Friday, July 29, 2011
Subspecialist offers olive branch to hospitalists
Today I would like to say thanks to a group of colleagues that too often go un-thanked.
These would be my hospital-based internal medicine friends: hospitalists are what they are called.
This idea came to me after reading Dr Robert Centor's post on KevinMD. (For the record, Dr. Centor is one of my favorite physician-masters-of-the-obvious. He writes frequently on his blog, db's Medical Rants.) In his usual concise manner, he laments the lack of respect that many sub-specialists show hospitalists.
I feel differently about my hard-working colleagues.
As a sub, sub-specialist who works primarily in the hospital, I would like to say how grateful I am to have knowledgeable, hospital-based internists available.
I believe, and write frequently about the importance of seeing the forest through the trees. A good doctor must see the big picture: a little atrial fib, for instance, isn't a major problem if you can't move, eat or have widespread cancer.
But for good patient care, the details are important too. Hospitalists are good at details. In fact, an internists' area of expertise is in using, considering and synthesizing such specifics. They mesh together a patient's history, exam, laboratory values, X-rays, and other specialists' opinions. I feel strongly that having thinkers on the case is a good thing.
What's more, as the technology of medicine expands, the sub-specialists' scope of expertise grows even more narrow. This fact only increases the value of internists.
Take this humorous story as an example of such narrowness of scope:
A nurse and I were chatting outside a patient's room in the intensive care unit. A day or so before, I had implanted a pacemaker. We overheard the patient and his wife arguing about whether I could write him a prescription for his blood pressure medicine. The patient said, "Doctor Mandrola can write me a prescription for this medicine." The wife countered, "No he can't. He isn't a real doctor; he's just the guy who put in your pacemaker." From that day on, this nurse reminds me that I am just an installer, or these days, an ablator. Barely a real doctor.
As one who hangs a lot of self-esteem on how well my patients do, I am grateful to have recently-trained, detailed oriented, conscientious hospitalists around to help me, help my patients.
And I do not begrudge them for finding a job that pays well, and ends at the end of the shift. Good on you; you are probably less likely to get AF.
Thanks, all you hospitalists!
This post by John Mandrola, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.
Becoming a medical school memory champion via cartooning
AUTHOR'S NOTE: Congratulations to all of our MS2 who recently took the dreaded USMLE 1 Exam! Unfortunately, much of medical school is about memorization, and believe it or not, there is a science to memorization. I learned this from one of our students, Gabrielle Schaefer, MS2, who describes her experience meeting a 'memory champion' and picked his brain for some memory tricks for Step 1, including cartoon images. As I spoke at the Comics in Medicine conference in Chicago a few weeks ago, it seemed fitting for her to describe her journey.
Right around the time I was beginning an epic five-week studying stint to prepare for STEP 1 of the Boards, Joshua Foer happened to be a guest on The Colbert Report (my go-to 20 minute study break). Joshua Foer is this ridiculously young and talented journalist who won the U.S. Memory Championships (yes this exists). If his name sounds familiar you may be thinking of Jonathan Foer, his equally talented older brother who is also a writer.
Anyway, Joshua Foer was promoting his recently released book "Moonwalking with Einstein: The Art and Science of Remembering Everything." The book is about memory and his adventures in the world of memory competitions. Apparently there is a small group of people who get together each year and have memory competitions which consist of several memory "events" including faces of strangers, poetry, random words, numbers, binary digits, stacks of cards, etc. Participants wear noise cancelling headphones and blinders (think sunglasses with two little holes drilled out) to reduce distracters as much as possible. After attending the U.S. competition as a journalist he wound up being tutored by and English memory master and winning the completion the next year (the U.S. memory scene is not very developed, the Germans are much more serious).
Foer stressed that memory champions are not born with extraordinary powers of memory. They training themselves to use some established memory techniques and are constantly developing new ways on remembering things. This intrigued me since I wondered if I could use some of these techniques to master the overwhelming volume of facts needed for the Boards. I started reading his book and loved it. It's very pop-science quick read. When chatting with one of my best friends who was studying for the Bar, she says, "Oh Josh Foer is giving a talk at this spot in Echo Park this weekend, let's go pick his brain for ideas." (I studied in Los Angeles).
So we went, and I managed to get up the nerve to ask him for any advice. In the most bizarre coincidence, he tells me that his wife is also a second-year medical student studying for the boards (bet she'll do just fine!). Since visual mnemonics are big in the memory world, he explained that when making a visual aid, the funnier, scarier, raunchier, and stranger it is, the easier it is to remember. He recommended trying to enrich the image with as much detail as possible. He also explained that, though these images help you remember, thinking up good ones takes a lot of creative energy and can be exhausting. That's one of the things you work on developing when training for a memory championship, the capacity to conjure up rich, creative images really quickly. He signed my First Aid for the Boards, and I went home and started using that idea by making cartoons (a la Micro Made Ridiculously Simple).
He was right, creative effort is draining. Sometimes, it took forever to think of something that would stick, but the stuff I made cartoons for is in the vault! Here is an example of a visual aid I made myself for a mucopolysccharidosis, Hurlers. In this image there is a gargoyle (Hurler's causes gargoylism) hurling a ball (Hurler's). He has a dark spleen and liver (spleno- and hepatomegaly) and rain clouds for eyes (clouded corneas). He is also panting and gasping because of airway obstruction. What I love about this picture is that if I can remember one part of the image (one thing about Hurler's) the rest of the image (the rest of the facts) come back to me.
The other nice thing I noticed is that on a lot of Boards questions you narrow it down to two answers, but it's been a while since you looked at that material and you are 70% sure you picked the right answer. If I made a picture like this I was sure, clouded cornea's goes with Hurler's, not the related Hunter's disease. I used some other techniques from the book: the "memory palace" for biochemical pathways; the "major system" to remember lab values. While memory tricks don't lend itself to everything, it was really helpful for stuff that is difficult to reason through (lysosomal storage diseases, embryology).
–Gabrielle Schaefer, MS2
Thanks to Gabrielle for describing her experience! And who said doodling in class never got you anywhere?
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--Self-surgery seems viable to some
A man impatient to fix his hernia operated on himself with a butter knife and then burned the wound with a cigarette, police reported. He was taken to a hospital psychiatric unit on a 72-hour hold, and the hospital will likely repair the hernia.
Most famously, a Russian physician accompanying an Arctic mission in 1960-61 had to remove his own appendix. As it turns out, he wasn't even the first surgeon to do so. There's been any number of self-surgeries by physicians.
Still, emergencies arise, and nonclinicians have had to fend for themselves over the years. Hiker Aron Ralston was trapped by a boulder for three days before he amputated his arm. Lobster fisherman Doug Goodale severed his own arm, which had become caught in a winch while a storm loomed at sea. An Australian miner trapped under equipment two miles underground severed his arm to free himself.
A woman once performed her own Cesarean section, saving herself and her newborn. A man once tried to repair his genitals after an injury at his workplace. Both presented to physicians for follow-up care.
Self-mutilation as surgery has also been reported over the years, sometimes by transsexuals seeking to change their genitalia, and also by people who believe in trepanation, the idea that drilling a hole in one's own head will improve health. A British aristocrat and art student did so, and ran for Parliament in the platform of trepanation for public health.
While it's actually quite possible to operate on oneself, surgery should be left to the professionals.
Thursday, July 28, 2011
Thrombolytics: to give or not to give
For years now, we've all heard the drum beat. Billboards in cities have proclaimed it. Various medical associations have touted its importance. Stroke symptoms have to be treated immediately! Give clot-busting drugs, also known as thrombolytics.
Until, of course, those in favor of giving the drugs (namely neurologists) realized that A) Not everyone with a stroke, aka brain attack, has insurance, and B) people have a very inconsiderate habit of having said strokes at the most inconvenient of hours. For instance, after 5 p.m., on the weekends, on holidays. The nerve!
