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

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Monday, January 31, 2011

FDA reports on association of breast implants and a rare form of lymphoma

Yesterday the FDA issued an alert about a possible link between breast implants--saline or silicone--and a rare form of lymphoma called anaplastic large cell lymphoma (ALCL). These lymphoma cases are exceedingly rare, but the association appears to be significant.

The FDA is reporting a total of approximately 60 ALCL cases in association with implants, worldwide. Of these, 34 were identified by review of published medical literature from 1997 to May 2010; the others were reported by implant manufacturers and other sources. According to the FDA's detailed findings, there may be some overlap between the published case reports and those otherwise identified, which would lessen the sum. The agency estimates the number of women worldwide with breast implants is between 5 and 10 million.

In women who don't have implants, ALCL is an infrequent tumor, affecting approximately 1 in 500,000 women is the U.S. per year. This form of lymphoma--a malignancy of lymphocytes, a kind of white blood cell--can arise almost anywhere in the body. But ALCL cases arising in the breast are unusual. The FDA reports that roughly 3 in 100,000,000 (or 0.000003%) women are diagnosed with ALCL in the breast per year in the U.S.

These are very small numbers. Still, the finding of ALCL tumors by the implant capsules is highly suggestive. Almost all of the implant-associated ALCL cases were T-cell type, whereas most breast lymphomas are of B-cell type. The lymphomas arose in women with both silicone and saline-type implants, and in women with implants placed for purposes or augmentation and for reconstruction after mastectomy.

The clinical features varied among the reported cases. From the FDA's review: " ... the median time from breast implant placement to ALCL diagnosis was 8 years, with a range from 1 year to 23 years. Most patients were diagnosed when they sought medical treatment for implant-related symptoms such as persistent seromas, capsular contractures, or peri-implant masses warranting breast implant revision operations. In each case, lymphoma cells were found in the effusion fluid (seroma) surrounding the implant, in the fibrous capsule, or within a peri-implant mass. Typically, there was no invasion beyond the fibrous capsule into the breast parenchyma.

Figure 1 illustrates the location of the reports of ALCL adjacent to the breast implant.

This illustration shows the breast implant placed under the skin and breast tissue. The implant is separated from the breast tissue by a fibrous scar capsule. ALCL lymphoma cells are shown in the effusion fluid between the breast implant and the capsule and attached to the capsule itself.Figure 1. Presence of ALCL cells in close proximity to a breast implant. In most cases, the ALCL cells were found in the effusion fluid (seroma) surrounding the implant or contained within the fibrous capsule. ALCL is lymphoma, a type of cancer involving cells of the immune system. It is not cancer of the breast tissue, and typically, invasion of the lymphoma beyond the fibrous capsule into the breast parenchyma was not observed. Modified from Thompson et al, (2010).

With such a small number of cases worldwide, it's hard to draw evidence-based conclusions regarding the appropriate treatment of these rare lymphomas. More from the FDA: "Treatment was reported for 20 patients. Most had the implants removed, and some went on to receive treatment with radiation and/or chemotherapy. Overall, the outcomes appeared to be more favorable than would typically be expected for systemic ALCL. Outcomes were reported for 19 cases. Of these, 14 patients had no evidence of disease at last follow-up. However, most cases were diagnosed with early stage disease, and follow-up on many cases was limited."

At this time, the FDA is advising health care providers to be aware of the possible diagnosis, to carefully evaluate breast implant patients with suspected ALCL, and to report all confirmed cases to the agency.

As for patients, the situation is troubling. The incidence of these tumors is quite low, almost immeasurable, and the prognosis based on the few treatment reports seems good. But many women do have some fluid, contractures, thickening and other complications around the implant capsules. Most of those physical aberrations surrounding the implants are not lymphoma.

It's a Pandora's box, but one that needs be opened. The problem is that if we biopsy every abnormality, such as a minor thickening or fluid accumulation adjacent to a breast implant, we'll hike up the costs and, more importantly, the complications associated: With every needle stick there's a risk of infection, additional scar formation and more.

On the other hand, you wouldn't want to overlook a treatable, early-stage lymphoma. Women need to know of the risks of implants, which can only be determined if doctors thoroughly investigate these sorts of complications. Lymphoma, including ALCL in my experience as a treating oncologist, can be very subtle.

So far the plastic surgeons have done a good job minimizing this issue in the press, which seems to be playing along. But I hope doctors, including plastic surgeons who thus far have minimized the issue in the press, will take this FDA alert seriously, so that women can make more informed choices regarding breast implant surgery.

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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QD: News Every Day--Dark days ahead for Medicaid

State governments continue to balance their budgets by gashing Medicaid.

Arizona, which wants to drop coverage for 280,000 Medicaid recipients, is seeking a waiver from the federal requirement that states not reduce Medicaid eligibility. Spending for the program has nearly doubled in the past three years, from 17% of the general fund to 30%.

Tennessee officials are preparing to cap Medicaid use at eight doctor and hospital visits a year. The state has a $1 billion budget shortfall.

Texas, which is considering eliminating Medicaid altogether, is looking to pass a budget that would cut Medicaid reimbursements to long-term care facilities by 33% and hospital payments by 10%.

It's not until 2014 that Medicaid’s reimbursement rate will rise to match Medicare's, possibly enticing doctors to accept it then. So legislators and governors are looking at what they can cut, including payments to physicians now.

Often, the cuts will cause states to lose out on federal matching funds. Tennessee, for example, wants to reduce state spending by $103 million, meaning they'd miss out on $203 million in federal matching funds. In Texas, one health administrator said the state gets $1.50 for every $1 it spends.

And if states cut their Medicaid budgets, the cost of care gets shuffled, but it doesn't disappear. Private insurance rates rise, for example.

The states' budget crises come at a time when Medicaid hospitalizations are rising. Hospital admissions of Medicaid patients jumped by 30% between 1997 and 2008, compared to a 5% growth in privately insured patients, reports the Agency for Healthcare Research and Quality (AHRQ).

AHRQ found that:
--Over the period, a hospital's average cost for a Medicaid patient stay rose 11%, compared to a 34% cost increase for privately insured stays and the 26% increase for uninsured patients, adjusted for inflation.
--In 2008, the average Medicaid patient stay cost a hospital $6,900 and about the same for an uninsured patient, compared to $8,400 for a patient stay covered by private insurance, adjusted for inflation.
--Altogether, Medicaid patient stays cost hospitals about $51 billion, compared to $117 billion for privately insured patient stays and $16 billion for uninsured stays in 2008, adjusted for inflation.
--Medicaid was the primary payer for more than 18% of the nearly 40 million hospital stays in 2008.

But it's not all bad news. Washington state salvaged two programs through a Medicaid waiver that will let the state and federal government share the cost. The waiver, intended originally as a short-term bridge to national health care reform in 2014, will provide about $7.7 million a month in new federal funds, or roughly 40% of the cost of programs funded primarily by state dollars.

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Don't treat pre-op exams like pop quizes

What's one of the biggest culprits for the rise of unnecessary medical testing? Preoperative evaluation.

Before most patients undergo surgery or an invasive procedure, they are normally sent to their primary care physicians for a "preoperative evaluation." This is a visit to determine if they are medically stable enough to undergo the operation.

Tests like bloodwork, an EKG, or a chest X-ray are frequently ordered. For those with suspicion of coronary artery disease, a stress test is sometimes considered, based on the patient's symptoms.

According to a recent study, however, many of these tests may be unwarranted. Not only do they waste money, they also can potentiate further, more invasive, studies that stem from incidentilomas.

