Thursday, June 30, 2011

Can physical exams save health care costs?

I've often heard physicians say that "The history is 90% of the diagnosis." In other words, they can usually determine the underlying cause of a patient's problem just by listening to their account of how it evolved. The physical exam is merely to confirm the diagnosis, and is often cursory, limited, or ignored.

I believe that the physical exam is far more important than it seems, and I learned this during my recent oral medical specialty board examination. Although I have been sworn to secrecy regarding the content of the test questions, I will share an epiphany that I had during the exam.

The examiners' job is to describe a patient and then ask the examinee what else she'd like to know and what she'd do next. With each description, I found myself struggling to visualize the patient, wishing I could see their face and hear their tone of their voice as they described their condition. I hadn't realized that so much of my clinical judgment was based on laying eyes on a patient. I needed to see if they were in pain, if they were straining to breathe, if their skin was pasty or pale, if they were disconnected and potentially drug-seeking, if they were fidgety, if they were articulate, forgetful, or well-groomed. All of these subtle cues were gone. I was left staring at the examiner, who himself couldn't describe the patient more fully because he was to stick to the script, reading verbatim from a prepared list of signs and symptoms.

And then something interesting happened. Based on the short description of an imaginary patient's complaint, I began to go down an inappropriate (and expensive) diagnostic pathway. Since I couldn't see the patient, and some of the symptoms could have been life-threatening, I suggested some pretty aggressive measures. I would not have ordered any of these tests had I been able to see the patient in person, because I would have been able to see what was actually wrong quite quickly.

I realized that when two doctors plan for the care of a patient they've never met, all manner of inappropriate and expensive testing and treatment can occur. So I wondered to myself: what will happen to our health care system if we continue to divorce ourselves from patient contact? When diagnostic algorithms become even more rigid, and patients are pressed into diagnostic code categories with pre-determined courses of action prescribed for them long in advance? It's going to become easier and easier for people to be locked in to an incorrect diagnosis, and subjected to a battery of expensive, and unnecessary tests and procedures, when all that was needed was a pair of human eyes and a thoughtful exam at the very beginning.

I'm pleased to report that I passed my specialty board exam, and I'm now certified in Physical Medicine and Rehabilitation. However, as I consider my clinical future, I know that to be a good diagnostician, I must spend time with my patients in person, and I'm looking forward to it.

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

Rob a bank to get health care

Just when you think things can't get any nuttier with American health care, here comes the strange and sad case of James Richard Verone. Mr. Verone, age 59, was laid off from his job of 17 years as a Coca-Cola deliveryman. He went through his savings and took a part-time position as a convenience store clerk but he had no health insurance. He had a back ache from lifting and bending and pain in his foot that caused him to limp. He also suffered from carpal tunnel syndrome and arthritis. When he noticed a protrusion on his chest he knew he needed medical attention. What is an impoverished, uninsured guy to do?

Image from the Gaston County (North Carolina) Sheriff's OfficeHe woke up, showered, put on a freshly ironed shirt and walked into a bank and handed the cashier a note demanding $1 and medical attention and then he waited for police to show up and arrest him. Before his caper, he sent a letter to the local paper, listing the return address as the Gaston County Jail.

"When you receive this a bank robbery will have been committed by me," he wrote. "This robbery is being committed by me for one dollar. I am of sound mind but not so much sound body."

Mr. Verone, who has never before been in trouble with the law, has already seen some nurses and has a jail doctor appointment on Friday. He wants the protrusion on his chest treated and he hopes to get back and foot surgery. (Mr. Verone needs to know that surgery is a last option and there are many treatments and steps before such aggressive action is contemplated)

Mr. Verone believes that if the United States had a health-care system that offered people more government support, he wouldn't have to make the choice he did.

Before you write this guy off as a kook, consider this. With back pain, carpal tunnel and a chest protrusion, he cannot go on the open market and buy insurance, even if he could pay the premium, which would probably exceed $1,500/ month and have a $5,000 deductible and exclude certain conditions. He is essentially uninsurable. Since he is working, he may not qualify for Medicaid. There are millions of James Verones all across the United States. They pay for care out of their pockets when they can, use the emergency room when they can't stand it anymore and suffer pain and disability far more than they seek help. As James Verone says, "If you don't have your health you don't have anything."

The Affordable Care Act is supposed to help Americans like James Verone get affordable health insurance. Most of the provisions do not go into effect until 2014 which gives the opponents lots of time to overturn it and keep things just as they are.

I doubt that James Richard Verone's scheme will work. You can't be kept in jail for simple larceny and get free health care. He will probably be fined and turned out on the street to limp back to work and struggle with his chest protrusion on his own.

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

QD: News Every Day--Stifling laughter safest for those who faint from it

Laughter is the best medicine, and now, here's the best medicine to treat laughter. Fainting from laughter happens, albeit rarely, and is probably a vasovagal response, reports a case series in the medical literature.

Dubbed "Sitcom Syncope," the series of three patients and a literature review of other cases evaluated patients who reported loss of consciousness during vigorous laughter. The series was reported by Prashan H. Thiagarajah, MD, an ACP Associate Member at the Allegheny General Hospital in Pittsburgh, Pa., and colleagues in Postgraduate Medicine.

The three patients reported seven fainting spells induced by vigorous laughter that were witnessed friends or family.

All patients were hospitalized and underwent a complete history and physical, 12-lead echocardiogram, chest radiograph, routine blood analysis, transthoracic echocardiography, Holter monitoring, carotid duplex study, stress testing, polysomnography, and head-up tilt table testing. In each cases, structural heart disease and cerebrovascular disease were ruled out.

In head-up tilt table testing, blood pressure, heart rate, and respiratory rate were recorded every two to three minutes, and a video clip was shown to induce laughter after 20 minutes. All patients had an abnormal response, either a significant decrease in systolic blood pressure or inappropriate heart rate response when returned to the upright position.

Gelastic syncope may be a variant of vasodepressor syncope, the researchers wrote.

"We suggest that gelastic syncope is a unique and separate subset of neurally mediated syncope similar to tussive or micturition syncope," they wrote. Coughing, urination or laughing produces repetitive short breaths, inducing a Valsalva-like hemodynamic response that increases intrathoracic pressure, decreases the return of venous blood from the systemic circulation, and reduces stroke volume.

The authors continued, "The normal physiologic response to a reduction in stroke volume is a compensatory increase in heart rate. Patients with gelastic syncope, much like those with other forms of vagally mediated syncope (tussive and micturation), have an impaired heart rate response and have an uncompensated reduction in stroke volume, and when severe, lose consciousness."

The usual therapeutic interventions should help these patients, the doctors said. While some patients reported stifling their laughter, researchers suggested alternatives: drinking two liters of liquid a day, dietary salt supplements, compression stockings, physical maneuvers such as gripping hands and tensing arms and legs, and avoiding prolonged standing. If behavioral therapies fail, consider first beta-blockers and then midodrine.
Wednesday, June 29, 2011

Does becoming a doctor mean sacrificing a family?

Recently, the New York Times has published provocative op-eds involving physicians. The first tackled physician bullying. Next was the cost of medical education. And, most recently, was the phenomenon of part-time, mostly female, physicians. This is obviously a live-wire topic, sure to generate passionate commentary.

In the piece, anesthesiologist Karen S. Sibert goes over ramifications of part-time physicians. They comprise mostly of women, as 40% of female physicians between the ages of 35 and 44 reported working part time.

In the context of the primary care shortage, however, this presents problems to patients: "It isn't fashionable (and certainly isn't politically correct) to criticize "work-life balance" or part-time employment options. How can anyone deny people the right to change their minds about a career path and choose to spend more time with their families? I have great respect for stay-at-home parents, and I think it's fine if journalists or chefs or lawyers choose to work part time or quit their jobs altogether. But it's different for doctors. Someone needs to take care of the patients.