So across the country, physicians in emergency departments like mine are finding themselves expected by the court of public opinion to give a potentially dangerous drug (albeit a sometimes useful drug) without any neurologist being available to evaluate the patient. Our emergency department thought we had a telemedicine link; even that has failed, as nearby physicians in our regional referral center don't feel keen to take responsibility for our patients. Our own neurologists, of course, have slipped out the back door on this one. Too much trouble. Too much hassle. But really, really important, so somebody (like physicians in already over-burdened emergency departments) needs to be there to do the right thing.
Medicine is a bullet-train speeding towards a great chasm, and the bridge is out my friends. Less specialists, less medicine, less research, less primary care and worst of all, most nefarious of all, less moral accountability. The government and lawyers have been systematically taking up the tracks and laying the charges for decades.
Stroke care, so important that its own proponents don't want to do it, is merely one more sound of the screeching brakes of our profession, racing toward disaster. The passengers? All those poor people who thought it was safe and under control.
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.
Medical myths exposed: Do we want truth or Zeus?
We have had many family conversations about education reform over the years. Whistleblower readers have seen some of this creeping through some prior posts. It's an issue that affects every American and deserves the efforts of our most talented and innovative thinkers to elevate the system to a higher orbit.
One of the mantras of traditional reformers is that smaller classes for students are optimal. Indeed, local school boards and teachers' unions often warn of expanding or exploding class sizes if requested levies are not passed. They know that we parents believe that class size varies inversely with the quality of education. Ask parents if they would prefer a class of 20 or a class of 30 students for their youngsters and all will opt for the former.
Are smaller classes really better, or do we just believe they are because our intuition instructs us that it is? Is something true because it seems self-evident to us?
I found recent New York Times article on this issue very enlightening. There are education experts who are not convinced that larger classes compromise educational quality. Are they right? I can't say, but I'm happy to see that not everyone is drinking the Kool-Aid. Assumptions are not data.
The medical profession is permeated by myths that we physicians and the public believe to be true, but may not be, or have not been rigorously tested. Practices and procedures that are done routinely and repeatedly are considered to be standard medical practice. In other words, evidence is not needed.
Consider the following medical procedures and offer a view if they are sound practices or medical myths.
--Lowering your cholesterol level will have a significant impact on your risk of developing heart disease or stroke.
--Influenza vaccine is a highly effective vaccine and should be administered yearly to all eligible individuals.
--It is important for physicians to check patients' reflexes during physical examinations to determine if subtle neurologic injury is present.
--Vitamin supplements are important to maintain good health.
--Early detection of disease leads to better outcomes.
--Probiotics cure everything and should be mandated for all school children.
--Periodic laxative use is advised to cleanse the colon of injurious toxins.
--Adults should have their abdomens examined at least every 3 years to discover if any tumors or organ enlargement have occurred.
--Yearly eye examinations are necessary to screen for glaucoma and other eye disorders.
--Colonoscopies have been proven to prevent colon cancer.
-- The prostate-specific antigen (PSA) test saves lives and should be measured periodically in men starting at age 50.
--If a cardiac catheterization shows a narrowed artery, then a stent should be inserted to prevent a heart attack from developing.
--Pelvic examinations in women are important opportunities to detect ovarian cancer at an early stage.
--Mammography is proven to save lives.
--Fiber supplements benefit patients with irritable bowel syndrome.
--Patients with acute back pain benefit from an early MRI to guide medical treatment.
--Medical bloggers always tell the truth.
Is our medical advice coming from sound evidence or from the mythological gods on Mount Olympus?
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--Chest pain unrelated to heart attack severity
Severe chest pain isn't related to the likelihood of acute myocardial infarction at presentation or death, or to acute myocardial infarction or revascularization within 30 days, researchers found.
There are 6 million visits to the emergency department for chest pain, of which 2 million result in admissions each year, but only a minority of these have an ischemic cause.
But 2% to 5% of patients with acute myocardial infarction are inappropriately discharged, and failure to accurately diagnose acute myocardial infarction accounts for 20% of malpractice dollars. Attorneys glom onto high pain scores when questioning an emergency physician's judgment in discharging a patient.
So, researchers did a secondary analysis of a prospective cohort study of patients presenting with potential acute coronary syndrome to the emergency department of the Hospital of the University of Pennsylvania in Philadelphia. Pain on arrival was scored from 0 to 10 based on nurses' triage, with severe pain defined as 9 or 10. The primary outcome was acute myocardial infarction during the visit. Researchers also looked at death, acute myocardial infarction, revascularization including percutaneous coronary intervention, or coronary bypass artery grafting at 30 days. Results appeared at the Annals of Emergency Medicine.
Of 3,306 patients with chest pain documented upon admission, 3.2% were diagnosed with a myocardial infarction. Severe pain was not strongly associated (adjusted relative risk [aRR], 1.43; 95% confidence interval [CI], 0.91 to 2.22).
By 30 days, 34 patients had died, 105 patients underwent revascularization and 111 patients had a heart attack. There was no relationship between severe pain and acute myocardial infarction (relative risk [RR], 1.28; 95% CI 0.93 to 1.76) or 30-day composite outcome (RR, 1.19; 95% CI, 0.91 to 1.56). Inhospital acute myocardial infarction was not related to pain duration greater than 1 hour (aRR 1.36; 95% CI 0.89 to 2.07), or severe pain (aRR 1.43; 95% CI 0.91 to 2.22). Thirty-day outcomes were not related to pain duration greater than 1 hour (aRR 0.8; 95% CI 0.60 to 1.06), or severe pain (aRR 1.39; 95% CI 0.95 to 1.97).
Patients with chest pain should still be evaluated, the lead author commented. While chest pain is the chief complaint of the majority of patients with acute myocardial infarction, patients may not recognize as many as one third of myocardial infarctions.
"[A]lthough pain management is an important issue to address clinically, pain severity itself should not be a factor in evaluating patients' risk for acute coronary syndrome in terms of discharge decisions," the authors concluded. "Of course, it would still be important to relieve the pain for the sake of patient comfort."
Wednesday, July 27, 2011
Asthma treatment used for chronic sinus infections
Many people are already aware of nebulizer treatments to help with breathing during asthma attacks and other pulmonary conditions.
What many people may not be aware of is that such nebulizer treatments can also potentially be used for chronic sinus infections. One of the best known companies offering such treatment is Sinus Dynamics.
Using one of several different nebulizers, compounded liquid medications (antibiotics and/or steroids) selected by the physician are nebulized/atomized which the patient then breathes into the nasal passages. The small size of the particles allow medication to theoretically move through the tiniest of sinus openings directly onto the infected tissue. Treatments are quick, generally lasting 3 to 5 minutes (depending on medication and device). Here's a video demonstrating how it is used.
Sinus Dynamics specifically is contracted by over 14,000 insurance companies across the nation, which means that most patients are able to receive their treatment for little to no cost out of pocket. Most ENT doctors are already familiar with this product.
Personally, I prescribe this mode of treatment for the particularly difficult sinus infection that has not responded to oral antibiotics and sinus surgery. The major advantage of such a device is not only the fact that it is topical, but much stronger antibiotics can be prescribed that otherwise would be toxic if given orally. Furthermore, more than one medication can be administered simultaneously (for example, a steroid, tetracycline antibiotic, and ceftazidime antibiotic).
Typically, I require a culture with sensitivities to determine what medication would be optimal for this mode of treatment. Another requirement is prior sinus surgery given studies showing greater effectiveness of the delivery system.
Once cultures are obtained and a determination of the optimal medication to treat, a prescription is faxed to the company who will then take care of the insurance coverage and then ship the device and medication(s) to you. The normal turn-around time is less than one week depending on the prescription.
An instructional video is included with the prescription as well as customer service representatives via phone to walk through the first treatment if needed.
Of course, sinus nebulizer treatment is not the only topical treatment than can be provided.
Other topical sinus treatments which may be just as effective if not more include saline flushes containing medications (which can be compounded by any willing pharmacy) as well as application of antibiotic ointments directly into the sinus cavity (which is performed by the ENT under endoscopic guidance).
