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

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Monday, February 28, 2011

QD: News Every Day--Travelers bring measles back to the U.S.

Two separate incidents have prompted health officials to inoculate travelers and co-workers of people who brought active measles infections with them into the U.S.

The first was a woman returning to from London, connecting through Denver International Airport to Albuquerque, N.M. Health officials are still seeking people who may have sat near the woman on the plane. The second woman returned from France to her office in Boston while ill, reports Reuters. Officials inoculated 180 co-workers in the building.

Photo by CDC/ Cynthia S. Goldsmith; William Bellini, Ph.D. This thin-section transmission electron micrograph revealed the ultrastructural appearance of a single virus particle, or The Centers for Disease Control and Prevention reports that measles outbreaks occur regularly on a global basis. "Measles outbreaks are common in many areas, including Europe, making the risk for exposure to measles high for many U.S. travelers and U.S. citizens living in other countries (expatriates)," says the CDC website. "Because of this risk of measles in both developed and developing countries, all international travelers should be up to date on immunizations, regardless of the travel destination. In addition, expatriates should make sure they are vaccinated against measles, especially in areas where outbreaks are reported."

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Friday, February 25, 2011

QD--News Every Day: Doctors' garments colonized by bacteria within hours of starting work

Bacterial contamination of physicians' newly laundered uniforms occurs within three hours of putting them on, making them no more or less dirty than the traditional white coats, researchers reported.

This colorized 2005 scanning electron micrograph depicts numerous clumps of methicillin-resistant Staphylococcus aureus bacteria, magnified 2,390 times. Content provided by CDC/Jeff Hageman, MHS, via the CDC's Public Health Image Library (PHIL)Researchers sought to compare bacterial and methicillin-resistant Staphylococcus aureus contamination of physicians' white coats to freshly laundered short-sleeved uniforms, and to determine the rate at which bacterial contamination happens. They reported results in the Journal of Hospital Medicine.

ACP Internist's blog recently took up the debate as well. The issue has cropped up over the years, assessing not only the cleanliness but the professionalism inherent in the white lab coat.

Researchers conducted a prospective, randomized, controlled trial among 100 residents and hospitalists on an internal medicine service at Denver Health, a university-affiliated public safety-net hospital. Subjects wore a white coat or a laundered, short-sleeved uniform.

At the end of an eight-hour workday, no significant differences were found between the extent of bacterial or MRSA contamination of infrequently washed white coats compared to the laundered uniforms. Sleeve cuffs of white coats were slightly but significantly more contaminated than the pockets or the midsleeves, "but interestingly, we found no difference in colony count from cultures taken from the skin at the wrists of the subjects wearing either garment," researchers wrote.

And, there was no association found between the extent of bacterial or MRSA contamination and the frequency with which white coats were washed or changed. Colony counts of newly laundered uniforms were essentially zero, but after three hours they were nearly 50% of those counted at eight hours.

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How the Internet hijacks medical science

In his new book, "Tabloid Medicine: How The Internet Is Being Used to Hijack Medical Science for Fear and Profit," Robert Goldberg, PhD, explains why the Internet is a double-edged sword when it comes to health information. On the one hand, the Web can empower people with quality medical information that can help them make informed decisions. On the other hand, the Web is an unfiltered breeding ground for urban legends, fear-mongering and snake oil salesmen.

Snake oil! By tellumo via FlickrGoldberg uses case studies to expose the sinister side of health misinformation. Perhaps the most compelling example of a medical "manufactroversy" (defined as a manufactured controversy that is motivated by profit or extreme ideology to intentionally create public confusion about an issue that is not in dispute) is the anti-vaccine movement. Thanks to the efforts of corrupt scientists, personal injury lawyers, self-proclaimed medical experts, and Hollywood starlets, a false link between vaccines and autism has been promoted on a global scale via the Internet. The resulting panic, legal feeding frenzy, money-making alternative medicine sales, and reduction in childhood vaccination rates (causing countless preventable deaths), are sickening and tragic.

As Goldberg continues to explore the hyperbole behind specific "health threats," a fascinating pattern emerges. Behind the most powerful manufactroversies lies a predictable formula: First, a new problem is generated by redefining terminology. For example, an autism "epidemic" suddenly exists when a wide range of childhood mental health diagnoses are all reclassified as part of an autism spectrum. The reclassification creates the appearance of a surge in autism cases, and that sets the stage for cause-seeking.

Second, "instant experts" immediately proclaim that they have special insight into the cause. They enjoy the authority and attention that their unique "expertise" brings them and begin to position themselves as a "little guy" crusader against injustice. They also are likely to spin conspiracy theories about government cover-ups or pharmaceutical malfeasance to make their case more appealing to the media. In many cases the experts have a financial incentive in promoting their point of view (they sell treatments or promote their books, for example).

Third, because mainstream media craves David and Goliath stories and always wants to be the first to break news, they often report the information without thorough fact-checking. This results in the phenomenon of "Tabloid Medicine."

Fourth, once the news has been reported by a mainstream media outlet, the general population assumes it's credible, and a groundswell of fear drives online conversation on blogs, websites, and social media platforms.

And finally, celebrities take up the cause while personal injury lawyers feast on frightened consumers who now believe that they are victims of harm perpetrated on them by the "medical industrial complex." Meanwhile flustered government health officials have no scientific evidence of harm, but cannot prove a lack of association without further research (and that takes time). So they offer what seems like tepid reassurances, which are perceived by some to be tantamount to an admission of guilt.

And that's how a lie becomes an urban legend. Perception is nine-tenths of reality.

st jacobs oil by Tim & Selena Middleton via FlickrHow is it that we fall for manufactroversies again and again? Goldberg argues that the answer may be found in our own psyches: "People aren't programmed to respond to [science]; we are made to be moved by the individual and the identifiable and to generalize from the single to the many." (p. 177)

In other words, good science doesn't make good television. We are suckers for an emotional story, we aren't good at understanding relative risks, and we will always be more scared of sharks than automobiles, even though the latter kill exponentially higher numbers of us.

Beyond the fact that we are internally programmed to listen more closely to hysteria than reality, Goldberg suggests that there's another barrier to medical progress. And that is our fundamental belief that medicines should present us with zero risk. As a culture we have developed a risk aversion to treatment options that is so strong that we expect the FDA to discontinue a drug at the first whiff of a concern, real or perceived. We have adopted the Precautionary Principle: "The Precautionary Principle does not merely ask us to hypothesize about and try to predict outcomes of particular actions, whether these outcomes are positive or negative. Rather, it demands that we take regulatory action on the basis of possible 'unmanageable' risks, even after tests have been conducted that find no evidence of harm. We are asked to make decisions to curb actions, not on the basis of what we know, but on the basis of what we do not know." (p. 40)

And thanks to the Internet's ability to decrease the signal to noise ratio, perceived harms of various medications can result in full blown manufactroversies with lightening speed. Goldberg cites several cases where life-saving drugs have been withdrawn from the market because of a negligible risk in a small sub-population of patients, leaving those who would benefit to search for the drug overseas or to simply suffer without treatment. In other cases, tiny risks are blown out of proportion, so that the benefits that outweigh them are ignored at patients' peril.

In this new Internet era, Goldberg suggests that Americans need to develop more highly developed critical thinking skills, so that they can detect the difference between a true health benefit (or threat) and an exaggerated one (promoted by "Tabloid Medicine"). There has never been a greater need for physician and scientist "voices of reason" to speak out via online media to provide guidance to a public assailed daily by claims of "miracle cures" and "deadly environmental hazards."

In the end, Goldberg argues that personalized medicine, and a search for biomarkers that can predict patient response before they begin a medical treatment, may be the best way to reduce the risk of harm and maximize health benefits. His theory is that if drug side effects can be reduced to near zero, there won't be as much hysteria and misinformation online about them.