The Association of American Medical Colleges estimates that, 15 years from now, with the ranks of insured patients expanding, we will face a shortage of up to 150,000 doctors. As many doctors near retirement and aging baby boomers need more and more medical care, the shortage gets worse each year.

The United States isn't alone in dealing with this issue. In Canada, for instance, the newsmagazine Maclean's did a front-page story on the topic back in 2008. In it, the president of the Canadian Medical Association bluntly stated, "female doctors will not work the same hours or have the same lifespan of contributions to the medical system as males."

Dr. Sibert is correct in pointing out that our health system cannot accommodate the incoming generation of physicians who prefer a better work-life balance.

She proposes that medical students be forced to choose: Students who aspire to go to medical school should think about the consequences if they decide to work part time or leave clinical medicine. It's fair to ask them--women especially--to consider the conflicting demands that medicine and parenthood make before they accept (and deny to others) sought-after positions in medical school and residency.

Indeed, her wry advice to a medical student who valued work-life balance was, "If you want to be a doctor, be a doctor."

In other words, medicine or family. Not both.

If that's truly the case, it's unlikely that many medical students will sacrifice their family for their career.

And, to be honest, why should they?

Physicians today are often vilified in the media, as well as by health policy experts. As we reform our health system, it is the physicians who are often targeted as ones most responsible for soaring health costs, and yet their concerns often are ignored. The bureaucratic hoops doctors have to jump through to care for their patients continue to worsen. To top it off, there is constant pressure to replace physicians with less expensive options.

Simply put, doctors and the work they do, are becoming devalued by society. It's no wonder that physicians' commitment to the profession is wavering.

It's one reason why physicians today, both male and female, prioritize work-life balance. Those who don't risk burning out. And, as internist Robert Centor poignantly notes, "I would rather see a committed part-time physician than a burned out full-time physician."

Instead of pointing the finger at part-time doctors, it is our health system that needs to change, and adapt to physicians who choose to place both medicine and their family on an equal pedestal.

This post by ACP Member Kevin Pho, MD, originally appeared on MedPage Today's, social media's leading physician voice. Voted best medical blog in 2008, and with over 100,000 subscribers on Facebook, Twitter, and LinkedIn, is the Web's definitive site for influential health commentary.

QD: News Every Day--Pain's toll warrants new treatment approaches

Pain affects at least 116 million adult Americans annually and costs the nation between $560 billion and $635 billion annually, says a new report from the Institute of Medicine (IoM). Much of this pain is preventable or could be better managed, added the committee that wrote the report.

The breakdown of pain's impact includes the costs of health care ($261-$300 billion) and lost productivity ($297-$336 billion) attributable to pain, according to a press release. These figures do not include lost tax revenues. Medicare bears one-fourth of U.S. medical expenditures for pain, totaling at least $65.3 billion, or 14% of all Medicare costs in 2008. Medicare, Medicaid, the Department of Veterans Affairs, TRICARE, workers' compensation, and other federal and state programs paid out $99 billion in 2008 for pain.

Pain is a chronic disease unto itself, and there is a moral imperative to treating it with a comprehensive, interdisciplinary approach that includes the patient. Chronic pain has a distinct pathology that triggers changes throughout the nervous system that often worsen over time. "It has significant psychological and cognitive correlates and can constitute a serious, separate disease entity," the report reads.

The majority of care and management should take place through primary care providers and patient self-management, with specialty care reserved for more complex cases. Health care organizations should take the lead in developing innovative approaches and materials for patient self-management.

The report acknowledges that opioids crate problems of drug diversion and abuse, even as questions remain about their long-term usefulness. But, "[W]hen opioids are used as prescribed and appropriately monitored, they can be safe and effective, especially for acute, post-operative, and procedural pain, as well as for patients near the end of life who desire more pain relief."

Pain often produces psychological effects, such as anxiety, depression, and anger. While interdisciplinary approaches are the most promising, there are too many barriers to that approach, including reimbursement for clinicians.

As a result, costly procedures often are performed when other actions should be considered, such as prevention, counseling, and facilitation of self-care. Insurers and government health care programs are not designed to efficiently pay for an interdisciplinary approach of integrated patient management. The report calls on Medicare, Medicaid, workers' compensation programs, and private health plans to find ways to cover interdisciplinary pain care.

In addition, adequate pain treatment and follow-up is hampered by uncertain diagnosis and societal stigma, especially when patients do not respond to treatment.

"Understanding chronic pain as a disease means that it requires direct treatment, rather than being sidelined while clinicians attempt to identify some underlying condition that may have caused it," the report reads.

Education should include a "substantial" amount of training. For example, a recent study found that only five of the nation's 133 medical schools have required courses on pain and just 17 offer elective courses. Licensing and certification exams should include assessment of pain-related knowledge and capabilities. Programs that train specialists or offer training in advanced pain care need to be expanded.

The committee called for coordinated, national effort with results expected as soon as the end of 2012 including:
--Create a comprehensive population-level strategy for pain prevention, treatment, management and research;
--Develop strategies for reducing barriers to pain care;
--Support collaboration between pain specialists and primary care clinicians, including referral to pain centers when appropriate; and
--Designate a lead institute at the National Institutes of Health responsible for research.

Others efforts should be in place by 2015, including providing educational opportunities in pain assessment and treatment in primary care. ACP Internist reported on prescription opiate abuse and outlined ways internists can intervene, as well as available resources to help them with this patient group.
Tuesday, June 28, 2011

Vampires and urban legends: Teaching residents about health care costs

This past weekend, I gave a talk at the Committee of Interns and Residents, the largest housestaff union in the United States. The most inspiring moment of the meeting that I witnessed were the two standing ovations earned by Dr. Koffler for advocating for residents to get paid in 1936 (her first paycheck was $15 a month!). How could I follow that ... especially with a talk on how to train cost-conscious physicians? Those who know my work well may even wonder how I got invited to talk about this. Well, earlier this December, I wrote on the blog about my holiday wish list for medical education and #2 was a curriculum on cost conscious practice for medical trainees. In addition to lack of a formal curriculum, there were several other barriers on teaching residents how to practice cost-conscious medicine that I discussed.

Vampire Killing Kit by JoshBerglund19 via Flickr and a Creative Commons License Faculty are not trained. The largest barrier of course is that faculty don't know how to do this. A study in Journal of Hospital Medicine showed that faculty physicians could not identify what things cost.
No one knows what the cost of anything is. Because each hospital negotiates its own prices with suppliers, it is very difficult for residents to know how much things cost. In trying to find out how much your hospital charges for various tests, you may end up on a wild goose chase until you find the helpful person who may or may not even be in your state!
Bad systems promote costly workarounds. Most of the time, residents are too concerned that they won't be able to get a test or worse, it will delay a patient's discharge. The system is set up to order the test even if the attending thinks about it. Some of our own data shows that interns learn during internship to misrepresent tests as urgent to get the job done.
Rumors and hospital legends spread quickly. The highly connected residency program can actually spread rumors about how much things cost or give rise to urban legends when patients actually pay and don't pay.
Underordering, not overordering, is penalized. Due to the highly litigious environment, most attendings encourage residents to err on the side of getting a test since the biggest fear we all have is of missing the "can't miss" diagnosis. More reasons doctors over-order tests are here.