Published in Obstetrics & Gynecology, researchers: "reviewed medical records for women who underwent gynecologic surgery at their center between 2005 and 2007. They found that 95% of the 1,402 patients received all the recommended testing, but 90% had at least one test that was not necessary based on guidelines from the National Institute of Clinical Excellence (NICE).

"None of the 749 urine tests, the 407 liver function tests, or the 1,046 tests of blood clotting factors were appropriate, while 99% of the 427 chest X-rays ordered were not appropriate. Only 36% of the electrocardiograms and 29% of complete blood counts were in accordance with "evidence-based" guidelines."


There are several reasons. Of course, malpractice worry is at the back of most doctors' minds. As the chief author puts it, "'Number one, certainly, a lot of this is medicolegal,' meaning, basically, doctors don't want to get sued for not having a test done."

Also, the entire medical team needs to be on the same page. Meaning, the preoperative guidelines for the primary care doctor, surgeon, and anesthesiologist has to be the same.

If I don't feel like a certain preoperative test is necessary, for instance, it shouldn't be ordered by a consultant. This is difficult in most practices, where the preoperative doctor, surgeon and anesthesiologist operate under separate auspices.

Having everyone under the same roof, such as in a large, integrative practice, can help in consolidating the recommendations and, perhaps, reduce $3 billion wasted on unnecessary preoperative tests.

Kevin Pho is founder and editor of KevinMD.com, also on Facebook, Twitter, and LinkedIn.

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 40,000 subscribers and 28,000 Twitter followers, KevinMD.com is the Web's definitive site for influential health commentary.

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Friday, January 28, 2011

QD: News Every Day--Cardiac care costs could triple by 2030

Real total direct medical costs of cardiovascular disease (CVD) could triple, from $273 billion to $818 billion (in 2008 dollars) by 2030. Real indirect costs, such as lost productivity among the employed and unpaid household work, could increase 61%, from $172 billion in 2010 to $276 billion.

Results appeared in a policy statement of the American Heart Association.

CVD is the leading cause of mortality and accounts for 17% of national health expenditures, according to the statement. How much so? U.S. medical expenditures rose from 10% of the Gross Domestic Product in 1985 to 15% in 2008. In the past decade, the medical costs of CVD have grown at an average annual rate of 6% and have accounted for about 15% of the increase in medical spending.

The spending is associated with greater life expectancy, "suggesting that this spending was of value," the authors wrote. But as the population ages, direct treatment costs are expected to increase substantially, even though lost productivity won't, since seniors are employed at lower rates.

If current prevention and treatment rates remain steady, CVD prevalence will increase by about 10% over the next 20 years. The estimate reflects an aging population, and one that is increasingly Hispanic. To prepare for future cardiovascular care needs, the American Heart Association projected future costs. By 2030, 40.5% (116 million) of the population is projected to have some form of CVD.

So, prevalence estimates for hypertension, CHD, heart failure, and stroke were generated using data from the 1999 to 2006 National Health and Nutrition Examination Survey. Medical cost projections were derived from the 2001 to 2005 Medical Expenditure Panel Survey. This methodology avoided double counting of costs for patients with multiple cardiovascular conditions.

Overall, hypertension has the greatest projected medical cost. The increased prevalence of hypertension is in part attributable to the aging of the population, but there's a 15% relative increase in its prevalence after age adjustment. Increasing body mass index contributed to more than 50% of the increase in hypertension.

"Reversing the obesity epidemic will play a pivotal role in favorably impacting the projected hypertension trends," the authors wrote. "Hypertension accounts for 18% of CVD deaths in Western countries and is a major risk factor for stroke, [coronary heart disease] and heart failure. Thus, the total medical costs for hypertension inclusive of these downstream diseases are approximately double the cost of hypertension itself, making hypertension a particularly valuable target to modify the future total costs of CVD."

But the projections don't necessarily have to come to pass, according to the statement. "Although these projections are sobering, they need not become reality, because CVD is largely preventable," the authors wrote. "Therefore, a greater focus on prevention may alter these CVD projections in the future."

For example, emerging evidence shows that prevention and awareness should begin earlier in life than it does now, as would lower sodium intake (by 3 g per day), awareness of genetic variations that lower cholesterol, better biomarkers such as C-reactive protein, and imaging tests such as coronary artery calcium scoring.

Looming shortages in primary care, but also in the fields of pharmacy and in cardiology, will also diminish care.

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Why should medical ethics matter?

Medical ethics has properly gained a foothold in the public square. There is a national conversation about euthanasia, stem cell research, fertilization and embryo implantation techniques, end-of-life care, prenatal diagnosis of serious diseases, defining death to facilitate organ donation, cloning and financial conflicts of interest. Nearly every day, we read (or click) on a headline highlighting one of these or similar ethical controversies. These great issues hover over us.

We physicians face ethical dilemmas every day in the mundane world of our medical practices. They won't appear in your newspapers or pop up on your smartphones, but they are real and they are important. Here is a sampling from the everyday ethical smorgasbord that a doctor faces. How would you act under the following scenarios?

--A physician has one appointment slot remaining on his schedule. Two patients have called requesting this same day appointment. The first patient who called has no insurance and owes the practice money. The second patient has medical insurance coverage. Neither patient is seriously ill. Who should get the appointment?

--Two hours before a doctor is to see a patient, her husband calls to relate private information that he fears the patient will not share with the physician. Should the physician disclose this conversation to the patient? What is the risk if she discovers at a later time that a confidential conversation occurred?

--A patient has been non-compliant with medical care. He has missed appointments and does not take his medication reliably. The physician is contacted by a local emergency room after the patient arrives there for a medical evaluation. Can the doctor ethically decline to treat this patient who has repeatedly rejected the physician's advice?

--Many physicians dispense medication samples to their patients. Is this practice ethical in that it raises drug prices for everyone since drug companies must fund these giveaways?

--An attorney contacts a physician to testify against a fellow doctor who is accused of committing medical malpractice. The physician and the accused doctor both work in a small community hospital. The facts suggest that a medically negligent act has occurred. Is the physician ethically obligated to testify against his colleague?

--A cardiologist decides not to accept smokers in his practice as he views this behavior as a direct attack on his medical treatment and strategy. All smokers in his practice are notified that if they do not quit within six months that they will need to select another physician. The cardiologist states he will actively counsel and treat all smokers on the available options for nicotine addiction. Can this physician ethically dismiss smokers from his practice who can't or won't quit?

--A patient asks a doctor to fill out a temporarily disability form for back pain present for two weeks prior to the office visit. During this time, the patient did not seek any medical care. Is it ethical for the doctor to sign off on this request?

While none of the examples above will make the front page of your morning newspapers, they are newsworthy. They are under the radar, but need to be exposed. While the public square is crowded with the monumental ethical controversies of the day, we need to reserve a small corner there for everyday ethics. Ethics in the office should not be a private matter. Become a subscriber!

This post by Michael Hirsch, FACP, 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, January 27, 2011

What is a "complete" physical?

A reader requests: "Can you do a post on what procedures constitute a thorough physical, in your opinion? I haven't had one in several years and thinking of making an appointment now. The last doctor I went to didn't even listen to my heart or go through the motions with feeling my belly and that stuff. And of the last three doctors I went to, I realized they didn't bring up my immunization records. Is this usually left for the patients to bring up on their own?

Good question. What exactly is a physical? Does it include blood work? What about an EKG? And a cardiac stress test? Is an "executive physical" an orgy of "more is better," previously paid lavishly, really better than a "camp physical?"