As for me, I know that I still think about sharks when I go to the beach. I can't help it. It's hard-wired. However, I also have an inner dialogue about how irrational I'm being, and how I'm more likely to be hit by lightning than eaten by a great white. I think that if we can help people (including the mainstream media) to add that second sanity narrative back into our health conversations, we'll have more true patient empowerment.

In my opinion, personalized medicine is part of the solution, but it doesn't solve the deeper issue within each of us, that we will always be drawn to exaggerated claims and "sexy" news headlines. Healthy skepticism comes with education and self-awareness, the pursuit of both is what makes a true Scientific American.

Related books I also recommend:
Snake Oil Science: The Truth About Complementary And Alternative Medicine Barker Bausell takes a look at how we draw false conclusions from scientific studies and how snake oil salesmen justify what they do.

Deadly Choices: How the Anti-Vaccine Movement Threatens Us All Paul Offit delves deeply into the greatest manufactroversy of recent times.

Bad Science: Quacks, Hacks, and Big Pharma Flacks Ben Goldacre describes some modern day snake oil salesmen in Britain, and how they pull off their lies.

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

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Thursday, February 24, 2011

QD: News Every Day--The five most expensive prescription drug classes are ...

The top five therapeutic classes ranked by total expense are metabolic, central nervous system, cardiovascular, gastrointestinal, and psychotherapeutic, altogether totaling $155.7 billion, or two-thirds of prescription drug expenses by U.S. adults in 2008.

Two-thirds of American adults use a prescription drug, totaling the $232.6 billion in expenses. The Agency for Healthcare Research and Quality compiled a statistical brief showing that drug classes varied widely in how they made the top five list. While 46% of adults with a prescribed drug expense bought a central nervous system agent, they are relatively cheaper on average. Gastrointestinal agents had the highest average expense per prescription ($133), or more than three times the average expense of the cheapest class, which was cardiovascular agents ($39). But 46% of adults who take a prescription drug use a central nervous system agent, while 17.7% take a gastroenterological one.

Metabolic agents had the highest total expenses ($52.2 billion), or more than one-fifth of all prescription drug expenses. The rest of the list by total expenditures were central nervous system agents ($35.1 billion), cardiovascular agents ($28.6 billion), gastrointestinal agents ($20.2 billion), and psychotherapeutic agents ($19.6 billion).

The estimates presented are derived from the Household and Pharmacy Components of the 2008 Medical Expenditure Panel Survey (MEPS). Expenditures include payments from all sources including out of pocket, private and public insurance sources for outpatient prescription drug purchases during 2008. Over-the-counter medicines are excluded, as are prescription medicines administered in an inpatient setting, clinic or physician's office.

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Wednesday, February 23, 2011

QD: News Every Day--Statins rose tenfold as their use in primary prevention is questioned

The percentage of adults 45 years of age and over taking statins increased from 2% in 1988-1994 to 25% in 2005-2008, reports the chartbook "Health, United States 2010" released by the National Center for Health Statistics of the Centers for Disease Control and Prevention. In 2005–2008 nearly one-half of men 65 to 74 years of age took a statin drug in the past 30 days, compared with just over one-third of women in that age group.

Health, United States from the National Center for Health Statistics, Centers for Disease Control and Prevention.The chartbook reported a concurrent decline in the percentage of Americans with high serum total cholesterol (greater than or equal to 240 mg/dL), which may be attributable to increased use of cholesterol-lowering medications, especially statins.

Initial studies of statins' cholesterol lowering effects in the New England Journal of Medicine and the Journal of the American Medical Associationin patients at high-risk for heart disease contributed to widespread belief it would work in all patients.

But in the past year, using statins for primary prevention has come into question. A meta-analysis in the Archives of Internal Medicinecombined data from 11 randomized trials involving 65,229 participants followed for approximately 244,000 person-years. Researchers found no statistically significant benefit of statins on mortality, even in the highest risk group (risk ratio, 0.91; 95% confidence interval, 0.83-1.01).

And, a systematic review of the effects of statins reported in the Cochrane Database of Systematic Reviews suggests that the evidence is less clear for people without a past history of cardiovascular disease. Researchers conducted a systematic review of 14 randomized control trials (34,272 patients) dating from 1994 to 2006, all comparing statins with usual care or placebo. Duration of treatment was minimum one year and with follow up of a minimum of six months.

"Although reductions in all-cause mortality, composite endpoints and revascularizations were found with no excess of adverse events, there was evidence of selective reporting of outcomes, failure to report adverse events and inclusion of people with cardiovascular disease," the authors wrote. "Only limited evidence showed that primary prevention with statins may be cost effective and improve patient quality of life."

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Tuesday, February 22, 2011

QD: News Every Day--Internist's newest patient is an entire neighborhood

Yale Internist Gregg Furie, MD, is taking on an entire neighborhood as part of an urban design project in New Haven, Conn. He and a pediatrician will aid the city and designers on their Downtown Crossing/Route 34 project to create a healthier, more pedestrian-friendly environment.

The 10-acre project will change access to the interstate, build an office tower, link the city's downtown to its medical district and add pedestrian- and bicycle-friendly streets. Dr. Furie told the New Haven Independent that the assessment is "a relatively new tool for urban planners to identify impacts and minimize adverse effects in advance."

The three areas of Dr. Furie's diagnosis will be pedestrian and bike safety, more activities for walkers and decreasing the more than 200 accidents that have occurred annually for the past three years.

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Monday, February 21, 2011

QD: News Every Day--Circadian rhythms influence coronary stent thrombosis

Add coronary stent thrombosis to the list of cardiac events influenced by circadian rhythms, with more events occurring during the early morning hours and in a summertime window of late July and early August.

Coronary stent thrombosis joins several other adverse cardiac events that also follow a circadian pattern, such as stroke, unstable angina pectoris, acute myocardial infarction and sudden cardiac death, according to researcher published in JACC: Cardiovascular Interventions.

you've been warned by Robert Couse-Baker via FlickrMost studies that addressed circadian variations in cardiovascular disease were done before the advent of stents, so, researcher from Mayo Clinic-Rochester conducted a retrospective analysis of medical records and the clinic's registry, finding 124 patients who presented with coronary stent thrombosis between February 1995 and August 2009.

Researchers determined the time of day, day of week, and season of year that the stent thrombosis occurred and recorded when potential triggers were present. In addition, the team categorized each stent thrombosis based on the number of days since the initial stenting procedure: early=0 to 30, late=31 to 360 days, very late=more than 360 days.

The association between the onset of stent thrombosis was lowest at 8 p.m. and highest at 7 a.m. (P=0.006). However, when the team divided the analysis into early, late, and very late stent thrombosis, only the association between early stent thrombosis and time of day remained significant (P=0.030, P=0.537, P=0.096, respectively). Day of week wasn't associated, but stent thrombosis rates peaked between the end of July and the beginning of August (P=0.036)

In search of potential triggers, the team determined physical activity level before the onset of stent thrombosis in 62 patients. Of these patients, 33.9% were sleeping, 25.8% were lying or sitting, 29.0% were engaged in light-to-moderate physical exertion, and 11.3% were engaged in heavy physical exertion. Other medical conditions were also identified as possible triggers among the full 124-patient study sample, including medication noncompliance (5.6%), hospitalization for surgery or invasive diagnostics (4%), and acute infections (4%).

Authors speculated on physiological factors that may contribute to stent thrombosis in the morning hours: hypercoagulability and hypofibrinolysis; a higher activity level of the renin-angiotensin-aldosterone hormone system between 6 a.m. and 8 a.m., which causes higher blood pressure and heart rate; a higher degree of blood viscosity in the morning, which is magnified by sitting upright after a night of supine sleep; and lowered levels of antithrombotic medication in the morning just before the patient awakens and takes a new dose.

The lack of an association between stent thrombosis and the day of the week is unlike other adverse cardiac events that occur more often on Mondays. Researchers believe that that mental stress from employment plays a more limited role in stent thrombosis. A higher rate of stent thrombosis in the summer months, meanwhile, may be attributed to higher activity levels in warm weather.