So what can we do to teach residents about cost-conscious practice? Well here are just a few of the things we can do.
Empower residents to find out how much their hospital charges for things. As I said at the conference, we may need to start a support group for those that start down this daunting path, but it is the first step to understanding how to control costs. Starting with senior leadership could be helpful. After all, how many C-suite leaders would not want to find out how to teach residents to control their costs? There is also a related movement to improve price transparency for patients.
Show residents how much they spend. At least in the case of daily phlebotomy, a recent study dubbed "Surgical Vampires" (due to the daily blood draws ordered by the surgical interns) highlighted that letting residents know how much things cost actually reduced the cost of lab ordering per patient and resulted in $50,000 saved over 11 weeks! Studies with electronic health records at the point of care show even greater results!
Use unbiased resources that promote better cost-effective decisions. Specialty societies like the American College of Physicians and the American College of Radiology are now starting to create guidelines that encourage cost-effective practice through more judicious use of imaging or other therapeutic modalities. The popular $4 dollar list for medications is another example.
Incorporate discussions of costs into routine educational conferences. At Harvard, one chief resident started a Hospital Bill Morning Report for the residents to review what a patient bill is like. In our medical student lectures on radiology, the costs of the tests are also now discussed.
Educate patients that less is sometimes more. Letting patients know about the risks of overordering tests, specifically workups of incidentalomas and pseudodisease, may be helpful in explaining your new approach to cost-conscious medicine. The pushback from patients may be the fear of rationing, which is of course irrational since it already occurs. A helpful summary for patients on high value cost conscious medicine appeared in Annals of Internal Medicine.

As with all things, there is the potential for unintended consequences in teaching cost-conscious medicine. The most egregious of which would be to hide behind the veil of practicing cost-conscious medicine in order to shirk work and avoid getting an indicated test when needed. This is especially important to watch out for as burnout sets in late in the academic year. So, as we resist our inner vampire urge to order blood tests and uncover hospital urban legends and myths about healthcare costs, it's equally important not to morph into the haphazard and dangerous cost-cutting monsters that we all fear most.

Vineet Arora, MD, is a Fellow of the American College of Physicians. She 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, supervising internal medicine residents and students caring for general medicine patients, and serves as a career advisor and mentor for several medical students and residents, I also direct the NIH-sponsored Training Early Achievers for Careers in Health (TEACH) Research program, which prepares and inspires talented diverse Chicago high school students to enter medical research careers. This post originally appeared on her blog, FutureDocs.

QD: News Every Day--Prescription opiates causing more treatment admissions

Prescription opiates rose to one-third of all treatment admissions in 2009, from 8% in 1999, reflecting the rising trends in prescription opiate abuse. There were nearly 2 million substance abuse treatment admissions in 2009 among people ages 12 and older were reported to the Treatment Episode Data Set, a reporting system involving treatment facilities from across the country.

Five substance groups accounted for 96% of admissions: alcohol (42%), opiates (21%), marijuana (18%), cocaine (9%), and methamphetamine/amphetamines (6%), reported the Substance Abuse and Mental Health Services Administration. The data came from 49 states and Puerto Rico. Georgia and the District of Columbia did not report admissions for 2009. One person can be reported as multiple admissions in a year.

Treatment admissions for alcohol decreased from 48% in 1999 to 39% in 2005, but then increased steadily to 42% in 2009. And, 44% of admissions for alcohol abuse involved other drugs. People often arrive in treatment programs with multiple problems, including dependency or addiction to multiple substances of abuse, the report noted, and treating this population requires an integrated system of care.

Alcohol was the leading drug of abuse for treatment admissions among all major ethnic and racial groups except persons of Puerto Rican origin, who cited opiate abuse as their leading problem.

Marijuana-related admissions rose from 13% in 1999 to 18% in 2009. Marijuana was either the primary or secondary reason for substance abuse treatment in 86% of all admissions involving those between the ages of 12 and 17.

Cocaine admissions fell from 14% to 9% from 199 to 2009. Methamphetamine/amphetamines admissions rose from 4% of all admissions in 1999 to 9% in 2005, but then decreased to 6% in 2009.

In April, the Obama Administration released Epidemic: Responding to America's Prescription Drug Abuse Crisis, a comprehensive action plan for reducing prescription drug diversion and abuse by supporting the expansion of state-based prescription drug monitoring programs, and recommending more convenient and environmentally responsible disposal methods to remove unused medications from the home.

Coincidentally to the report's release, the journal Pain Medicine published a special supplement on pain, in which the lead editorial outlined the issues involved for physicians. Among the main concerns:
--A significant proportion of people who die from opioid-related overdose had histories that included risky behaviors, psychiatric disorders, and/or substance use disorders. These behaviors can threaten effective opioid therapy, and while clinicians may recognize them, they often lack the language to describe them.
--When pain is the principal complaint at the time of the first opioid prescription, many patients who eventually enter detoxification treatment are recidivist, or had early first use of alcohol or illicit drugs.
--Physician error also causes harm, and methadone presents special challenges.

ACP Internist reported on prescription opiate abuse and outlined ways internists can intervene, as well as available resources to help them with this patient group.
Monday, June 27, 2011

Should doctors wear white coats?

The doctor's white coat has been a symbol of the profession for decades. In the 1800's and up through the early 20th Century, doctors wore street clothes while performing surgery, rolling up their sleeves and plunging dirty hands into patient's bodies. They often were dressed in formal black, like the clergy to reflect the solemn nature of their role. And seeing a doctor was solemn indeed as it often led to death.

A 1989 photograph from the Mass General Hospital shows surgeons in short sleeved white coats over their street clothes, and in the early 20th Century the concept of cleanliness and antisepsis was starting to take hold in American medicine. Both doctors and nurses started donning white garb as a symbol of purity. The white coat took on more and more symbolic meaning and the "White Coat Ceremony," where medical students are allowed to don the formal long white coat, has even been a rite of passage upon graduation from medical school.

For the past few years, the American Medical Association and other medical societies have debated if it is time for the white coat to be retired. A study of New York City doctors in 2004 showed their ties were a source of infectious microorganisms. The British health service barred ties, lab coats, jewelry on the hands and wrists and long fingernails because of infection. Researchers from Virginia Commonwealth University showed bacteria from a white cotton lab coat can cause infection just minutes after touching skin. Another study reported that the majority of medical personnel change their lab coats less than once a week.

At this time there are no recommendations for doctors regarding wearing lab coats. I've not seen a good comparative study on the hazards (or benefits) of wearing the white coat. Are street clothes any more sanitary? Isn't the real issue hand washing and good hygiene from caregivers?

A number of surveys of patients show they "overwhelmingly" prefer their physicians to wear white coats. Patients seem to have more trust in and comfort with physicians who wear the coat. For many patients it is still a symbol of professionalism and good care and it helps them identify the physician.

I must admit I like my white coat. It has pockets that are filled with my needed paraphernalia and tools. It protects my clothes, and when I don it, I take on a professional personae. I'm no longer a wife, mother, insecure female, nor am I worried about (fill in the blank). I am a doctor. It helps me shift into a professional role with focus and clarity. I know it is psychological, but for me, it works.

So what do you think? Do you like your doctor in a white coat? Would you prefer regular street clothes? Physicians, do you still wear the white coat?

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

QD: News Every Day--Rock-a-bye baby, and the rest of us too

Gentle rocking puts people to sleep quicker and improves its quality, researchers concluded.

Lying on a slowly rocking bed (0.25 Hz) facilitated faster sleep and increased the duration of stage N2 sleep among 12 healthy male volunteers ages 22 to 38 with good sleep habits. Participants took two 45-minute afternoon naps, once with the bed stationary and again while rocking. Researchers assessed sleep by questionnaires and actimetry recordings, and reported their results in Current Biology.

In all 12 men, rocking accelerated sleep onset, as evidenced by a shorter duration of stage N1 sleep and a reduction of stage N2 latency. Rocking also increasing the duration of stage N2 sleep and the mean spindle density per 30-s epoch. Spindle density increased significantly from the second half of the nap and persisted throughout the entire duration of stage N2. Rocking also increased EEG power of slow wave activity, predominantly during the last third of stage N2.

But how? And so what?

First, vestibular/somatosensory pathways have anatomical links with structures implicated in emotions such as the amygdala, which affects the regulation of sleep-wake states. Second, rocking may modulate sleep-wake centers via direct or indirect connections between sensory systems and hypothalamus or brainstem. Third, sensory inputs could affect the synchrony of neural activity within thalamo-cortical networks because both somatosensory and vestibular inputs send direct projections to thalamic nuclei.

