of care for patients with diabetes. This work fostered an interest in innovative models of primary care delivery. Her blog, DrDialogue, acts as a conversation about health topics for patients and health professionals. This post originally appeared there.

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QD: News Every Day--Doctors twice as likely to e-mail another provider than a patient

Only 6.7 percent of office-based physicians routinely e-mailed patients about clinical information in 2008, according to an issue brief from the Center for Studying Health System Change.

Only 34.5% of office-based, ambulatory care physicians reported that information technology for communicating with patients about clinical issues via e-mail was available in their practice in 2008. Of that third, 19.5% routinely e-mailed patients, or 6.7% overall, while the rest were split between occasional use or non-use. The study sample was restricted to 4,258 office-based physicians and the response rate was 62%.

In contrast, twice as many physicians spent at least some time each work day e-mailing physicians and other clinicians.

Among 16 clinical tasks that can be supported by health information technology, such as viewing lab or diagnostic test results, reviewing medication lists or e-prescribing, e-mail communication with patients ranked third to last with respect to availability and last in terms of routine use.

Internal medicine doctors more commonly used e-mail than subspecialists, but practice size was a large influence. Solo practitioners were far less likely (13.6%) than larger, group practice settings to use e-mail to convey clinical information to patients. Hospitals (18.7%) and academic settings (25.9%) were more likely. But even among the highest users, physicians in group/staff-model HMOs, only 50.6% reported routinely e-mailing patients. And, physicians 55 an older were less likely to use e-mail, not only because of age but because they were likely to be in a smaller practice setting.

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Friday, October 8, 2010

Diabetes lessons

As doctors, sometimes the biggest lessons that we learn about disease pathology are those that we learn from the people that have that disease. Diabetes is one such disease.

I recently gave a show-and-tell lecture about insulin pumps to the new interns and residents as well as the third-year medical students on their pediatric clerkship with the inpatient endocrine service. We discussed different types of pumps (point A on the picture) and they got to push the buttons and send a bolus or change a basal rate. They also looked at real-time continuous glucose monitors (CGM), (points C and D on the picture) sensors used to check glucoses levels every five minutes.

However, they were most interested in the insertion devices and gadgets that accompany the pumps and the sensors. Their eyes were wide open and their teeth gritting when they themselves thought about going through this torturous ritual of site insertions and changes every two to three days. As one of the nurse educators that I work with who has diabetes demonstrated his own pump site (point B on the picture) and CGM sensor, the students and young doctors were clearly impressed with the bravery that having diabetes forces you to have.

Looking at the multiple sites on the nurse's abdomen also reminded the students of how diabetes forces you to have a lack of vanity. Diabetes also forces you to have a lack of control over your body, which we all are destined to learn at different points in our life. Finally, diabetes takes a bit of your childhood away. No textbook can teach you that.

This post by Jennifer Shine Dyer, MD, MPH, appeared at Get 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--Politics, policy and health in flux

Medical organizations are donating heavily to doctors running for the U.S. House. Dentists, ophthalmologists, radiologists, surgeons, neurologists and ENTs have contributed heavily. The goal is to get doctors onto committees where they can have the most impact. So far, the candidates have trended heavily Republican and have, in at least one campaign, vowed to overturn health care reform. The stakes are high if opposing legislators succeed, because they could underfund or block portions of reform to the point that it works poorly or not at all. (Politico, New England Journal of Medicine)

Spurred by antibiotic resistance seen in almost every drug class, FDA Commissioner Margaret Hamburg, FACP, is turning the agency's attention toward animal feed. With little to no development of new antibiotics in the pipeline, the agency is discussing regulations for animal feed and guidelines for human use. (Wall Street Journal)

Scientists should be able to use stem cells for biomedical research, according to a recent Harris Interactive/HealthDay poll. Almost three quarters of adults surveyed are in favor of using embryonic stem cells left over from in vitro fertilization. These poll results remain consistent with a similar survey released in 2005.

The poll was conducted online Sept. 28-30 and included 2,113 adults. Among its other findings:
--73% (versus 72% in 2005) believe that stem cell research should be allowed "as long as the parents of the embryo give their permission, and the embryo would otherwise be destroyed."
--58% of Republicans think stem cell research is acceptable (versus 24% opposed), as do 69% of Catholics and 58% of born-again Christians. 16% of Catholics and 22% of born-again Christians oppose it.
--Two-thirds of the respondents agreed that, "If most scientists believe that stem cell research will greatly increase our ability to prevent or treat serious diseases we should trust them and let them do it."

Complete data are available online. (HealthDay)

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Snor'n' in the USA

I'm not a drum-banger for the latest "epidemics" to come to media attention, whether it's H1N1, Vitamin D, or getting your kids CAT-scanned routinely.

But there comes a time in every blogger's life when he must comment on something that does bubble up into consciousness a tad, shall we say, often.

I'm talking here about an epidemic that we are learning more about each passing day. Something that you or someone you know or sleep with may be diagnosed with, and ultimately treated for (an interesting national problem in its own right): Obstructive Sleep Apnea (OSA).

What is it, you ask?

A new national scourge? Stop the presses! Can I catch it?

Well, the main thing you should know is that the rise in prevalence of OSA is directly proportional to two main factors:
--We now have a treatment that works, thus making us look to diagnose the condition more.
--Probably the key factor: OSA is most often (note not always, for there are variants) correlated with being overweight or obese. As we are a nation of expanding waistlines, you can see the correlation.

Do you snore? Is your sleep fitful, and are you tired a lot of the time? Ever fallen asleep at the wheel? Has a bed partner ever commented that even through your snoring, you sometimes stop breathing?

A yes to any of those (even basic old snoring) can be suggestive of sleep apnea.

To get tested, of course: "Talk to your doctor or health care professional."

You'll spend the night in a sleep lab, hooked to a polysomnogram (poly=many, somno=sleep, gram=tracing or recording): a device that records your pulse, heart rhythm, blood oxygenation, breathing, muscular contraction and brain wave activity while you sleep. If you stop breathing or "under breathe," resulting in a loss of blood oxygen, you test positive.

How can we treat it? Lose weight! Exercise!

What do we really do?

Welcome to CPAP-land. CPAP stands for Continuous Positive Airway Pressure. In a nutshell, you use a machine that blows air into your nose or mouth, keeping your airway open.

Volia. No more snoring. No more apnea (stopping breathing). Better sleep. Less fatigue. More energy.

Since this is now a well-recognized medical problem, health insurers pay for this equipment. Hello another billion dollar medical industry.

So classically American: Using technology to work around the underlying problem--our inability to lead less sedentary, gluttonous lives.

I'm scared we're evolving into the blobby people portrayed in the film Wall-E.

What is the endpoint of all this? Are we destined, as a people, to hook ourselves to machines all night so that we can sleep better? If you're an insomniac, it'd be a worthy tradeoff.

Can the day be not too distant when we hook machines to us all the time (I don't just mean iPads.)? Will we be able to implant electrodes in our head so that we can e-learn without having to crack the books?

What other bodily functions can be augmented by hook-on machines that work while we sleep?

All right, then. Sleep tight!

This post originally appeared at GlassHospital. 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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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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