Here's the thing: There is no such thing as a "complete physical examination." There are literally hundreds of different maneuvers and procedures that encompass various aspects of physical diagnosis. Performing every last one of these on even a single patient would not only take many hours, it would be a colossal waste of time.

A "physical" is a misnomer. The clinical portion of a medical workup is more correctly termed the "history and physical." Of the two, everyone agrees that the history--information elicited from the patient, sometimes from family members or other medical records--is far more likely to yield useful information. It is the information gleaned from the history that guides the physical.

Knee pain? The history should include mechanism of injury, and physical exam should evaluate for McMurry, Lachman and drawer signs, among other maneuvers. Belly ache? Need to know about associated symptoms such as nausea, vomiting, stool pattern, flatus, and the exam better include careful auscultation (listening) for bowel sounds and palpation (feeling) for masses, fluid, possible shifting dullness, plus eliciting any guarding or rebound, and probably a rectal exam looking for blood. It makes no sense to use a tuning fork for Rinne and Weber tests to evaluate different kinds of hearing loss on someone with heartburn. Likewise, evaluating the debilitating heel pain of plantar fasciitis does not require listening to the lungs. I trust you get the idea.

The question appears to be about the "routine physical" in the absence of any specific medical concern. A more accurate term for this is a "preventive service" visit, for which there are specific guidelines.

First and foremost, I need to make sure that there really are no medical concerns. More than once I've had a patient request a "complete" physical--there was something deliberate about the way they pronounced the word "complete"--when it quickly became clear that there was a concern, usually sexual or rectal, that the patient was reluctant to mention. Obviously, their thought was that I would discover the problem on my own during the examination, and it would be taken care of without them having to say anything. Unfortunately, as I told these patients, it doesn't work that way. There really is no way to bypass the history. I like to tell people that no one ever died of embarrassment, even though they may have wanted to.

Once I'm sure the patient really is healthy, we can proceed.

The mainstay of the preventive visit is still the history, though in this case it takes the form of a risk factor assessment: Any family history of certain conditions (cancer, heart disease), plus lifestyle issues like smoking, diet, and exercise habits. It's been stated that upwards of 90% of modern American ills could be prevented if no one smoked, everyone exercised regularly, avoided excessive sun exposure, and maintained an ideal body weight, a figure with which I do not disagree. Determination of the patient's immunization status is also part and parcel of the history portion of a preventive visit.

When you stop to think about it, the whole idea of prevention is to find things that may be wrong with the patient that they can't feel (i.e. before they have symptoms), that can produce symptoms eventually, and that we can do something about to prevent that from happening. When you look at it like that, the list of possible entities is surprisingly short:
--High blood pressure
--High cholesterol
--Chronic kidney failure
--Certain cancers and pre-cancers

Although I'm sure people will think they can add to that list, the vast majority of other conditions really do present with symptoms of some kind, however subtle.

Next, as with the "sick" visit, we perform a targeted physical examination.

I would have to say that measurement of the blood pressure is perhaps the single most important component of a preventive physical. High blood pressure is not only asymptomatic, but guides me to examine the eyegrounds (the back of the eye, the retina) with my ophthalmoscope, looking for early evidence of damage from blood pressure. I make sure to listen to the carotid arteries in the neck. I've found bruits (a whoosh, whoosh, whoosh sound) indicative of dangerous narrowing that can presage a stroke that are completely asymptomatic! I make it a point to listen to the heart regularly. I've detected murmurs, abnormal sounds between the lub and the dub, indicating damaged heart valves, and sent people to surgery before any damage occurred to the heart muscle itself. Bear in mind, though, that a targeted cardiovascular exam may not be indicated in everyone. Beyond that, everyone (including me) has their own set of standard maneuvers that constitute looking someone over briefly but thoroughly.

Other preventive care procedures such as Pap tests, clinical breast examinations, mammographies, colonoscopies, PSAs and so on are recommended at specific intervals for specific ages of patients of appropriate genders. USPSTF doesn't appear to have any specific guidelines on "routine" blood testing, except for specific conditions (annual fasting blood sugars looking for diabetes in patients with a positive family history, for instance). Screening fasting cholesterol testing once every five years is probably appropriate, again, guided by family history and other factors discovered in the personal history.

So the answer to the question, "What constitutes a thorough physical?" is the same as the answer to a surprising number of question I am asked: It depends.

This post by Lucy Hornstein, 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--Shiver yourself thin?

British researchers are trying to causally link raising the thermostat to obesity prevalence.

Picture by Ryan DuBosar"Domestic winter indoor temperatures" appear to be rising, the researchers wrote, as is obesity. They focused on a causal link, focusing on acute and long-term effects of being comfortable in the winter.

They write, "Reduced exposure to seasonal cold may have a dual effect on energy expenditure, both minimizing the need for physiological thermogenesis and reducing thermogenic capacity. Experimental studies show a graded association between acute mild cold and human energy expenditure over the range of temperatures relevant to indoor heating trends."

They also look at brown adipose tissue (BAT), aka "brown fat," the type of fat that actually consumes energy instead of stores it. We all have this fat as infants, to help us regulate our body temperatures until our bodies learn to do it on their own. The researchers suggest that "increased time spent in conditions of thermal comfort can lead to a loss of BAT and reduced thermogenic capacity."

Determining a link "may raise possibilities for novel public health strategies to address obesity," although I shiver to think what those strategies might entail.

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Why 'the end of internal medicine as we know it' might be a good thing

A recent post on the Health Affairs blog proclaimed "The End of Internal Medicine As We Know It." What the post is really asking about is the future of primary care in the world of health care reform and the creation of accountable care organizations (ACOs). While doctors should be naturally concerned about change, I don't completely agree with this article.

ACOs are organizations that are integrated and accountable for the health and well-being of a patient and also have joint responsibilities on how to thoughtfully use a patient's or employer's health insurance premium, something that is sorely lacking in the current health care structure. These were recently created and defined in the health care reform bill.

Yet the author seems to suggest that this is a step backwards: "Modern industry abandoned command-and-control style vertical integration decades ago in favor of flatter, more nimble institutions."

Not true. Successful organizations are ones that are tightly integrated, like Apple, FedEx, Wal-Mart and Disney.

The author talks briefly about how Europe in general does better than the U.S. in terms of outcomes and costs and has a decentralized system. All true. However, contrasting Europe and America isn't relevant. After all, who isn't still using the metric system? Therefore solutions found outside the U.S. probably aren't applicable due to a variety of reasons. Americans like to do things our way.

What I do agree on is that doctors need to be part of the solution and ensure that the disasters of decades ago, like labeling primary care doctors (internists and family physicians) as gatekeepers rather than what we really do, never happen.

I love primary care. I've worked at Kaiser Permanente in Northern California since 2000. I have long-term relationships with my patients. They see me when they are well. They see me when they are sick. They have me as their personal doctor. There are no mid-level practitioners (nurse practitioners or physician assistants) in my unit. I'm supported by information technology, staff to help those members with chronic conditions, and collegial specialist colleagues.

In other words, I'm doing what almost every primary care doctor wants: long-term meaningful relationships with patients, no hassles from insurance companies, the ability to retrieve information quickly and easily, and support for specialty colleagues who are equally focused on the well-being of the patient and who respect me as much as I respect them.

Perhaps the death of primary care as it currently exists with crushing administrative hassles, loss of work-life balance, increasingly short office visits, and paper charts which often has inadequate information or are unavailable isn't a bad idea after all.

Now I understand that Kaiser Permanente looks very much like an ACO. I also know it isn't for everyone--doctors or patients--and isn't the only solution for the country. Certainly doctors should be wary if every self-proclaimed ACO is really that or more of the same in the fee-for-service world but simply disguised in the ACO term.

