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

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Tuesday, May 31, 2011

QD: News Every Day--Doctors improve pay, signing perks

Primary care physicians received higher median first-year guaranteed salaries in single-specialty practices, while specialty-care physicians received more in multispecialty practices, according to a survey.

Primary care physicians received a median first-year guaranteed salary of $165,000 in multispecialty practices and $172,400 in single specialty practices. Specialty physicians earned a median first-year guaranteed salary of $258,677 in multispecialty practices and $240,596 in single-specialty practices. Since 2008, both primary and specialty-care physicians have either seen their first-year guaranteed compensation increase or stay the same.

Geography and other bonuses at signing also affected compensation, reported the Medical Group Management Association in its Physician Placement Starting Salary Survey: 2011 Report Based on 2010 Data.

Median first-year compensation was the same for primary care physicians across the Eastern, Midwest, and Southern U.S., at $170,000 per year. Specialty care physicians’ median first-year compensation varied more. In the Southern and Western sections, first-year compensation was highest at $275,000 and $270,000, respectively. The Midwest and Eastern regions held the lowest median first-year compensation for specialists, at $250,000 and $220,000, respectively.

In addition to first-year guaranteed compensation, benefits such as signing bonuses, loan forgiveness, and amount of paid relocation expenses helped shape physician recruitment. Employers were more likely to offer loan forgiveness packages to primary care physicians than specialty-care physicians. Also accompanying job offers:
--56% of physicians received signing bonuses,
--12% received loan forgiveness packages, most of which were $50,000 or less, and
--56% accepted paid relocation.

A press release explained that demand for physicians has made recruiting more difficult while the doctors themselves have become better at negotiating employment terms and signing bonuses.

The survey comprises 4,295 providers categorized by specialty, as well as starting salary information on 1,986 physicians directly out of residency or fellowship. All voluntary participated.

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Friday, May 27, 2011

QD: News Every Day--Cheapest sunscreens ranked most effective

Just in time for Memorial Day, Consumer Reports ranked sunscreens, finding out which ones are best. The good news is that it's the less expensive brands.

Foot by Aine D via Flickr and a Creative Commons licenseConsumer Reports ranked them on usability, not medical criteria such as potential side effects of active and inactive ingredients. The American Academy of Dermatology delves into that more in-depth,

Oxybenzone has been an ingredient in sunscreen since 1978, and contrary to recent reports, it's not been linked to hormonal alterations or other significant health issues, the AAD stated in a press release. Retinyl palmitate is a form of vitamin A that used in sunscreens as an antioxidant to improve product performance against the aging effects of UV exposure. Despite test tube studies and one unpublished report using mice, topical and oral retinoids are widely prescribed to treat a number of skin diseases, such as acne and psoriasis, and there is no published evidence to suggest either increase the risk of skin cancer in these patients.

Vitamin D synthesis is also not an issue, the AAD stated. The AAD recommends consuming vitamin D from foods naturally rich in it, such as dairy and fish, fortified foods and beverages, or vitamin D supplements. The organization recently updated its position statement on vitamin D based on the published review of the increasing body of scientific literature conducted by the National Academy of Sciences Institute of Medicine. A summary of that report and more on vitamin D and calcium supplements is available here.

Conveniently, Consumer Reports provided the warning signs that moles are actually skin cancer, the ABCDE mnemonic of Asymmetry, Border, Color, Diameter and Evolving.

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Thursday, May 26, 2011

Tell 'em what you think.

ACP members went to Washington to lobby their elected officials yesterday, but in a pre-Leadership Day speech, Nancy Nielsen, MACP (who was once profiled in ACP Internist and now serves as a senior advisor at the Center for Medicare & Medicaid Innovation) encouraged docs to give a piece of their minds to CMS, as well.

Comments on proposed rules for accountable care organizations are being accepted until June 6, she noted, and doctors should get involved in the discussion about how ACOs will be paid for the improved care they provide.

"The important thing here is for you to comment on this," said Dr. Nielsen. "Would you need an infusion of cash up front to do whatever it is you need to do? Or would it be more helpful to have it as a per beneficiary per month payment you can count on? You want to think about that and comment on it. You might have some other ideas about how the advance payment ought to be distributed."

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Ronald McDonald promotes obesity: Call in the Navy SEALS!

As Whistleblower readers know, I have a six-day-a-week love affair with The New York Times. I love the paper's reportage, but not its editorial policy. However, it's important to seek out other views on the issues of the day. This is an opportunity to defend your beliefs by disarming the opposition's argument, or to change your mind.

Ronald McDonald by sfxeric via Flickr and a Creative commons licenseThe news these days is very dark. There's an apocalyptic aura as we read about terror, war and natural disasters occurring all over the globe. And, since we all like reading about villains, the news media readily supplies us with demons to root against and to distract us from more serious challenges that hover over us.

In this past week, there were four prime villains that the national media offered up for us to consume:
--Osama bin Laden
--Mouammar Khadafi
--Mahmound Ahmadinejad
--Ronald McDonald

Don't let Ronald's sunny visage fool you. Behind his painted smile and underneath his red hair is an evil mind who is devoting his life to promoting obesity and ruining our kids. To recall a bold pronouncement issued by a prior Republican president who was poised to send troops into danger across the globe, "This aggression will not stand"' Ronald must be stopped.

Full page ads appeared in several major newspapers asking McDonalds to fire Ronald McDonald, whose nefarious purpose is to lure mindless kids to ingest too much fat, too much sugar and too many calories. Even Happy Meal toys were targeted by the organizing group Corporate Accountability. They properly recognized that these "toys" were dangerous mind control devices that subliminally cause cravings for Big Macs with extra cheese.

Where's the outrage? How has this purveyor of poundage been permitted to operate freely for decades?

Hopefully, the Patriot Act has given law enforcement and the intelligence community enough tools to gather damning evidence against Ronald. I suspect that the Hamburglar is wearing a wire. Legal experts are already debating whether a future trial should take place in a civilian court or a military tribunal. I lean towards the latter, not wanting Ronald to have a public platform to spew his poisonous propaganda, which might include coded language to awaken sleeper cells.

What punishment would be just for such a demon? Gitmo? Solitary confinement in a federal prison? Perhaps, an entire year requiring Ronald to swallow 3 Happy Meals a day would be enough to rehabilitate him and to flip him to our side.

Once Ronald has been taken out, then we can focus on other villains who are plotting evil against us. Do you really think that Mickey Mouse and Goofy are just innocent cartoon characters?

This post by Michael Kirsch, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who 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.

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QD: News Every Day--Physicians don't profit from tests, prescriptions

Physicians don't make money from the tests, prescriptions, procedures and admissions they order, according to a new survey by the staffing and technology company Jackson Healthcare. At most, 6.2% of physicians' total compensation comes from the doctor's orders, the survey reported.

Direct income from medical orders comprised:
--0.5% from charges from prescriptions,
--1.0% from charges from lab tests,
--1.1% from charges associated with hospital admission,
--1.3% from charges associated with facility fees for surgeries, and
--2.3% from charges from diagnostic imaging.

The survey of 1,512 physicians challenged claims that physicians won't stop practicing defensive medicine because they profit from their medical orders, the company stated in a press release.

"Many outside the industry believe that physicians make a lot of money on the tests, prescriptions, procedures and admissions they order," said Richard Jackson, chairman and CEO of Jackson Healthcare. "The reality is that most (82%) do not make any money from their orders. For the remaining that do, it constitutes a fraction of their total compensation."

Mr. Jackson cited the Stark Law, which he said makes it very difficult for physicians to profit from their medical referrals and orders. Also, the trend of new physicians choosing employment over independent practice plays a role.

