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

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Monday, October 31, 2011

Mammograms could save more lives than you might think

I could write a book on what's wrong with today's breast cancer screening "news."

What I'm wondering is how to bring mainstream health journalists and women who are, lately, choosing not to have mammograms, to their senses about a persuasive but flawed argument put forth by a Dartmouth epidemiologist and others in a crew of seemingly like-minded, hopefully well-intentioned, some perhaps tenure-seeking and others grant-needing, circulatory bias-confirming academics who meet and discuss and write about the so-called dangers of mammography.

Maybe some doctors and journalists think they're doing the right thing by informing a naive body of women who, in the words of a Los Angeles Times writer today, presumes that we think only correlative and simple thoughts.

From the article "Screening mammograms save fewer lives than you think: "If you or someone you know discovered she had breast cancer thanks to routine mammography screening, and if you or that friend with breast cancer got treatment and today is cancer-free, it's natural to assume that the mammogram was a life-saver.

But odds are, it wasn't.

More likely, the cancer that was picked up by that mammogram would have been just as treatable even if it hadn't been caught until you or your friend felt a lump in the breast. It's also entirely possible that the cancer wouldn't have killed you (or your friend) if it had been left alone, untreated.

More than 75% of women who found out they had breast cancer from a screening mammogram fell into one of these two categories, and no more than 25% of them can give the test credit for saving their lives."


In the 5th paragraph of this news item: "So says a study published online Monday by Archives of Internal. The authors, Dr. H. Gilbert Welch and Brittney A. Frankel of the Dartmouth Institute for Health Policy and Clinical Practice, used data from the National Cancer Institute to arrive at this conclusion ..."

First things first: the title makes an assumption about what I, or you, or any reader, thinks.

Next this high-profile piece tells readers that, sometimes, people incorrectly draw inferences based on their personal experiences rather than from science. (Really? Do we need a nominally straight news story from the Los Angeles Times to explain this?)

We're given two factoids: first that over 75% of women diagnosed with breast cancer by screening mammography wouldn't have died from the cancer if they hadn't had mammography; and second, that no more than 25% of those same women can rightly credit a mammogram for saving their lives.

But this is just one stat, or falsehood, based on the true, assumption-free relationship between 75% and 25%.

Dr. H. Gilbert Welch, who recently likened mammography-taking to gambling, plays freely with impressive-sounding information sources. He and his coauthor used data from the NCI. Seemingly hard to argue with those kinds of numbers. But they used old data, again, and employ numerous assumptions (what the authors call generous, but I wouldn't) to render calculations and "prove" their point published in the Archives of Internal Medicine.

The manipulative tone is set in the paper's abstract: "... We created a simple method to estimate the probability that a woman with screen-detected breast cancer has had her life saved ..."

Simple? Don't you believe it.

There's a Well post in the New York Times today covering the same Archives of Internal Medicine article. Not surprisingly, this draws positive feedback in the comments and Twitter-chatter. Some of the more understandable discussion comes from women with metastatic disease whose tumors were missed by screening mammography. Notably, neither paper quotes an oncologist.

Here in the U.S. where we do spend too much on health care, we all know women whose breast tumors were missed by screening mammograms. This happens, and it's awful, but it doesn't and certainly shouldn't happen so often as some doctors seem to think. Extrapolating from personal observations to draw conclusions about a procedure's value is flawed reasoning, either way.

I agree with many of Dr. Susan Love's school, and most of the NBCC agenda, and others that say breast cancer prevention would be better than treatment. How could I not?

But until there's a prevention for breast cancer, which I'm sorry to report is unlikely to happen before 2020, especially because it's really 15 or 20 or maybe even more diseases that would, presumably, need distinct methods of prevention, and until there are better, less damaging and less costly remedies, mammography may be the best way for middle-aged women to avoid the debilitating and lethal effects of late-stage disease. And for society to avoid the costs of that condition and its treatments, which are huge.

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

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Supporting the unsupportable

This is entirely my fault. I have been staying away of late from more confrontational posts about alternative medicine, mostly out of fatigue. I also would prefer to blog about medicine, family, and various train-of-thought nonsense. But I went and got myself quoted and a number of folks seem displeased. Supporters of chiropractic neck manipulation, a practice I recommend against, are quoting a number of studies and making a number of comparisons that aren't really supportable, so I have to respond.

First, my bias: for a medical practice to be routinely recommended, it should work, and how much it works should be worth whatever risk attends it. In order to prove its worth, there should be studies that, in aggregate, support the practice. For those studies to be taken seriously, the must be well done and the practice must have a plausible mechanism of action.

Let's look at neck pain. This is a common condition, affecting most of the population at some point, but rarely associated with significant disability; those are what the statistics say, but when your neck hurts, you want it to feel better and you might seek professional advice. And, like low back pain, neck pain does tend to recur. It also tends to remit spontaneously, especially in younger people, the same people unlikely to have significant spine pathology. In assessing neck pain outside the setting of trauma, X-rays, a common practice among both chiropractors and doctors, do not appear to help guide diagnosis in a significant way.