Researchers concluded that rhythmic rocking may enhance synchronous activity within thalamo-cortical networks. They wrote, "The use of rocking to soothe sleep thus belongs to our repertoire of adaptive behaviours in which a natural mechanism of sleep (thalamo-cortical synchronization) has been harnessed in the simplest manner since immemorial times," such as rocking infants to sleep.
Friday, June 24, 2011

Should doctors treat their patients like customers?

I can't remember; are they patients or our customers?

Are our patients really customers? Are they clients? Does this term, borrowed from the business world, really hold water in the current climate of health care? I believe if you ask most practicing physicians and nurses, other than those in charge of administration of groups and hospitals, they would say that they have patients, not customers, and that the whole idea is driving them batty.

The customer service model is very popular. Entire lectures and conferences exist to enforce this enlightened way to view patient care. I understand the drive, to an extent. The people we see in our hospitals and emergency departments need to feel valued and need to feel we are competent and caring. This matters especially in highly competitive markets because the ones who are happy keep coming back. This also matters because people who feel valued may be less likely to sue us. There is some logic to the customer service world view.

Unfortunately, there is madness in the mix. Especially in these days of enforced charity, these days of compulsory volunteerism on the part of professionals, customer is the last word we would use for some of those who receive our services.

First of all, customers in the business world have unique characteristics, identifying traits, if you will. Customers shop for bargains (usually not pressured by a perceived emergency to buy a car at the first dealership they come to), then they pay for the product or service they receive. When a customer enters a retail store and purchases clothing or food, they immediately provide that business with cash, credit card, or check. If they leave with the product but do not pay, they are subject to criminal penalty. If they write a bad check, they may be penalized with a fine from the store, or may be arrested for a pattern of writing bad checks.

However, no one is penalized for abusing our system of health care. Very few in positions of authority are even willing to use the term abuse because it might seem unkind or might lack a certain politically correct sense of compassion. But that falsely inflated sense of compassion has resulted in a wholesale abdication of discernment. And it has infected the medical and nursing professions. Now we are afraid to use our own knowledge and good sense in deciding who is ill, who is not, who is lying, and who is speaking the truth. Every complaint and perception of every customer is given equal weight and validity.

Worse, even as the abuses grow and salaries drop, even as physicians and nurses leave their professions in frustration and exhaustion, enlightened persons in positions of authority are devising new ways to encourage patients to use our services for free and are adding new services we are supposed to supply, also for free.

This makes it difficult to view the world with a customer service mentality. Night after night, patients come to emergency departments with ridiculous dramas with confabulated stories concocted to receive narcotics and sedatives, with complaints they would never waste money on with a real doctor. And they do it because they won't have to pay anything. They ride with their neighbors, who happen to be coming to the hospital, and check in because I was here anyway, knowing that the professional on site is responsible for their well-being, knowing they can sue if he makes a mistake, and knowing they owe that person, ultimately, nothing. Not even the respect to keep them from saying, It's about time, when their wait is long. These customers are draining the life from medicine.

What do businesses do? In the nonmedical business world, there are also customers who cause trouble. They purchase and return constantly. They try to steal. They attempt to create self-inflicted injuries on store property with an eye toward lawsuits. They cheat on special deals. Do businesses try to encourage them to continue coming to the store? No. Do managers look over the customer satisfaction surveys of shoplifters and wring their hands? Do they apologize to clients who assault their employees, and offer them coupons to continue being valued customers? Try it sometime, and see how welcome you remain.

This customer service drive has caused us to apply a twisted kind of democracy to our policies, where every client has an equal vote in whether the physician, nurse, or hospital is doing a good job. But even democracy, without proper checks and balances, just allows the tyranny of the masses. And the masses, especially the masses of health care customers, are not uniformly enlightened enough to tell us how to conduct the age-old business of medicine. If they are, and we believe they are, we should simply put prescription drugs, X-rays, and lab tests in vending machines and take ourselves out of the system.

In the end, however, there is a more perverse, more dangerous aspect to using the terms customer and client to refer to those persons we once saw as patients. Once, we revered our patients because of our ethical, professional, and even spiritual dedication to their needs and our skills, rather than fawning after them for their money. Now, we are too committed to the belief that we deserve a certain amount of money. Now we are enslaved to houses, cars, ex-wives, and ex-husbands. We believe that our children need sports cars when they leave for college, and that we have to retire in golf communities. Because we are so indentured, we are, as a profession, willing to bend for anyone to edge the bottom line upward. And so we are prostitutes to even the worst customers, to satisfaction surveys, to financial credentialing. Doctor and dollar, it seems, sound so much alike.

And what about our customers? When they were patients, we took risks, we stayed up all hours. We strove for excellence for them, as well as for our own material success. We sat at the bedsides of patients with meningitis, we stalked the sources of epidemics, we were bound to them by more than gold. We still do it for customers and clients, but I fear it is with less fervor, less certainty. Witness the lack of call coverage, the unwillingness of young physicians to be available, the early retirements, the desire for nonclinical careers in medicine and nursing. Is it worth my life to care for a customer? Is it worth my health to save a client? Are they worth time away from the ones I love? The danger and the cost always seemed acceptable for patients, to whom I had a sacred duty. It seems less so for customers and clients.

I don't expect it to stop. I'm sure we'll keep getting bombarded with reminders about customers and their needs, and more to the point, their desires. But I'd like to see a little reality injected into the discussion. Because so far, we've steadily lost track of what it really means to be a customer and what it really means to be a patient. And difference, on every level, is more than semantic. It's monumental.

This post by Edwin Leap, 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.

QD: News Every Day--Coffee boosts hepatitis C treatment

Drinking three or more cups of coffee daily was associated with three times more likelihood of virologic response among patients with advanced hepatitis C-related chronic liver disease when taking peginterferon plus ribavirin.

Coffee for three by Shorts and Longs | The Both And via Flickr and a Creative Commons licenseResearchers noted their observations in Gastroenterology.

The lead-in phase of Hepatitis C Antiviral Long-Term Treatment Against Cirrhosis trial (HALT-C) enrolled hepatitis C patients who had an Ishak fibrosis score of 3 or more, had failed previous interferon treatment, and had no evidence of hepatic decompensation or liver cancer. Patients received 180 micrograms per week of peginterferon alpha-2a and 1,000 mg/day ribavirin for those weighing less than 75 kg and 1,200 mg/day for those weighing more. 885 patients reported consumption of 110 food items during the past year, including coffee and tea.

Researchers recorded early virologic response (2 log10 reduction in level of hepatitis C virus RNA at week 12; n=466), and undetectable hepatitis C virus RNA at weeks 20 (n=320), 48 (end of treatment, (n=284), and 72 (sustained virologic response; (n=157).

Median log10 drop from baseline to week 20 was 2.0 (interquartile range [IQR], 0.6-3.9) among nondrinkers and 4.0 (IQR, 2.1-4.7) among patients that drank three or more cups/day of coffee (P<.0001). After adjustment for demographics, alcohol, cirrhosis, ratio of aspartate aminotransferase to alanine aminotransferase, dose reduction of peginterferon, and other covariates, odds ratios for drinking three or more cups/day vs. nondrinking were 2.0 (95% confidence interval [CI]: 1.1-3.6; P=.004) for early virologic response, 2.1 (95% CI: 1.1-3.9; P=.005) for week 20 virologic response, 2.4 (95% CI: 1.3-4.6; P=.001) for end of treatment, and 1.8 (95% CI: 0.8-3.9; P=.034) for sustained virologic response

Coffee has more than 1,000 compounds, any one of which could be involved in virologic response, the authors noted. Caffeine isn't likely one, though, since tea had no impact and there was no lowered hepatitis C levels among coffee drinkers at baseline. An intriguing candidate includes kahweol, a diterpene in coffee, which affects virologic response.