"There are two primary reasons physicians order tests and treatments they consider medically unnecessary," said Mr. Jackson in the release. "They are personally financially liable for patient awards and they want to avoid the hassles of going to court."

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Wednesday, May 25, 2011

When physicians have to say no: Does patient satisfaction suffer?

The short answer: No.

At least not in the context of a strong physician-patient relationship.

Many physicians have legitimate concerns about the prospects of having their salary or level reimbursement linked to patient satisfaction. I would too given the way most health care providers go about measuring and interpreting patient satisfaction data.

A major concern of physicians is the issue of patient requests, particularly the impact of unfulfilled (and unreasonable) requests upon patient satisfaction. According to researchers, explicit patient requests for medications, diagnostic tests and specialty referrals occur in between 25% to 40% of primary care visits. This figure is much higher when requests for information are factored in.

In studies, primary care physicians accommodate patient requests for medications and diagnostic tests approximately 75% of the time. Physicians however accommodated only 40% of specialist referral requests. Physicians negotiated alternatives solutions to patient requests 22% of the time and denied patient requests the remaining 3% of the time. Information requests were met approximately 95% of the time by physicians.

Denial of patient requests has little impact on patient satisfaction.

It is not at all clear from the research that physician denial of patient requests for medications, tests or specialist referrals has any negative effect on patient satisfaction. In the studies referenced here, little to no association was found between unfulfilled patient requests and patient satisfaction.

The one exception to this finding is where physicians fail to meet patient requests for health information. In such instances patient satisfaction was lower. This is not surprising when one study categorized the quality of physician responses to patient information requests as follows:
--32% were of requests were fulfilled with a "terse" physician response
--33% percent were fulfilled with an "intermediate" response
--32% percent with an "elaborate" response.

Experts advise negotiating patients' requests

It has been said that clinical encounters such as occur during office visits involve a "process of negotiation between the clinician and patient." As such, physicians are advised to use the influence accorded them by their patients to help them understand the pros and cons of their request so as to negotiate actions are really needed.

Physicians that are truly concerned about their patient satisfaction score are better served by looking after the quality of their patient communications skills.

Additional resources:

Kravitz RL, Bell R a, Franz CE, et al. Characterizing patient requests and physician responses in office practice. Health Services Research. 2002;37(1):217-38.

Kravitz RL, Bell R a, Azari R, et al. Direct observation of requests for clinical services in office practice: what do patients want and do they get it? Archives of Internal Medicine. 2003;163(14):1673-81.

Peck BM, Asch DA, Goold SD, et al. Measuring Patient Expectations – Does the Instrument Affect Satisfaction or Expectations? Medical Care, Vol. 39, No. 1 pp. 100-108.

Keitz S a, Stechuchak KM, Grambow SC, Koropchak CM, Tulsky J. Behind closed doors: management of patient expectations in primary care practices. Archives of Internal Medicine. 2007;167(5):445-52.

Editor's Note: The following strategies appeared in ACP Internist for handling patient requests:
"Learning to parry patient requests," ACP Internist, March 2011

"Successful strategies found for refusing antidepressant requests," ACP InternistWeekly, March 2, 2010

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

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Drawing lines

Envision a scenario: Milt is 87. Over the years he's developed diabetes, high blood pressure, arthritis, lumbago (back pain), hearing loss, too many moles to count, and high cholesterol. He sees his doctor three times a year for checkups on these conditions and to keep his long list of medicines stockpiled. He also sees a specialist or two.

random lines By jorgempf via Flickr and a Creative Commons licenseRecently Milt developed "a touch" of pneumonia and was hospitalized for three days. Since being there, his doctor informed him that his kidneys "aren't filtering as well as they used to." The doc tells Milt that his kidneys are functioning at about 50% of what they were as a younger man, but not to worry since we know that people do just fine with one kidney.

As often occurs with chronically ill elders, Milt winds up back in the hospital six weeks later with "congestive heart failure." His heart is not pumping blood effectively, so fluid is backing up in the lungs causing shortness of breath. His legs are swollen. The hospital doctors treat Milt with diuretics to "get the extra fluid off," but in doing so his kidneys now worsen.

Nephrology is consulted.

Based on Milt's lab data and urine output over the last 48 hours, the consultant tells the docs that Milt's effective kidney function is zero. The consultant says the only option is dialysis. Without it, Milt will die due to kidney failure.

Fortunately, since 1972, anyone with end stage renal disease in the U.S is entitled to coverage for such treatment.

When the law passed, it was largely in response to the unfairness perceived in who was selected for dialysis treatment when it first became mainstream. When a resource is scarce, someone is inevitably going to be left out.

Fast forward about 40 years, and see this really interesting article from my favorite medical journal, the New York Times.

Dialysis, the article notes, was originally intended for people in whom substituted kidney function would permit them to return to productive lives. As we continue living longer, more and more patients fall into the category of becoming "eligible" for dialysis treatment. As with many medical decisions, deciding whether to undertake it is not as easy as it seems:

"Dialysis is difficult, especially for the old and sick. Most of the nation's 400,000 dialysis patients spend several hours, three days a week, hooked up to a machine, and additional time traveling back and forth to the clinic.

"They have to restrict salt and fluids, and the procedure is so exhausting that some patients rest for the remainder of the day. Although dialysis may alleviate symptoms like fluid accumulation in the legs or lungs, it can lead to dizziness, weakness, leg cramps, nausea and other problems. Complications like bloodstream infections or clogged blood vessels where the dialysis needles are placed are common, often requiring surgery or hospital stays. Ultimately, about one patient in five is unwilling to go on with it."

Having treated patients of advanced age with many co-morbidities, I can say first hand that there are some patients I wish had chosen against dialysis. (Here is the courageous story of one.) Not because I'm stingy or want to be on a "death panel." But because I want them to live out their days with dignity and in comfort, not tethered to medical appliances and suffering for long stretches.

The thorny ethical question is "when should dialysis not be offered?" In the U.S., we have yet to successfully address this question in most of the workaday world of medicine.

Where would you draw the line?

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--In the brain, emotional pain resembles physical pain

Heart-ache can be a literal thing, as well as a metaphor for all those weepy, jilted-lover torch songs.

Consensus thinking in the peer-review literature is that the parts of one's brain responsible for physical pain, the dorsal anterior cingulate and anterior insula, also underlie emotional pain.

Researchers at Columbia University in New York recruited 40 people who'd recently ended a romantic relationship, put them in a functional magnetic resonance imaging machine, and recorded their reactions to physical and then emotional pain.

Physical pain was created by heating the person's left forearm, compared to having the arm merely warmed. Emotional pain was created by looking at pictures of the former partner and remembering the breakup, compared to when looking at a photo of a friend.

The fMRI scans showed physical and emotional pain overlapped in the dorsal anterior cingulate and anterior insula, with overlapping increases in thalamus and right parietal opercular/insular cortex in the right side of the brain (opposite to the left arm).

The theory is that the parts of the brain that process social rejection developed by co-opting brain circuits responsible for physical pain. Researchers wrote in the Proceedings of the National Academies of Sciences that, "The current findings substantively extend these views by demonstrating that social rejection and physical pain are similar not only in that they are both distressing, they share a common representation in somatosensory brain systems as well."

Now, researchers are considering the role of different types of emotional pain in somatoform diseases and in fibromyalgia.

Of course, this has been common knowledge for a while. Watch as Nazareth performs their cover of the classic tune, "Love Hurts."

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Tuesday, May 24, 2011

QD: News Every Day--Emergency doctors seek tort reform

The American College of Emergency Physicians (ACEP) is calling for malpractice reform in the emergency department to protect physicians and lower health care costs.