In a typical primary care practice, neck pain without alarm signs (such as weakness, fevers, weight loss) tends to be treated quite conservatively, with stretches, Tylenol or non-steroidal anti-inflammatory drugs (NSAID) for pain relief, and tincture of time. When this fails to give relief, patients are often referred for imaging and physical therapy. It's certainly plausible that manipulation of the neck, whether done by a chiropractor, masseuse, physical therapist, or beneficent spouse may help. The question becomes does it help, and if so how much and with what risk.

NSAIDs, despite their easy over-the-counter availability, are potent drugs and come with significant risks, risks which increase with length of use and with other risk factors. NSAIDs probably increase the risk of cardiovascular events in certain subsets of patients, and are one of the two primary causes of stomach ulcers. But short term treatment with NSAIDs, as would be typical for someone with benign neck pain or low back pain, is relatively safe. There is very little risk to an otherwise healthy young person who uses NSAIDs at a normal dose for a week or two. They probably do not lead to quicker resolution of an episode of neck pain, but they may give comfort while the episode resolves.

From what I gather having read the above-referenced blog post, the main arguments seem to be that chiropractic neck manipulation never leads to vertebral artery dissection, and that other treatments are much more dangerous.

As to the first claim, my colleague Mark Crislip has given a nice explanation of the data, the gist of which is that we shouldn't be seeing vertebral artery dissections in young people, and the fact that many of these rare events are coincident with chiropractic neck manipulation should give us pause.

The writer's strong emphasis on the risk of NSAIDs is based on a misunderstanding of the use of NSAIDs to treat benign neck pain. What patients choose to do on their own is less relevant, but as physicians, we rarely give long courses of high-dose NSAIDs to these patients. They tend to get better on their own, and short courses of NSAIDs in young, healthy patients come with little risk.

Most benign neck pain is self-limited. According to the study cited by the chiropractors: "Quality of life years (QALYs) associated with standard NSAIDs, Cox-2 NSAIDs, exercise, manipulation, and mobilization were compared in a decision analytic model. None of the active treatments was found to be clearly superior to any other in the short or long term when estimates of the course of neck pain, adverse event risks, treatment effectiveness and risk, and patient-preferences for health outcomes were considered."

Given that most treatments for neck pain probably provide a bit of relief while the condition resolves on its own, what most physicians and chiropractors should do is simply get out of the way. Patients should be assessed for non-benign causes of their pain, NSAIDs can be prescribed safely for short term use, and patients will get better. There is no evidence that chiropractic provides additional benefit, especially in the long term.

But when it comes to risk, there is a small but definite association between chiropractic neck manipulation and the rare form of stroke known as vertebral artery dissection. This correlation is most clearly seen in young patients, those who would not normally suffer from strokes. Given the lack of superiority of chiropractic, and the small but real association with VAD, I stand by my advice that one should not allow a chiropractor near the neck.

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog, White Coat Underground. The blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.

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QD: News Every Day--Human brains consistent despite other racial differences

Human brains have a consistent molecular architecture despite all the other genetic differences across individuals and ethnicities, according to two studies that recorded when and where genes turn on and off in multiple brain regions throughout life.

Source: JNenad Sestan, MD, PhD, Yale University Department of Neurobiology and Kavli Institute for Neuroscience, via NIHDespite individual and ethnic genetic diversity, the human prefrontal cortex shows a consistent molecular architecture, as shown in this picture. The vertical span of color-coded areas is about the same, indicating that our brains all share the same tissue at a molecular level, despite distinct DNA differences on the horizontal axis. Each dot represents a comparison between two individuals.

The research appeared in the Journal Nature and was described by the National Institutes of Health in a press release.

The first study focused on how genetic variations are linked to the expression of transcripts in the brain's prefrontal cortex, the area that controls insight, planning and judgment, across the lifespan. They studied 269 postmortem, healthy human brains, ranging in age from two weeks after conception to 80 years old, using 49,000 genetic probes.

This information about when and where specific genes are expressed in the brain from pre-natal stages to the end of life brings new hope for understanding how this process can go awry in schizophrenia, autism and other brain disorders.

A second study concluded that men show more sex-biased gene expression, especially prenatally. Some genes found to have such sex-biased expression had previously been associated with disorders that affect men more than women, such as schizophrenia, Williams syndrome and autism.

The researchers characterized gene expression in 16 brain regions, including 11 areas of the neocortex, from both hemispheres of 57 human brains that spanned from 40 days post-conception to 82 years, analyzing the transcriptomes of 1,340 samples.

Among key findings from this second study, they concluded that more than 90% of the genes expressed in the brain are differentially regulated across brain regions and/or over developmental time periods. Sex differences in the risk for certain mental disorders may be traceable to transcriptional mechanisms. More than three-fourths of 159 genes expressed differentially between the sexes were male-biased, most prenatally.