It is up to your ENT physician to determine what is the best course of treatment based on your history, endoscopic sinus evaluation, culture results, CT scans, and response to prior medical regimens.
It should also be noted that there have been several studies performed suggesting such nebulizer treatment for sinus infections to be ineffective. However, it certainly is worth trying when all else has failed (or insurance has denied other treatment protocols).
Nebulized antibiotics for the treatment of refractory bacterial chronic rhinosinusitis. Ann Pharmacother. 2011 Jun;45(6):798-802. Epub 2011 Jun 7.
Current concepts in topical therapy for chronic sinonasal disease. J Otolaryngol Head Neck Surg. 2010 Jun;39(3):217-31.
A prospective controlled trial of pulsed nasal nebulizer in maximally dissected cadavers. Am J Rhinol. 2008 Jul-Aug;22(4):390-4.
Nebulized bacitracin/colimycin: a treatment option in recalcitrant chronic rhinosinusitis with Staphylococcus aureus? A double-blind, randomized, placebo-controlled, cross-over pilot study. Rhinology. 2008 Jun;46(2):92-8.
Deposition of aerosolized particles in the maxillary sinuses before and after endoscopic sinus surgery. Am J Rhinol. 2007 Mar-Apr;21(2):196-7.
Comparison of topical medication delivery systems after sinus surgery. Laryngoscope. 2004 Feb;114(2):201-4.
This post by Christopher Change, 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.
Doctors adapting and trying to survive
Close your eyes and think of a doctor. Do you see a Marcus Welby type? A middle-aged, smiling and friendly gentleman who makes house calls? Is his cozy office staffed by a long time nurse and receptionist who knows you well and handles everything for you? If that is what you envision, either you haven't been to the doctor lately or you are in a concierge practice where you pay a large upfront fee for this type of practice. Whether you live in a big city or a rural community, small practices are dissolving as fast as Alka Selzer. Hospitals and health systems are recruiting the physicians, buying their assets (unfortunately not worth much) and running the offices.
Doctors are leaving small practices and going into the protection of larger groups and corporations because of economic changes that have made it harder and harder for small practices to survive. The need for computer systems, increasing regulations, insurance consolidation, skyrocketing overhead and salaries coupled with low reimbursement has signaled the extinction of the Marcus Welby practice. Some older doctors are finishing out their years and will shutter their offices when they retire. Young to middle age physicians are selling out to large groups and new physicians would never even consider this type of practice. They are looking for an employed model from the outset.
Every doctor I know who is currently in private practice is weighing his/her options for survival. Doctors are learning and performing new services for which patients will pay out of pocket. Botox, anti-aging therapy, weight loss, retainer services, home visits, cosmetic services, acupuncture, prolotherapy and medical directorships are all outside of the Medicare/insurance payment world. Physicians are surviving with these creative revenue producers and doing the best that they can.
The world of medicine has changed. Health care reform is rewarding integrated care and this will be good for patients and quality. Doctors need the capital that large systems can provide to put in the electronic health record and support its use. They need the protection of health systems to pay their overhead and ensure that employees are trained. It is unlikely that large organizations can run lean offices but they can provide standards that improve care and patient experience. I am in favor of practice standards and a continuum of care between primary care, specialists and the hospital.
Marcus Welby practiced in a silo. He could remove your appendix, deliver your baby, deal with your wayward teenager and help grandma die peacefully. The truth of the matter was he had no technology, just hand-holding and about 10 medications to offer.
This is 2011 and things have changed.
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--Health care acquired infections the ire of WHO's new patient safety envoy
The World Health Organization's new patient safety envoy will take on health care acquired infections in his new role, he announced last week. Liam Donaldson, England's former Chief Medical Officer, pointed out in his first report as envoy that patient safety incidents occur in 4% to 16% of all hospitalized patients, and that hospital-acquired infections affect hundreds of millions of patients globally.
A WHO report outlined the problem.
High-income countries had pooled health care acquired infection rates of 7.6%. The European Centre for Disease Prevention and Control estimated that 4.1 million Europeans incur 4.5 million health care acquired infections annually. In the U.S. the incidence rate was 4.5% in 2002, or 9.3 infections per 1,000 patient-days and 1.7 million affected patients.
In Europe, these infections cause 16 million extra days of hospitalization and 37,000 deaths, and contribute to 110,000 more every year. Annual financial losses are estimated at approximately 7 billion Euros in direct costs. In the U.S., such infections caused 99,000 deaths in 2002. The annual economic impact was estimated at approximately $6.5 billion in 2004.
Intensive care unit stays lead to significantly more infections of about 30% of patients. Pooled cumulative incidence density was 17 episodes per 1,000 patient-days in adult high-risk patients in industrialized countries, according to the WHO report. Pooled cumulative incidence densities included 3.5 catheter-related bloodstream infections per 1,000 central line days, 4.1 urinary tract infections per 1,000 urinary catheter days, and 7.9 ventilator-associated pneumonias per 1,000 ventilator days.
The picture in the developing world was more fragmented:
--Hospital-wide prevalence of health care acquired infections varied from 5.7% to 19.1% with a pooled prevalence of 10.1%, with higher-quality studies providing higher incidence rates (15.5% vs. 8.5%).
--Surgical site infections were the most common source, with incidence rates ranging from 1.2 to 23.6 per 100 surgical procedures and a pooled incidence of 11.8%. Surgical site infections range from 1.2% to 5.2% in developed countries.
--ICU-acquired infection rates in developing countries varied from 4.4% up to 88.9% and pooled cumulative incidence density was 42.7 episodes per 1,000 patient-days.
--Pooled cumulative incidence densities were 12.2 bloodstream infections per 1,000 central line days, 8.8 urinary tract infections per 1,000 urinary catheter days, and 23.9 ventilator-associated pneumonias per 1,000 ventilator days.
Tuesday, July 26, 2011
Debunking medical myths: Paying for leaving against medical advice
Like Mikey, the Life cereal kid who died from mixing Pop Rocks and Coke, or the spider eggs in Bubble Yum that help make it so soft and chewy, Medicine has its share of urban legends.
Did you know, for example, that if you're hospitalized and decide that you want to leave "Against Medical Advice" [AMA], that your insurer won't pay for the hospitalization?
Apparently, this canard is pervasively believed amongst doctors and passed from generation to generation of trainees just like the nonsense about cute ol' Mikey.
A few years ago, a medical student came to me with a case of moral distress. She had seen the doctor-in-training with whom she was working become upset at a patient for declining an invasive heart procedure.
Rather than try to reason with the patient and convince her that the test was indeed indicated and would be of greater benefit than possible harm, the resident doctor in question quickly became rattled and informed the patient that if she refused the procedure and signed out AMA, she'd be financially responsible for the entire cost of the hospitalization, as her insurer would decline to pay.
The student was horrified at such browbeating of a patient; in addition, using the hospital bill as a cudgel to coerce cooperation smacked of the worst kind of paternalism and just seemed wrong. "Aren't there ethical safeguards against this?" she wondered.
Her moral distress led to a research project that debunks this notion [we hope] once and for all.
I can't give you the specifics (an article on our findings is under review at a medical journal) just yet, but GlassHospital and FutureDocs are happy to share with you the educational fruits of our findings to date. You can click here to learn more in true interactive fashion, or if you prefer, watch only the cameo-encrusted video tour-de-force right below. [Who is that guy playing angry Mr. Smith? He looks familiar. And who, for heaven's sake, does his wardrobe?]
Let us know your thoughts! On the video, the website, the urban legend. What other medical urban legends would you like to see debunked?
This post by John H. Schumann, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.
QD: News Every Day--Simple guidelines decreased unneeded antibiotics
Simple guidelines disseminated by the media, medical societies and the Internet significantly reduced antibiotic prescriptions in Quebec for three years compared with the rest of the country, and reduced costs as well, a Canadian study found.
Following an outbreak of Clostridium difficile, health care professionals in Quebec targeted physicians and pharmacists with an education campaign that reduced outpatient antibiotic use, according to a study published in Clinical Infectious Diseases.