Coffee intake has been associated with lower level of liver enzymes, reduced progression of chronic liver disease and reduced incidence of liver cancer. But authors cautioned, "Because few other data on the association of coffee drinking with virologic response are available, the association observed here needs replication in other studies."
Thursday, June 23, 2011

First gear weekends

May is one of my hospital teaching months.

I have the privilege of taking care of patients sick and vulnerable enough to need hospital care. In addition, I have the opportunity to work with medical residents and students, who always teach me new things in exchange for the 'wisdom and experience' that I bring to the bargain in acting as their supervising physician.

One of the maddening things I've noticed about hospitals is that very little gets done on weekends. This is true from the smallest community hospitals to the major teaching meccas.

It doesn't make any sense.

How can we work in overdrive for five days every week, madly admitting, diagnosing, and discharging patients amidst a flurry of medication, lab testing, radiology, and arranging of follow-up services, only to slow down to a crawl every Friday afternoon?

Let's look at the airline industry for comparison. Medicine is often compared unfavorably to airlines. Airlines allow price comparisons. Airlines reward loyalty. Airlines have a blame-free culture of safety that says, "We're all in this together. If one of us goes down, we all do." So anyone is empowered to call a safety check when something isn't right.

Hospitals? Not so much.

Do airlines put their passengers on board planes every weekend only to hold them on the tarmac until Monday morning rolls around? Who would stand for that?

Americans decry how much is spent annually on health care, yet 29% of every week in a hospital runs so slowly that essentially nothing gets done. [With a long weekend, it's 43%!]

What do I mean by 'nothing?'

Certainly hospitalized patients get outstanding nursing care around the clock. They get good doctoring and respiratory care, too. They get excellent food service, environmental service (cleanup), and nursing aides who help with many tasks. I don't mean to disparage any of these folks. They work hard. Medication is dispensed. Heck, some hospital patients even convalesce and start to feel better.

But hospitals aren't in the convalescence business anymore, at least during the five days of the work week. Those days are a flurry of ultrasounds, radiology tests, physical/occupational therapy assessments, and interventional procedures, like having feeding tubes placed, biopsies done, and elective surgeries performed.

Other industries have figured out how to schedule their employees to optimally meet demand for services on weekends. Airlines. Restaurants. Factories. Retail establishments. Police and firefighters.

Why are hospitals so special?

I admit, I like to have my weekends off like most other people. It's especially useful for those of us that are parents.

But who is the weekend slowdown really benefiting?

Not the patients. They have stay in the hospital longer.

Not the hospital. They have a bed that could be used for a newer, sicker patient.

Not the doctors or trainees. They are mostly in 'babysitting' mode waiting for specialized services that won't fire up again until Monday.

I'm often told that there's a shortage of ultrasound technologists in America. Are they to blame? Try getting an ultrasound on a weekend. Cue the tumbleweed.

Radiologists, especially the kind that are good at biopsying body parts or putting in invasive catheters safely, are never available past Friday mid-afternoon. Tumbleweed drifts.

I just know if I were a patient (I am), I would be pretty peeved to spend a May weekend in the hospital when I could be home with my family. Oh, did I mention that my diagnosis and plan of care depends on the biopsy or the line getting placed? Crap.

Wait 'til Monday, I guess.

Bonus points and innovation awards to the smarties who can solve this one. Doesn't seem like rocket science to me. Could be an easy marketing advantage: Bedrock hospital. Where 24/7 is not just a figure of speech. We figure out what's wrong and we get you home. Faster than the other guys.

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, seeks to bring transparency to medical practice and to improve the patient experience.

QD: News Every Day--Patients, not physicians, key to halting opioid abuse

The fight against painkiller abuse should focus on patients, not prescribers, who were a source of drugs for three in 10 drug abusers and the sole source for one in five, a study found.

William C. Becker, MD; and Fellows of the American College of Physicians Daniel G. Tobin, MD, and David A. Fiellin, MD, reported their results in a research letter in the Archives of Internal Medicine.

They examined results 3,238 adult drug abusers from the National Survey on Drug Use and Health conducted from 2006 through 2008. Of the respondents, 855 (30.7%, percentage adjusted for sampling strategy) reported having a physician source of opioids. Those more than 50 years old were 2.5 times more likely to receive drugs from a physician, likely because older patients visit the doctor more often, and more oftentimes visit for pain management.

Furthermore, those who'd abused opioid analgesic or been addicted to them within the past year were twice as likely to have gotten them from a physician. Those who'd abused or been addicted to other substances were only 0.6 times as likely to have had a physician as a source.

Among those with a physician source, 465 of 855 (64%, percentage adjusted for sampling strategy) had no other source than the doctor. From the entire study sample, 20% reported physician sources only. Of the respondents with a physician source, 36% also had at least one source involving friends or family.

"This suggests that public health efforts to mitigate nonmedical opioid use that occurs outside the sphere of the physician-patient relationship (eg, medication sharing, dealer purchase, theft) may result in substantial benefits," the authors wrote. "Furthermore, physicians need to be cognizant of the risks not only to patients to whom they prescribe opioids, but also to those with whom the prescription recipient lives or associates."

ACP Internist outlined the physician's role in monitoring for opioid abuse in its May issue, including a guide to available resources for physicians. The same issue featured Drs. Becker and Fiellin discussing best practices for treating pain, and ways to escalate from non-drug therapy to non-opioid therapy to narcotics.
Wednesday, June 22, 2011

How the VA can help our female veterans

Women are the fastest growing segment in the U.S. military, already accounting for approximately 14% of deployed forces. According to statistics from the Department of Veterans Affairs (VA), 20% of new recruits and 17% of Reserve and National Guard Forces are women. As the number of women continues to grow in the military, so does the need for health care specifically targeted to their unique concerns.

Historically, lower rates of female veterans have used the VA system. "Research has shown that women didn't define themselves as veterans in the past, and this is changing," said Antonette Zeiss, PhD, a clinical psychologist and Acting Chief for Mental Health Services at the VA Central Office in Washington, D.C.

Now, "Women are among the fastest growing segments of new VA users with as many as 44% of women returning from Iraq and Afghanistan electing to use the VA compared to 11% in prior eras," said Sally Haskell, MD, Acting Director of Comprehensive Women's Health, at the VA Central Office.

This change is due in large part to the wars in Iraq and Afghanistan, and the different military service opportunities available to women there. Although women are technically prohibited from participating in front-line combat, they have served in counterinsurgency operations in large numbers. Women are also often in convoys, which may be attacked, leading to serious injuries resembling those of their male counterparts.

"We found in the cohort of veterans of Iraq and Afghanistan using VA care in their first year after deployment that the most common conditions in female veterans were back problems, joint disorders, post traumatic stress disorder (PTSD), mild depression, musculoskeletal disorders, adjustment disorders, skin disorders, major depression, ear and sense organ disorders and reproductive health disorders," said Dr. Haskell.

In addition, female veterans are more likely than their male counterparts to be confronted with childcare issues. "Women veterans may also need to reestablish childcare when they return home," said Dr. Zeiss. "The VA is increasing family-oriented services and offering options to include the family in health care, if the veteran wants."

According to a recent study in the journal Women's Health Issues, female veterans had similar rates of physical conditions in the first year after combat, but higher rates of certain mental disorders, including depression and adjustment disorders. Men had slightly higher rates of PTSD.

According to the National Institute of Mental Health, PTSD is a condition that develops after a distressing ordeal that involved physical harm or the threat of physical harm. PTSD can cause a multitude of symptoms including: flashbacks, bad dreams, frightening thoughts, avoidance, difficulty remembering things, stress, anxiety, anger, being easily startled, and sleep and eating disturbances. Among military personnel serving in Operation Iraqi Freedom and Operation Enduring Freedom, more than 17% of service members screened positive for PTSD.

There are some notable gender differences when it comes to PTSD. According to survey results from PTSD in Women Returning From Combat, a report by the Society for Women's Health Research, clinicians treating female patients reported more depressive symptoms in women, while men exhibited more irritability and anger, nightmares and flashbacks.