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Friday, October 28, 2011

Arsenic in your apple juice is safer than Dr. Oz in your education

There's arsenic in apple juice, and I just poured my daughter a big glass. Go ahead, call Child Protective Services.

On his show last week Dr. Oz tried to scare us about arsenic in apple juice. It was a feat of ratings-driven fear-mongering that was shameful even by daytime TV standards. His show tested various brands of apple juice for arsenic, announced that the levels were too high, and concluded that we should all be worried.

Sunlight on natural apple juice by AdamKR via Flickr and a Creative Commons licenseActually, he conducted the wrong kind of test and misinterpreted the results. (If you're interested in the scientific details, this scathing article in Forbes has a great review.) Dr. Oz was widely criticized, including by other physicians. The FDA released a very reasoned update reminding us that apple juice is safe. The FDA regularly tests apple juice for arsenic and has been doing so for years. So Dr. Oz was forced to back-pedal and reassure us that he's not worried about drinking apple juice. Phew! That's a relief.

This week Dr. Oz published an op-ed in the Chicago Tribune explaining that he was simply trying to "raise an alarm" about food safety and that "we need more stringent restrictions on arsenic in fruit juice."

Huh? He said he has no concerns about the safety of juice. There's no evidence that arsenic levels in juices (or in any other food or beverage) are dangerous and no evidence that anyone is getting arsenic toxicity from their diet. Other than that, he has a good point, or at least a very popular show.

But why did his ploy work? Why did he get so much attention? Why didn't the couple of million people (!) who watch his show search the CDC or FDA websites about arsenic, yawn slowly, and move on to a different subject? Why didn't they discover on their own that the scariest thing about apple juice is the calories? Overweight people shouldn't touch the stuff. After decades of drinking fruit juices daily they might suffer the complications of diabetes, but they would still have no effects from the arsenic.

Why would we take the word of a TV entertainer and thoracic surgeon about food safety instead of the opinion of people with PhDs in biochemistry who spend their careers keeping food safe? Like me, Dr. Oz last studied biochemistry as an undergraduate. The only thing his training prepares him to answer about apple juice is, "How long before my heart surgery can I have anything to drink?"

For better or for worse, we're hard-wired to pay attention to scary stuff. So a reasoned explanation that everything is OK will never get as much attention as a bogus warning that you're poisoning your children. As an open society we are being challenged to learn to give credibility to those who have earned it and ignore those who have abused our trust. Can we do it?

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. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.

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Coaching doctors as they continue their medical education

The New Yorker had a story, Personal Best, by Atul Gawande, MD. It's about coaching, and the seemingly novel idea that doctors might engage coaches, individuals with relevant expertise and experience, to help them improve their usual work, i.e. how they practice medicine.

Coach Rich Ellerson by West Point Public Affairs via Flickr and a Creative Commons licenseDr. Gawande is a surgeon, now of eight years according to his article. His specialty is endocrine surgery. When he operates it's most often on problematic glands like the thyroid, parathyroid or appendix. Results, and complications, are tracked. For a while after he completed his training he got better and better, in comparison to nation stats, by his accounting. And then things leveled off.

The surgeon-writer considered how coaches can help individuals get better at whatever they do, like playing a sport or singing. He writes: "The coaching model is different from the traditional conception of pedagogy, where there's a presumption that, after a certain point, the student no longer needs instruction. You graduate. You're done. You can go the rest of the way yourself ..."

He wonders about how this might apply in medicine: "... Knowledge of disease and the science of treatment are always evolving. We have to keep developing our capabilities and avoid falling behind. So the training inculcates an ethic of perfectionism. Expertise is thought to be not a static condition but one that doctors must build and sustain for themselves."

Dr. Gawande wondered if engaging a coach, a senior surgeon he knew and respected, to observe his moves in the operating room, and, perhaps, offer suggestions, might be beneficial to his operating skills. He tries it, and finds that perhaps by tweaking a few aspects of a procedure, like where he stands relative to the operating field and surgical light, how the drape is positioned relative to others assisting, and the position of his elbows, he might lesson some risks or reduce the duration of surgery.

By reading the whole article, I gleaned a bit on the history of coaching in America (supposedly this dates back to Yale-Harvard football rivalries in 1875), and Dr. Gawande's personal history of tennis playing at an Ohio high school. All interesting.

At the end of the piece, Dr. Gawande describes a patient awaiting anesthesia before surgery. She asks him about a man standing in the operating room with a notebook in his hand, and Dr. Gawande responds that he's a colleague, and eventually admits the man is "like a coach."

He explains to the woman: "I asked him to observe and see if he saw things I could improve."

"The patient gave me a look that was somewhere between puzzlement and alarm," he writes. "She did not seem reassured."

Her reaction is perfectly understandable. Who would want a doctor who still needs to learn what he's doing?

This article interests me at several levels. First, it's really about graduate medical education, and how doctors might continue to learn after they complete med school, residency and fellowship training. Although the term "coach" may seem strange as applied to medical practice, the concept of a doctor being observed, and even taped during a procedure or interview or physical examination of a patient, as part of a re-credentialing or boards certification process, is not so new.