Eleven user-friendly guidelines were sent to all physicians and pharmacists in January 2005. Topics included upper and lower respiratory tract infections, urinary tract infections and C. difficile. Emphasis was placed on not using antibiotics for viruses, and prescribing the shortest possible duration of treatment.
Approximately 30,000 printed copies were distributed, and another 193,500 copies were downloaded from the Medication Council's website. (The guidelines are still available here.)
During the year after the guidelines' release, outpatient antibiotic prescriptions in Quebec decreased 4.2%. In other Canadian provinces, the number of these prescriptions increased 6.5% during the same period. In 2004, antibiotic consumption per capita was 23.3% higher in Canada generally than in Quebec. After the guidelines, the difference between Quebec and the other Canadian provinces increased by 4.1 prescriptions per 1,000 inhabitants (P=.0002), which persisted 36 months later. Antibiotic costs fell $134.5 per 1,000 inhabitants in Quebec compared with the rest of Canada (P=.054).
Of special note to researchers was use of the Internet, particularly mobile devices. They wrote, "With the advent of hand-held electronic devices and their increasing use by all categories of health care professionals, information disseminated by this mean becomes instantly available, reaching private offices and remote areas. Geographic and site-of-care barriers do not exist anymore with these approaches."
Monday, July 25, 2011
Lowering cancer care costs by reducing tests after treatment
This is the second in a series of posts on Bending the Cost Curve in Cancer Care.
We should consider the proposal, published in the New England Journal of Medicine, gradually over the course of this summer, starting with "suggested changes in oncologists' behavior," #1:
1. Target surveillance testing or imaging to situations in which a benefit has been shown. This point concerns the costs of doctors routinely ordering CTs, MRIs and other imaging exams, besides blood tests, for patients who've completed a course of cancer treatment and are thought to be in remission.
The NEJM authors consider that after a cancer diagnosis many patients, understandably, seek reassurance that any recurrence will be detected early, if it happens. Doctors, for their part, may not fully appreciate the lack of benefit of detecting a liver met when it's 2 cm rather than, say, just 1 cm in size. What's more, physicians may have a conflict of interest, if they earn ancillary income by ordering lab and imaging tests.
My take: It's clear that some and possibly most cancer patients get too many and too frequent post-treatment surveillance tests. Believe it or not, yours truly, whose life was saved by a screening digital mammogram, maintains a healthy fear of excess radiation exposure. I agree to X-rays, CT scans, myelograms and whatever else my doctors suggest only when I'm reasonably confident that the test result would influence a treatment decision.
My impression is that, in general, oncologists' habits of ordering routine, interval-based imaging for patients in remission after cancer treatment (such as a scan every three or four or six or 12 months) are arbitrary and unsupportable by any published data. These sorts of practices, which vary among communities, arise like this: A senior, smart and well-intentioned oncologist at a major teaching hospital, circa 1990, orders newfangled CT scans of the chest, abdomen and pelvis on his lymphoma patients every four months for two years, and then every six months for two years, and then every 12 months, for no reason other that he thinks it's a good idea. The patients like it; they're reassured, and he (the oncologist) feels good about having prescribed the drugs that caused their sustained remission. Talk about a positive feedback loop! (We needn't even invoke financial incentives as a motivating force.) And then that's just how it's done by all the fellows he's taught over the years, who then branch out into other communities and even other countries, and teach…
Now, things may be changing a bit, as patients like me are starting to fear radiation exposure, and also are starting to question doctors' recommendations more than they did even a few years ago. Younger doctors, too, have more requirements to continue their medical education in order to keep practicing at most hospitals and maintain their board certificates, and so they, too, may be more questioning of these archaic practices.
About post-treatment screening with scheduled blood work, I see this issue somewhat differently than do the NEJM authors, mainly in that I'm optimistic about simple blood tests, in the future, that may provide affordable and clinically relevant information to patients who've undergone treatment with tumors at high risk of recurrence.
As the authors point out, there are some old tests, such as CEA screening, that can be helpful in monitoring for recurrence in patients with a history of colon cancer. In general, blood tests are less dangerous and less expensive than imaging studies. Besides, in patients with aggressive tumors that might respond to new targeted drugs, tests that measure circulating tumor cells (CTCs) in small blood samples, and could assess cells for new mutations, at low costs in the future (not now), might render some blood tests useful and even cost-effective, in the future.
Finally, I'd like to throw in a concern I have about some clinical trials, in case any study designers or persuasive cancer IRB members happen to be reading this post: Some of the clinical trials for new cancer drugs may require too many follow-up MRIs, CTs and other scans. Even if Pfizer or any other company foots the bill, by partici-pating in the trials patients shouldn't be subjected to excessive radiation or even just the unpleasantness and hassle of a said-to-be-safe test like an MRI. This pet peeve is especially concerning in some trials requiring multiple post-treatment PET scans, the most rad-intense of common imaging methods.
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--Practices adopting the patient-centered medical home
Almost 70% of medical practices are already adopting the patient-centered medical home or interested in becoming one, with more than 20% already accredited or recognized as one by a national organization, reports the Medical Group Management Association.
MGMA's study found the majority of practices interested in becoming a medical home were family medicine (nearly 36%), followed closely by multispecialty practices with primary and specialty care (more than 30%) and pediatrics (more than 10%). Among those already a medical home, almost 45% were family medicine practices, followed by multispecialty practices with primary and specialty care at almost 35%. Physician-owned practices represented less than 55% of accredited or recognized medical homes, compared to less than 25% for hospital-owned medical practices.
MGMA sampled 341 primary care and multispecialty practices nationwide in April 2011. The organization issued its findings from The Patient Centered Medical Home Study: 2011 Report based on 2011 Data, available to order.
According to the study, the top five most common processes practices engaged in as part of the medical home model were:
--assigning patients to a primary care clinician (more than 80%)
--addressing patients' mental health issues and referring them to appropriate agencies (more than 70%)
--exchanging clinical information electronically with pharmacies (more than 70%)
--involving patients and family in shared decision making (more than 70%)
--maintaining chronic disease registries (more than 45%)
The study also indicated the top five challenges cited by PCMHs during their transformation:
--establishing care coordination with referral physicians (more than 50%)
--financing the transformation (more than 40%)
--coordinating care for high-risk patients (almost 40%)
--modifying or adopting an electronic health record (almost 40%)
--projecting practice revenue, costs, etc. as a result of the transformation (more than 35%)
The majority of existing medical homes were recognized through the National Committee for Quality Assurance, with 70% earning Level 3 recognition. The process took the majority of respondents, on average, one year to complete. Ninety-one percent of study respondents said that they want one set of standards for medical home evaluation.
As many as 75% of existing medical homes reported they were participating in a pilot or demonstration. 90% of pilot participants also were receiving fee-for-service payments from payers as part of the pilots and only 57% received management fees.
In addition to the study, MGMA developed a free comparison tool available for order to assess how each of the national programs meets the medical home guidelines released by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association. Programs included in the tool belong to The Accreditation Association for Ambulatory Health Care, The Joint Commission, The National Committee for Quality Assurance and URAC.
Join the conversation about medical homes and other new practice models such as accountable care organizations at ACP's LinkedIn group page. Physicians are lamenting the impact these practice models have had in their workplaces.
Friday, July 22, 2011
Doc, can I use this natural supplement?
A little while back, I saw a patient in my reflux practice who had recently stopped her proton pump inhibitor and substituted licorice root to help keep her acid reflux symptoms under control. She told me that her symptoms were still under good control with the licorice root, and asked me if I was all right with her staying on it instead. Since she did not have any mucosal injury (esophagitis) or other complications from GERD, my main question that I had to answer was about the safety of licorice root .
So I looked it up, just to be sure I was doing my due diligence. If you aren't aware of the possible side effects of licorice root, the major ones to be aware of are:
--high blood pressure
Fortunately, these only tend to occur at large doses (more than 3 grams per day for several weeks) when the licorice root contains glycyrrhizin. In short, I thought it was fine for her since she was otherwise in good health, and the dose was not that large.