The report also revealed that female patients were more receptive to psychotherapy, while male patients expressed a stronger preference for medication. One key sex difference that almost 65% of doctors noted was that sexual trauma (previous or otherwise) was an issue in the treatment of their female patients but not at all for male patients.

Military Sexual Trauma (MST), a term coined by the VA, is the experience of sexual assault, or severe, repeated sexual harassment experienced during military service. MST can be experienced by both women and men and many VA facilities have designated a Military Sexual Trauma Coordinator to oversee the screening and treatment referral process.

When it comes to MST, "Many women would like to have women providers," said Dr. Zeiss. "Every facility needs to find out what gender providers are available, especially with sensitive topics. In my experience, men who experience sexual trauma also request women providers."

Growing numbers of women in the military have posed challenges and sparked changes in VA services. "We are changing the treatment environment so women feel safe, supported and get the care they need," said Dr. Zeiss.

Meehan S. Improving Health Care for Women Veterans Health Services Research and Development Service, Office of Research & Development, Department of Veterans Affairs, Washington, D.C.

Fihn S. Washington D.C.: Women's Health Conference; Women's Health: A Research Priority in VA. November 8-9, 2004.

Haskell S, et al. The Burden of Illness in the First Year Home: Do Male and Female VA Users Differ in Health Conditions and Healthcare Utilization, Women's Health Issues. 21-1 (2011);92-97.

This post by JenniferWider, 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.

To avoid E. coli, pass the sprouts and hold the meat

As I write this, there is still uncertainty about the source of the Escherichia coli outbreak in Europe that has killed more than 20 people. But whatever the ultimate conclusion is regarding the delivery vehicle for this deadly bug, don't blame the sprouts.

Soybean farming by Keith Weller, USDA Agriculture Research ServiceDon't blame the beans, broccoli, peas, chickpeas, garlic, lentils, mung beans or radishes, either, although all of these crops are currently the focus of ongoing investigation. In fact, I encourage a "not guilty" verdict for the entire plant kingdom.

There is much we don't yet know about the current E. coli outbreak, but what we do know is scary. The bacterium is apparently new on the scene, never before having been isolated. In addition to obvious and lethal virulence, the bug carries with it a number of antibiotic-resistant genes, making it hard to kill. Good at killing while bad at being killed makes a pathogen very bad news indeed.

Since the source and origins of this organism are still matters of conjecture, how can we exonerate the plant foods on which it is currently hitching a ride? We can do it by learning from the follies of history.

After all, we have been here, or in fixes much like this, before. Among the better known of the dangerous E. coli variants is 0157H7. Like the current menace, E. coli 0157H7 is a recently emergent strain, disseminated as a hitchhiker on foodstuffs and capable of killing people. While E. coli 0157H7 has ridden leaves of lettuce and spinach into infamy, this is an enemy whose origins we have met, and we know they are all about meat, not vegetables. When it comes to public health mayhem from mutant germs, plants are innocent bystanders.

Because we eat quite a lot of meat, quite a lot of meat must be produced. Large-volume meat production means large farms, large herds, and large, centralized, highly efficient processing plants. At best, this all translates into relative neglect of any individual steer, and a relative inability to inspect the quality of every steak. At worst, it offers reminders of the "jungle" to which Upton Sinclair introduced us all at the turn of the 20th century.

And it means feed animals are raised as an industrial commodity, rather than as creatures. Their natural diets are disregarded, and they are fed whatever leads to the fastest growth and greatest profit. The origins of E. coli 0157H7 are not mysterious; they relate to changes in the feed of cattle. We say "you are what you eat," and since the construction materials for growing bodies come from food and nowhere else, it is literally true. It is just as true if you happen to have hooves.

Cattle eating grasses have a healthy gastrointestinal tract that is not conducive to the growth of this particular mutant germ. Cattle being fed grains instead of grasses, and in many cases, ground-up bits of other animals including their own species, develop abnormal conditions in their gastrointestinal tract, such as a change in the pH level. It is this abnormal environment within cows that consume abnormal diets that gave us E. coli 0157H7. The jury is still out on the new E. coli variant, but precedent likely predicts the trial outcome for our current tribulations.

We and our resultant health not only are what we eat; we are to some extent what we feed what we eat.

Until quite recently, E. coli 0157H7 was the bad bug in town. Less than two years ago, in October 2009, the New York Times told us the gripping and heart-rending tale of how E. coli ravaged the health of a young woman named Stephanie Smith. The New York Times, focusing on modern food-processing methods, told how tens of thousands of cattle, millions of pounds of beef, hundreds of miles of transport and acres of food-processing plants all came together to produce the hamburger patty that destroyed this young woman's life. Ms. Smith developed an unusually dire case of E. coli 0157H7 infection after eating a contaminated, pre-packaged ground beef patty, prepared at home by her mother.

The Times did a fine job of highlighting the lapses and vulnerabilities in food processing and food inspection that account for food-borne illness in general, and the destruction of Ms. Smith's life in particular. But the Times limited its investigative assault to aspects of the food supply and its oversight. The true problem resides one layer deeper than that, in the food demand.

Go as far as that article went, and you will be left to believe we might have prevented new Stephanie Smith-like tragedies borne of new E. coli strains with higher standards of corporate responsibility and more vigilant inspection by federal authorities.

Go one step beyond, however, and you will see we need to rethink our food. As long as we indulge our appetites for so much meat, hamburgers will be dangerous to our own health as well as that of the planet. Into the bargain, they will challenge any semblance of morality by fostering, and apparently condoning, the brutal treatment of our fellow creatures that their large-scale consumption inevitably requires.

I am not intending to indict meat consumption; we as Homo sapiens have long, perhaps always, included some meat in our diet. But in a world of some 7 billion human beings and modern food-production methods, our dietary patterns reverberate in ways they never did before. In the end, we must concede it is an appetite for large quantities of meat derived from abused, drugged, mass-produced, mass-slaughtered cannibalistic cows that is responsible for E. coli 0157H7, mad cow disease and probably the new germ sailing on sprouts (or whatever) into unsuspecting households.

When you get to the meat of the matter, mutant germs in our food almost never have much to do with the innocently by-standing vegetables and fruits they tend to contaminate. They have everything to do with how we raise, and feed, the animals by which we feed ourselves. At least six good arguments for a greener diet have been made. Every super bug nurtured by modern animal husbandry adds another, as does the growing challenge of growing enough food for all concerned.

There is no doubt that opportunistic bacteria will continue to exploit the new environments we create by putting matter into the feed of cows, pigs and chickens that never belonged. Then when waste matter from those animals gets into fields of spinach, or sprouts, plants will be accomplices in the peril.

That's what's the matter. It's not about the sprouts.

David L. Katz FACP, MPH, FACPM, 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. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

QD: News Every Day--Internists getting paid more; hospitalists in demand

Primary care physicians are getting paid more, two surveys agree, while hospital employment is rising.

Internists earned $205,379 in median compensation in 2010, an increase of 4.21% over the previous year, reported the Medical Group Management Association's (MGMA's) Physician Compensation and Production Survey: 2011 Report Based on 2010 Data. Family practitioners (without obstetrics) reported median compensation of $189,402. Pediatric/adolescent medicine physicians earned $192,148 in median compensation, an increase of 0.39% since 2009.

Among specialists, anesthesiologists reported decreased compensation, as did gastroenterologists and radiologists. Psychiatrists, dermatologists, neurologists and general surgeons reported an increase in median compensation since 2009.

Regional data reveals primary and specialty physicians in the South reported the highest earnings at $216,170 and $404,000 respectively. Primary and specialty-care physicians in the Eastern section reported the lowest median compensation at $194,409 and $305,575. This year's report provides data on nearly 60,000 providers.

Recruiting firm Merritt Hawkins reported that general internal medicine was one of its top two most requested searches for the sixth consecutive year. Family physicians were the firm's most requested type of doctor, followed by internists, hospitalists, psychiatrists, and orthopedic surgeons.