Second, it's curious how the coaching concept might apply to some medical specialties more than others. Surgery is a more physical activity than, say, the practice of hematology or oncology. Still, there are new facts constantly coming to light, and changing conventions, about which doctors in all field should be aware. So I think it's wise for all physicians to be actively learning or perfecting their knowledge base. But this might be best accomplished in some areas by written, test-based evaluations, such as typically happens upon taking licensing exams and (more rigorously) specialty board exams.

As for coaching, we might call it something else, like "professional assessment" every few years. Sure, it's disconcerting for patients to think that their selected surgeons or other doctors aren't at the top of their skill-set, or think they aren't. But what's scarier is when their physicians think they can't get better at their work (like performing colonoscopies, or spinal taps, or interpreting the readout of a new-model flow cytometer). Even when and if a doctor does a procedure flawlessly, details, like how he processes specimens--whether to place a fresh biopsy piece into formalin or normal saline solution, or into a new kind of tube--change over time. These small differences can affect the sensitivity and specificity of a diagnostic procedure, besides the complication rate.

I agree with Dr. Gawande that the best doctors are constantly learning, and choose to so. They're humble enough to ask a coach, or a colleague, or an examiner, to make sure they're doing their daily work as best as they possibly can.

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

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QD: News Every Day--Study finds specific gene linked to cold sore susceptibility

Investigators identified a specific, a previously obscure human gene associated with susceptibility to herpes simplex labialis (HSL), the common cold sore.

Image from Centers for Disease Control and Prevention/Dr. HermannCold sores affect 70% of the U.S. population. This study follows previous ones identifying a region of chromosome 21 as a base for genes possibly linked to cold sore outbreaks.

To narrow in further on the chromosome, this study used single nucleotide polymorphism genotyping in genome-wide, family-based linkage studies of 618 people from 43 large families. The investigators found a positive link between the frequency of outbreaks, hereditability and the presence of a specific gene, C21orf91, on chromosome 21. Results appeared in The Journal of Infectious Diseases.

Now, the researchers propose that C21orf91 be designated the Cold Sore Susceptibility Gene-1 (CSSG1).

An editorialist pointed out that if confirmed, additional research may then begin to determine possible therapies, as well as examine if the same gene also plays another role in the body.

"The rapidly decreasing cost of next generation sequencing opens up a host of new gene hunting strategies, especially for rare variants of large effect," the editorial states. "The spotlight now falls on C21orf91, first for replication of these results, then for functional studies, perhaps in the future for therapeutic applications, and, also, for studies to determine whether it plays a similar role in recurrent genital herpes."

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Thursday, October 27, 2011

Considering the risks and benefits of birth control options

From a message posted on Facebook: "Is the pill safe? The International Agency for Research on Cancer in a 2007 study made by 21 scientists reported that the pill causes cancer, giving it the highest level of carcinogenicity, the same as cigarettes and asbestos. It also causes stroke, and significantly increases the risk of heart attacks. Several scientific journals have stated that the natural way of regulating births through the Billings Ovulation Method has no side-effects, and is 99.5 % effective."

The Billings Ovulation Method (BOM) is a method of natural family planning where women are taught to recognize when they have ovulated by examining their cervical mucus, allowing them to avoid intercourse during fertile periods or conversely, to have intercourse during fertile periods when pregnancy is desired. We used to call people who used the rhythm method "parents," but BOM is more reliable than older abstinence methods.

I'm a big fan of oral contraceptives. They contributed to women's liberation by giving us a reliable method of planning, delaying, or avoiding pregnancy. They also have medical uses that go beyond contraception. Birth control pills (BCPs) have had such an important impact that they are known as simply "The Pill." We have always known they were not 100% risk free; but we also know they are less risky than pregnancy itself. There are other methods of birth control; but they are generally less effective and less convenient. For those who want permanent solutions, tubal ligation and vasectomy are available; but even they have occasional failures. What does science tell us about the effectiveness and safety of BCPs as compared to other methods?

Effectiveness
According to the Wikipedia entry, the Billings Ovulation Method has a failure rate of 0-2.9% with perfect use and 1-5% with typical use. (They cite the original references for these figures). The corresponding numbers Wikipedia gives for "the pill" are 0.3% and 8%. The American Congress of Obstetricians and Gynecologists' numbers for the pill are a bit less optimistic: they say, "With typical use, about 8 in 100 women (8%) will become pregnant during the first year of using this method. When used perfectly, 1 in 100 women will become pregnant during the first year."

A handy table on the Family Doctor website compares the failure rates of various birth control methods. It lists periodic abstinence methods as having a 20% failure rate, but that includes the less effective rhythm methods as well as the methods based on mucus examination.

Cancer? It causes some cancers and prevents others
Information on cancer and oral contraceptives can be found here. There is an increased risk of cervical cancer, but most cases are related to HPV infection, so hopefully the new vaccines will eliminate much of that risk. There is an increased risk of liver cancer in low risk populations but not in high-risk populations. The risk of breast cancer may or may not be slightly increased: studies do not agree.