In the organization's recent poll, 44% of emergency physicians said the biggest challenge to cutting emergency department costs is the fear of lawsuits, and 53% said they conduct so many tests for fear of being sued. Also, 68% of respondents said there has been no improvement in the number of medical specialists willing to take call in the emergency department since health care reform legislation passed last year.

When the emergency physicians were asked what they believe is the biggest challenge to cutting emergency department costs, they responded:
When they were asked why emergency physicians conduct the number of tests that they do, they responded:Estimates on the costs of defensive medicine range from $60 billion to $151 billion per year, the organization wrote in a press release, while the total costs of emergency care were $47.3 billion in 2008, or 2% of all health care spending.

The organization, based in Dallas, cited its home state's tort reform as a model to follow. ACEP stated that since Texas passed liability reform in 2003:
--33 rural counties have added at least one emergency physician, including 24 counties that previously had none, the organization said,
--Texas saw the second biggest improvement for emergency department wait times among all states, according to a 2010 report from Press Ganey, and
--Texas improved access to medical care despite the highest uninsured population in the nation.

Whether tort reform in Texas succeeded or did not is up for discussion.

Yet, ACEP supports legislation proposed in the U.S. House of Representatives, H.R. 5 and H.R. 157, which are both aimed at liability reform. H.R. 5 would. among other things, cap noneconomic damages in lawsuits at $250,000, while H.R. 157 would extend to all emergency physicians the same legal protection that physicians in the Public Health Service have.

ACEP president, Sandra Schneider, MD, also raised the specter of quality measures for medical care, which are designed to discourage the overuse of testing but might open physicians to litigation, said Dr. Schneider. "For example, under new CMS guidelines, the use of head CTs is being discouraged. Fewer head CTs will mean that physicians miss maybe 1% of serious head bleeds. So a small percentage of people with head bleeds will be missed, and there are no liability protections for those physicians who may be sued as a result."

ACEP conducted the poll in March by e-mail to 20,687 emergency physicians, and 1,768 responded. The survey has a theoretical sampling error range of plus/minus 2.23.

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Monday, May 23, 2011

QD: News Every Day--Stay away from hospitals on days beginning with 'S'

Hospital admissions have significantly worse outcomes during the weekend compared with weekdays, reports a study in the Archives of Surgery.

To uncover whether the mortality rate after nonelective hospital admission is higher during weekends than weekdays, researchers conducted a retrospective cohort analysis of patients.

The study team looked at all patients with a nonelective hospital admission from Jan. 1, 2003, through Dec. 31, 2007, from the admitted to hospitals in the Nationwide Inpatient Sample, a 20% sample of U.S. community hospitals. Researchers abstracted vital status at discharge and calculated the Charlson comorbidity index for all patients. They then adjusted for demographics, comorbidity, and hospital characteristics and compared mortality rates of weekends and weekdays.

Among the nearly 30 million patients with nonelective hospital admissions during the 5-year study period, 6.8 million were admitted on weekends and more than 21 million were admitted on weekdays. Inpatient mortality was reported in 185,856 patients (2.7%) admitted for nonelective indications during weekends and 540,639 (2.3%) during weekdays (P<.001).

There was significantly higher mortality during weekends for 15 of 26 (57.7%) major diagnostic categories. Mortality was 10.5% higher during weekends (odds ratio, 1.10; 95% confidence interval, 1.10-1.11) compared with weekdays after adjusting for all other variables.

Researchers couldn't explain the cause but speculated that differences in hospital staffing and services offered during the weekend compared with weekdays played a part.

Hmmmm. If there's a weekend effect, and that weekend happens during the July effect, then what happens?

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Saturday, May 21, 2011

Why do patients stop taking their medications?

Lots of smart people over the years have been trying to figure out why people stop taking their medications within the first 12 months. Within the first 12-months of starting a new prescription, patient compliance rates drop to less than 50%. This rate is even lower for people with multiple chronic conditions taking one or more prescription medications.

If these medications are so important to patients, why do they just stop taking them? It defies common sense. Sure issues like medication cost, forgetfulness, lack of symptoms, and psychosocial issues like depression play a role in patient non-compliance. But there also something else going on ... or in this case not going on.

The problem is that doctors and patients simply don't talk much about new medications once prescribed. Here's what I mean. Let's say that at a routine check-up a physician tells a patient that he/she wants to put them on a medication to help them control their cholesterol. The doctor spends about 50 seconds telling the patient about the medication. The patient nods their head takes the prescription and boom, the visit is over.

Let's say the patient actually gets the prescription filled. For some people that is a leap of faith considering the likely chain of events up to that moment:
--The physician didn't really make a good case for why they needed the medication. If the doctor wanted me to take it he/she should have been emphatic about it, as in "I recommend you take this," not the simple "I want to try something", or to describe what it would do or what would happen if the patient didn't take it.
--The doctor didn't mention how the new medication would interact with the two other pills I am already taking.
--Consequentially, the patient may not believe they really need the medication.

Fast forward 12 months. The patient has been back to see the same doctor twice for problem unrelated to cholesterol. At neither of these appointments did the doctor mentioned or ask how the patient was doing with the new medication. The doctor did mention the need for a blood test to check for liver issues and that they should recheck the cholesterol levels at the next visit.

So at this point the patient concludes the following about the new medication:
--The doctor never talks about cholesterol or brings up the subject of the medication. I assume I am taking it correctly.
--If the doctor doesn't mention it (the medication) it must not be important.
--I haven't notice any difference in my health. I guess I don't need the medication.

Sure, the patient should have asked their doctor if they had any questions about the new medication. But patients seldom ask their doctor questions. Sure they could ask the pharmacist ... but the pharmacist would tell them to just ask their doctor.

It's so much easier for the patient to just not refill the prescription.

We have all heard the expression that whatever doesn't get measured doesn't get done. Well the same thing is true for when it comes to physician-patient communications. Whatever issues doctors don't talk with patients about will not get done over the long haul either. In this case patients simply stop taking prescribed medications.

As primary care slowly shifts from episodic, acute care to continuous care with the aid of electronic medical records and the focus of patient-centered care, things should get better with respect to patient compliance. It needs to. Give the current focus on episodic acute care too many chronic health issues simply are not being addressed for one visit to the next.

That's what I think. What's your opinion?

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

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Friday, May 20, 2011

In the advent of portable ultrasound, the stethoscope still finds use

Recently, the Wall Street Journal did a great piece on how mobile technology is being used in medicine. They looked at the major avenues of use, from the hospital to personal to emergency care settings.

They gave an example of how a cardiologist has stopped carrying a stethoscope, and now just uses mobile ultrasound, a modality we have highlighted numerous times in the past.

Eric Topol, MD, [a Fellow of the American College of Physicians] a cardiologist in San Diego, carries with him instead a portable ultrasound device roughly the size of a cellphone. When he puts it to a patient's chest, the device allows him to peer directly into the heart. The patient looks, too; together, they check out the muscle, the valves, the rhythm, the blood flow.

"Why would I listen to 'lub dub' when I can see everything?" Dr. Topol says.

As mentioned in our article on mobile ultrasound, research continues to show how the modality can be used to improve outcomes, such as with central line procedures.

With the continued improvements in ultrasound mobility, will physicians be required to become more proficient in the modality?

I would argue yes. For cardiac sounds, it will replace the stethoscope in the future, and it will eventually become a part of medical school curriculums once pricing goes down. Right now the price point is $8,000. The value added by ultrasound is tremendous. The ability to look at not only cardiac pathology, but abdominal, eye, venous, arterial, and more.

Would a cardiologist be able to use a mobile ultrasound tool better than a primary care physician to look for cardiac abnormalities? Of course, but that's the case with a stethoscope as well. Most physicians today are proficient with a stethoscope--not masters--and the same paradigm could be applied to a mobile ultrasound tool.