Nonetheless, there is an important reminder here: just because something is natural, doesn't mean it is completely without side effects. Even natural substances are still chemicals.
If you are a patient, please discuss all of your supplements with your physicians. In this case in particular, extreme use can actually cause rare life threatening problems. If you are a doctor or other health care professional, be sure to ask your patients about any herbs and supplements they might be taking.
Ryan Madanick, MD, is an ACP Member, 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. This post originally appeared at his blog, Gut Check.
QD: News Every Day--Married men more likely to seek earlier heart attack care
Till death do us part, indeed! Women encourage their spouses to seek earlier treatment for medical care for myocardial infarctions, even when they're not present when chest pain starts.
Researchers hypothesized that a spouse, including common law relationships, would encourage quicker treatment even if the woman wasn't there, because wives were more likely than husbands to assume a caregiver role and encourage quicker treatment.
They established the Enhanced Feedback for Effective Cardiac Treatment (EFFECT) study, a retrospective cohort of a population based sample of 4,403 eligible patients with acute myocardial infarction from Ontario, Canada, who sought care from 86 eligible hospitals from April 2004 to March 2005. In Canada, marital status is recorded for every emergency patient.
Patients were excluded if they had transferred facilities, had missing data for onset of pain, or had no chest pain upon presentation. The primary analysis broke down patients who presented more than six hours after chest pain. They recorded any quality or nature of chest pain. A secondary analysis that looked at results 2, 6 or more than 12 hours after the initial onset of pain was done on 3,840 patients for whom the exact time of onset of chest pain was known. Results appeared online July 18 at CMAJ, the journal of the Canadian Medical Association.
Being married was associated with lower odds of delayed presentation (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.30 to 0.71, P less than 0.001) than among single patients. Among men, the OR was 0.35 (95% CI 0.21 to 0.59, P less than 0.001), and among women marital status was not significant (OR 1.36, 95% CI 0.49-3.73, P=0.55).
For all patients meeting the secondary analysis criteria, being married was associated with reduced odds of presentation after 2, 6 or 12 hours of delay (OR 0.45, 95% CI 0.31 to 0.64, P less than 0.001), relative to being single. For men, the odds ratio was 0.39 (95% CI 0.25 to 0.62, P less than 0.001), and was not significant for women (OR 0.72, 95% CI 0.35 to 1.48, P=0.37).
Researchers noted that among patients with a known exact time of the onset of chest pain, the adjusted time saved was a "remarkable" half-hour. Only calling an ambulance had a greater influence on the time to presentation.
Researchers noted that, unlike other studies, they included only patients who had chest pain. "Because women are more likely to have atypical symptoms, the association of delayed presentation with female sex may disappear once women without chest pain are excluded."
Thursday, July 21, 2011
Abandon primary care for 'Advanced Care Medicine'
In his last post, DrRich pointed out to his primary care physician (PCP) friends that their chosen profession of primary care medicine is dead and buried--with an official obituary and everything--and that it is pointless for PCPs to waste their time worrying about "secret shoppers" and other petty annoyances.
It is time for you PCPs to abandon "primary care" altogether. It is time to move on.
Walking away from primary care should not be a loss, because actually, primary care has long since abandoned you. Whatever "primary care" may have once been, it has now been reduced to strict adherence to "guidelines," 7.5 minutes per patient "encounter," placing chits on various "pay for performance" checklists, striving to induce high-and-mighty healthcare bureaucrats (who wouldn't know a sphygmomanometer from a sphincter) to smile benignly at your humble compliance with their dictates, and most recently, competing for business with nurses.
This is not really primary care medicine. It's not medicine at all. It's something else. But whatever it is, it's what has now been designated by law as "primary care," and anyone the government unleashes to do it (whether doctors, nurses, or high school graduates with a checklist of questions) now are all officially primary care practitioners.
What generalist physicians (heretofore known as primary care physicians) need to realize is that "primary care" has been dumbed-down to the point where abandoning it is no loss; indeed, it ought to be liberating to walk away from it.
The beauty is that to survive and flourish, you don't really need to change your medical ideals or even your medical behavior (unless, of course, you have bought in to the strict adherence to guidelines, checklists, etc.) You simply need to practice medicine exactly as you were trained to practice it, taking all the time needed for careful, thoughtful attention to detail; seeking out the meaningful nuances in your patients' medical conditions; personalizing both diagnostic and therapeutic recommendations not only for your patient's medical problems, but also for their psychosocial and economic circumstances; relishing the challenge of making the difficult diagnoses, and managing the complex medical disorders that so often break from the designated norm; and treating guidelines as just that, as often-helpful guideposts, rather than mandates; and most important of all, embracing the classic doctor-patient relationship in all its particulars, and having the latitude to become a true advocate for your individual patients within a hostile healthcare system. In short, you can go back to being a real doctor, and not a cipher in some bureaucrat's database.
There are only two things you need to do to move in this direction.
First, abandon the "primary care" label. Remember, primary care is now the standards-based, checklist-driven, one-size-fits all, "high-quality" system of practice imposed by government bureaucrats, a practice which is now open to both doctors and nurses (and, in the future, most likely to others). That's not what you do. So find a new name for yourself.
The choice of nomenclature is yours, of course, but DrRich humbly suggests "Advanced Care Medicine."
What you do is not primary care; it's far more advanced than that, and nobody could do it without the sort of extensive training you have. "Advanced Care Medicine" captures that notion. This name also opens the possibility of referrals from the new-style, government-sanctioned PCPs, some of whom undoubtedly will come to recognize that at least 20% of their patients will present as clinical puzzles that do not fit very well with any of the standard medical diagnoses with which they are familiar, and another 20% will not respond to the recommended therapy as the guidelines say they must. These patients obviously will need advanced management, management beyond what a modern primary care practitioner is able (or allowed) to offer. Why not refer them to an ACM physician?
Second, you need to establish practices whereby you are paid directly by your patients. You need to do this because it is the only method available for avoiding the bureaucratic nightmare that wrecked your former profession of primary care in the first place. Payment models can be established that will allow most patients, anyone, say, who can afford a cell phone contract or cable TV, to participate. (Making your services readily available will blunt the obligatory attacks of "elitist!" which will be aimed your way in the attempt to shame you back into the primary care gulag). There really ought to be nothing particularly revolutionary about this kind of practice, since it was the norm throughout most of the history of medicine until 40 years ago. It is likely that many patients who today would never consider paying any doctor out of pocket will eventually change their minds, once it becomes apparent to them the depths to which primary care medicine has fallen in the United States, and that as a result their lives are on the line.
In any case, when you are paid by your patients, you answer to your patients (not some hostile bureaucrat), and the quality of the care you deliver is measured by your patients (and not some other hostile bureaucrat). There are no externally imposed time-limits to your office visits, no checklists you must complete, no bizarre documentation rules you must follow for reimbursement, no guidelines you must obey even if it makes no sense for your patient. Those things are for the modern, government-approved PCPs to concern themselves with, poor souls, and you do not dwell among these unfortunates anymore.
And happy it is that primary care medicine is killed off now, at this time, because time is of the essence. DrRich has already pointed out that an essential feature of our new progressive health care system will be to make it illegal (in the name of fairness) for individuals to spend their own money on their own health care. For Advanced Care Medicine (or whatever you may choose to call it) to become a viable path, you've got to begin immediately to make it a fait accompli to establish it as something patients value, and which they fully expect as a personal health care option, and furthermore, as an indispensable referral resource for those sad souls, physicians, nurses and others, who retain the label "PCP," and who will be powerless (if not clueless) when it comes to providing complex medical care to patients who come in with a difficult diagnosis, or more than one diagnosis, or who otherwise display guideline-unfriendliness.
So at the end of the day, the fact that Obamacare has formally brought primary care medicine to a merciful end may turn out to be a positive thing.