While stent thrombosis has decreased in recent years because of dual antiplatelet therapy and improved stent design, researchers said further benefits could result from some simple steps, such as optimizing medical treatment during high-risk periods and taking antithrombotic medication in the evening rather than in the morning to prevent lowest levels of medication during the most hazardous hours.

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Un-maligning the ER

As I mentioned in an earlier post, the ER is the portal of entry to our hospitals now, for better and for worse.

On the plus side, this means that most patients being admitted to general medical and surgical services (the big exception here is elective surgery--patients having elective operations don't need to be triaged) have a workup at least started and are triaged appropriately to their destination.

A good ER evaluation should answer the following questions:
1. What's the nature of the illness? Are we dealing with the heart, the brain, or an abdominal organ? Is the cause an infection, a blockage, or a blood clot?
2. Based on #1, where will the patient best be situated? Will the patient need intensive care, or will the "regular" floor be sufficient to attend to the issues at hand? Should the patient be admitted to a surgical team or a medical (non-surgical) team? Depending on the hospital, does the patient get admitted to a teaching service (where residents perform the care under the supervision of attending [fully trained] doctors) or a non-teaching service? Should the patient be on a specialty service (e.g. cardiology, GI, or oncology), with a hospitalist (a trained internist who mostly sees only hospitalized patients) or a generalist (an internist or family physician who sees hospitalized patients as part of the spectrum of services they provide).

Even with these two straightforward questions, the decision-making can become fairly complex, given all of the available options.

And in teaching hospitals, an extra layer of complexity is added as doctors from different services sometimes fight not to admit the patient to their roster of patients.

Contesting an admission might occur with good intentions, but one thing is for certain: it delays getting the patient out of the ER and up to a hospital ward, which compounds the problem of ER backup and overcrowding.

Monday morning quarterbacking occurs in hospitals on a daily basis. "If this patient had been admitted to the Intensive Care Unit (ICU) in the first place, a lot of these mishaps could have been avoided," is a frequent refrain heard the morning after a very sick patient has been admitted.

In teaching hospitals, admitting and triage decisions take longer, since the resident doctors, both in the ER and the ones working on the hospital floors are learning the skills of triage. There's a subtle (and not-so-subtle) dance that goes on to choose the service and the location. Most of the time it's very straightforward. The few times that it's not can lead to major worry on the part of everyone.

Patients admitted to general medical services from the ER usually come in two varieties:
1. Completely undifferentiated illness, with a first time presentation. For example: new onset shortness of breath. There are myriad possibilities, and a deft ER will help sort our which are most likely.
2. An acute exacerbation (heightening) of a chronic medical condition. Of the two presentations, this is the far more common. In an aging population with a preponderance of chronic illness (diabetes, hypertension, survivable cancers, strokes, and cardiac conditions), patients can have a perturbation of their bodily balance (e.g. a salty food binge) that can result in acute on top of chronic illness.

We've moved away from the direct admission. This occurs when a doctor evaluates a patient in the office, and determines that there's a variety #2 going on--an acute flare of a chronic condition.

Such a patient does not likely need an extensive workup to determine the nature of the illness, since it's long ago been defined. The patient requires a titration of medication in a supervised fashion (many of these medicines alter the body chemistry, and can upset the heart or kidneys) to alter the physiology back toward balance, and then the patient can be discharged.

Yet since we've become so reliant on the ER to triage everyone, we've fallen into a predictable pattern of sending all patients destined for admission to the ER.

"Let the ER sort it out," is the oft-thought, rarely-spoken mantra of a busy office physician.

Is it any wonder the ER is so crowded when on top of having people use the ER as a medical home, we have doctors shunting patients through the ER as a portal of entry?

The hospital's admitting office does not want to receive and then admit patients who might be "unstable." At the hospital at which I work, if a patient even has an IV placed (customary for a patient admitted to a general medical service) they are deemed too "unstable" to wait in the admitting area.

Something has to give.

It would be nice for patients if they could be admitted to their hospital bed as quickly as possible. The patient is relatively powerless to decide how they get into the hospital.

There's a real opportunity for the place that figures out how to transition people who are sick from the outside world to the inside-hospital world in a more seamless fashion.

In a world of medical consumerism, that'd be something to boast about.

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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Friday, February 18, 2011

Treating the common cold

For the last week I have had a cold. I usually get one each winter. I have two kids in school and they bring home a lot of viruses. I also work in a hospital, which tends (for some reason) to have lots of sick people. Although this year I think I caught my cold while traveling. I'm almost over it now, but it's certainly a miserable interlude to my normal routine.

No273 13 Oct 2009 Sneeze by mcfarlandmo via FlickrOne thing we can say for certain about the common cold, it's common. It is therefore no surprise that there are lots of cold remedies, folk remedies, pharmaceuticals, and "alternative" treatments. Finding a "cure for the common cold" has also become a journalistic cliche. Reporters will jump on any chance to claim that some new research may one day lead to a cure for the common cold. Just about any research into viruses, no matter how basic or preliminary, seems to get tagged with this headline. (It's right up there with every fossil being a "missing link.")

But despite the commonality of the cold, the overall success of modern medicine, and the many attempts to treat or prevent the cold, there are very few treatments that are actually of any benefit. The only certain treatment is tincture of time. Most colds will get better on their own in about a week. This also creates the impression that any treatment works. No matter what you do, your symptoms are likely to improve. It is also very common to get a mild cold that lasts just a day or so. Many people my feel a cold "coming on" but then it never manifests. This is likely because there was already some partial immunity, so the infection was wiped out quickly by the immune system. But this can also create the impression that whatever treatment was taken at the onset of symptoms worked really well, and even prevented the cold altogether.

What works
There is a short list of treatments that do seem to have some benefit. Nonsteroidal anti-inflammatory drugs (NSAIDs), like aspirin, ibuprofen and naproxen, can reduce many of the symptoms of a cold: sore throat, inflamed mucosa, aches and fever. Acetaminophen may help with the pain and fever, but it is not anti-inflammatory and so will not work as well. NSAIDs basically take the edge off, and may make it easier to sleep.

Decongestants may also be of mild benefit. Antihistamines have a mild benefit in adults, but not documented in children. There are also concerns about safety and side effect in children. Overall, other than some TLC and NSAIDS (although not aspirin) parents should probably not give their children anything for a cough or cold. The benefit of antihistamines in adults is very mild and of questionable value. There is better evidence for antihistamines in combination with a decongestant, but the benefits are still mild. Nasal sprays are probably better than oral medication, and overall use a much lower dose. These treatments do not seem to have any effect on the course of the cold, but may relieve symptoms. Perhaps the best use of nasal spray decongestants is just prior to going to sleep, to reduce a post nasal-drip cough that can be very disruptive to sleep.

There is weak evidence for the use of hot liquids. There does not seem to be any advantage to chicken soup over other hot liquids, like tea. They may provide a symptomatic benefit in clearing the sinuses and loosening phlegm so that it can be cleared easier. Since this is a low-risk intervention (just make sure the liquids are not too hot for small children), if it makes you feel better, go for it. There also may not be any advantage over just humidified air to help keep the membranes moist. Honey may be soothing, but there is no evidence of real benefit.

A neti pot looks like a small teapot with a thin spout that is meant to pour hot liquids up your nose to irrigate your sinuses. The evidence for the use of neti pots is mixed. Briefly, there is no evidence for their routine or preventive use, and in fact they may be counterproductive. However, they may be useful for acute symptoms of sinus congestion. The concept is actually simple and well established--irrigating an infected space to help wash out the germs and prevent impaction. There is probably no benefit to using a neti pot for a regular cold unless you have significant sinusitis and feel that your sinuses are clogged. And again, this is probably no better than just moist air or hot liquids.