Furthermore, since ultrasound uses sound waves, and not radiation, more physicians proficient in ultrasound could lead to less X-rays or CT scans. Recent data on cumulative doses of patient radiation exposure highlights the need for ultrasound use when possible.

Although you can use ultrasound to look at pulmonary pathology, such as for pulmonary embolisms, sound still plays a key role. Hearing the interval improvements in a patient's expiratory or inspiratory wheezing is essential when treating a patient with acute exacerbation of COPD.

While there are cases the stethoscope would be useful, especially in regards to certain pulmonary sounds, it's not outlandish to think mobile ultrasound could be the essential tool physicians carry around, while the stethoscope becomes relegated to PRN use.

We'd love to hear what you think in our comments section, whether you agree or disagree.

[EDITOR'S NOTE: ACP Hospitalist addressed portable ultrasound technology adoption in its May 2011 issue.]

This post by Iltifat Husain 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--Poll shows split on using the ankle-brachial index

Despite poor awareness and a lack of training on handling peripheral artery disease, internists can and should be able to recognize the symptoms and manage 95% of such cases. Experts advise using the ankle-brachial index as a quick and effective diagnostic method.

Rebecca J. Beyth, ACP Member, demonstrates the ease and quickness of the ankle-brachial index in diagnosing peripheral artery disease. Photo by Eric Zamora/UF News BureauBut internists often don't. As was reported in ACP Internist's previous cover story on the subject, the ankle-brachial index can be a major part of preventing peripheral artery disease, itself a major predictor of strokes and heart attacks, over and above the Framingham risk score.

The ankle-brachial index is the ratio of the ankle to the arm systolic pressure. A ratio of 0.90 or less indicates peripheral artery disease. Its sensitivity is 79% to 95%, and its specificity is 95% to 100%. It takes less than five minutes to perform in the office.

Yet, among the 85 respondents, 36 (42.35%) said "It's a quick and easy test." Another 27 (31.76%) thought, "It's difficult to fit into the standard visit." The final 22 (25.88%) said, "I don't use the ABI to screen patients for PAD."

Illustration by David CutlerFor those who said they don't (or those who don't but didn't vote) take the time to revisit how to conduct an ankle-brachial index exam in our story. And take the time to vote in ACP Internist's latest poll, addressing how internists handle food allergies in their practice.

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Thursday, May 19, 2011

Your 'well' is my 'sick' as insurers pick semantics over payments

Insurance companies are supposed to pay for health care, although they do everything they can think of to avoid doing so. One company in particular (a small player here though a much bigger gorilla in other markets) does so by playing with words, even when another behemoth lost a lawsuit over the same issue.

The topic involves paying for preventive services while a patient is in the office for care of an acute illness or management of a chronic condition. The way we communicate with insurance companies about what we do in the office is by way of codes; CPT codes, to be precise. There are separate codes to differentiate between preventive services and the so-called Evaluation and Management (E/M) services. The latter are your basic office visit codes covering all the "cognitive" services I offer, as opposed to procedural codes, where I actually do something to you other than talk with and examine you.

In general, you can only have one office visit per day. However if you happen to ask me to take a mole off while you're in for a diabetes check, or if I find that you're wheezing when you just came in for a checkup, there is a way to code for more than one appropriate service at a time by using something called the -25 modifier.

The -25 modifier is added to the E/M code to indicate that the evaluation service was completely separate from the procedural one. That is, the diabetes exam had nothing to do with the mole, or the asthma was completely separate from the Boy Scout physical. For a long time, many insurance companies refused to pay for an E/M code in addition to a preventive visit. Here for a pap but came down with a chest cold? Sorry; you have to choose which one you want me to take care of today, because although they really are completely separate services, I can't get paid for both.

Then this little insurance company, call them "Company A," lost a class action lawsuit over just this issue, and had to pay out big time. You'd think others might have taken notice; sadly, not. What's infuriating, though, is how they now play with words to avoid paying.

Here's how it works: their provider relations people tell me on the phone that preventive services are "well visits." By this semantic equivalence, evaluation and management services, all other visits for acute illness or chronic disease, are "sick visits". And of course, how can you be "sick" and "well" at the same time? Mutually exclusive, you see.

False, wrong and illegal as hell. But what realistic recourse do I have? Other than dropping that plan, and inconveniencing/alienating a chunk of patients, none. Sometimes it sucks to be small.

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--7% of physicians adopted video chat with patients

Seven percent of U.S. physicians use online video conferencing to communicate with any of their patients, according to a study of physician digital adoption trends.

The study captures a snapshot of technology, including mobile platforms, electronic health records, electronic prescribing and interaction with patients, pharmaceutical and health care market research company Manhattan Research said in a press release.

Psychiatrists and oncologists are more likely to be using video conferencing with patients. But physicians added that reimbursement, liability and privacy are still major barriers to communicating online with patients.

Major findings include:
--Physician smartphone ownership has risen in the past decade:
2001: 30%
2004: 40%
2007: 50%
2009: 64%
2010: 72%
2011: 81%
--75% of U.S. physicians own an Apple device such as an iPhone, iPad or iPod.
--30% of U.S. physicians own an iPad and an additional 28% plan to purchase one within the next six months.
--Physicians expressed strong interest in being able to access electronic medical records through the iPad.

The survey was the latest in an annual series focused on how U.S. physicians use the Internet, digital media, mobile devices and other technologies for professional purposes and patient interaction. It was conducted among 2,041 U.S. practicing physicians, including primary care physicians, pediatricians, cardiologists, oncologists, gastroenterologists and OB/GYNs.

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Wednesday, May 18, 2011

PowerPoint bulleted list theorem (Why we should not use long bulleted lists)

Most of us associate PowerPoint with lectures in large darkened halls with many slides of bulleted lists accompanied by a droning voice. So what is wrong with the bulleted lists in PowerPoint? I was preparing to conduct a workshop on PowerPoint and Education and found some theoretical basis for why we should not use bulleted lists when presenting. As you see, I do use them freely in documents.

[Author's Note: This is presented as a theorem just to make it interesting. It is just my very simplistic interpretation of work done by many people and better presented elsewhere. See the references at the bottom. Readers should refer to the Atkinson, Mayer reference below for an excellent and more detailed description of these concepts. My hope here it to get readers interested both the cognitive theories related to this topic and the practical applications of these.]

Some of the biggest advantages of using tools like PowerPoint are:
1) use of multimedia elements,
2) integration with audience response systems,
3) creating branching/non linear presentations based on audience needs,
4) more legible text, clearer images,
5) ability to re-purpose/reuse material from other presentations (can be dangerous), and
6) options for distribution and sharing.

Thus, it is quite obvious, why PowerPoint (and other technology) is used so much in education. It is very important to remember the steps for using technology in learning:
1) understand how people learn,
2) think about how educators can facilitate this learning process, and
3) then think about how technology can help improve this facilitation process.

When we keep these three steps in mind while designing our presentations, it will lead to better use of PowerPoint. When the presentation "fails" it is most likely because we ignored one or both of the first 2 steps and jumped straight into the technology (PowerPoint).

Compare this bulleted list in PowerPoint:


To this:



Statement:
Using bulleted lists while narrating during presentations is detrimental to students' learning.

Axioms:
--Working memory (formerly called short-term memory)
---Processes incoming data/information
---Connects it with existing knowledge/wisdom
---Encodes it into long-term memory

--Working memory has limited capacity to process information
---It has two separate channels
----verbal/auditory input
----visual input
---Each channel has a limited processing capacity
---Text is processed by both visual and verbal channels (you know now where this is going, right?)