However, for primary care doctors looking for a better way to care for patients, it is a very viable and sustainable solution. If the future for primary care looks like what I see and do every day, then I believe the future will be bright.

Primary care doctors looking for a better future in primary care and willing to move to Northern California should do more research here.

In the end, patients may benefit from ACOs. I know my patients do.

This post by Davis Lu, 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, January 26, 2011

QD: News Every Day--State of health care in the Union

QD: News Every Day--State of health care in the Union
Short and sweet. That's how President Obama addressed health care reform in his State of the Union address last night. In less than 700 words, he outlined how he'd improve but not retreat on what's been enacted into law.

He's willing to work on changes, he said, naming malpractice reform and reducing onerous paperwork burdens for small businesses. But, he cautioned, "What I'm not willing to do is go back to the days when insurance companies could deny someone coverage because of a pre-existing condition." President Obama had invited two real people to his address to highlight the law's successes. One is a brain cancer survivor who can access health insurance through high-risk pools created by the law. The other is a small business owner who lowered health insurance costs by $10,000 for his nine employees, a probable jab at the "job-killing" title of an attempted yet futile repeal vote last week.

The president's remarks come at a time when the public is of two minds on health care reform. While many state they don't like the entire package, they also love individual aspects of it. The individual mandate remains widely unpopular, but allowing those with pre-existing conditions to access insurance is widely popular, as does Medicare and Social Security.

The Republican response by Rep. Paul Ryan, R-Wis., Chairman of the House Budget Committee, responded that, "The President mentioned the need for regulatory reform to ease the burden on American businesses. We agree--and we think his health care law would be a great place to start." The House has voted for a repeal and Senate Republicans are preparing legislation and promising to ask for a vote. (Los Angeles Times, Politico, Kaiser Health News, Greenville [South Carolina] Online)

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Tuesday, January 25, 2011

QD: News Every Day--America's longevity gap blamed on smoking, obesity

Americans spent more on health care than other countries and still lag in longevity, largely due to smoking and obesity. How much so was laid out by the National Institute on Aging, which estimated smoking caused 78% of the gap in life expectancy for women and 41% of the gap for men between the U.S. and other high-income countries (European Union, Australia and New Zealand, and Japan) in 2003.

Smoking was much more widespread 50 years ago in the U.S. than in Europe or Japan, the report states. Americans smoked more, and also more intensively. Consequences are still playing out in today's mortality rates. From 1950 to 2003, the gain in life expectancy at age 50 was 2.1 years lower among U.S. women compared with the average of nine other high-income countries (5.7 vs. 7.8 years gained, respectively).

Reprinted with permission from Explaining Divergent Levels of Longevity in High-Income Countries, 2011 by the National Academy of Sciences, Courtesy of the National Academies Press, Washington, D.C.Trend in highest recorded level of male life expectancy achieved versus trend in life expectancy in the United States. Data from Oeppen and Vaupel (2002) [Supplemental tables]; Human Mortality Database (http://www.mortality.org/ [accessed December 8, 2010]).

Because there appears to be a lag of two to three decades between smoking and its peak effects on mortality, how smoking will affect life expectancy can be predicted for the next 20 to 30 years. Life expectancy for men in the U.S. is likely to improve relatively rapidly in coming decades because of reductions in smoking in the last 20 years, the report says. For U.S. women, whose smoking behavior peaked later than men's, declines in mortality are apt to remain slow for the next decade.

Reprinted with permission from Trend in highest recorded level of female life expectancy achieved versus trend in life expectancy in the United States. Data from Oeppen and Vaupel (2002) [Supplemental tables]; Human Mortality Database (http://www.mortality.org/ [accessed December 8, 2010]).

Obesity may account for a fifth to a third of the shortfall of life expectancy in the U.S. relative to the other countries studied, although there is still a good deal of uncertainty in the literature regarding possible trends. For example, while lung cancer deaths are a reliable marker of the damage from smoking, no clear-cut marker exists for obesity.

Increasing obesity in the U.S. may offset the longevity improvements expected from reductions in smoking. However, recent data suggest that the prevalence of obesity in the U.S. has leveled off, and some studies indicate that the mortality risk associated with obesity has declined.

Lack of universal access to health care in the U.S. also has increased mortality and reduced life expectancy, the report says, though this is a less significant factor for those over age 65 because of Medicare. Available indicators for cancer and cardiovascular disease, the main causes of death at older ages, do not suggest that the U.S. health care system is failing to avert preventable deaths. In fact, cancer detection and survival appear to be better in the U.S. than in most other high-income nations, and survival rates following a heart attack also are favorable.

Over the last 25 years, life expectancy at age 50 in the U.S. has been rising, but at a slower pace than in many other high-income countries, such as Japan and Australia. This difference is particularly notable given that the U.S. spends more on health care than any other nation. The National Institute on Aging asked the National Research Council to examine evidence on its possible causes.

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Monday, January 24, 2011

Beyond a spoonful of sugar

First there was that draconian immigration law. Then came the news about the cash-strapped state cutting Medicaid funding for certain types of transplants.

[And of course now the horrible news about the shooting rampage in Tucson.]

spoonful of sugar by truds09 via FlickrJust when I thought Arizona would legislate itself into least-favored state status, there was this article by Pam Belluck in the New York Times. The quick summary: Beatitudes nursing home in Phoenix is an outlier in the care of patients with Alzheimer's dementia, because the staff there are empowered to give the patients what they want. Really. Any time of day or night.

Chocolate? Check.

A nip of brandy? You betcha!

Grandma (Mom?) wants to play with dolls? God bless her ...

This article, part of an ongoing Times series called "The Vanishing Mind," carries the subtitle "Therapy Based on Comfort."

Therapy based on comfort? I love this idea! Ultimately, what else is there?

I find myself asking this question more and more. Health care and hospital practice is all about sacrificing comfort in the name of answers: diagnosis and treatment answers. [Hey! and let's not forget prognosis answers ...] When did medicine, like life, become "no pain, no gain?"

And this newfangled philosophy by Beatitudes is front page news! Literally.

Belluck's article splashed across the front page the same month that the ever-crusty New England Journal of Medicine carried a piece titled "The Emerging Importance of Amenities in Hospital Care."

What earth-shattering trend will the NEJM reveal to us next? "Shelter keeps people warm and dry?"

What's interesting about the way this nursing home treats its patients is, well, the outcomes:
--The patients eat more.
--They're less agitated. They wander less.
--The nursing home has therefore cut way back on its use of sedative drugs and physical restraints.
--This makes the families of these loved elders much happier.

The staff feel better about the care they're delivering, since they're empowered to try to negotiate their way out of challenging situations by giving the residents of the nursing home what they want, rather than telling the residents what they "must" do to comply with the home's (and presumably state and federal) regulations.

Okay, you say, but this is an isolated example. A nice example of a defined population (Alzheimer's patients) and a select environment (the nursing home).

But what prevents us, other than the inertia of old habits and institutional culture, from holding to these principles in other realms of health care?

Couldn't we provide patients with comfort in hospital settings? Why does it always seem to be either/or?

We move vigorously to treat diseases, but when they become resistant or the treatments themselves too toxic, why only then do we switch to comfort mode? The article commented on here is only the tip of the iceberg in poking holes in that theory.

Remember that you heard it here first: The massive federal health care overhaul (coming to you full-fledged in 2014) will alter the landscape dramatically. Health care entities that offer value, convenience, service, knowledge, and above all comfort, will sip from the chalice of health care innovation and reward.