What doesn't work
In short, everything else.

Over-the-counter (OTC) cough suppressants simply do not work and are not safe in children. If you have a serious cough, the kind that can cause injury, you need prescription medication (basically narcotics, like codeine). Also, in most cases using a cough suppressant makes no sense, especially in combination with an expectorant. You want to cough up the mucus and phlegm. If your cough is caused by a sore throat, take an NSAID. If it's post nasal drip, treat the congestion as above. And if it's severe, see your doctor. But don't bother with OTC cough suppressants.

I have covered echinacea previously in detail. It does not work for the prevention or treatment of the cold or flu.

Vitamin C has been a favorite since Linus Pauling promoted in decades ago. But decades of research has not been kind to this claim. The research has failed to find a consistent and convincing effect for vitamin C in treating or preventing the common cold. For routine prevention, the evidence is dead negative. For treating an acute infection, there is mixed evidence for a possible very mild benefit, but this is likely just noise in the research.

What about homeopathic treatments? Since homeopathy is one big pseudoscientific scam, its products are nothing but water, and they don't work for anything, I don't need to go into more detail here.

Finally, there is some evidence that zinc or zinc oxide may reduce symptoms of a cold, but this evidence is mixed and unconvincing at present. At best the benefit is very mild (again, likely within the noise of such studies). Further, zinc comes with a nasty taste (something that also complicates blinding of studies) and many people may find this worse than symptoms it treats. Zinc oxide nasal sprays have been linked to anosmia (loss of smell, which can be permanent) and is certainly not worth the risk to treat a self-limited condition like the cold, even if they did work, which is unclear.

Conclusion
The common cold remains a difficult syndrome to treat effectively. In most cases it is best to just let the cold run its course. Limited use of NSAIDs and decongestants may be helpful. Otherwise, if there is an intervention that is risk free and makes you feel better, do it.

We all need to feel comforted when we're sick. But don't waste your time or money on other medications, supplements, herbs, or other concoctions. There are also endless snake-oil products out there, too many to deal with here. A good default position is simply not to believe any product that claims to prevent or treat the common cold. And don't be compelled by the anecdotal evidence of your neighbor's cousin's boss. Everyone thinks they have the secret to treating the cold, but no one does. It's all placebo effect and confirmation bias.

This post by Steve Novella, 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--Locum tenens hiring on the rise

The use of temporary physicians is rising, filling until permanent physicians can be hired amid the ongoing shortage of doctors nationwide, a locum tenens firm has found. The company estimates between 30,000 and 40,000 physicians worked on a locum tenens basis in 2010.

The survey, by Staff Care, polled hospital and medical group managers about their use of locum tenens. 85% said their facilities had used temporary physicians sometime in 2010, up from 72% in 2009.

Psychiatrists and other behavioral health specialists were the most sought-after specialty (22% of all requests), followed by primary care physicians, defined as family physicians, general internists and pediatricians (20%) and internal medicine subspecialists (12%). Hospitalists were 9%.

According to the survey, the primary reason cited by 63% of health care facilities was to fill a position until a permanent physician could be found. 46% percent of health care facilities now use locum tenens physicians to fill in for physicians who have left the area, compared to 22% in 2009. 14% use locum tenens doctors to either help meet rising patient demand for medical services or to fill in during peak times, such as flu season. 53% use locum tenens physicians to fill in for physicians who are on vacation, ill or for other absences.

Most locum tenens physicians plan to stick with temporary practice in the short-term, the company noted. 60% said they plan to practice on a locum tenens basis for more than three years, 28% for one to three years and 12% for less than a year.

Freedom trumps pay, the company noted, as 82% cited flexibility as a benefit, compared to 16% who identified pay as a benefit. Other reasons cited for working as a locum tenens include absence of medical politics (48%), travel (44%), professional development (21%) and searching for permanent practice (20%).

The locum tenens option is important to maintaining physician supply, the company concluded, because during a time of physician shortages it allows doctors who might be considering full retirement to remain active in medicine.

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Thursday, February 17, 2011

Looking over the USDA's new nutritional guidelines

Ever since I had breast cancer, I've paid more attention to the food I serve in my home than before. While a balanced diet is no fail-safe for avoiding disease, I do think it's prudent to be aware of the variety and quantity of food we eat.

Photo by Keith Weller, USDA Agricultural Research ServiceIn most medical schools we teach surprisingly little on nutrition. The curriculum's usual emphasis is typically on vitamin metabolism: like how much iron we need in milligrams per day, how nutrients interact with medications and enzyme pathways, and that sort of thing. Most of what I know that's practical I've learned from reading books, like Michael Pollen's In Defense of Food, and the USDA's new Dietary Guidelines for Americans (7th Edition).

From the press USDA and HHS joint press release: "Because more than one-third of children and more than two-thirds of adults in the United States are overweight or obese, the 7th edition of Dietary Guidelines for Americans places stronger emphasis on reducing calorie consumption and increasing physical activity.

The New York Times summed up the new guidelines nicely in its headline: Government's Dietary Advice: Eat Less. But it's not a trivial report. Rather, it's a hefty-if-printed 112-page PDF that includes some excellent, hard-to-find-elsewhere information on nutrients. Highlights include Figure 5-1, which demonstrates with abundant clarity that we don't eat sufficient fruits, vegetables, whole grains or most other recommended foods.

A personal favorite is Appendix 11, which charts the "Estimated EPA and DHA and Mercury Content in 4 Ounces of Selected Seafood Varieties"--handy if you serve fish for dinner at least twice per week, and like me, figure it's best to hedge on potential toxic effects by serving a variety of fish.

More from the press release, on tips that will be provided to help consumers translate the dietary guidelines into their everyday lives:
--Enjoy your food, but eat less.
--Avoid oversized portions.
--Make half your plate fruits and vegetables.
--Switch to fat-free or low-fat (1%) milk.
--Compare sodium in foods like soup, bread, and frozen meals – and choose the foods with lower numbers.
--Drink water instead of sugary drinks.

All of these points seem wise, simple messages we might share with our patients.

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--Less than one-third of PCPs stock all adult vaccines

Less than one in three primary care practices offer all 10 recommended adult vaccines, citing a variety of financial and logistical reasons.

Researchers sponsored by the Centers for Disease Control and Prevention sampled 993 family physicians and 997 general internists. Of the respondents, 27% (31% of family practitioners and 20% of internists) stocked all 10. Results appear in the Feb. 17 issue of the journal Vaccine.

The 10 vaccines were hepatitis A; hepatitis B; human papillomavirus vaccine (HPV); combined measles, mumps, and rubella (MMR); meningococcal conjugate vaccine (MCV4); pneumococcal polysaccharide (PPSV23); tetanus diphtheria (Td); combined tetanus, diphtheria, and pertussis (Tdap); varicella; and zoster.

Of the responding practices, 2% plan to stop vaccine purchases, 12% plan to increase them and the rest had no plans to change their vaccination stocking habits. But physicians who identified themselves as their respective practices' decision makers for stocking vaccines were more likely to decrease the number of different vaccines stocked for adults (11% vs. 3%; P=.0001).

The National Vaccine Advisory Committee, a group that advises the various federal agencies involved in vaccines and immunizations, arrived at even bleaker figures in 2009, reported the April 2009 issue of ACP Internist. For example, 62% of decision makers in practices said they had delayed purchase of a vaccine at some time in the prior three years due to financial concerns. And in the prior year, 16% of practice decision makers had seriously considered stopping vaccinations for privately insured patients due to the cost and reimbursement issues.

The vaccines most frequently stocked were Td and PPSV23. Zoster was the least frequently stocked, with more than 40% of respondents citing inadequate reimbursement or inconsistent insurance coverage. For the other seven vaccines, internists were more likely (and sometimes nearly twice as likely) not to stock the vaccine than family practitioners. While many vaccines are more likely used among adolescents, the researchers noted, many internists still provide care to these patients and to young adults, forcing them to seek vaccination elsewhere.