--Meaningful learning requires substantial amount of cognitive processing in both channels
---Select and pay attention to incoming data
---Organize the data
---Integrate it with prior knowledge


Argument:
Information presented in a manner that overloads the processing power of the Working Memory makes learning difficult.

Bulleted lists which are multiple concepts presented as text are processed by both the visual and verbal channels.

When you start talking around these lists, the words you speak are processed by the verbal channel.

The audience struggles:
--to correlate the text on the screen with the words you speak
--to grasp which bullet you are talking about
--to decide whether to just read the slide or listen to you talking

This struggle is not germane to getting a deeper understanding of the presented material. It actually takes away from the learning process.

Conclusion:
Presenting (long) bulleted lists while narrating during presentations is detrimental to learning.

Quod erat demonstrandum!

Corollary1:
While narrating in a presentation, showing an appropriate image on the screen is better than showing a bulleted list. This leverages the dual channels to facilitate learning.

Corollary 2:
Putting both an image and a lot of text on a single slide is detrimental to learning. This can overwhelm the visual channel.

References:
Working memory (Baddley and Hitch) [PubMed][Wikipedia]
Dual Coding Theory (Paivio) [PDF article][Wikipedia]
Cognitive Load Theory (Sweller) [EduTech Wiki]
Select Organize Integrate Theory (Mayer)
Cognitive Theory of Multimedia Learning (Mayer and Moreno)
List of learning theories at Learning-theories.com
Richard Mayer's full text article [PDF]
5 ways to reduce PowerPoint overload (Atkinson and Mayer)

Neil Mehta MBBS, MS, FACP, practices internal medicine at a large tertiary care hospital in Ohio. He is also the Director of Education Technology (Academic Computing) for his medical school and in charge of his hospital system's home grown Learning and Content Management System. He is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management. This post originally appeared at Technology in (Medical) Education.

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QD: News Every Day--Hating co-workers shortens life expectancy

Getting along with co-workers had more of an impact on mortality than one's relationship with a supervisor, or even than having a heavy workload, Israeli researchers found. And, the amount of latitude afforded an employee varied by sex; men with more control had lower mortality and women, more mortality.

I'm Happy, Don't Ruin It by sakanami via Flickr and a Creative Commons licenseResearchers investigated the effects of the Job-Demand-Control-Support (JDC-S) model and its components of workload, control, and peer- and supervisor-social support, on all-cause mortality. Job demands were defined as perceived workload; job control was defined as discretion in how to perform the job, and social support was defined as "overall levels of helpful social interaction available on the job from both co-workers and supervisors."

The prospective study measured 820 healthy employees referred in 1988 to their HMO's screening center by their employers for routine exams. Those referred for physical or mental health problems were excluded. Follow-up data on all-cause mortality were obtained from computerized medical files in 2008. Results appeared in the May issue of Health Psychology.

During follow-up, 53 deaths occurred. Mortality was significantly lower for those reporting high levels of peer social support. (HR=.59) but not for those reporting high levels of supervisor social support (HR=.39).

Subgroup analysis showed that for the men, control reduced the risk of all-cause mortality (HR=.48), but it increased mortality risk in women (HR=1.70). A separate confirmatory factor analysis supported this.

And, the main effect of peer social support on mortality risk was significantly higher for those ages 38 to 43 but not for those younger or older than that group.

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Tuesday, May 17, 2011

iPhone apps for physicians: Medical apps I want

Your humble Luddite Whistleblower has leapt across the sea to reach the Isle of Technology. I now own and operate an iPhone, which identifies me as groovy, hip and cool, three adjectives that none of our five kids ever use to describe their technophobic father. I'm told that my text messages are too long and too frequent. I am admonished that it is not necessary for me to photograph moments of high drama, such as a kid eating breakfast, and then to disseminate the image to my contact list. I am reminded often that I am slow to grasp the mechanical intricacies of the device, such as switching from ring to vibration mode.

You may wonder how it was possible that I, who consider using an ATM to be a high level computer operation, could make the iPhone, my phone. I knew I couldn't fail, despite my trepidation of all things cyber. I had a secret weapon, a 'Plan B'. Actually, I had Plan Z, the most powerful asset that anyone in my situation could hope for. Z stands for Zachy. One sentence will explain all and may provoke screams of envy from those who have no available similar resource: Zachy is our 14-yr-old kid!

Zachy is our youngest son and lives and dreams in the cyberworld. Like his contemporaries, he relies on computers to communicate and interact with the world. He is excited to devise new mousetraps that seem unnecessarily complex. When he receives a phone call, he can reroute the call so that it the caller's voice will emerge out of a speaker from another techno-contraption in his room. Is this cool? Yes. Is it easier than simply answering the phone? You decide.

Of course, the real appeal of the iPhone is the apps. Since app to me means appendectomy, I assumed that the iPhone was a well-designed physician's tool. Relax readers, I have since become educated and have increased my apptitude. I can now spend time I don't have searching for cool apps that will solve problems I don't have.

Some apps I have

Dragon. This is a must-have app and is well worth the price. It's free. It permits you to dictate directly into the contraption and then transforms your voice into text with reasonable accuracy. This is great for TWD, or texting while driving, an act that no responsible physician has ever committed.

Epocrates. Another gratis app, although the company hopes you will upgrade to one of their premium products. I've used Epocrates for years, and consult it nearly every day. It's a quick and easy resource for all medications, including dosage, adverse reactions, drug interactions, contraindications and cost. How many medications do we really need to take care of patients? Probably, two dozen or so.

Liver Calc. My partner is always showing off when he rounds on liver patients and calculates the MELD score in his progress notes. Who can remember this stuff? It reminds me of the Ranson criteria for pancreatitis that we medical students were forced to memorize. (I remember Dr. Ranson from my medical school days. He was warm and fuzzy--NOT!). Do these liver scores help actual patients or merely provide grist for board examinations? With this app, I can now calculate on the spot a variety of scores for liver patients, most of which this board certified gastroenterologist has never heard of. Anyone out there heard of the RUCAM criteria?

Medscape. This is a very comprehensive site, but seems to cruise more horizontally across the medical landscape than vertically. Will I ever use it? Not sure. The goal, I am learning, is not to use apps, but just to collect 'em.

Epocrates Disease Game. This is a cool way to spend time in the airport when your flight is delayed and the smiling airline personnel will not divulge the updated departure time regardless of threat or bribery. Tap the app and a medical image appears in stages, until the entire screen shows the finding. Choose the correct diagnosis among the three given choices. For those who were born during the Eisenhower era, this game reminds me of solving the rebus in the classic TV game show Concentration.

Apps I want

Colon Cleanse app. This is a double plug in app. You plug in the device into the headphone jack of the iPhone and plug the larger end into the rectum. Attach the accessory funneled cleansing tube to a standard faucet, and watch the toxins disappear.

Medical Coding app. This turns your iPhone into a high voltage device, similar to the Invisible Fences that are used to restrain pets to a given area. Tap the app and then place the iPhone in your front pocket. After seeing a patient, if you code higher than you should on your EMR, you will get a light shock. The intensity will increase until you have expressed remorse, atoned and coded properly. I expect that Medicare will provide incentives for using this technology in the coming years.

Formulary app. This will be fun for the entire office. When the physician guesses the drug that is on the patient's formulary, carnival music starts blaring from the iPhone. Since this occurs rarely, do not worry that this App will be disruptive to your office routine.

Am I getting just a bit slAPP hAPPy? Probably, so. The APPendix may be a vestigial structure, but the iPhone Apps are like the oxygen drive. You can try holding your breath, but how long can you hold out?

This post by Michael Kirsch, FACP, appeared at MD Whistleblower. Dr. Kisrch is a full time practicing physician and writer who 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.