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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QD: News Every Day--'Death panels' a shorthand way of stating a lengthy issue

The phrase "death panels" has become political shorthand, a way of undercutting health care reform on the back of the difficult issue of end-of-life planning.

The link has always been tenuous, the idea being that Medicare reimbursing physicians for the time they spent with patients would lead to the government influencing the discussion that would occur.

Entering into the discussion today are a physician, a physicist and a polemicist.

First, the physician. Ardis Dee Hoven, FACP, chair of the AMA Board of Trustees, kicks off the discussion about end-of-life care, calling it "practicing good medicine." She continues: "It is not a mechanism to inappropriately limit care or access to care. As these discussions take preparation, thought and time on the part of physicians, they are also something for which doctors should be paid."

Dr. Hoven concludes, "So much of modern medicine is about the miracles of high technology that it's easy to lose sight of the most low-tech part of medical practice: the relationship between physician and patient. This is never more important than as a person's life moves toward its close. ... It's a difficult subject, dealing with a difficult time of life, but it's one that neither the medical community nor our society should walk away from."

Next, the physicist. In support of the link is Harvard physicist Mike Stopa, who reckons that we have to acknowledge the role of economics and scarce resources when parceling out health care. He writes: "G.K. Chesterton once wrote that vulgar notions (and jokes) invariably contain a 'subtle and spiritual idea.' The subtle and spiritual idea behind 'death panels' is that life-prolonging medical technology is an expensive, limited commodity and if the market doesn't determine who gets it, someone else will. ... The resistance to incorporating end-of-life planning into Medicare is based on the rational fear that such planning will be used to coax patients into forgoing life-extending technologies that Medicare administrators may deem risky, of marginal benefit, or unlikely to succeed--an estimation that could be based in part on the cost of the technology.

Finally, the polemicist. Also supporting "death panels" that link end-of-life planning and health care rationing is Michael F. Cannon, director of health policy studies at the Cato Institute. He defended the term after it was called "Lie of the Year." He wrote, "President Obama had just proposed a government panel that, under standard principles of administrative law, would have the power to ration medical care just as Palin predicted. For support, I quoted a former Medicare administrator and other Medicare scholars. ... [T]he evidence shows that ObamaCare is a government takeover of health care, and Sarah Palin's 'death panels' claim was essentially true. If that makes me Liar of the Year, so be it."

Reimbursement for end-of-life planning had been proposed and withdrawn from health care reform, and enacted and again withdrawn, over fears that it's a hidden form of rationing health care. The term 'death panels' was effective, but it escalated reimbursement policies into a political issue.

(For further reading on how to ease end-of-life counseling, ACP's clinical practice guidelines appear in the Annals of Internal Medicine.)

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Friday, January 21, 2011

Should doctors be banned from asking if a patient owns a gun?

Via an article entitled "Proposed Law Would Ban Docs From Asking If Patient Owns Gun" from First Coast News:

TALLAHASSEE, Fla.--A state lawmaker has filed a bill that would ban doctors from asking their patients if they have a gun in the home.

Rep. Jason Brodeur, R-Sanford, said he has heard of a number of cases in which doctors asked their patients that question, which he thinks should be off limits.

Gun Smoke Red By The Knowles Gallery (Charles Knowles) via Flickr"What we don't want to do is have law-abiding firearm owners worried that the information is going to be recorded and then sent to their insurance company," he said. "If they're on Medicaid maybe it's sent to the government. If the overreaching federal government actually takes over health care, they're worried that Washington, D.C., is going to know whether or not they own a gun and so this is really just a privacy protection."

Under the legislation, a doctor could face a fine of up to $5 million or be sent to prison for up to five years for asking about guns in the home.


I understand the stated intent as recorded in this news item: Gun ownership is being recorded, lots of things are reported to insurance companies and the government, and this bill is an attempt to keep this information out of those circles, at least as obtained in a doctor's office where people still believe what they say is between them and their doctor. It should be, but lots of things should be absolute that aren't.

Also, as a gun owner I'm aware there are individuals and groups who want to do away with private firearms ownership. I don't believe in black helocopters or vast conspiracies. I do believe that given the right crisis guns have been grabbed on flimsy pretense (New Orleans after Katrina, for instance). I do not believe making more lists of gun owners is a terrific idea. (Standard "no violent felons," etc. disclaimer here: If you're not allowed by law to have them, then don't, and I won't cry when yours are taken legally.)

Guns are able to be kept safely in homes provided the gun owners (and parents of children) exercise diligence. I think pediatricians asking about guns in the home (providing it's not, "Do you have an Eeeevil Gun! Gun! in your home?!") can be useful to prevent tragedy. Before you start typing, shot kids are a tragedy--a preventable one when precautions are taken. From a public health standpoint, asking about guns in the home is on par with car seats from a "user right" standpoint. One dead kid from an unsecured weapon is too many. Shot adults are a similar tragedy, but they're not the group impacted by the usual doctors (pediatricians) asking about guns in the home.

This law is wrong. I have no doubt it would be overturned in court as a restriction on speech (which it certainly is), and it's, well, kinda dumb. Want to keep lists like this out of the hands of insurance companies and Medicaid? Use your legislative authority and prevent them from keeping such lists. Problem solved: Nobody's free-speech rights are infringed and doctors can get back to public health interventions.

(As an adult ER doc, I never ask this. I live in Texas and presume everyone has a gun in the home.)

Oh, and my personal way to prevent firearms accidents in kids: Lock them up (the metal things) until they're old enough to get right from wrong, then demystify the guns. This way they're no longer forbidden objects to be sought out, they're tools they know about, they know (generally) how they work, and they know to leave a house if a friend finds a mysterious gun.

This post by Allen Roberts, 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--Vaccines' link to autism like un-ringing a bell

18% of American believe that vaccines can cause autism, 30% remain unsure and 52% of Americans don't think vaccines can cause autism, according to public opinion polling done after research linking vaccines to the condition was reported as fraudulent.

While 69% of respondents said they had heard about an association between vaccination and autism, 47% knew that the original Lancet study had been retracted, and that recently the research is reported as being fraudulent.

The poll also found that 86% of parents who have doubts about the vaccine said that their children were fully vaccinated, compared to 98% of parents who believe vaccines are safe, and that 92% of children are fully vaccinated.

The poll was conducted after news reports were published that said Andrew Wakefield, the lead researcher of the research linking autism to the MMR vaccine, had used faked data.

More than 20 studies since Wakefield's have disputed the association between vaccination and autism.

The online survey of 2,026 adults from Jan. 11 to 13 was done by Harris Interactive and HealthDay. (AP/Fox News, CNN, BMJ, WebMD)

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What's new in hypertension with JNC 8 on the horizon?

If David Letterman were to make a Top Ten list called: "Things that Doctors do that Really Matter," treating hypertension would certainly make the cut. Hypertension is highly prevalent within our society, with about one in three U.S. adults affected. The relationship between blood pressure and cardiovascular risk is continuous and independent of other cardiovascular risk factors. Treatment of hypertension has been demonstrated to reduce risk of stroke by 35 to 40% and risk of myocardial infarction by 20 to 25%. If you are reading this thinking, "but I've always had low blood pressure," here's some cheerful news: 90% of adults who have normal blood pressure at age 55 will develop hypertension as they age. Thus, the detection and appropriate management of elevated blood pressure is one of the most important tasks in the practice of providing primary care to adult patients.