Besides zoster, no single reason predominated to not stock a vaccine, leading researchers to conclude that no single financial action or policy change will likely have a significant positive impact. However, they did note that PPSV23 was a performance marker in the Healthcare Effectiveness Data and Information Set, and increasing the number of vaccines included in its measurements for adult patients might help.

Researcher wrote, "To fulfill the medical home concept, however, it would seem that primary care physicians should provide the full range of vaccines, including those that might be infrequently indicated."

ACP's tools for its Adult Immunization Initiative are online.

ACP's Center for Practice Improvement and Innovation offers an easy-to-follow primer on vaccination and vaccine management.

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Wednesday, February 16, 2011

QD: News Every Day--President's budget shuffles health care spending

More details are available about President Obama's proposed federal budget, including details on how health agencies will receive more money, less money or new priorities for spending.

Cards shuffling by flicktoast via FlickrThe budget proposes to extend current Medicare payment rates to physicians for two more years. And, it proposes specifics on how to cover that cost, by tightening spending and using more generic drugs.

While Health and Human Services Department spending would decline by 2% to $892 billion (the first decline in 20 years), its two largest entitlement programs, Medicare and Medicaid, remain unchecked.

The Centers for Disease Control and Prevention's overall budget would rise from $10.8 billion to $11.2 billion. More money would shift toward mandatory programs for childhood vaccinations, domestic HIV/AIDS programs and diabetes or smoking cessation. Its discretionary spending budget would be reduced from $6.5 billion to $5.9 billion, for programs in occupational safety and health, environmental health and state disaster planning.

The National Institutes of Health's budget would rise from $31.3 billion to $32.3 billion, with moneys shifting toward biomedical research.

And the FDA budget would increase FDA spending to $2.7 billion for FDA, with an emphasis on increasing food safety and supplies of medicine, medical equipment and blood.

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Tuesday, February 15, 2011

QD: News Every Day--President's budget proposes two-year doc fix

President Barack Obama's 2012 budget proposes higher physician Medicare reimbursement for two more years, just one part of a much larger plan to lower the deficit by $1.1 trillion over 10 years. The proposal, which is actually one of a series of delays to a 25% pay cut, would be offset by around $62 billion in spending restrictions by Medicare and Medicaid, and using more generic drugs in federal health programs.

According to the White House release, "The Budget goes further by proposing to continue the current payment levels and offset the costs for the next two years with specific health savings and assumes sustainable growth rate relief in future years will be fully offset, consistent with recent congressional action. The Administration is committed to working with the Congress to achieve permanent, fiscally responsible reform and to give physicians incentives to improve quality and efficiency, while providing them with predictable payments for the care they furnish to Medicare beneficiaries."

The President's goal is to halve the federal budget deficit by the end of his first term in office. Republicans said they were "unimpressed" and vowed to push for deeper spending cuts and lower taxes than the President proposed.

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Monday, February 14, 2011

Should physicians wear white coats?

A while back, a first-year med student asked me if I think physicians should wear white coats. There's a debate about it, she mentioned. Indeed, in the spring of 2009 the AMA considered an unenforceable mandate that physicians in the U.S. not wear white coats. The news was getting around that doctors spread infection from one patient to the next by our garments.

My thoughts on this have always been clear. "Yes," I answered. "But they've got to be clean white coats."

This week I came upon two stories that led me to pick up the thread on the white coat debate. First, a recent post from the Singing Pen of Doctor Jen, by Jennifer Middleton MD, MPH, who writes from western Pennsylvania: "We physicians might make assumptions about what patients want us to look like, but what does the evidence say? A cross-sectional survey in Tennessee a few years ago found that patients prefer family physicians who wear white coats. Another study in a South Carolina internal medicine office found that patients "overwhelmingly" preferred physicians in white coats. A Northeast Ohio OB residency found similarly; patients preferred a white coat and professional dress to scrubs. A quick PubMed search pulls up the same theme over and over: The patients studied have more trust in, and comfort with, physicians who wear white coats."

Today in the New York Times, a piece by Sandeep Jahuar, MD alludes to the issue by its title: Out of Camelot, Knights in White Coats Lose Way. He considers disillusionment of many doctors with medicine as a profession. He writes: "Physicians used to be the pillars of any community. If you were smart and sincere and ambitious, the top of your class, there was nothing nobler you could aspire to become. Doctors possessed special knowledge. They were caring and smart, the best kind of people you could know. Today, medicine is just another profession, and doctors have become like everybody else: insecure, discontented and anxious about the future."

As a doctor, I think physicians should wear white coats for several reasons. First, the white coat reminds the wearer that medicine is a special kind of profession, that doctors have extraordinary obligations to patients. Second, the white coat recalls medicine's basis in science, from which we wouldn't want to stray too far. Third, it's to protect ourselves: going home to dinner with your family, loaded with hospital germs, is just not smart.

As a patient, I like it when my doctors where a white coat. It's reassuring in a primitive kind of way; it makes me feel like the physician is a real doctor who is capable of taking care of me. But the coat should be clean--every day a fresh one, with extra changes if needed.

Of course there are some circumstances when the white coat is appropriately relegated elsewhere: in places like the OR, in most psychiatrists' offices and in pediatrics, so as not to scare the children, I once learned although I'm not convinced it would.

It takes a certain effort for a doctor to put on a white coat. When I used to get called back in late at night, or after weekend rounds, I'd occasionally just go straight to the patient's ward or ER, without stopping by the room where my coat was kept. That was easier, sure, but when I skipped the white coat I felt as if I weren't fulfilling my part of the deal: to look and act like a doctor should.

Patients need that, usually. And maybe that's a hang-up, a superficial wanting, a simple reassurance of authority. But maybe it's also a sign that you're serious in your duties as a physician, that you're not cutting corners, that you will do everything you can to fulfill your obligation to the persons under your care, that you know who you are as the doctor.

Maybe, when younger doctors elect not to wear the white coats, for whatever legitimate reasons, or out of laziness in finding a clean one, it's really that they don't want the responsibility the coat conveys.

It could also be that they're just hot, or uncomfortable.

I'll leave this open, at that.

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--Court orders injured teen to have surgery

An injured teen is recovering after court-ordered spinal surgery, after the boy's parents refused the operation amid concerns of potential paralysis from the surgery and in favor of the family's practice of herbal remedies and homeopathy.

The teen was recovering Friday at Thomas Jefferson University Hospital in Philadelphia and is likely headed home for recuperation.

Doctors wanted to operate to prevent paralysis, after the boy bruised his spine after butting heads with another student in a wrestling match. The family refused, and Delaware County (Pennsylvania) Office of Children and Youth Services put him in protective custody and headed to court.

The teen's mother appeared on local television, showing video that she said showed the boy had a full range of motion and that she's concerned about surgical complications.

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The therapeutic relationship in "The King's Speech"

Recently I saw "The King's Speech." The film is about King George VI, Duke of York, and his struggle with a speech impediment--a stammer. The story tells of how King George IV, "Bertie," worked with an actor turned speech therapist, "Lionel," to overcome a chronic ailment, which was the source of significant psychosocial stress. I found myself reflecting on what aspects of the therapeutic relationship displayed within the film were so successful. Despite his lack of official credentials, I felt that Lionel Logue displayed tremendous professionalism as a care provider.

One aspect, I believe, was the genuine friendship that developed between the two men. Whether it is advisable for doctors and patients to be friends has been a matter of debate. Within the field of psychiatry this has been seen as a boundary violation that is fraught with problems. However, within other fields of medicine boundaries may not be as rigidly enforced. In my view friendship, at times, can enhance a therapeutic relationship.