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QD: News Every Day--Hospital medication side effects, injuries rise 52%

Illnesses and injuries from medicines given in hospitals jumped 52% between 2004 and 2008, from 1.2 million to 1.9 million, according to a report from the Agency for Healthcare Research and Quality (AHRQ).

The adverse events were made up of drug reactions, adverse drug events and medication errors. (Although the data came from the hospital and emergency settings, the adverse outcomes could have originated elsewhere.) The study uses data from AHRQ's 2008 Nationwide Inpatient Sample and 2008 Nationwide Emergency Department Sample.

Although people most often arrived at the emergency room due to an unspecified drug, the next four most common treat-and-release medicines were known sources: pain killers (118,100); antibiotics (95,100); tranquilizers and antidepressants (79,300); and corticosteroids and other hormones (71,400).

For patients already admitted to the hospital, the top five categories of drugs that resulted in an adverse event were corticosteroids (283,700 cases); painkillers (269,400); blood-thinners (218,800); cancer and immune system drugs (234,300); and heart and blood pressure medicines (191,300).

Most common specific causes of drug-related adverse outcomes in U.S. hospitals, by setting of care, 2008.

A majority of inpatient drug-related adverse outcome cases (53.1%) were 65 and older, while a very small proportion (3%) were less than 18 years old. By comparison, among all inpatient cases, adults 65 and older accounted for 35% of stays while 15.9% of stays occurred in children less than 18 years old. Almost 36% of treat-and-release emergency department visits with drug-related adverse outcomes were made by patients aged 18 to 44 years. Although this age group had the greatest proportion of visits with drug-related adverse outcomes of any age group, they also had the highest percentage of visits overall at 43.9%.

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Monday, May 16, 2011

Watch out for medical claims made in press releases

Every once in a while, a press release comes along that's worth mocking publically. Here's one of them.

In honor of National Mental Health Month, one PR flack pitched Philip Stein watches. In the flack's words: "The highlighted element of the watch is the brand's exclusive wellness technology that helps wearers improve sleep and reduce stress. The watch is embedded with a metal disk that emits natural frequencies into the body wearer and in turn, affects the wearer's energy field. It's called 'Natural Frequency Technology' and is a new patented technology studies suggest help to improve sleep quality and reduces stress."

Really. That's what the flack said. Right off the bat, he's gone from mental health issues to sleepless nights from stress. Not content with confounding the two issues, he continues: "Dr. Jeff Gardere, America's well-known psychologist, is Chief Medical Executive for Philip Stein Watches and had been running a practice for over 20 years. He recognized during that time that there was a huge need to educate the public on the possible severities of stress and everyday lifestyle changes that everyday people can make without a prescription. Dr. Gardere found a natural way to reduce stress and prescribed his patients with a high-end accessory Philip Stein Watch."

The psychologist "prescribed" a watch. I wonder if my insurance company would pay for that scrip? The watches start at $1,000, with a few that didn't list the price, just a phone number to call instead.

As it turns out, the watch manufacturer advertises its product's medical benefits right on its home page. And they tout a randomized, double blind, placebo-controlled, crossover evaluation right on their website. What they can't tout, because it's not in the study itself, are things such as statistical significance to their outcomes.

The study concluded, "While the current overall results are not statistically significant, a substantial number of subjects demonstrated improvements in the measured individual sleep parameters. Feeling more refreshed after sleep was the primary outcome measure that most clearly separated from placebo. There was not a clear indication that the combination of devices was better than the single device alone condition across all of the sleep parameters. A direct comparison of devices was not conducted in this study. Factors effecting the overall statistical significance of these results could have been environmental (a first night effect), subject inclusion or exclusion criteria, or a placebo effect. Results of this pilot study suggest future studies to determine clinical effectiveness of NFT and SleepNFT should be conducted."

The best way a watch could help sleepless nights is to remind its wearer that it's time to go to bed.

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QD: News Every Day--Botox procedure volumes above pre-recession peak

Patients are returning to doctors in record numbers for Botox, a corporate executive announced at a health care summit.

The CEO for Botox maker Allergan, Inc., announced at the Reuters Health Summit last week that, "Happily, for all of the facial aesthetics and even breast aesthetics markets, we are now at a place that we are beyond the peak pre-recession."

He told Reuters demand for cosmetic procedures hit bottom in the spring of 2009 in the wake of the global financial crisis. But sales of Allergan's dermal fillers are 20% above where they peaked before the recession, fueled not just by the super-rich, but by consumers with an annual household income of at least $50,000.

"It's correlated with people's confidence about the future, maybe how much money they have got on their credit card at the time," the CEO added.

The news comes at a time when many uninsured patients can't afford a hospital visit, and when Medicare is becoming increasingly insolvent. We may die young from all this, as they say, but we'll have good looking corpses.

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Saturday, May 14, 2011

Mystery symptom of itchiness during pregnancy could indicate a dangerous liver problem

If a pregnant woman finds herself scratching and itching during the third trimester, these symptoms should not be ignored. Each year, approximately 0.1% to 15% of pregnant women are affected by a liver disorder called Intrahepatic Cholestasis of Pregnancy (ICP).

ICP patients tend to develop symptoms of itchiness of their hands and feet that becomes progressively worse and then spreads all over their body. The itchiness usually worsens at night and if untreated can cause jaundice and several life-threatening complications to the unborn fetus. When a pregnant woman complaints of itchiness (pruritus) all over her body, the first order of business is to determine whether a rash is present. If a rash is absent, ICP should be suspected.

The liver is the largest gland in the body and in addition to filtering harmful substances such as alcohol, it is also responsible for processing fats, carbohydrates and proteins. To process fat, the liver makes bile salts. In ICP, bile salts are increased, which contributes to the symptoms of itchiness. Affected women will not only be plagued by pruritus but their unborn babies are at risk for stillbirth, preterm labor, fetal distress and abnormal heart rates.

South American women and especially those from Chile have a greater risk of developing ICD, as do women from South Asia and Sweden. However, North American born women in the U.S. have also been affected as well as women with Hepatitis C. Female hormones such as estrogen and progesterone contribute to the development of ICP, as does genetics. The diagnosis of ICP is made by specific laboratory tests. Once the diagnosis is confirmed, the patient should be referred to a maternal fetal medicine specialist for further management. ICP is a high risk condition and the baby usually has to be delivered early because the mother cannot tolerate the intense itching. There is a special medicine that can be prescribed to reduce the elevated bile acids but it should be given under the supervision of a physician specializing in high-risk pregnancies.

A complaint of severe itching that develops during the third trimester should not be ignored or given Benadryl if the symptoms have lasted for more than three days. At minimum, lab work should be ordered. Remember, a healthy baby doesn't just happen. It takes a smart mother who knows what to do.

This post by Linda Burke-Galloway, 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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Friday, May 13, 2011

Most hospitals have similar performance scores

Quality measures. Patient satisfaction surveys. With our new health care reform law, these "performance measures" are the new black in health care.

Hospitals are currently spending, conservatively, tens of millions of dollars to bolster these "performance measures" in hopes of securing a refund of a mere 1% of payments that CMS will soon withhold from them in the name of "assuring" quality improvement.

But what if, nationwide, there wasn't a big difference in these measures between hospitals? What happens then? Might payments then be made on political grounds?

Performance measures have been collected for some time now in anticipation of this new payment initiative by the government, so data exist to evaluate. In fact, Kaiser Health News was nice enough to aggregate the findings from our government's Hospital Compare website for my review.

So I calculated the mean, median and standard deviation of the results of all of this data collected across 50 states and 2 territories and found very little difference in measures collected between states:Perhaps most remarkable is the fact that none of these data are skewed (means are virtually identical to the medians) and that there is very little variability (2-6%) between the data sets.