And by all means, don't sweat President Obama's "secret shoppers," or any other cutesy ploys which our policy experts may dream up in the future to amuse themselves, and to distract you from the real issue (which is the demise of your profession). When those phony secret shoppers call for a phony appointment, simply tell them you have openings for any patient, at very reasonable rates and at a time of their choosing, and that they can see a real doctor who will treat them with dignity, care, expertise and respect. Or on the other hand, you can remind them, they can take their chances with one of those embittered or indifferent, underutilized or under-trained, oppressively over-regulated or complaisantly submissive, new-style PCPs specified under Obamacare.
Even Obama's secret shoppers would have to think twice about a choice like that.
This post by Rich Fogoros, 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.
Emergency room: Revolving door or backstop?
I received a call recently from an emergency room (ER) physician about a patient who presented there with rectal bleeding. Does this sound blogworthy? Hardly. We gastro physicians get this call routinely. Here's the twist. The emergency room physician presented the case and recommended that the patient be discharged home. He was calling me to verify that our office would provide this patient with an office appointment in the near term, which we would. We had an actual dialogue.
This was a refreshing experience since the typical emergency room conversation of a rectal bleeder ends differently. Here's what usually occurs. We are contacted and are notified that the patient has been admitted to the hospital and our in-patient consultative services are being requested. In other words, we are not called to discuss whether hospitalization is necessary, but are simply being informed that a decision that has already been made.
There is a tension between emergency room physicians and the rest of us over what constitutes a reasonable threshold to hospitalize a patient. I have found that many ER docs pull the hospitalization trigger a little faster than I do. What's my explanation for this? Here are some possibilities.
--pressure from hospitals to fill beds
--pressure from admitting physicians who seek to increase their in-patient volumes
--belief that hospitalization markedly reduces medical malpractice risk of ER physicians
--desire to eliminate uncertainty that a benign complaint is masquerading as a serious condition. "It's probably your heartburn, but let's observe you overnight just to be sure."
--pressure from patients and families to be hospitalized
--uncertainly that a patient will follow-up with a physician after ER discharge
--ER physicians are making the proper judgment to admit the patient, while we specialists and primary care physicians cavalierly advise discharge.
What's the harm of hospitalizing a patient for a day or two, just to be sure, or to expedite a medical evaluation that might take a few weeks to accomplish as an out-patient? Here are a few drawbacks to that option, and I'm sure that patients and physicians can add to the list.
--risk of hospital acquired misadventures including infections, medication errors and side-effects
--overutilization of medical care. Hospitalized patients are routinely visited by numerous consultants who proceed to attack their organs of interest with zeal and enthusiasm
Every physician can attest to how much hospital illness is caused by hospital life and is unrelated to the original medical issue. We see this every day.
I understand the tension between the ER and the outside medical world. The ER is under a unique set of pressures and concerns, and the rest of us need to be mindful of this. Nevertheless, patients would be better served if there were more discussion and collaboration between medical colleagues to determine whether hospitalization or discharge is the preferred option. A recent study confirms that communication between ER physicians and primary care physicians needs healing.
Many patients and their families mistakenly think that hospitalization is the safer choice. Think again.
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--More hospitals offering palliative care
Nearly two-thirds of all hospitals now have a palliative care program and larger hospitals have even more access, reports the Center to Advance Palliative Care in a snapshot of the specialty's growth in the past decade.
According to the most recent data analysis, 1,568, or 63%, of U.S. hospitals with more than 50 beds have a palliative care team, an increase of 138.3% since 2000, when there were more than 600 hospitals with teams.
Larger hospitals are more likely to have a palliative care program. More than 80% of hospitals with more than 300 beds have a palliative care team, while less than one-quarter of hospitals with fewer than 50 beds report a team.
The analysis was conducted in March 2011. The primary source of hospital data was the AHA Annual Survey Database for FY 2000 through 2009. For FY 2008 and FY 2009, supplemental data were obtained from the National Palliative Care Registry. Hospitals were excluded if they had less than 50 beds after excluding nursing home unit beds.
For more on palliative care's growth in internal medicine and hospital medicine, read ACP Internist's coverage from Internal Medicine 2011. Palliative care physician Jean S. Kutner, FACP, asked the audience for a show of hands about the best timing for palliative care at the start of her session, and most audience members responded that they would recommend palliative care early in the course of disease. "I love it," said Dr. Kutner, "It must be 2011 and not 10 years ago."
Wednesday, July 20, 2011
Some patients just won't take 'no' for an answer
A 62-year-old black man presents with a two inch (that's inch; not centimeter) lump under his left arm. It is determined that he needs to have it biopsied in order to tell for sure what it is. The differential diagnosis includes a simple reactive lymph node, lymphoma, leukemia, granuloma, sarcoidosis, and several other more esoteric entities, all of which require tissue for definitive pathologic diagnosis.
Patient Who Will Not Be Reassured: What is it, Doctor Dino?
Me: We won't know for sure until we get the report from the biopsy.
PWWNBR: But what do you think it is?
Me: I have no idea. We have to see what the pathologist says.
PWWNBR: Could it be cancer?
Me: It could be any one of several different things. Yes, cancer could be one of them, but there's no way of knowing without the biopsy.
PWWNBR: Dr. Dino, do I have cancer?
Me: I don't know. We can't tell until we get the biopsy report.
PWWNBR: But what do you think?
Me: I really don't know. There are some features about it that make me think one thing, but there are other features that make me think something else. So the only thing to do is get the biopsy and see what it shows.
PWWNBR: What do I have?
Me: You have a mass under your arm that needs to be biopsied.
PWWNBR: But what is it?
Me: There's no way to know for sure until we talk to the pathologist.
PWWNBR: Dr. Dino, what do you think it is?
Me: I can't tell just by feeling it. We need to get the biopsy and wait until the report is ready.
PWWNBR: Do you think it's cancer?
Me: I have no idea what it is, and the only way to find out is to see what the tissue looks like under the microscope.
PWWNBR: But what is it, Dr. Dino?
and repeat ...
and again ...
and yet again ...
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.
What to do about Niacin?
I have been getting a lot of questions regarding the use of Niacin since the media recently reported that the NIH had stopped their AIM-HIGH study. AIM-HIGH was designed to see if adding Niacin to patients on a statin who still had low HDL and high triglycerides would improve cardiovascular outcomes (heart attacks, strokes). Though we know that high triglycerides and low HDL are both strongly associated with heart disease, that Niacin will raise HDL and lower triglycerides and even few early studies did show raising the HDL with Niacin did work; this large, randomized NIH sponsored showed no evidence of improvement.
Though the actual data from the study has not been released, we do know that the NIH stopped the study a year early because there was no benefit seen and possibly some harm in the form of excess stroke. One possibility is that patients were taking statins at doses that lowered their LDL to very aggressive levels (target range of 40-80). Some have postulated that with an LDL that low, you will never get a heart attack or stroke. So, Niacin may indeed work, but not with super reductions of LDLs with statins.
One of the main points of from these findings is that we have to be careful when it comes to using surrogate endpoints (like LDL and HDL) for treatment. For example, lowering the LDL with a statin reduces heart attacks and strokes. However, lowering the LDL with ezetimibe (Zetia) doesn't seem to do this (see here for more details) This might be the case for Niacin and HDL as well.
I have never been a big fan of Niacin because it causes pretty bad flushing, increases uric acid/gout, and most importantly, raises blood glucose. Most of my patients are diabetic/prediabetic, so raising their blood sugar is not something I am too fond of. The other drugs that can raise HDL and lower triglycerides are fibrates. Gemfibrozil has clearly demonstrated this in a large VA study (VA-HIT). The problem with gemfibrozil is that it can interact with statins, causing some serious side effects. Statins are the one med that clearly works in just about everyone with increased cardiac risk. Fenofibrate works the same way, but can be used safely with a statin. However, when they tried to demonstrate cardiovascular improvements with fenofibrate (FIELD study), the primary outcome was not statistically significant. One of the differences between VA-HIT and FIELD is that more patients were on statins in FIELD, since FIELD was a more recent study and regular use of statins had become standard of care. However, in the diabetic patients with low HDL and high triglycerides, the FIELD study did show that fenofibrate reduced heart attacks and strokes. The ACCORD lipid study (another large, randomized, NIH-sponsored trial), attempted to prove benefit by adding fenofibrate to all diabetics on a statin, but failed. However, similar to FIELD, in those diabetics with low HDL and high triglycerides, fenofibrate added to a statin did reduce heart attacks and strokes. The consistency of these findings therefore have some merit.