Average compensation for internists rose again this year, from an average of $191,000 in 2009-2010 to $205,000 in 2010-2011, the firm reported.

Primary care physicians have become a particular focus of recruiting efforts because medical students have been avoiding primary care. So, residency programs, particularly in family medicine, fell short of filling their available positions.

The trend toward physician hospital employment continues, though. 56% of Merritt Hawkins' physician search assignments were for hospital jobs, up from 51% the previous year 23% five years ago. Average compensation for hospitalists rose from an average of $208,000 in 2009-2010 to $217,000 in 2010-2011.

Physicians seek the stability of employment, noted the report, while hospitals are seeking to align with accountable care organizations, bundled payments and other physician-aligned and integrated delivery mechanisms demanded by health care reform legislation. Internist Jonathan Plotsky, MD, a Member of the American College of Physicians, told The Washington Post that he's contemplating such a switch because, "All the rules are changing." Still, he added, he worries about the impact of turning over his patients to others.

Only 2% of recruitment searches by the private firm were for independent solo practitioners, down from 17% five years ago, the firm noted.

Physician productivity and compensation is still based on volume, despite calls for paying for quality measures or cognitive services. While health care reform promotes reimbursement based on quality of care and cost efficiency metrics, physicians are still compensated on the number of patients they see, the amount of revenue they generate, or the number of Relative Value Units (RVUs) they accrue. More than 90% of recruitment searches in the 2011 Review that featured physician production bonuses reward physicians for fee-for-service volume, while less than 7% reward physicians for meeting quality of cost objectives.

Other findings include:
--Salaries have almost entirely replaced income guarantees. Only 9% of physician search assignments Merritt Hawkins conducted in 2010-2011 featured income guarantees, down from 21% in 2006-2007 and down from 41% in 2003-2004.
--74% of searches in 2010-2011 featured production bonus. 52% were based on RVUs.
--Psychiatry was Merritt Hawkins' fourth most requested search assignment in 2010-2011, up from 10th four years ago, likely due to patient aging, a stagnant economy, two wars, and a limited supply of practitioners.
--Reimbursement cuts and declines in elective procedures have significantly reduced volume of search assignments for certain specialists. Radiologists, cardiologists and anesthesiologists, all among Merritt Hawkins' most requested search assignments four to five years ago, were the firm's 17th, 18th, and 19th most requested assignments in 2010-2011.
--Signing bonuses, relocation and continuing medical education allowances remain standard in most physician recruitment incentives packages, rather than the occasional carrot they were in years past.
--Housing allowances rose to 6% of job offers in 2010-2011, up from less than 1% in previous years, because some physician candidates cannot relocate without them.

The firm's 2011 Review of Physician Recruiting Incentives tracks over 2,660 physician recruiting assignments Merritt Hawkins conducted nationwide from April 1, 2010 to March 31, 2011.
Tuesday, June 21, 2011

Big news on niaspan, cholesterol drugs and biomarkers

The New York Times alerted me, this evening: "Lowering bad cholesterol levels reduces heart attack risks, and researchers have long hoped that raising good cholesterol would help, too. Surprising results from a large government study announced on Thursday [May 26] suggest that this hope may be misplaced. ... Common wisdom has been that such patients should take a statin drug like Lipitor or Zocor to lower bad cholesterol and, in many cases, the vitamin niacin to raise their good cholesterol. But in the trial, niacin provided no benefit over simple statin therapy.

It wasn't clear to me which was the study, but Bloomberg News explains: Niaspan failed to prevent heart attacks and may have boosted stroke risk in a U.S.-funded study that calls into question the benefit of raising good cholesterol to combat the leading cause of death. The National Institutes of Health said today it stopped a 3,414-person study early after the addition of Niaspan to simvastatin, a standard therapy for high cholesterol, was linked to strokes in 1.6% of patients, compared with 0.7% in the control group. The combination failed to reduce heart attacks, heart-related hospitalizations and the need for procedures to reduce chest pain and restore strong blood flow.

Photo by Elaine Schattner, MDSo niacin, what's supposed to lower triglycerides and raise HDL--the "good" cholesterol--turns out to be a bust, at least when it's given in the form of Abbot's Niaspan.

As to how well cholesterol levels reflect a person's real risk for heart and other vascular disease, I've been skeptical for years.

Still, I have faith in oatmeal, with skim milk and fruit, for breakfast.

This post originally appeared at Medical Lessons, written by Elaine Schattner, ACP Member, a nonpracticing hematologist and oncologist who teaches at Weill Cornell Medical College, where she is a Clinical Associate Professor of Medicine. She shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology and as a patient who's had breast cancer.

QD: News Every Day--Graphic cigarette labels meant to deter smoking

Nine graphic health warnings will appear on the top half of every pack of cigarettes sold in the United States and in every advertisement starting September 2012 in an effort to deter smoking.

Images include a smoker with a hole in his throat, chest staples on a corpse and mouth cancer. Others include infants in smoky environments. The warnings will appear on the top half of both the front and rear panels of each cigarette package, and in the upper portion of each cigarette advertisement, occupying at least 20% of it. Each warning is accompanied by a smoking cessation phone number, 1-800-QUIT-NOW.

The Food and Drug Administration selected the nine images from 36 submissions after reviewing the scientific literature, analyzing the results from an 18,000 person study and considering more than 1,700 comments from the tobacco industry, retailers, health professionals, public health agencies, medical organizations and consumers.

The FDA estimates this regulation will reduce the number of smokers by 213,000 in 2013 and more each year through 2031. The agency also estimates there will be 16,544 to 19,687 smoking preventions annually, and 1,749 to 5,802 quality-adjusted life-years saved annually.

Global research among 14 countries indicates that graphic images encourage smoking cessation. The FDA's new graphic warnings bring the U.S. in compliance with the methodology from that report. (Other countries include pictures of miscarried fetuses and representations of impotence in their warnings. For a slide show of what the world's cigarette pack labels look like today, click here.)

To measure the impact of the graphic labels, the FDA sampled 18,000 people. The agency released the study results online.

The agency sampled current smokers 25 or older, ages 18 to 24, and ages 13 to 17 who are current smokers or who may be susceptible to start smoking.

The study tested two to seven warning images per warning statement with a control group for each warning. The control group viewed a hypothetical pack of cigarettes with no warning image but just the warning statement presented in the style or format of the current standard warning. The treatment groups viewed a hypothetical pack of cigarettes that included the graphic warning label.

Respondents answered questions about their reactions to the cigarette package, related attitudes and beliefs, and intentions to quit (young adults and adults) or start smoking (youth). At the end of the survey, subjects were asked to recall which warning statement and image they saw earlier in the survey. One week after completing this survey, subjects were re-contacted and asked to recall the warning statement and image to which they were exposed.

The most graphic or emotional labels elicited the strongest reactions and were ranked as difficult to look at compared to the control groups. But, the study concluded, those are the labels that are likely to be most effective in warning smokers of the health risks involved.
Monday, June 20, 2011

Time for Medicare to quit ignoring primary care

An article by Brian Klepper and Paul Fischer at Health Affairs has me all fired up. Finally these two health experts are calling it like it is. The Wall Street Journal, New York Times and EverythingHealth have written before about the way primary care is undervalued and underpayed in this country and how it is harming the health and economics of the United States.

A secretive, specialist-dominated panel within the American Medical Association called the RUC has been valuing medical services for decades. They divvy up billions of Medicare and Medicaid dollars and all insurance payers base their reimbursement on these values also. The result has been gross overpayment of procedures and medical specialists and underpayment of doctors who practice primary care in internal medicine, family medicine and pediatrics). These payment inequities have led us to a shortage of these doctors and medical costs skyrocket as a result. As Uwe E. Reinhardt says, "Surely there is something absurd when a nation pays a primary care physician poorly relative to other specialists and then wrings its hands over a shortage of primary care physicians."