The fact that these data are so similar across states is a testament to the nationwide health care quality that U.S. citizens can currently expect in America.

But these data also lead to a disturbing question: if the data are so similar across every state or territory, will similar findings hold true between hospitals? How is the average Joe or Sally (or Joe or Sally government worker) going to see a meaningful difference in performance measures between states OR hospitals when they show performance differences of as little as +/- 3%?

The realistic answer?

They can't.

This post by Westby Fisher, 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--Early antiretroviral treatment prevents HIV spread between sexual partners

HIV-infected men and women with relatively healthy immune systems who received immediate oral antiretroviral therapy (ART) were 96.3% less likely to pass on the infection to their uninfected partners and remained healthier than those whose treatment was delayed, according to a multinational clinical study.

Though set to run until 2015, the Phase 3 clinical trial (HPTN 052) was halted early by an independent data safety monitoring board after finding unequivocally that early ART provided sexual partners substantial protection from acquiring HIV. Antiretroviral therapy will be offered to the HIV-infected persons in the delayed treatment arm and study participants will be followed for at least one year.

"This is excellent news," said Myron Cohen, MD, a Fellow of the American College of Physicians and the study's principal investigator, "The study was designed to evaluate the benefit to the sexual partner as well as the benefit to the HIV-infected person. This is the first randomized clinical trial to definitively indicate that an HIV-infected individual can reduce sexual transmission of HIV to an uninfected partner by beginning antiretroviral therapy sooner."

HPTN 052 enrolled 1,763 HIV-serodiscordant couples, 97% of whom were heterosexual. The study was conducted at 13 sites across Africa, Asia and North and South America. HIV-infected participants were determined to be relatively healthy by a CD4 cell count between 350 and 550 cells/mm3 and the absence of any AIDS-related events such as Pneumocystis pneumonia within 60 days of entering the study. The HIV-uninfected partners all tested negative for the virus within 14 days of entering the study. All participants were at least 18 years of age and the median age was 33 years at the time of enrollment, 52% of the participants were male, and the couples agreed to participate in the trial for five years.

886 couples were randomly assigned to receive a three-drug HIV treatment combination, and 877 were assigned to deferred treatment, where the HIV-infected partner received ART only after his or her CD4 count dropped below 250 cells/mm3 or an AIDS-related event occurred. Both groups received regular HIV testing, safe-sex counseling, free condoms, testing and treatment for sexually transmitted infections, and treatment for any HIV-related complications.

Among the 877 couples in the delayed ART group, 27 HIV transmissions occurred, and in the immediate treatment arm, one transmission occurred. Genetic analysis confirmed that the source of the new infection was the previously HIV-infected partner.

In the originally HIV-infected individuals themselves, 17 cases of extrapulmonary tuberculosis occurred in the delayed ART group, compared with 3 cases in the immediate ART group. There were also 23 deaths during the study, 13 in the delayed ART group and 10 in the immediate ART group.

"Previous data about the potential value of antiretrovirals in making HIV-infected individuals less infectious to their sexual partners came largely from observational and epidemiological studies," said National Institute for Allergy and Infectious Diseases (NIAID) Director Anthony S. Fauci, MD, a Master of the American College of Physicians. "This new finding convincingly demonstrates that treating the infected individual, and doing so sooner rather than later, can have a major impact on reducing HIV transmission."

The trial is conducted by the HIV Prevention Trials Network and funded by the NIAID. The 11 antiretroviral drugs used in the study in various combinations were made available by their manufacturers.

"With these results we should redouble our efforts to diagnose individuals with HIV earlier," said HIV Medicine Association Chair Kathleen Squires, MD, a Fellow of the American College of Physicians. "The U.S. federal treatment guidelines were modified recently to recommend earlier treatment for people with HIV infection to improve health outcomes for this patient population. We now have further evidence that effective treatment not only benefits the individual but also will help reduce the spread of this disease."

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Thursday, May 12, 2011

HeLa, HIPAA and the ethics of informed consent

Recently I read the book The Immortal Life of Henrietta Lacks by Rebecca Skloot. This book is a must-read for anyone involved in medical research. The book tells the story of a woman, Henrietta Lacks, and her family. Ms. Lacks was treated for cervical cancer at John's Hopkins in 1951. Her malignant cervical cells (HeLa) were harvested and disseminated to become the first "immortal" cell line widely used for scientific research, including their use in the development of the polio vaccine. The story details what occurred in the aftermath of Ms. Lacks' death to her family, a poor African-American family living in Maryland--a family, which in today's lingo, had very poor "health literacy." The account brings up key ethical issues of biomedical research that were evolving during that era.

The story of the HeLa cells began after the Nuremberg trials of World War II, which involved experimentation on concentration camp prisoners of the Holocaust and the eventual Nuremberg Code and World Medical Association's Declaration of Helsinki in 1964, which described a code of ethics for research involving human subjects.

At the time of Henrietta Lacks, the concept of informed consent was still in its infancy. Institutions, such as John's Hopkins, where Ms. Lacks received her care, did not have Institutional Review Boards (IRBs) to govern and approve their research protocols. The events of the Lacks family took place in the same era as the "Tuskegee Experiment" (1932-1974), conducted by the U.S. Public Health Service. Tuskegee gained notoriety by studying the natural history of untreated syphilis in poor African-American sharecroppers in Tuskegee, Alabama. Its participants were led to believe that they were receiving syphilis treatment from the Public Health Service, when in fact the treatment (penicillin) was being withheld for the sake of research.

Nuremberg and Tuskegee shaped the precedent for federal regulation of biomedical research involving human subjects with the creation of the Belmont Report in 1979, which describes the core ethical principles that must be met in conducting biomedical research on human subject. At this time federal regulation was enacted calling for the implementation of IRBs to oversee human subject research in all institutions involved in conducting research. Those of us who have participated in research at academic institutions should be well aware of this history, which we all review in our IRB certification process.

What is interesting to me about the Henrietta Lacks story is comparing the evolution of biomedical research ethics in that era (1940s-70s) with the ethical dilemmas that face us today. At the time of HeLa cell dissemination, informed consent was at the forefront of discussion, whereas in our current era we have struggled with two core elements of ethics in biomedical research: privacy and managing conflicts of interest. In 1996, the HIPAA privacy rule was enacted establishing nationwide security standards and safeguards for the use of electronic health care information as well as the creation of privacy standards for protected health information. HIPAA went through various iterations prior to its evolution into its current version issued in 2002. Similar to the response that occurred in reaction to federal policy outlining requirements for informed consent, researchers of today have oft complained that HIPAA has been an impediment to scientific progress and research. The latest HIPAA debate has revolved around federal requirements that medical providers and insurers notify patients in the event of discovering a privacy breech. Multiple examples of such privacy breaches have been described in the media ranging from stolen laptops to identity theft. Interestingly, in 2010 a health plan, Cignet Health, in Maryland was sued over non-compliance with HIPAA and fined a monetary penalty of $4.3 million dollars. However, the suit was not over a breach of confidentiality; rather, it was over Cignet's refusal to allow 41 of their patients access to their own medical records.

In addition to sorting out privacy at is relates to biomedical research, medical care, and electronic communications, the other core ethical issue defining our era is conflict of interest. In 2008, Sen. Charles Grassley, (R-Iowa) brought to light conflicts of interest that were prevalent in the world of psychiatry. At the time, according to Grassley's investigation, 30% of funding for the American Psychiatric Association, the premier professional organization in the field of psychiatry, came from the pharmaceutical industry. What followed suit was an unveiling of pharmaceutical ties that were reported to contaminate the thought leaders of many research institutions in all fields of medicine.