Another successful aspect of this therapeutic relationship was Lionel's exploration of not only the biologic, but the psychosocial contributors to King George's speech disorder, which had roots in his childhood family dynamics. I am a believer in the biopsychosocial model of medicine. In order to understand and treat illness, one needs to understand not only the biological factors, but the psychological and the social context in which the illness occurs. This is also known as "holistic medicine," though this terminology is widely misused today by those who confuse it with "naturopathy" or "homeopathy."

A third aspect that enhanced the patient-caregiver relationship was that it was non-hierarchical, neither Lionel was "Doctor," nor Bertie was "King." It was important to Lionel that each man should be equal in the context of treatment, and he insisted that each call the other by his first name.

Finally, Lionel was very discreet, serving as trusted guardian of his patient's confidential health information. He protected his patient's privacy and autonomy.

Medical Professionalism is one of the core competencies of the American College of Graduate Medical Education used in the evaluation of medical trainees. A growing movement has attempted to define the best way to measure and teach professionalism. The core attributes of Medical Professionalism were defined by a Charter drafted in 2002. A recent paper in JAMA discusses specific behaviors and systems that support medical professionalism.

Some key elements described in The Charter are:

--Professional competence
--Honesty
--Protecting patient confidentiality
--Maintaining appropriate relationships with patients
--Commitment to scientific knowledge
--Improving quality of care
--Improving access to care
--Allocating a just distribution of resources
--Maintaining trust by managing conflicts of interest
--Participating collaboratively within the profession to maintain professional standards

I see professionalism not as a static set of values and behaviors, but as flexible standards that are shaped throughout the course of one's career both through observation and through trial and error.

In "The King's Speech" Lionel admits to Bertie that he has pushed too hard, was insensitive, and took a wrong tact. He comes to apologize to his difficult patient. The willingness to admit fallibility and error is another important aspect of medical professionalism.

This film could be a great tool for teaching medical trainees.

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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Friday, February 11, 2011

"Clinically proven?" There's no such thing

I heard yet another commercial on the radio this morning for some menopausal cure-all that was "clinically proven" to reduce hot flashes, improve sleep, increase energy, help you lose weight, and probably cure bad breath to boot. Anyone who calls in the next 10 minutes gets a month's supply for free. "Hurry." Don't.

At least they finally stopped running the one for the colon cleansing product that helped remove the "five to ten pounds of waste some experts* believe are spackled along the inside of the large intestine." (*Emphasis mine. "Some experts" also believe the moon landing was a hoax, the Holocaust never happened, and homeopathy is effective medicine.) Somehow this colon cleansing stuff helps you preferentially lose belly fat. Not really sure what belly fat has to do with five to ten pounds of stuff spackled inside your intestine, but they're not selling logic. "Call right now for your free sample." Or not.

Then there was the pediatrician hawking the natural, safe, clinically-proven effective sinus cure that sounded suspiciously like saline spray. "Hurry and call right now." Don't bother.

Words are my friends, and I hate to see people abuse them.

"Clinical" is an adjective referring to "that which can be observed in or involves patients." It's the hands-on part of medicine that can't be replicated in a lab or taught from a book. There is virtually no such thing as "proof" in the scientific sense. Laboratory and patient-based medical research can strongly suggest things. Scientific evidence can accumulate supporting things, and the more the better, of course.

When I send a patient for an X-ray or other imaging study, I get a report back (eventually) from the radiologist describing what was seen, along with an interpretation of what those images might mean. Reports that are anything other than completely clear-cut usually end with the phrase, "Correlate clinically." This means that whatever it was they saw could mean any number of different things depending on the signs and symptoms present in the specific patient. I know the patient; the radiologist just sees the images. I'm the one who's supposed to put it all together. This is a correct use of the term "clinical."

"Clinically proven" is a meaningless combination of words that mean someone is trying to sell something. Isn't there some kind of rule against making stuff up, even in advertising? Obviously people are used to it in politics, but those are opinions, to which everyone is entitled. What people are NOT entitled to is their own facts. There is no clinically proven remedy available without a prescription for menopausal symptoms, quick and painless weight loss, or sinus congestion that can be purchased from a radio ad, because there's no such thing as "clinically proven."

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--Statistics tally spending on kidney disease

Medical spending to treat kidney disease totaled on average $25.3 billion annually from 2003 to 2007 (in 2007 dollars). Almost half of the expenditures ($12.7 billion) were spent on ambulatory visits.

On average, 3.7 million adults (1.7% of the population) annually reported getting treatment for kidney disease, reports a statistical brief from the Agency for Healthcare Research and Quality. During 2003-2007, for those ages 18-64, more than half of the total kidney disease expenditures were from ambulatory visits (53.1%) compared with about one third (30.3%) from inpatient visits. Among those age 65 and older, ambulatory visits accounted for 46% of the total kidney disease expenditures and hospital stays were 43%.

Similar amounts were spent on prescription medicines ($1.4 billion) and emergency room visits ($1.5 billion). Hospital stays amounted to $9.1 billion. Medicare paid 40% of the total expenditures to treat kidney disease.

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Thursday, February 10, 2011

Gratitude

I just read a book called 365 Thank Yous by John Kralik. I heard an interview with the author on NPR, and it caught my attention.

Kralik had been down on his luck in 2007: divorced twice, overweight, with a struggling law firm that he'd started, he was also failing in a new romantic relationship. He was worried about losing his seven-year-old daughter, too, in a custody dispute.

Kate Spade Thank You Notes by ralph and jenny via FlickrHe made a momentous decision: Instead of feeling sorry for himself (easy to do given his predicaments), he decided to be grateful for what he had. To show it, he vowed to write a thank you note every day for the next year.

What do you think happened?

His life changed for the better. His relationship improved. His clients started paying their bills and his firm's financial footing solidified. His health improved. He eventually achieved his lifelong dream of becoming a judge. To top it off, he turned his personal quest into a writing project. Within minutes of writing a book proposal, he received responses from agents who hoped to shepherd his project.

Every writer's dream ...

I'll grant you that it sounds hokey. But there are a couple of things the book demonstrated to me.

Making a commitment to change is never easy. Kralik decided to change his perspective, and his results are indeed stunning. But he's quite open about the fact that it was a process, and a lengthy one at that. He had times when he felt like giving up. Crises arose in which he didn't write a note for several weeks. Sometimes he just flat out felt that he had nothing to be grateful for. But he always came back to his task.

And people really responded to him, from government officials, to clients, to his Starbuck's barista. Everyone likes gratitude. We are human. It helps to know that our work and our humanity are appreciated.

There are other personal resonances. Kralik hails from Cleveland. Even as a lawyer, he shunned corporate law for his own values-driven law firm. He wrote a mission statement, and was rankled with inner turmoil when he strayed too far from it.

I guess to sum it up I'd write Judge Kralik a thank you letter of my own:

Dear Judge Kralik:

Thank you for sharing your story with me.

I am truly inspired by how you were able to turn your life around. As a doctor, I am touched by the mission-driven aspect of your legal work. In addition, I find that your quest to allow gratitude to suffuse every aspect of your life really provided a beautiful level of harmony to your story. I plan to share your story with patients and colleagues; I am always moved by ideas and examples that take something simple (e.g. the thank you note) and make it a habit that can lead to a virtuous cycle.

Congratulations on your professional and personal successes. I hope that they continue.

Genuinely,
John Henning Schumann, M.D.

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--Eggs are back on the menu

Enriched chicken feed may have resulted in eggs having less cholesterol and more Vitamin D than previously measured, reports the U.S. Department of Agriculture.

Eggs! by Carly & Art via FlickrA large egg today has about 185 milligrams of cholesterol, down 14% from 215 milligrams in 2002, according to new research from the USDA's Agricultural Research Service, reports USA Today. Also, an egg today has 41 international units (IUs) of Vitamin D, up 64% from 25 IUs measured in 2002. (That's still only about 7% of the 600 IUs recommended per day.)