Klepper, Fischer and author Kathleen Behan make a bold suggestion. Let's quit complaining about the RUC and their flawed methodologies. Let's quit admiring the problem of financial conflicts of interest and the primary care labor shortage. It's time for the primary care specialty societies, the American Academy of Family Physicians and the American College of Physicians (my addition) to pull out of the RUC. Yes, just quit and do it in a public manner.

There would certainly be a negative public relations backlash when a prestigious specialty society says, "We're mad as hell and not going to take it anymore". The AMA would have to take notice, as would the Centers for Medicare and Medicaid Services. If the American College of Physicians and the American Academy of Pediatrics would also defend its primary care physicians, it would send a strong and powerful message. Primary care has been decimated and the RUC is to blame, pure and simple.

Klepper and Fischer say "We have had two decades of declining reimbursement that has gutted primary care's viability ..." We should all care because every modern nation that exceeds our outcomes for lower cost does so by valuing primary care and supporting it as part of health care policy. If we are really serious about health care reform and bringing costs under control, we first have to build the infrastructure of public health and that is strong, viable primary care for all Americans.

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

QD: News Every Day--Cell phones, brain cancer link disputed again

Gliomas in cell phone users are not clustered in the parts of the brain nearest to where people hold their devices, a finding that at least partly punctures the idea that the radiation the devices emit can cause cancer.

Insofferenza all'Uso by Alessandro Pinna via Flickr and a Creative Commons licenseAuthors reported in the American Journal of Epidemiology on a study of 888 patients with gliomas from seven European countries from 2000 to 2004. Researchers looked at whether gliomas occured in the areas of the brain with the most exposure by two methods. A case-case analysis compared tumor locations with varying exposure levels. A case-specular analysis used a hypothetical reference location for each glioma, and compared the distances from the actual and specular locations to the handset.

In the case-case analyses, tumors were located closest to the source of exposure among never-regular and contralateral users, but results weren't statistically significant. In the case-specular analysis, the mean distances between exposure source and location were similar for cases and speculars.

The lead author told Reuters that results are reassuring but not conclusive because cancer can take a long time to develop, and only 5% of the people in the study had been using mobile phones for at least 10 years.

The American Cancer Society looked at about 30 papers in the literature and concluded there is no known link between cell phones and tumors. "However, these studies have had some important limitations that make them unlikely to end the controversy about whether cell phone use affects cancer risk," the ACS wrote. Limitations included limited follow-up that patients with brain tumors do not report more cell phone use overall than controls, and that most studies found no dose-response relationship with increased use.

The National Cancer Institute reported that the largest study to date, Interphone, drew no conclusions after it couldn't find an association.

But the do-they-or-don't-they issue arose again in May, when the World Health Organization added cell phones to its list of possible carcinogens. CNN's article notes that cell phone makers advise holding the phones slightly away from the head, and to avoid using them or in elevators, buildings or remote locations, where the devices emit more radiation as they search for a clear signal from the cell phone tower.

Actually, the closest part of the body to a cell phone is the hand. But no one studies hand cancer, do they?
Friday, June 17, 2011

QD: News Every Day--Federal government debuts its preventive health plan

The federal government released its National Prevention and Health Promotion Strategy to ensure health at every stage of life.

Seventeen federal agencies consulted with outside experts and stakeholders to draft the plan, which was mandated by the health care reform act.

The four preventive strategies are:
--creating healthy and safe communities, such as encouraging employers to adopt telecommuting options that decrease pollution from commuting and encourage more physical activity,
--expanding preventive services in clinical and community settings, such as improving access to diabetes education programs
--empowering individuals to make healthy choices, for example, by applying mobile phones apps and culturally appropriate communication methods, and
--eliminating health disparities, such as having providers hire staff from minority groups.

Seven priorities include:
--tobacco cessation
--drug and alcohol abuse
--healthy eating
--active living
--injury- and violence-free living
--reproductive and sexual health
--mental and emotional wellbeing

Specific initiatives already underway include America’s Great Outdoors Initiative, the Neighborhood Revitalization Initiative, and Executive Order 13548 to make the federal government a model employer of people with disabilities.
Thursday, June 16, 2011

A near miss 'never event': A truly futile PEG tube

I barely escaped from an embarrassing situation recently in the hospital. I was consulted to place a feeding tube, called a PEG, in an ICU patient. We gastroenterologists are rarely consulted for our opinion on whether these tubes make sense, which they often don't. We are recruited to these patients simply to perform the technical function of inserting the tubes, so that Granny, or Great-Granny, or Great-Great ... won't starve. Multiple medical studies have demonstrated that providing this nutrition to individuals with advanced dementia doesn't benefit them. In addition, while it may seem intuitive that artificial feeding provides comfort, this may not be the case. It may provide more comfort to the physicians and family than it does to the patient.

PEG tube kit by Gilo1969 via Wikipedia Commons and Creative Commons Attribution-Share Alike 3.0 Unported license The above paragraph is not a rigid presentation. Obviously, the decision to place and accept a feeding tube must be individualized. Regardless, it is inarguable that too many of these tubes are being placed for the wrong reasons.

An ICU nurse contacted me to place a feeding tube in one of her patients. There was a large group of visitors hovering around the bedside. As is every physician's custom, I asked the nurse to summarize the patient's hospital course and the active medical issues. The consulting physician had requested a PEG feeding tube and a tracheostomy tube. This latter tube is inserted surgically into the windpipe and is connected to a ventilator. (Patients who cannot be weaned off of respirators often have these trach tubes inserted as the original breathing tubes cannot remain in the throat beyond a few weeks.) I asked how long the patient had been on a ventilator, and she replied that she was breathing on her own. Even a concrete thinking gastroenterologist thought it was odd to place a trach tube in a patient whose own lungs apparently were functioning adequately. This would be analogous to placing a PEG tube in a patient who had just supersized his fast food order.

While this scenario never achieved "never event" status, it does illustrates how medical mistakes can happen. The consulting physician confused two of his patients. The patient assigned to me needed neither a PEG nor a trach, but one of her neighbors did. I was relieved that I didn't enter the patient's room to discuss the pros and cons of feeding tubes to the large group assembled there. What if I did enter the room and there were no visitors? What if the patient was demented and wasn't eating well? One can imagine how a never event can happen, especially if necessary safeguards and checks are bypassed or ignored.

I have already expressed in a prior post about why unnecessary PEG tubes are placed. I left one reason off the list. Luckily, it didn't happen in this case.

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.

QD: News Every Day--New sunscreen labels to clarify what products protect against

New FDA labels on sunscreens will let consumers know which products reduce the risk of skin cancer and early skin aging, as well as clarify the effectiveness of products by their Sunburn Protection Factor (SPF).

Image by the FDASunscreen products that pass the FDA's test for protection against both ultraviolet A (UVA) and ultraviolet B (UVB) rays can be labeled as "Broad Spectrum." (Sunburn is primarily caused by UVB radiation.) Products that have SPF values between 2 and 14 may be labeled as Broad Spectrum if they pass the required test, but only products that are labeled both as Broad Spectrum with SPF values of 15 or higher may state that they reduce the risk of skin cancer and early skin aging when used as directed.

Any product that is not Broad Spectrum, or that is Broad Spectrum but has an SPF between 2 to 14, will be required to have a warning stating that the product has not been shown to help prevent skin cancer or early skin aging, the agency said in a press release.

In addition to the new labeling, the FDA has proposed to limit the maximum SPF value on sunscreen labels to "50+", because there isn't enough evidence to show that products with higher values provide any more protection. FDA is now seeking public input on that. The FDA is also reexamining the safety information available for active ingredients included in sunscreens marketed today.

For more resources to offer patients on sunscreens, the best sunscreens are often the cheapest brands. And, FDA dermatologist Jill A. Lindstrom, MD, offers a few safety tips for sunscreen use.