Those of us who treat hypertension hopefully have heard of the Joint National Committee (JNC) guidelines on hypertension. The latest set, "JNC 7," came out in 2003. Since 1978, when the National Heart, Lung and Blood Institute (NHLBI) formed its first multidisciplinary panel (JNC 1) to review the evidence and formulate its summary, these guidelines have been the major clinical practice rule set governing appropriate treatment of hypertension. It's been nearly a decade and JNC 8 is expected to be released in the spring of 2011.

Recently I had the pleasure of listening to a talk at the Georgia Chapter meeting of the American College of Cardiology by Dr. Keith Ferdinand, Clinical Professor of Medicine, Division of Cardiology at Emory and Chief Science Officer of the Association of Black Cardiologists. Dr. Ferdinand, who has served on previous NHLBI JNC committees reviewed the last decade of data that is likely to impact the newest set of hypertension guidelines.

Some of my take home points from this talk are listed below:

Evidence supports the treatment of hypertension in octogenarians. Patients treated with indapamide (a diuretic) with or without perindopril (an ACE inhibitor) had 30% reduced risk of stroke and a 21% reduced risk of death from any cause.

The blood pressure treatment goal for diabetic patients may be revised, based on the ACCORD intensive blood pressure lowering trial, to less than 140/90 (currently less than 130/80). ACCORD found no cardiovascular benefit for the primary endpoint with more aggressive lowering of blood pressure (to less than 120 systolic versus less than 140 systolic) in high risk hypertensive diabetic patients.

ACCORD did find a small reduction in a secondary endpoint, total stroke and non-fatal stroke, in study participants treated to the more aggressive blood pressure goal. In addition the placebo group in ACCORD was noted to have on average relatively well controlled blood pressure.

The ONTARGET trials found that there is not good evidence to support either renal or cardiovascular benefit from the combined use of ace inhibitors with ARBs for high risk patients. These randomized controlled trials looked at ramipril, telmasartan, and their combined use with respect to renal and cardiovascular outcomes.

In refractory hypertensive patients, spironolactone 25 mg should be considered as an additional agent.

Amongst the class of thiazide diuretics there may be differences amongst agents and their prescribed dosages in terms of efficacy for cardiovascular risk reduction. The longer acting chlorthalidone may be more effective than the shorter acting hydrochlorothiazide. Some of the most widely cited studies providing evidence for the use of thiazides as first line treatment for hypertension are based on study of chlorthalidone or using higher doses of HCTZ (50 mg) than those normally prescribed.

The combination of ACE inhibitor (benazepril) and dihydropyridine calcium channel blockers (amlodipine) may be superior to the ace inhibitor and diuretic (hydrochlorothiazide) combination for hypertension treatment (ACCOMPLISH).

Atenolol is falling out of favor, with a relative lack of evidence supporting its use as a first line therapy for hypertension. More attention is likely to be given to beta blocker selection on the basis of demonstrated cardiovascular outcomes (metoprolol, carvedilol) in JNC 8.

As a primary care physician I found it very useful to hear Dr. Ferdinand's opinion about what's to come with respect to JNC 8's hypertension guidelines. I already will be changing some of my practice based on this knowledge. I look forward to reading the guidelines and hearing the reaction of experts in the spring of 2011. It appears as though with hypertension, as with other fields of medicine, there will be a growing emphasis on specific drug and dose selection as opposed to class of drug selection.

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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Thursday, January 20, 2011

Mississippi learning

Governor Haley Barbour of Mississippi recently suspended the life sentences of sisters Gladys and Jamie Scott on the condition that Gladys donate a kidney to her older sister Jamie, who has end-stage kidney failure and is dependent on dialysis treatment three times per week.

The sisters served sixteen years of their life sentences, and had become a cause celebre in social justice circles (both the NAACP and the ACLU were involved in their petitions to overturn the sentences) for the harshness of their punishments. Their crime? In 1994 they were convicted of being accomplices to an armed robbery that netted the main bandits $11 in cash, according to press reports.

Gov. Barbour is on record stating that he no longer felt the sisters were a danger to society. That and Jamie's dialysis is costing the state prison system on the order of $200,000 per year.

In her petition for pardon, younger sister Gladys came up with the idea to donate one of her kidneys to her big sister. She was quoted as saying that she made the decision herself and would go through with it, pardon or no pardon. [The sisters were pointedly not pardoned; they merely had their sentences suspended. Their petition to seek pardons continues, with or without a transplant.]

The conditional release set off a furor in parts of the medical community, particularly the transplant and medical ethics sectors. The President of the American Society of Transplantation wrote a letter to Governor Barbour "respectfully requesting" him to de-link the kidney donation from the suspension of their sentences. The linkage gives the impression of a quid-pro-quo: "You donate your kidney, we'll let you out of jail." Such coercive tactics are not morally, ethically, or legally permitted in the United States, where the law of the land (NOTA, 1984) forbids commerce (or even 'objects of value') in exchange for organs.

I've thought about this story a lot; I concluded it would be fun and interesting to break down the plot and its meanings from all of the players' perspectives:

Jamie Scott: I'm sick: Sick of being in jail for a pretty small crime, and sick from kidney disease. Did I mention sick of dialysis treatments? Verdict: Win-win: out of jail, and possibly a kidney which will be better treatment.

Gladys Scott: I'm happy to help my sister, jail or no jail. Governor wants me to donate as a condition of getting out, then so be it. I'd do it anyway. Verdict: win-win, doing a mitzvah, getting out of jail. Potential cost: donor surgery. Also, potential for re-incarceration if she doesn't wind up donating, though pundits think that's unlikely.

Governor Barbour: I'm letting these sisters out, which seems like the right thing. But I'm extracting the promise that one sister will donate to the other. This pleases my conservative constituencies. Verdict: win-win, he gets to placate both sides by his actions, and look fiscally prudent as well (the state will save the estimated $200,000 per year). The sisters promptly moved to Florida after their release, which will invoke federal and Florida money for their future health care needs.

Other patients awaiting kidney transplants: There's hope that one day our country will increase the likelihood of someone donating to me by offering incentives to do so. Verdict: hung jury.

Other potential kidney donors: This lady got something in return for her kidney (her freedom). What will I get other than gratitude? Surely my kidney must have some market value? Maybe at least if I go through with this I could get my health care for life paid for? Verdict: double jeopardy.

The hospital where the proposed transplant may happen in the future: We'll benefit from the media attention; we must be careful not to look like we condone the Governor's quid-pro-quo appearing deal, and say the 'right' things. Verdict: win, with some downside potential.

Medical ethicists: This trade defies our current norms; there is a lot of debate in our community about compensating donors; most stakeholders remain resolutely opposed to compensating donors, though there seems to be a rising chorus of critics interested in changing these norms. Verdict: lose-lose, looking like sticks in the mud (implying that for principle Gladys should stay in jail), and having our values trampled by political (and medical/economic) opportunism.

What are your opinions on this story?

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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QD: News Every Day--Formal votes begin to scuttle health care reform

The U.S. House voted 245 to 189 to repeal health care reform on Wednesday night, and began today the committee work to draft a replacement measure. Committees are looking at eliminating "job-killing" legislation (that is, health care reform itself), organizing oversight committees as the White House attempts to implement the law, and eventually defunding provisions required to carry out the act, such as cutting funding for Health and Human Services studies.

The repeal vote is not just symbolic, Republicans assert. While the reform repeal legislation will proceed no further, the House will continue to defund and oversee the administrations' efforts to bring the law into ... well, into law. A lot has to happen by 2014, when more of the act's provisions kick in, and Republicans hope to chip away at the act, all while gathering ammunition on health care reform (and in a larger sense, government spending as a whole) for future elections.