The agency regularly does nutrient checks on popular foods, this time analyzing eggs taken from store shelves in 12 locations around the country. The American Egg Board said in a press release that hen feed is made up mostly of corn, soybean meal, vitamins and minerals. Nutrition researchers at Iowa State University are also looking into reasons why cholesterol in eggs is decreasing.

The government's Dietary Guidelines for Americans recommend that most people eat less than 300 milligrams of total dietary cholesterol a day, and people at a high risk of cardiovascular disease should eat less than 200 milligrams a day. The average American man consumes about 337 milligrams of cholesterol a day and the average woman consumes 217 milligrams, reports the Los Angeles Times.

One egg a day fits within the average, healthy American's diet, reports WebMD, citing research funded by the Centers for Disease Control and Prevention and by the American Egg Board (owners of the slogan "incredible, edible egg").

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Wednesday, February 9, 2011

QD: News Every Day--Doctors, patients wish they knew each other better

Physicians said in a survey that noncompliance with advice or treatment recommendations was their foremost complaint about their patients. Most said it affected their ability to provide optimal care and more 37% said it did so "a lot."

Three-quarters of patients said they were highly satisfied with their doctors. But they still had complaints ranging from long wait times to ineffective treatments.

Those are just some of the findings from two surveys, the first a poll of 660 primary-care physicians conducted by the Consumer Reports National Research Center in September 2010 and the second a poll of 49,000 Consumer Reports subscribers in 2009. The magazine reported its results online.

In the doctors' poll, physicians named these top challenges:
--76% of doctors said when it came to getting better medical care, forming a long-term relationship with a primary-care physician would help "very much."
--61% said being respectful and courteous toward doctors would help "very much," while 70% said respect and appreciation from patients had gotten "a little" or "much" worse since they had started practicing medicine. This was a two-way street, since patients reported the same feelings.
--42% physicians said health plan rules and regulations interfered "a lot" with the care they provided.

Also noted in the poll, 37% of physicians thought they were "very" effective when it comes to minimizing pain and discomfort for their patients, though 97% thought they were "somewhat" effective. But, 79% of patients said their doctor helped to minimize their pain or discomfort, according to the Consumer Reports blog. The gap might be explained by doctors thinking of their overall effectiveness with all of their patients, including those with chronic pain conditions that are difficult to diagnose and treat, and who are as a group less satisfied with their physicians.

Next, the patients said what they thought would help their relationship with a physician:
--31% said they wished they had more information before choosing a doctor. Not knowing much up front about a doctor's personality or treatment style was a real obstacle for patients in search of a good match.
--More than one-quarter of patients indicated some level of discomfort with their doctors' inclination to prescribe drugs.
--9% said they had e-mailed their doctor directly in the previous year.

Possibilities to enhance communication include:
--Patients could take notes during the appointments. 89% of doctors said that keeping an informal log of treatments, drugs, changes in condition, notes from previous doctor visits, and tests and procedures could be helpful. But only 33% of patients routinely did so.
--Research online, but carefully. 61% of patients said they researched health information on the Internet to help with their medical care. Almost half of physicians surveyed said online research helps very little or not at all.

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ACP bloggers up for weblog awards

Readers of the ACP blogs may recognize two frequent contributors and Fellows of the American College of Physicians, Toni Brayer, MD, and Kim Manning, MD. Both are finalists in the Seventh Annual Medical Weblog Awards conducted by MedGadget. If you've enjoyed either columnist and their posts on ACP's blogs, please take the time to vote for them.

Kimberly Manning, FACP, posts content from her blog Reflections of a Grady Doctor, at ACP Hospitalist. She's entered in the Best Literary Medical Weblog category. Toni Brayer, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century. She's entered in the Best Health Policies/Ethics Weblog category.

Voting will close at 23:59:59 on Sunday, February 13.

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Tuesday, February 8, 2011

QD: News Every Day--Overdiagnosis and the potential for harming patients

Screening and diagnosing healthy, asymptomatic people with a barrage of tests has created a culture of illness, write three Dartmouth physicians and researchers in the book Overdiagnosed: Making People Sick in the Pursuit of Health.

In one interview with Kaiser Health News, co-author H. Gilbert Welch, MD, MPH, described the outcomes for 2,500 women who receive an annual mammography starting at age 50 for 10 years. One woman among that group will avoid dying from breast cancer. Nearly half will have an abnormal mammogram, causing needless worry. Half again will have a biopsy. Between five and 15 will be overdiagnosed and receive treatments for a non-problematic cancer.

Not all screening is bad, the authors acknowledge. "If a woman feels a new breast lump, she should come in to see her doctor--that’s not screening, that’s diagnosing," Dr. Welch told The Boston Globe.

The value of screening and preventive measures is constantly being examined. In the past year alone, studies large and small have looked at whether colonoscopy prevents colon cancer, whether screening for osteoarthritis prevents fractures (and is it effective for men), whether false positives from CT scans for lung cancer do more harm than good and does starting mammography too early have any value?

The book also questions the value of wellness programs that outline specific clinical values for blood pressure, cholesterol and blood sugar, as well as the wisdom of an annual physical. Dr. Welch hasn't had an annual exam since childhood, adding "The virtue of having a regular primary care physician is to establish a relationship and to establish the set of values that will guide your care."

For more on the need for an annual physical, see ACP Internist's cover story "Rethinking the value of the annual physical" from our January 2010 issue.

Screenings have become a consumer product to the degree that Consumer Reports has published a review on the matter. More than 8,000 people were asked whether they had received any of 10 heart-specific screening tests in the last five years. Nearly two-thirds of them, all between 40 and 60 years old, had seen a doctor in the last 12 months, and had no history or symptoms of any form of cardiovascular disease. Yet, they said they would definitely have a complete battery of heart-screening tests if they were free.

More importantly, many of the respondents already had: 50% had undergone an electrocardiogram; 21%, an exercise stress test; 7%, an ultrasound of the carotid arteries. Most of them did so without talking with a doctor about the accuracy of the tests, potential complications, or what they would need to do with the findings. 87% completely or somewhat agreed that it was "better to have a scare that turns out to be nothing than to not get tested at all."

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Cheney's got heart

Dick Cheney's heart troubles have been well-documented. Now comes the news that the former Vice President is considering a heart transplant. On Jan. 30 he turned 70, an age at which most transplant programs in the U.S. consider patients too old for the rigors of transplant surgery.

Currently, Cheney's life depends on an artificial pump known as a left ventricular assist device (LVAD). LVADs have only been in mainstream clinical use for the last 15 years. They are an adaptation of heart-lung bypass machines, used for decades in coronary artery bypass surgery. Cardiothoracic surgeons realized that damaged hearts could themselves be bypassed to keep patients alive while awaiting a new pump--either the mechanical kind (an "artificial heart," still a work in progress) or a heart from a cadaveric donor. Over the years, LVADs have been refined to the point where they weigh only 500 grams (slightly more than a pound) and can safely be powered by external batteries. Consequently, patients with LVADs are now able to move around freely and leave the hospital, unlike the early days of assist devices, when patients were literally tethered to the wall.

An LVAD is placed under the skin of the abdominal wall (in front of the stomach), with its blood entry port inserted into the heart's left ventricle, and the exit spout directed into the aorta, the body's main blood vessel. The LVAD's power wire (about the thickness of your pinkie, called a "drive line") tunnels from the device under the skin of the abdominal wall, and out the right side of the abdomen where it's connected to a battery. When at home, a patient like Cheney needs to always be vigilant to charge his batteries so that he can have adequate range. The batteries are worn externally, ideally tucked in the pockets of a garment like a hunting vest.

At present, the longest a patient has survived with an LVAD is six years and counting. As more high visibility patients like Cheney use the devices, their transition from temporary option to permanent solution becomes more the norm. So what are the downsides?