On the other hand, the pill clearly reduces the risk of uterine and ovarian cancers. And a meta-analysis found that the risk of colorectal cancer is also decreased.

The magnitude of these risks is small. I couldn't find any information about overall cancer risk: whether the increase in some types of cancer outweighs the decrease in others.

What the IARC really said
According to the Facebook poster, the International Agency for Research on Cancer (IARC) said oral contraceptives were as carcinogenic as cigarettes and asbestos. That's not what the IARC said at all. It does classify estrogen/progesterone in the same group 1 category as cigarettes and asbestos, but all that category means is that there is sufficient evidence to prove carcinogenicity in humans. It does not in any way imply that oral contraceptives are as carcinogenic as cigarettes and asbestos: they aren't. And the IARC entry clearly states: "There is also convincing evidence in humans that these agents confer a protective effect against cancer in the endometrium and ovary."

Other risks
BCPs increase the risk of deep venous thromboembolism and ischemic stroke. There is disagreement over whether they increase the risk of myocardial infarction. The absolute risk of all these conditions is low. It is greater in smokers and in those with other risk factors, and it is lower for the newer low dose BCPs.

The ACOG has prepared an excellent patient education pamphlet listing all the risks, benefits, side effects, and contraindications. It concludes: "The pill is a good choice for women who may want to get pregnant later. It is a safe and effective way to prevent pregnancy. It is easy to use, convenient, and reversible. The pill may protect against some cancers. Some benefits of pill use last months or years after you stop taking it. For almost all women, the benefits of pill use outweigh the risks."

Benefits
Critics of hormonal contraception fixate on the risks, but there are also a number of health benefits. The ACOG patient information pamphlet explains that BCPs reduce the risk of:
--cancer of the uterus and ovary,
--ovarian cysts,
--pelvic infection,
--bone loss,
--benign breast disease,
--symptoms of polycystic ovary syndrome,
--anemia (iron poor blood),
--ectopic pregnancy, and
--acne.

They also:
--help to keep periods regular, lighter, and shorter and reduce menstrual cramps,
--reduce symptoms of endometriosis and fibroids,
--may help with migraine headaches and depression, and
--can be used to schedule periods to avoid an inconvenient time (i.e., a wedding).

Other options
There are many other birth control options: condoms, diaphragms, other hormone delivery methods like cervical rings and injections, IUDs, spermicides, periodic abstinence methods, and therapeutic abortions. Some methods have the additional benefit of protection against sexually transmitted diseases. Some methods require specific actions at the time of intercourse, which some people object to as interfering with spontaneity. The periodic abstinence methods have the disadvantage of requiring periodic abstinence.

I remember reading years ago (the reference is long gone and I don't know if the information is still valid) that when all factors were considered including the risks from pregnancy itself when contraception fails, the safest method of birth control was to use condoms and do therapeutic abortions when they failed. That resulted in statistically less morbidity and mortality overall than any other method.

Of course there are other considerations that make this a less than ideal option. Emotions and religion create a lot of bias in the area of birth control. I suspect some people who reject oral contraceptives as "unsafe" might be quite willing to take other medications that have a similar safety profile but are not connected to ideological concerns.

Conclusion
BCPs are not risk-free, but the Facebook poster was wrong: their risks can't be compared to the risks from cigarettes and asbestos. There are other good alternatives that some individuals may prefer for various medical and non-medical reasons. For any method of birth control, the risks must be weighed against the benefits. Pregnancy itself is far riskier than any method of pregnancy prevention.

The safest, most effective method of birth control is orange juice. You may ask, "Before or after?" The answer is "Instead of." Most women and their partners would not consider that a satisfactory option.

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

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Cocoa may lower blood pressure, risk of heart disease and stroke

In case you missed it, I'm happy to report something that should please most everyone. A study published in BMJ showed that consumption of chocolate (candies, candy bars, chocolate drinks, cookies and deserts) lowered the rates of stroke, coronary heart disease and blood pressure. It seems that chocolate is good for you!

cocoa by monica renata via Flickr and a Creative Commons licenseThe study (which did not receive funding from the chocolate industry) included 114,009 people and performed a meta-analysis of the medical literature. They found that people who ate the most chocolate reduced their risk of heart disease by as much as 37% and their risk of stroke by 29%, compared with those who ate the least chocolate. Having chocolate regularly, rather than binging, seemed to bring the most benefit. They did not confirm the difference between dark, milk or white chocolate, nor were they able to say what amount is of most benefit.

Before you run out and eat a chocolate decadence cake or a bag of Hershey's kisses, there are a few caveats to consider. All chocolate may not be the same in terms of benefit and most American candy chocolate is made with high sugar and dairy fat, not cacao beans. The extra sugar and fat probably reduces the health benefits of pure chocolate. Pure chocolate has no sugar and no carbohydrates.