Amid all the debate, a lot of representatives on both sides of the aisle cling to a few statistics to promote their views. Health reform will kill jobs, or have little impact whatsoever. It will increase or decrease the deficit. It will cover more lives or lead covered lives to go untreated. A little bit of myth-busting is in order, then. Check out analyses here and here. (CNN, Boston Globe, The Leader [Corning, N.Y.], New York Times, Politico, The Hill, Washington Post, AP)

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Point-and-click medicine: The EMR game

Whistleblower readers know of my criticisms of the electronic medical record (EMR) juggernaut that is oozing over the medical landscape. Ultimately, this technology will make medical care better and easier to practice. All systems will be integrated, so that a physician will have instant access to his patients' medical data from other physicians' offices, emergency rooms and hospitals.

In addition, data input in the physician's office will use reliable voice activated technology, so that some antiquated physician behaviors, such as eye contact, can still occur. Clearly, EMR is in transition. I place it on the 40-yard line, a long way from a touch down or field goal position.

A colleague related a distressing meeting he had at the community hospital he works at. This hospital, like nearly every hospital in Cleveland, is owned by one of the two towering medical behemoths. I'm not a businessman, but I have learned that when something owns you, it's generally better for the owner than the owned. This meeting was about the hospital's upcoming EMR policy. Sometimes, these hospital meetings are ostensibly to seek physician input, but the true purpose is to inform the medical staff about decisions that have already been made.

In the coming months, this hospital will adopt a computerized ordering system for all patients. In theory, this would be a welcome advance. It would create a digital and permanent record of all physician orders that could be accessed by all medical personnel involved in the patients' care. It would solve the perennial problem of inscrutable physician handwriting, including mine.

One advantage that computerized ordering aficionados claim is that physicians' orders can now be standardized for various medical conditions, such as stroke, congestive heart failure and diabetes. Of course, patients are unique and may not neatly fit into packaged computerized ordering templates. Will deviating from these standard order sheets by easy, or will we need a 14-year old beside us to help us over the cyber hurdles? Most of us have been issuing medical orders on paper for decades, without loss of life or limb. When I write an order with a pen for a potassium supplement, for example, I have not found the task to be onerous. Will the computerized system be another example of solving problems that I didn't know that I had?

One of the physicians at the hospital meeting asked if the verbal order policy would remain. The response suggested that verbal orders would no longer be permitted. The physicians wondered how they would give admitting or other orders at 2 a.m. Would they have to boot up a computer at that time? What if a nurse calls for an urgent blood transfusion order when the physician is in his car? Does this enlightened verbal order "reform" sound like it originated from folks who understand doctors?

I have to hope that the speaker was misinformed, as this aspect of the policy is simply too dumb to survive, at least I hope so.

I am not a Luddite who opposes EMR on ideological grounds. I believe, and have written, that once perfected, it will accomplish its mission. My quarrel is with those who already claim that the goal line has been reached, or is in sight. I also believe that many of these systems were designed by folks who don't practice medicine or understand physicians' needs. What's good for billers and coders may not help physicians in exam rooms with living, breathing patients.

I am sure that most physicians who are retiring now do not regret that they will miss the steep vertical climb from paper to electronic medical practice. Personally, I am glad to be part of it, although I wish that "point-and-click" medicine was more about medicine than about pointing and clicking.

Perhaps, this approach can be extended to blogging. Right now, it takes me a while to pound out these posts. If I could use a packaged medical ranting blogging template instead, then I could post a Whistleblower twice daily. Point-and-click blogging. Hmm. I can see the goal line. Become a subscriber!

This post by Michael Kirsch, FACP, 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, January 19, 2011

QD: News Every Day--Physicians more pessimistic than patients about health care reform

While public opposition to health care reform has diminished since its passage, physician opinions are still negative, especially among specialists who see their value to the health care system decreasing as reform emphasizes primary care.

A survey reports that 65% of nearly 3,000 physicians in all specialties said the quality of health care in the country will deteriorate in the next five years. 17% of respondents believe the quality of health care will stay the same and 18% believe it will improve. Meanwhile, 30% of health care consumers believe that the quality of health care will improve.

Physicians cited as reasons for their pessimism personal political beliefs, anger at insurance companies and a lack of accurate planning in the reform act. Other reasons include that primary care physicians won't have the time to keep up with the extra workload, forcing more patients to depend upon nurse practitioners for primary care. When asked who will likely handle the 32 million Americans expected to receive health care following passage of the reform, 44% said primary care physicians will handle the load and 44% said that nurse practitioners will see them. (Physicians could vote for more than one category; options includes physicians assistants and specialists, for example.)

Among all physician respondents, 58% said health care reform would have a negative impact on patient care, 15% said it would have no effect and 27% said it would have a positive impact. Pediatricians and psychiatrists were the most optimistic, with 45% and 48% respectively believing that health care reform will have a positive effect. They were closely followed by primary care physicians (including family practitioners and internists), although more than half of this group expected health care reform would have a negative effect. Specialists in cardiology, dermatology, gastroenterology, and obstetrics/gynecology were more likely to believe health care would have a negative effect on patient care. Nearly 70% of surgeons felt so, and nearly 75% of ophthalmologists believed so.

The survey, which is ominously called "The 2011 National Physicians Survey Frustration and Dismay in a Time of Change," was conducted by HCPlexus, a health care consulting firm. Nearly 3,000 physicians (more than 900 of whom were in primary care) in all states and all specialties were asked about their perceptions of health care reform. The data was then tied to consumer health care opinion surveys done by Thomson Reuters.

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Ovarian cancer screening is still subpar

Cancer of the ovary is a particularly nasty disease. It often remains asymptomatic until it has reached an advanced, incurable stage, and scientists have been unable to develop an effective screening test for the disease like the ones in widespread use for cancers of the breast and cervix.

Ovarian carcinoma, from Practical Gynecology: A Guide for the Primary Care Physician, 2nd Edition, copyright American College of PhysiciansThe dismal status of ovarian cancer screening was underscored a year ago when an NIH-sponsored study showed that over 70% of cancers detected by transvaginal ultrasound and CA 125 biomarker testing--the two best ovarian screening tests we've got--had reached stage III or IV at the time the patients screened positive. That's about what happens when women aren't screened at all.

That wasn't the worst of it, however. In just the first year of that screening program, positive test results obligated 566 surgical procedures which uncovered only 18 cancers. That's an awful lot of unnecessary surgery and associated morbidity right there. Things were no better on the false-negative side of things. Overall, 89 cases of ovarian cancer were diagnosed during the NIH study, and a third of them had been missed by both screening modalities.

What's new?

The NIH study didn't evaluate the impact of screening on ovarian cancer mortality, but a recent study by Laura Havrilesky, MD, and colleagues at Duke did indeed address the point. Sadly, the results were abysmal.

Dr. Havrilesky's team developed a modified a Markov model to characterize the natural history of ovarian cancer, and used it to show that mortality would fall by a paltry 11 percent if a widespread screening program (in this case, CA 125 biomarker testing followed by pelvic ultrasound imaging for women with abnormal results) was put into place.

The scientists emphasized that the protean nature of ovarian cancer--not just its tendency to remain asymptomatic until an advanced stage--was a huge challenge in developing an effective screening tool. According to their analysis, some ovarian cancers tend to grow slowly, taking nearly three years before progressing to an advanced stage. Other ovarian cancers are more aggressive, reaching an advanced stage after only 13 months.

"If we assume ovarian cancers grow and spread at different rates, the best screening strategy available will only reduce the number of women dying from the cancer by 11 percent," Dr. Havrilesky said in a press release. "This is partially because the slower growing cancers are more likely to be caught by a screening test."