Bottom line: Statins remain the first choice for patients at increased cardiovascular risk and should be used at doses that meet individual LDL goals and/or lower LDL by 30-40%. After that, the rationale for treating low HDL/high triglycerides is now less clear. Before we see the actual data from the AIM-HIGH study, it would be premature to pull all patients off of Niacin. That being said, in my opinion, Niacin's days are likely numbered. Evidence for raising HDL and lowering triglycerides seems to be much stronger for fenofibrate, at least in diabetics, and fenofibrate does not seem to have the negative effects, specifically hyperglycemia, seen with Niacin.
Matthew Mintz, MD, is a Fellow of the American College of Physicians. He is board certified in internal medicine and has been practicing for more than a decade. He is also 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. This post originally appeared at Dr. Mintz' Blog. Conflict-of-interest disclosures are available here.
QD: News Every Day--IOM seeks 8 new preventive measures for women
Eight preventive health services for women should be added to the services that health plans will cover at no cost to patients under the Patient Protection and Affordable Care Act of 2010, according to a report by the Institute of Medicine.
The recommendations encompass diseases and conditions that are more common or more serious in women than in men. They are based on existing guidelines and an assessment of the evidence on the effectiveness of different preventive services. They include:
1) screening for gestational diabetes in pregnant women between 24 and 28 weeks and at the first prenatal visit for women at high risk for diabetes,
2) adding high-risk human papillomavirus DNA testing in addition to conventional cytology testing in women with normal cytology results starting at age 30, and no more frequently than every 3 years,
3) offering annual counseling on sexually transmitted infections for all sexually active women,
4) offering annual counseling and screening for HIV for sexually active women
5) reducing unintended pregnancies through the full range of Food and Drug Administration-approved contraceptives and sterilization procedures, and patient education and counseling for all women who could become pregnant,
6) offering comprehensive lactation support and counseling and costs of renting breastfeeding equipment,
7) screening and counseling for interpersonal and domestic violence, and
8) offering at least one well-woman preventive care visit annually for adult women to obtain the recommended preventive services, including preconception and prenatal care.
"This report provides a road map for improving the health and well-being of women," said committee chair Linda Rosenstock, FACP, dean of the School of Public Health at the University of California, Los Angeles. "The eight services we identified are necessary to support women's optimal health and well-being. Each recommendation stands on a foundation of evidence supporting its effectiveness."
Examples for the recommendations include:
Cervical cancer. Deaths from cervical cancer could be reduced by adding DNA testing for HPV, the virus that can cause this form of cancer, to the Pap smears that are part of the current guidelines for women's preventive services, the report concludes. Cervical cancer can be prevented through vaccination, screening, and treatment of precancerous lesions, and HPV testing increases the chances of identifying women at risk.
Breast feeding. Although lactation counseling is already part of the HHS guidelines, the report recommends comprehensive support. Evidence links breast-feeding to lower risk for breast and ovarian cancers; it also reduces children's risk for sudden infant death syndrome, asthma, gastrointestinal infections, respiratory diseases, leukemia, ear infections, obesity, and type 2 diabetes.
Diabetes. The United States has the highest rates of gestational diabetes in the world. It complicates as many as 10% of U.S. pregnancies each year. Women with gestational diabetes face 7.5 times the risk for Type 2 diabetes after delivery and are more likely to have infants by cesarean section and that have health problems after birth.
Family planning. Unintended pregnancies accounted for almost half of pregnancies in the U.S. in 2001. Women with unintended pregnancies are more likely to receive delayed or no prenatal care and to smoke, consume alcohol, be depressed, and experience domestic violence during pregnancy. Unintended pregnancy also increases the risk of babies being born preterm or at a low birth weight, both of which raise their chances of health and developmental problems.
Tuesday, July 19, 2011
QD: News Every Day--Older doctors adopting mobile technology, too
Smartphones and tablets have reached 80% of physicians across all practice types, locations and years in practice, and 25% of users are "Super Mobile" physicians who use both types of mobile devices. This is far beyond the general population's 50% adoption of smartphones and 5% adoption of tablets.
QuantiaMd, a free, online learning collaborative, released survey results that showed 44% of physicians who do not yet have a mobile device intend to buy one this year.
While younger physicians have higher adoption rates than older ones, current use of mobile devices by physicians longest in practice is above 60%, the survey showed. Among physicians with 30 years or more of practice, almost 20% already use a tablet device for work, and another 25% say they are extremely likely to do so. Physicians in their second decade of practice use tablets most frequently, even when compared to the newest physicians. This may be related to the experienced physicians' better earning power, according to the survey report.
Physicians far and away use their mobile devices to access drug and treatment reference information (69%). They also use them to find new information about treatments and research, make treatment and diagnosis decisions, make medical testing decisions, and access electronic medical records.
Of these physicians who use tablets, two-thirds, or 19% of all physicians, use their tablet for clinical work. Another 35% of physicians surveyed say they are extremely likely to do so within the next few years, which could result in tablet adoption rates of more than 50%.
The study included 3,798 physicians who were polled between May 5 to 12 on QuantiaMD.
Monday, July 18, 2011
Part-time women in medicine: Are they pulling their weight?
A number of years ago I was seeing a female executive for a physical exam. As I chatted with the sixty-something female CEO she remarked: "Women sell themselves short," attributing the lack of women in top management positions to their tendency to opt for less ambitious "mommy track" positions. While I had certainly heard these words before, that day they hit closer to home. At the time I was in year nine of employment at the Emory Clinic and feeling professional success in my job, which included a leadership position within my practice. I was the senior woman in my group, the university-based general medicine practice of Emory, and a busy and well-liked internist. Though at the time I had been recipient of various departmental awards, I was still an assistant professor, a detail that was, in fact, a chip on my shoulder. However, no woman in my practice had ever been promoted to associate professor.
When my first child was born in 1999 I had opted for "part-time" status, 75% of full-time, gradually increasing my work load after my second child turned four to 90% of full time. My husband is an interventional cardiologist and our work-life balance had been tough. Thankfully, I had a wonderful nanny who helped out at home.
Now, working full time in a medical practice that I started, I reflected on those years again after reading a recent editorial in the New York Times on part time women in medicine. The piece, Don't Quit this Day Job, authored by Karen Sibert, an anesthesiologist, argued that federal funding for residency training was wasted on women who increasingly opt for part-time positions. In fact over 50% of female physicians report seeing patients fewer than 40 hours per week (most commonly 30 to 40 hours per week), compared to men, who more commonly report spending 41 to 50 hours per week on patient care. When I posted Dr. Sibert's editorial on Facebook it was met with a flurry of impassioned negative responses by many of my female physician colleagues, who have opted for the flexibility of part-time primarily in order to accommodate their domestic roles as primary caregivers of young children.
In my experience women working "part-time" in medicine and earning "part-time" incomes often add professional work into their unpaid time--seeing extra patients, taking equivalent call despite a part-time salary, and in the academic setting, taking on unpaid teaching, or educational administrative positions. In fact, I recognize that it was my part-time status that enabled me to participate in these types of activities and actually helped my reputation in my division, allowing me to pursue professional interests that I would not have had time for otherwise.
In the past several decades women have made significant gains toward equal status in medicine. According to statistics from the Association of American Medical Colleges, in the year that I graduated from high school, 1986, 31% of medical school graduates were women. In 1994, when I graduated from medical school, 39% of graduates were women, and in 2010 48% of medical school graduates were women. However, as in other fields, women still lag far behind men in terms of their representation in leadership positions. In terms of income, significant gaps also remain. In the past these income disparities have been attributed to differences in work hours and a tendency for female physicians to enter primary care fields. However, a provocative recent study published in Health Affairs found that an average gap of $16,819 in salary between newly trained female and male physicians could not be explained by controlling for these factors.