A meta-analysis is not nearly as good or reliable as a prospective, controlled study. It is a review of past studies and a "pooling" of the data to come to conclusions. Because the studies are not consistent, there is no way to tease out the "types" of chocolate or even what is mean by eating "higher" quantities of chocolate. Some trends can be identified, but there is no true cause-effect with a meta-analysis. It simply points researchers in a direction. For these reasons, the authors recommended further research to prove (or disprove) that chocolate can actually benefit the heart.

Until those trials are done, we can take this information and be happy that there "may" be health benefits from eating chocolate. We already know that fats, sugar and excess calories are extremely health detrimental, but regular consumption of chocolate with a high cocoa content might be OK.

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.

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QD: News Every Day--Ghost authorship declined in past decade

Honorary and ghost authorship declined from 1996 to 2008, but not enough, study authors concluded.

Ghosts by Sean MacEntee via Flickr and a Creative Commons licenseThe problem is two sides of the same coin: honorary authors who are named as authors but didn't substantially contribute to the work, and ghost authors who made substantial contributions to the work but weren't named. Inappropriate authorship fell from 29% in 1996 to 21 in 2008, with no significant change in the prevalence of honorary authorship (from 19.3% to 17.6%) and significant decline in ghost authorship (from 11.5% to 7.9%).

To draw their conclusion, researchers conducted a cross-sectional survey using a web-based questionnaire among an international survey of corresponding authors of 896 research articles, review articles, and editorial/opinion articles published in six general medical journals with the highest impact factors in 2008: Annals of Internal Medicine, [Annals and ACP Internist are both published by the American College of Physicians.] JAMA, Lancet, Nature Medicine, New England Journal of Medicine, and PLoS Medicine.

Results appeared online Oct. 25 at BMJ, which, incidentally, publishes its authorship policy online.

In the 1980s, the International Committee of Medical Journal Editors (ICMJE) created guidelines for authorship that have been adopted by more than 600 medical journals. Of the six journals studied, Nature Medicine and New England Journal of Medicine do not require ICMJE disclosures, while the other four do.

Of the 545 articles with usable data on the honorary authorship questions, 96 (17.6%) met criteria for honorary authorship. Nearly all of these (93) were articles in which the corresponding author reported that one or more co-authors performed only one function, thus not meeting ICMJE authorship criteria. Prevalence ranged from 12.2% to 29.3% by journal (P=0.134), and was 25.0% for research articles, 11.2% for editorials, and 15.0% for reviews (P=0.0007).

The prevalence of honorary authorship in 2008 was 17.6% (95% confidence interval [CI], 14.6% to 21.0%) was not significantly different from the prevalence in 1996 (19.3% (95% CI, 16.7% to 22.2%), (P=0.439). The 2008 prevalence of honorary authors for research articles (25.0%, 95% CI, 19.7% to 31.1%) was significantly higher than in 1996 (16.3%, 95% CI 13.3% to 19.9%), (P=0.006), but was significantly lower for review articles (15.0%; 95% CI, 9.6% to 22.6%) compared to 25.5% (95% CI, 20.4% to 31.4%), (P=0.023) and editorials (11.2%, 95% CI, 7.5% to 16.3%) compared to 20.8% (95% CI, 13.1% to 31.2%), P=0.038).

A total of 49 (7.9%) of 622 articles met the criteria for ghost authorship. Prevalence ranged from 2.1% to 11.0% across the six journals, and was 11.9% for research articles, 6.0% for reviews, and 5.3% for editorials (P=0.017). Compared with the results for 1996, ghost author prevalence in 2008 was significantly lower (11.5%, 95% CI, 9.5% to 13.9%) compared to 7.9%, (95% CI, 6.0% to 10.3%), P=0.023). The prevalence of ghost authors was not significantly different by article type between 2008 and 1996.

When comparing the four journals that require authors to report their individual contributions with the two that don't, there was no statistically significant differences in the prevalence of articles with honorary authors (18.5% compared to 16.0%, P=0.461) or ghost authors (7.3% compared to 9.0%, P=0.455). The authors acknowledged that journals without publically disclosed requirements may have privately required it as part of the editorial process.

An editorialist commented, "The results showed that inappropriate authorship declined from 29% of articles in 1996 to only 21% in 2008, an improvement from previous studies cited by the authors, which were also based on the ICMJE criteria but lacked the breadth of the authors' 1996 and 2008 studies. However, this proportion of inappropriate authorship is a concern to institutions and journals responsible for integrity in scientific reporting."

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Wednesday, October 26, 2011

Seven secrets to successful, long-term weight loss

Most people who have lost weight understand how easy it is to gain it back. In fact, I often hear patients tell me that over the course of their lifetimes they've "tried every popular diet out there" and yet have failed to keep the weight off permanently. If that's your situation, you're not alone. It's estimated that only 20% of overweight individuals are successful at long term weight loss. But there is hope for success, and we can learn the secrets of "successful losers" from the National Weight Control Registry.