The authors didn't exactly throw up their hands in disgust at the poor prospects for ovarian screening, but they did suggest that policymakers consider directing funds towards prevention and treatment of the disease, and away from screening.

That said, most experts do recommend routine screening for ovarian cancer in women that have a family history of the disease and in those who carry genes known to increase the risk of developing it. As always, women with questions about these issues should consult their doctors.

Dr. Havrilesky's article appears in the journal Cancer.

This post by Glenn Laffel, 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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Tuesday, January 18, 2011

Can doctors and lawyers both be right about defensive medicine?

Nothing polarizes the heath care debate more than defensive medicine. A recent study from Health Affairs will only add more fuel to the fire.

Here's what I wrote a couple of years ago in USA Today: "When you consider that rampant testing is a major driver of escalating health care dollars, addressing defensive medicine should be a primary goal of cost containment." Is that still true?

Well, yes and no. MedPage Today summarizes the findings: "Costs associated with medical malpractice added about $55.6 billion to the nation's total health care costs in 2008--roughly 2.4% of a more than $2.3-trillion tab--and most of that money went to pay for tests, procedures, and treatments associated with defensive medicine, according to an analysis by Harvard researchers ..."

A second paper by J. William Thomas, PhD, of the Cutler Institute for Health and Social Policy at the University of Southern Maine, in Portland, and colleagues, analyzed the costs of defensive medicine across 35 medical specialties and concluded that "defensive medicine practices exist and are widespread, but their impact on medical costs is small."

In other words, both the doctors and lawyers are right. Defensive medicine is rampant, per the doctors, but its cumulative cost effect is much smaller than most physicians think, per the lawyers. (Although I'd argue that adding $55.6 billion to the nation's annual health care costs should not be so easily dismissed.)

So, what's next? Politically, malpractice caps are dead; tort reformers should abandon that option. Furthermore, arguing that tort reform will save significant sums of money is growing less viable. It's more important to re-frame the malpractice debate to focus on patients. That's where the malpractice reform crowd will have more solid evidence to stand on. Again, in a previous USA Today op-ed: "... nearly one in six cases involving patients injured from medical errors received no payment. For patients who did receive compensation, they waited an average of five years before their case was decided, with one-third of claims requiring six years or more to resolve. These are long waits for patients and their families, who are forced to endure the uncertainty of whether they will be compensated or not. And with 54 cents of every dollar injured patients receive used to pay legal and administrative fees, the overhead costs clearly do not justify this level of inefficiency."

Those who want to reform the malpractice system--namely, the majority of physicians--would be much more persuasive if they focused on how the current system is wholly inadequate in treating injured patients. That's something that conservative-leaning tort reformers and progressive heath reformers can agree on.

And it's the only way that plausible solutions, like health courts or no-fault malpractice, can move forward.

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 40,000 subscribers and 28,000 Twitter followers, KevinMD.com is the Web's definitive site for influential health commentary.

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QD: News Every Day--The future health reform (all the way to 2030)

Health care reform gets its review in the U.S. House today and tomorrow, fulfilling a Republican campaign promise to try and repeal it.

Republicans state one motive is public opposition to the law, but the strongest opponents are weakening. Public opinion polling now shows opposition has fallen since the November elections from 47% to 41%, while support grew from 38% to 40%. Among those who self-identified as Republicans, calls for repeal dropped from 61% to 49%. One possible reason might be that more people are seeing tangible benefits for the first time--coverage for children until age 26, for example.

After passing in the House, the bill (its full text is here) will then promptly die in the Senate. The work in Congress then begins, as the House machinery begins to chip away at health care reform by de-funding the law's most unpopular provisions, such as taxes on insurers and the individual mandate, and keeping alternative health care reforms in play until the next elections in 2012, when they can try to garner more control in Congress. In the meantime, Democrats will try re-branding health care reform, especially the misconceptions about its impact, while also pointing out its benefits.

Health care reform will continue to see tweaks, adjustments and overhauls as it grows or wanes under shifting Congresses and White Houses. How will it all turn out? By 2030, the whole system gets fixed, in this sci-fi look into the future by columnist Ezra Klein. (AP/MSNBC, Detroit News, Kaiser Health News, Wall Street Journal, Los Angeles Times, The CT Mirror, The Washington Post)

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Monday, January 17, 2011

A video about a patient who might have too much information

A link to a video, the Too Informed Patient, came my way several times lately.


The Too Informed Patient from Marketplace.

The puppeteer skit features the interaction between a young man with a rash and his older physician. The patient is an informed kind of guy--he's checked his own medical record on the doctor's website, read up on rashes in the Boston Globe, checked pix on WebMD, seen an episode of Gray's Anatomy about a rash and, most inventively, checked i-Diagnose, a hypothetical app (I hope) that led him to the conclusion that he might have epidermal necrosis.

Not to worry, the patient informs Dr. Matthews, who meanwhile has been trying to examine him ("say aaahhh" and more), he's eligible for an experimental protocol. After some back-and-forth in which the doctor, who's been quite courteous until this point--calling the patient "Mr. Horcher," for example and not admonishing the patient who's got so many ideas of his own, the doctor says that the patient may be exacerbating the condition by scratching it, and questions the wisdom of taking an experimental treatment for a rash.

"I just need you to sign this paper," says the patient.

The doctor-puppet pauses momentarily, seemingly resigned to a new role. After the patient leaves, the doctor thinks to weigh himself. The skit ends with the sounds of keyboard typing.

The piece supplies thought-provoking details in under two-and-a-half minutes. It's a useful teaching tool, among other things. There's been some discussion about it on the NPR site, the Patient Empowered Blog, the Health Care Blog and elsewhere. Some comments suggest annoyance, that the "informed patient" is misrepresented here as exaggerated or foolish, or that the skit is off-mark.

To me it rings true, representing an older doctor who's trying, open-mindedly but not at the cutting edge, to embrace new technology, and has the patient's interests at heart. His efforts and his knowledge are set aside.

[Thanks to the team who created this insightful production: produced by Gregory Warner and Mara Zepeda. Created by Sebastienne Mundheim of White Box Theatre, acted by Charles DelMarcelle and Doug Greene, and voiced by two actors from Philadelphia’s Pig Iron Theatre Company, and to NPR's Marketplace for presenting.]

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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Friday, January 14, 2011

QD: News Every Day--Primary care shortage worsening across the country

Primary care shortages are worsening around the country. Arkansas needs about 1,000 primary care physicians right now. In upstate New York, a third of hospitals have curtailed some services because of the shortage, forcing them to transfer patients to other facilities or hire temporary physicians. Rural areas of California are seeing a graying of their physician population, with 30% older than 60, and younger doctors aren't taking their place.

Primary care physicians in each community note that more patients defer care, seek it out in emergency rooms or travel hours to get what they need. And despite dedicated rural recruitment programs, or in some cases just a dedicated resident trying to recruit more peers, these areas will continue to experience a shortage. (Today's THV, [Syracuse] Post-Standard, San Francisco Chronicle, California HealthLine)

Health care reform
Debate to repeal health care reform will begin Tuesday in the U.S. House, testing how well Republicans can gain momentum in the wake of the shooting of U.S. Rep. Gabrielle Giffords.

All eyes will be on the tone of the debate. Health care debates have been particularly violent, and the bill will keep its name of "Repealing the Job-Killing Health Care Law Act." The plan is to try to keep debate focused on the law's impact, so expect message discipline to be strictly focused on the law's effects on jobs and the economy. (Washington Post, Politico, New York Times, Wall Street Journal.)

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Blog log

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Other blogs of note:

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

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

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

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

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

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