My own institutional affiliate was not immune and in 2008 Charles Nemeroff, renowned researcher in psychiatry and chair of the Department of Psychiatry at Emory University gave up his title and eventually left Emory after being investigating by Grassley. Academicians can attest to the changes that have occurred in the past several years with respect to disclosures of financial interest in research centers. Is it a witch-hunt, or is the cleansing of these relationships based in true ethical conflict? After all, isn't conflict of interest inherent in all of business?

The story of Henrietta Lacks was interesting from a historical perspective. It took decades to sort through informed consent. In contrast, the debates over health privacy and conflict of interest are still in their infancy. The fact that remains similar, however, is that the underprivileged, and medically "illiterate" are far more likely to be the subject of ethical violations than others, even in today's era. In the case of the Lacks family, poor communication and lack of confidence on the part of the medical establishment that the family would be able to grasp the content of the discussion resulted in a lack of informed consent. Today, who is more likely to be de-identified appropriately in a medical blog, a Hispanic patient at a county hospital, or a wealthy business executive? No wonder the underprivileged are often suspicious of traditional medicine.

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

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QD: News Every Day--Uninsured rack up $73 billion in unpaid hospital bills

Uninsured families can only afford to pay in full for 12% of most potential hospital stays, including those with higher income but no insurance, reports the U.S. Department of Health and Human Services.

Hospital stays for which the uninsured cannot pay in full account for 95% of the total amount that hospitals bill the uninsured. Other studies have estimated that the uncompensated cost of care that the uninsured cannot pay has risen to $73 billion a year, a significant portion of which is shifted into higher costs for Americans with insurance and their employers, reports HHS.

Approximately 50 million Americans are uninsured, and most have no savings. The median financial assets for all uninsured families are just $20, the HHS said. Even among higher income families, half of families with income at 400% of the Federal Poverty Level (FPL), or $89,400 a year for a family of four in 2011, have financial assets below $4,100.

But every year, nearly 2 million uninsured Americans are hospitalized, and 58% of these hospital stays resulting in bills of more than $10,000. Even the top 10% of uninsured families with the most assets are estimated to be able to pay the full bill for only half of potential hospital stays.

Researchers and think-tankers disagreed on the impact that the uninsured have on the health care system, since the uninsured are being charged the full rate instead of an insurer-negotiated discount rate, and because the government picks up much of the tab for uninsured visits to hospitals.

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Wednesday, May 11, 2011

Electronic pancreas may keep glucose in safe range overnight

A team led by researchers from University of Cambridge showed that closed loop insulin delivery was effective in controlling overnight blood glucose levels in patients with type 1 diabetes. The system took readings every fifteen minutes and automatically titrated a proper amount of insulin.

University of Cambridge researcher Dr. Roman Hovorka led two studies to evaluate the performance of the artificial pancreas in 10 men and 14 women, aged 18 to 65, who had used an insulin pump for at least three months.

The first study monitored 12 participants overnight after consuming a medium-sized meal (60 g carbohydrate) at 7 p.m. In the second study, the other 12 participants were monitored overnight after consuming a larger meal (100 g carbohydrate) accompanied by alcohol at 8.30 p.m.

The studies showed a 22% improvement in the time participants kept their blood glucose levels in a safe range, halving the time they spent with low blood glucose levels and reducing the risk of both short term and long term complications.

Link at Cambridge: Artificial pancreas promise for common diabetes complication ...

Abstract in BMJ: Overnight closed loop insulin delivery (artificial pancreas) in adults with type 1 diabetes: crossover randomised controlled studies

This post by Medgadget 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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The sad demise of the yeoman doctor

In American History we studied the yeoman farmer as the Jeffersonian ideal. The rugged individualist clearing the land, building his home, and creating fertile growing space in the hinterland to feed his family and eventually, the community.

Socrealizm: Farmer by zakwitnij via Flickr and a Creative Commons licenseThe yeoman farmer was almost entirely supplanted by agribusiness, as economies of scale were created by the efficiencies of amalgamating resources (land) and using technology to efficiently specialize (mono-crop culture).

(The counterweight to this has been the rise of organic farming, but even in that story there is a familiar pattern of big business leveraging itself in the newer market.)

Also being relegated to mythic status is the yeoman doctor, out there by himself (almost always him), caring for generations of family members in the same location. He would attend to his patients in the office, in the hospital, and after hours.

Now comes a wonderfully reported portrait of the last of this dying breed. The New York Times ran a front-page story about Dr. Ronald Sroka, a family doctor who's now taking care of his third generation of families in Crofton, Maryland.

Dr. Sroka has no partner. He doesn't have an electronic medical record. He eschews unnecessary testing since a) he knows his patients so well and b) he's very skilled at diagnosing things with a history and physical examination.

He owns his practice, in the time-honored tradition of doctors hanging out a shingle and making things work by the sweat of their brow. His wife (of course) helps run the business end of the practice.

Now that Dr. Sroka is nearing retirement age, he can't sell his practice. He can't even give it away.

Younger docs (I am one) don't want to work as hard as Dr. Sroka does. We want doctoring to be part of our lives, not the whole thing.

We trade the risk (and reward) of owning a practice for the security (and loss of freedom) of a salaried job in a larger organization.

The same kinds of issues are in play as with agribusiness: Consolidation brings leverage in negotiating contract prices; working for a large organization means economies of scale. The corporate entity takes care of overhead like malpractice, computer systems, even paying the nurses and medical assistants.

The Health Care Reform legislation (PPACA) passed by Congress in 2010 will only accelerate this process. Organizations that integrate care to provide high quality mean that the little guy will be left out in the cold. The sheer bureaucracy of the new changes (e.g. building "accountable care organizations" and "gainsharing risk") will make it harder and harder for solo practitioners and even small groups to survive on their own.

There will obviously be a few holdouts:

--Psychiatrists in Manhattan.
--Cosmetic surgeons.
--Concierge doctors, the model of which I think will lead to the rise of the
--Boutique practice. You want to go where everyone knows your name. Where you're treated like an individual. And you're willing to pay out of pocket for the privilege, avoiding the hassles of insurance altogether.
--"Diet" doctors, purveying their own "special" elixirs and potions.

If health care reform means more accessibility and better quality of care, then the changes will be welcome. Yet there will be major disruptions in our current practices and patterns for some time to come.

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--Much more practice needed to do colonoscopies correctly

Much more practice is needed than gastroenterological professional societies currently recommend, concluded Mayo Clinic researchers in Rochester, Minn.

Current recommendations are that 140 procedures should be done before attempting to assess competency, but with no set recommendations on how to assess it, wrote the author of the research. But it takes an average of 275 procedures for a gastroenterology fellow to reach minimal cognitive and motor competency.

Now, the American Society for Gastrointestinal Endoscopy is rewriting its colonoscopy training guidelines to reflect the need for more procedures and emphasize the use of objective, measurable tests in assessing the competency of trainees.

The study authors assessed the performance of 41 Mayo Clinic gastroenterology fellows who performed more than 6,600 colonoscopies from July 2007 through June 2010. The research team used a validated testing method called the Mayo Colonoscopy Skills Assessment Tool (MCSAT).

The MCSAT assesses areas such as intubation rates and timing, how safely and painlessly practitioners perform the procedure and how clearly the students recognize potential patient issues.

The study's findings may apply to specialties other than gastroenterology, according to a press release from the Mayo Clinic. While gastroenterology fellows may perform well more than 400 colonoscopies during their training, specialists in other areas, such as surgery or family practice, may perform significantly fewer procedures during their training.

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Contact ACP Internist

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

Blog log

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Other blogs of note:

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

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

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

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

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

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