In a flash of brilliance, sociologist Rina Wing and psychologist Jim Hill decided to create a database of weight loss success cases, and simply observe how they live their lives over decades of time. They called this research study the National Weight Control Registry, and it has been enrolling study subjects since 1994. What they've found is that those who have been successful at losing at least 30 pounds and keeping that weight off for at least 1 year share many behaviors in common. I believe that the closer we follow in the footsteps of these successful people, the more likely we are to be fit for a lifetime. So here goes, this is what the study subjects report:

1. They eat a low-calorie, low-fat diet. Only 10% of participants reported that they used a low-carb diet to maintain their weight loss, but those who chose the low-carb diet showed no difference in weight gain over a three year period (compared to the low-cal, low-fat majority). Interestingly, the low-carb group reported eating more total calories (and more fat calories) with less restraint, even with similar results.

2. They are extremely physically active. Though there isn't one particular type of exercise that was preferred, the average study participant burned about 2,600 calories per week (which is equivalent to about 8.5 hours of brisk walking). Roughly one-third of the people in the study reported burning more than 3,000 calories per week with physical activities.

3. They eat breakfast regularly. Seventy-eight percent of the study subjects reported eating breakfast every day.

4. They watch the scale. About three-quarters of the participants report weighing themselves at least once a week. Almost a third of the study subjects weigh themselves at least once a day.

5. They are consistent in what they eat, throughout weekdays and weekends. Interestingly, one of the characteristics of successful losers is that they don't eat a large variety of foods. The study subjects found food/meals that they liked, and repeated them regularly. They did not change what they ate during holiday seasons or special occasions.

6. They often lose weight on their own without the help of a formal weight loss program. About 45% of the successful losers did it without any outside assistance.

7. They watch less television. While the average American watches about 28 hours of TV per week, 62% of study subjects reported watching fewer than 10 hours per week, and 36% reported watching fewer than 5 hours per week.

The good news is that the research also showed that weight maintenance becomes easier over time. So even though it takes a lot of discipline to succeed at maintaining a healthy weight for a lifetime, it feels a lot easier over time.

The bottom line? To lose weight and keep it off, it's important to eat a calorie-controlled, consistent diet, beginning with a healthy breakfast each day. Participating in daily physical activity, avoiding sedentary behaviors such as watching a lot of television, and opting for regular weigh-ins with the bathroom scale are critical disciplines. Weight loss programs can help you succeed, but you can also do just as well on your own if you adopt the behaviors of the success stories from the National Weight Control Registry!

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

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10 eyes for looking at disease

Hypothesis: All disease is caused by some combination of:

Injury (caused by an exogenous agent, this would include hemorrhage)




Inflammation (caused by the human organisms response to injury)




Immune (caused by under, over, or inappropriate response of the human self-defense mechanism)




Infection (caused by an exogenous microbial vector)




Ischemia (caused by lack of blood flow)




Inadequacy (caused by mechanical failure)




Incompetence (caused by physiological failure, heart failure would presumably fall in both)




Intoxication (caused by poison)




Iatrogenic (caused by doctors)




Idiopathic (caused by an unclear reason that is not included in the above, the cop-out)




ACP Member Mike Aref, MD, PhD, 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. This post originally appeared at his blog, I'm dok.

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Better bedside manners? What's it worth to you?

How much are good bedside manners worth? Would you double your copay if you could be guaranteed an extra measure of TLC from your physician? Can we put price on a physician's warm smile, an understanding nod or a reassuring hand on your shoulder? Do patients have to contract with a concierge medical practice to receive this treatment?

I agree that our bedside manners with patients need some rejuvenation. It's not fair, however, to isolate this issue out of context. Physicians today are facing crunching pressures from various sources that we cannot always compartmentalize when we are facing our patients, even though we should.

Most folks believe that the bedside manners of the prior generation of physicians were superior to ours. Were our predecessors simply more compassionate and caring human beings than we are? I don't think so. I think the medical profession was a different beast then. I hypothesize that if these wizened physicians entered the profession today, that they would behave differently.

Context is so critical when examining any issue. Many physicians find today's patients to be demanding and entitled. Again, before pronouncing a verdict here, there are reasons and explanations behind this that need to be aired. Patients and physicians are both different today because the culture and nature of the profession has changed. How would Marcus Welby behave if he weren't making house calls with a black bag 40 years ago, but were now an employed physician in a large clinic who was sued every few years and whose medical quality was monitored by bureaucrats who determined his reimbursement?

Again, I'm not excusing deficient bedside manners, but the issue has nuance and complexity.

A Chicago couple, Matthew and Carolyn Bucksbaum, believe that bedside manners are worth a lot. These philanthropists are donating $42 million to the University of Chicago, which will create an institute under their names which will be devoted to teaching medical students good bedside manners. The hope is to ingrain values of compassion and empathy deeply enough into medical students that they will not be contaminated when they enter the medical arena later. The training would function like a suit of armor to protect young physicians from bedside manner decay and attack.

This is a fantastic initiative and I hope that other donors and medical institutions emulate the Chicago program. While medical schools do teach bedside manners and the importance of the doctor-patient relationship, it was undervalued, at least in my day. Younger physician readers can comment if times have changed.