Patients with LVADs require anticoagulation. They have to take medicine such as warfarin to make their blood 50% thinner than normal. This requires careful monitoring: blood thinned too much can cause hemorrhage; blood that's too close to normal can lead to formation of clots which in turn can embolize and cause strokes. The other big risk is infection; foreign material planted in the body is more susceptible to causing bacterial infestation of the blood stream which can seed other organs. Consequently, procuring a new heart would seem preferential for any patient with severe heart damage. No need for batteries. No drive line. No risk of hemorrhage and dramatically lessened chance of clots or infections.

Sign me up for transplant, right? Yet as with all things in medicine the reality is much more complicated than the sales pitch.

Let's assume for the moment that obtaining a heart isn't a problem. Tissue-typing to the recipient remains a challenge for all patients with severe heart failure. Patients like Cheney are often highly "sensitized," which means that they carry antibodies that will hasten rejection of the transplanted heart. This occurs because throughout the course of their illnesses, heart patients often receive blood transfusions or other foreign material (e.g. heart valves or vascular grafts) that induce high levels of antibodies. Even when the tissue matches sufficiently, recipients require lifelong expensive immunosuppressive drugs to lessen the likelihood of rejection. These drugs are potent, toxic, and raise the risk of opportunistic infections since they dampen the entire immune system.

Okay, so now a heart is available. The match is good. The patient has insurance or sufficient finances to be able to obtain and manage the necessary medication and postoperative care (this is determined during the screening evaluation). Can the patient survive the surgery? Obviously, this is a judgment call. If a patient has kidney problems, diabetes, or liver disease, he'll be unlikely to withstand the rigors of the surgery and the post-transplant care. In Cheney's case, the information he's chosen to make public does not address this issue. Let's continue our thought experiment and assume that other than his heart, he's fit as a fiddle. Should he allow himself to be listed as a candidate for transplant?

Currently, there are about 3,200 Americans waiting for hearts. Every year roughly 2100 patients get transplanted. Of those that get transplanted, the percentage in Cheney's age category (65+) hovers between 11-14%. Most transplantation programs in the United States use 65 as an age cutoff when considering who to transplant. Yet age is used as a "relative" rather than an "absolute" contraindication, when the patient in question has limited damage to other organs and a longer life expectancy.

From the viewpoint of an individual patient wanting to extend his life and avoid the inconvenience of walking around hooked to a medical device, a decision to go forward with transplant makes perfect sense.

Yet from the perspective of a society struggling to control stratospheric health care costs, such a decision by Cheney would be counterproductive. He's functioning well enough with his LVAD to continue his memoir (longhand) and make television appearances. Given the scarcity of transplantable hearts, seeing Cheney claim one that could otherwise go to a younger patient would reinforce his low regard for the social contract with fellow Americans. Further, it would exemplify how virtually all of our political leaders fail to grapple with placing reasonable limits on medical care that is exorbitantly costly but only marginally effective. A Cheney decision to forgo transplant, however, would send a clarion call of political and economic rectitude that would help erase the memory of his famed quip about conservation being merely a "sign of personal virtue."

Author's Note: Thanks goes to Dr. Savitri Fedson of the University of Chicago Medical Center for technical consultation on this post. Opinions herein are solely those of the author.

This post by John H. Schumann, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist in Chicago's south side, and an educator at the University of Chicago, where he trains residents and medical students in both internal medicine and medical ethics. He is also faculty co-chair of the university's human rights program. His blog, GlassHospital, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people that inhabit them.

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Monday, February 7, 2011

QD: News Every Day--'Difficult' patients

Physicians see nearly one in five patients as "difficult," report researchers. Not surprisingly, these patients don't fare as well as others after visiting their doctor.

Researchers took into account both patient and clinician factors associated with being considered 'difficult', as well as assessing the impact on patient health outcomes. They reported results in the Journal of General Internal Medicine.

Researchers assessed 750 adults prior to their visit to a primary care walk-in clinic for symptoms, expectations, and general health; for how they functioned physically, socially and emotionally; and whether they had mental disorders. Immediately after their visit, participants were asked about their satisfaction with the encounter, any unmet expectations, and their levels of trust in their doctor. Two weeks later, researchers checked symptoms again.

Also, clinicians were asked to rate how difficult the encounter was after each visit. Nearly 18% were "difficult." They had more symptoms, worse functional status, used the clinic more frequently and were more likely to have an underlying psychiatric disorder than non-difficult patients. These patients were less satisfied, trusted their physicians less and had a greater number of unmet expectations. Two weeks later, they were also more likely to experience worsening of their symptoms.

But the label works both ways, as physicians with a more open communication style and those with more experience reported fewer difficult encounters, researchers said.

On a lighter note, TV's comedy "Seinfeld" dedicated an entire plotline from one of its many episodes to Elaine, her doctor, and the label of being a difficult patient. It's worth watching here.

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Friday, February 4, 2011

QD: News Every Day--The Super Bowl is just a game, right?

Sports fans may literally live and die on their team's victories, according to researchers who examined cardiac mortality rates after the home team won and lost the Super Bowl.

Total and cardiac mortality rates in Los Angeles County increased after the football team's 1980 Super Bowl loss but overall mortality fell after the 1984 the team's Super Bowl win, researchers concluded from a review of death certificates reported in Clinical Cardiology.

First, authors gave a clinical review. Stress causes a cardiac cascade. The sympathetic nervous system increases and releases catecholamines. This triggers a rise in heart rate and blood pressure, and ventricular contractility increases oxygen demand, causing blood the sheer against and fracture atherosclerotic plaque, the authors explained. Stimulation of alpha receptors in the vasculature further constrict coronary vessels, increasing oxygen demand while limiting oxygen supply to the heart.

Drenched in champagne by Brett L. via FlickrNext, they gave a sporting review. Los Angeles has played twice in the Super Bowl, the first time losing to the Pittsburgh Steelers (who play in this Sunday's Super Bowl, incidentally) in 1980. The Los Angeles Rams, as they were known then, were a long-time hometown team and played the game in nearby Pasadena, Calif. "This game was high intensity," wrote the authors, "with seven lead changes before Los Angeles lost a fourth-quarter lead and the game."

Later, a new football franchise arrived in town, the Los Angeles Raiders. In 1984 the Los Angeles Raiders traveled to Tampa, Fla. to beat the Washington Redskins in a more mundane affair.

Now, the review of findings. Researchers combed death certificates based on age, race and sex to compare mortality rates for Super Bowl-related days with non-Super Bowl days and created regression models predicting daily death rates per 100,000.

Researchers reviewed death-certificates for the six weeks surrounding the Super Bowls from 1980 to 1988. Data included total number of deaths and cardiac-related deaths. Figures were broken down by sex, race and age less than or greater than 65 years for each of the two Super Bowls. To remove the impact of the known peak in total and cardiac death rates around the winter holidays, all analyses excluded data from Jan. 1 to Jan. 14.

After the Super Bowl loss, daily death rates increased for both men and women in Los Angeles County. Seniors had a larger absolute increase in all cause mortality during the Super Bowl loss days compared with the younger population, "with significant interaction between age and Super Bowl loss-variable for all-cause and cardiac-related mortality," the authors wrote. Whites and Hispanics had increased death rates on Super Bowl loss days.

"Based on our linear regression analysis, our study suggested that Los Angeles' 1980 Super Bowl loss increased total and cardiac deaths in both men and women and triggered more deaths in older patients compared with younger patients," the authors concluded. "Conversely, the 1984 Super Bowl win showed a trend for reduction of death rates, slightly better in older than younger patients and in women more than men."

And the fans file in by moacirpdsp via FlickrInterestingly, the authors didn't consider one important co-variable: Super Bowl food. It's been suggested that big holiday dinners may also cause a spike in heart attacks, so it stands to reason that Super Bowl menus would play at least some part.

This year's Super Bowl pits the Pittsburgh Steelers against the Green Bay Packers. Neither team has a rich history of fruits and vegetables, and the likely game-day offerings will likely feature bratwurst and cheese or golabki and pierogies.

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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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