Why should we care about having female physicians? Studies have suggested some differences between male and female physicians. Findings include:
--Women may spend more time with their patients.
--Women have different communication styles. They are perceived as more empathic and sensitive.
--Women tend to employ more participatory decision-making styles, which are correlated with higher patient satisfaction.
--Women tend to emphasize preventive services more.
--Women are more likely to discuss lifestyle and social concerns.
Of course these observed differences are highly variable depending on the individual physicians in question. Interestingly, male gynecologists have been rated as more empathic and sensitive than male physicians in other fields. Nonetheless, there is strong female preference for female gynecologists. The interaction between gender and patient preference is complex. One interesting study looked at 10,000 patients in an HMO setting and found that male patients of female physicians were the most satisfied customers, compared with female patients of these same female physicians, who were the least satisfied group. Patients have different expectations about communication between male and female physicians and this may impact their satisfaction with care.
Going back to the female CEO, I too have been let down at times by what I have perceived as a relative lack of career ambition in some female physicians. Thinking about it, however, I've been equally let down by male physicians with what I viewed as misguided professional goals. If women can best manage their careers in medicine as part-time then so be it. Society will benefit, perhaps we will learn something from one another, and women in medicine are already paying the price.
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.
QD: News Every Day--Paydays can lead to riskier behavior, death
Paydays increase mortality for a week because they fund behaviors that lead to traffic fatalities, heart attacks and substance abuse, according to a new study in press at the Journal of Public Economics.
To study the within month mortality cycle, economists studied four groups with known paydays: seniors on Social Security, military personnel, families receiving tax rebate checks in 2001, and recipients of Alaska's Permanent Fund dividends.
A large rise in mortality occurred, and it happened across a broad demographic base: young and old, low and higher income groups, and married and single people.
"There is increased economic activity after payday," said the economist who headed the study. "Some of the activity, like driving and trips to bars, will naturally increase risk. Many types of activities are also known to trigger heart attacks."
The economist discusses his results online.
Friday, July 15, 2011
QD: News Every Day---The latest bad news on obesity
A report released recently by the Robert Wood Johnson Foundation and the Trust for America's Health issued some grim warnings about the current and future state of the U.S.'s obesity epidemic.
Bluntly titled "F is for fat: How obesity threatens America's future 2011," the report found that obesity rates rose in 16 states since 2010 and that more than 30% of people are obese in 12 states, compared with one state just four years ago. The South is still the worst-faring region---nine out of 10 states with the highest obesity rates are located there.
The report compared today's data with data from 20 years ago, when no state's obesity rate exceeded 15%. Now, only one state---Colorado---has a rate below 20%. The report also points out that despite the increased attention paid to obesity by government (not to mention the media), no states posted a decrease in rates over the past year. Diabetes and hypertension rates have also risen sharply over the past two decades, the report said.
Recommendations to address the problem include preserving and in some cases restoring federal funding for obesity prevention and implementing legislation to improve nutrition in schools, among others.
Meanwhile, two researchers are making headlines for proposing a more extreme solution: removing dangerously obese children from their parents' custody. In the most recent Journal of the American Medical Association, Lindsey Murtagh, JD, MPH, and David S. Ludwig, MD, PhD, from the Harvard School of Public Health and the Optimal Weight for Life Program at Children’s Hospital in Boston, respectively, wrote that state intervention, including such options as counseling and financial assistance, could be the "only realistic way" to help children with life-threatening obesity. But in cases where support services aren't enough, they wrote, foster care and bariatric surgery may be the only remaining options. Although the former can be painful for the child and his or her family, it doesn't carry the physical risks of bariatric surgery. "Family reunification can occur when conditions warrant, whereas the most common bariatric procedure. . . is generally irreversible," they said.
The writers make clear that such a step should be considered only in the most severe cases---but that they suggest it at all seems to be yet another indication of just how bad the problem is, and how much worse things could get.
An article in ACP Internist's July/August issue discusses tips on talking to patients about obesity.
Thursday, July 14, 2011
QD: News Every Day: Believing in placebos?
Two new studies out this week examine the power of the placebo effect.
A double-blind, crossover pilot study published in today's New England Journal of Medicine examined 39 patients with asthma randomly assigned to receive active treatment with an albuterol inhaler, a placebo inhaler, sham acupuncture, or nothing. Each patient received one of these interventions in random order at four sequential visits scheduled three to seven days apart. The "block" scheduling was repeated twice, so that each patient made a total of 12 visits. Maximum forced expiratory volume in 1 second was measured at each visit with spirometry, and patients self-reported improvement ratings. Although albuterol increased maximum forced expiratory volume in 1 second by 20% compared with 7% for each of the other interventions, patients often couldn't tell the difference: Their self-reported improvement ratings were similar regardless of which intervention they received, and were statistically significantly greater than patients in the no-intervention group (50% for albuterol, 45% for placebo, 46% for sham acupuncture, 21% for no intervention).
In a randomized, controlled trial published in the July/August Annals of Family Medicine, researchers assigned 719 patients who'd just come down with the common cold to receive no pills, blinded placebo pills, blinded echinacea pills, or open-label echinacea pills. People who didn't take pills tended to be sicker longer, but patients who did and who believed echinacea would help their cold symptoms had shorter, less severe illness---even if they were assigned to placebo.
Both studies had limitations, including lack of information on severity of subjective symptoms in the former and lack of information on potential causal associations in the latter. But both trials offer interesting ideas about how placebos may help and hurt in clinical practice.
"The data shown here suggest that those who believe in echinacea's effectiveness may gain the most benefit from being randomly assigned to echinacea (or a pill that might be echinacea)," the authors of the Annals of Family Medicine study wrote. "We suspect that larger placebo effects are derived when a person chooses his or her own treatment rather than have it randomly assigned."
Meanwhile, according to the authors of the New England Journal of Medicine study, clinicians perhaps shouldn't stake too much faith on asthma patients' self-reports of improvement. "Many patients with asthma have symptoms that remain uncontrolled, and the discrepancy between objective pulmonary function and patients' self-reports noted in this study suggests that subjective improvement in asthma should be interpreted with caution and that objective outcomes should be more heavily relied on for optimal asthma care," they wrote.
Contact ACP Internist
Send comments to ACP Internist staff at firstname.lastname@example.org.
- 5 ways that health care IT must get better
- This is what we need more of
- Bad breath and oral health--what's new and what's ...
- Lifestyle medicine and the parable of the tiny par...
- When should doctors turn patients away?
- The pledge of the patient-centered physician
- Why I'm skeptical about marijuana's medical benefi...
- More on physician autonomy
- The basic health care transaction
- Largest Ebola outbreak in history continues to spr...
- May 2008
- June 2008
- July 2008
- August 2008
- September 2008
- October 2008
- November 2008
- December 2008
- January 2009
- February 2009
- March 2009
- April 2009
- May 2009
- June 2009
- July 2009
- August 2009
- September 2009
- October 2009
- November 2009
- December 2009
- January 2010
- February 2010
- March 2010
- April 2010
- May 2010
- June 2010
- July 2010
- August 2010
- September 2010
- October 2010
- November 2010
- December 2010
- January 2011
- February 2011
- March 2011
- April 2011
- May 2011
- June 2011
- July 2011
- August 2011
- September 2011
- October 2011
- November 2011
- December 2011
- January 2012
- February 2012
- March 2012
- April 2012
- May 2012
- June 2012
- July 2012
- August 2012
- September 2012
- October 2012
- November 2012
- December 2012
- January 2013
- February 2013
- March 2013
- April 2013
- May 2013
- June 2013
- July 2013
- August 2013
- September 2013
- October 2013
- November 2013
- December 2013
- January 2014
- February 2014
- March 2014
- April 2014
- May 2014
- June 2014
- July 2014
- August 2014
Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
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.
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, 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
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.
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.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
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.
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.
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.
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.
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.
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.
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
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.
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.
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).
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
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)
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,
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
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.
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.
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.
The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.