Can you really teach compassion or do you have to be born with it? A Chicago couple has wagered in a big way that it's nurture, not nature.

This post by Michael Kirsch, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

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QD: News Every Day--Minorities fuel med school applications to all-time high

First-time applicants to medical school reached an all-time high in 2011, increasing by 2.6% over last year to about 32,700 students, according to the Association of American Medical Colleges. Total applicants rose by 2.8% to nearly 44,000, with gains across most major racial and ethnic groups for a second year in a row.

The growth comes at a time when there is a growing need for doctors and a serious physician shortage, and the applicant pool is increasingly diverse, the AAMC reported in a press release.

Total number of applicants and enrollees from most major racial and ethnic groups increased in 2011:
--After a slight decrease (0.2%) in 2010, black applicants increased by 4.8% while enrollees increased 1.9%;
--Hispanic applicants increased by 5.8% and enrollees increased 6.1%;
--Asian applicants increased by 3.8% and enrollees increased by 3.3% over 2010;
--First-time female applicants increased 3% to nearly 16,000, and first-time male applicants grew nearly 2% to about 16,700 in 2011. The percentage of male (53%) and female (47%) enrollees remained steady from last year.
--American Indian applicants and enrollees decreased from 200 to 169 and 191 to 157, respectively.

The overall academic credentials of applicants remained strong, AAMC reported, with an average GPA of 3.5 and an MCAT exam score of 29. The majority of applicants reported slightly increased rates of premedical experiences in community service and medical research, with 82.5% reporting community service experience in medical and clinical settings, 68.4% in nonclinical community service, and 73% reporting experience in research.

Total enrollment increased by 3% over last year, with more than 19,000 students in the 2011 entering class. Medical schools have steadily been increasing their class sizes since the AAMC called for a 30% increase in enrollment in 2006 to help alleviate anticipated physician workforce shortages.

There has been a 16.6% enrollment increase over 2002, the base year used in calculating the 30% goal. Current projections indicate that medical schools are on target to reach the 30% enrollment increase by 2017.

The majority of this year's growth came from existing schools while a smaller portion came from first-year enrollees at medical education programs established in the past decade, the AAMC reported.

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Tuesday, October 25, 2011

Not its own reward anymore.

A couple of sessions at MGMA have mentioned good citizenship payments. The concept always comes up after discussion about systems that pay based on productivity, when someone points out that if you pay docs to rack up the RVUs, they might not bother to do anything else. The good citizen pay (usually a small chunk of overall income) rewards physicians for doing the stuff that makes them a "good citizen" of the practice-- serving on committees, heading up projects.

To me, there's something a little bit sad about the concept, or at least its name. Extrapolating to the outside world, should I have tipped the guy who held the elevator for me this morning or the woman who picked up my pen? Among all these friendly practice managers, this could get expensive. Lucky I'm heading back home to Philly.

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Making fun of doctors

Do you know what those managers say about you when they're among their peers? Actually, it was a doc who told this one, but the MGMA audience loved it.

What's the difference between a medical group manager and a toilet seat?
A toilet seat can only handle one ass at a time.

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The Cirque du Soleil could have fun with this.

I forgot. There was another thing in the talk by the Intel guy (who is named Eric Dishman, by the way) that struck me as pretty cool and new. He told us about how they've developed tiny little wireless computers to put in old people's pockets to assess their fall risk. It tracks their gait and wobbliness and can alert you if they seem more likely to fall. So for example, if you put an elderly woman on a new medication and then after she gets home, the computer reports she's stumbling around the house, it'll alert you to the need to change the medication. How far we've come from those “Help, I've fallen and I can't get up” necklaces.

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Would the Occupy Wall Street movement work for health care?

As Occupy Wall Street spread across the nation, I can't help but wonder if the same movement could occupy health care. After all, the basic tenants of the movement involve protesting against social and economic inequality, corporate greed, and the influence of corporate money and lobbyists on government. In the "Occupy" movement, there is a feeling there's an inside game and the game is rigged.

It would seem, then, that our new health care law, written by corporate interests and heavily influenced by lobbyists, could become a ripe target for the movement. We are beginning to see patients and doctors asking some very powerful questions: Why does the retail price of a pill have to exceed $10? Why does a single IV infusion of a chemotherapeutic agent have to cost $5,000? Why must we keep building hospital facilities that exceed $1 billion commonly, often in areas of extraordinary real estate prices? Why are insurance premiums consistently growing faster than inflation? Why are health care stocks and funds considered one of the best investments right now just as people are worried about affording health care? Why is health care reform making special interests happy while many doctors and patients are increasingly unhappy?

Must doctors accept the pervasiveness and intrusiveness of the inside game in health care? If they didn't, I wonder what doctors' placards might say?

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

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And you were worried about the NPs.

This morning at MGMA, I heard a health care technology expert from Intel speak, and aside from the revelation that Intel's been working on smartphones since before the rest of us knew what they were and still hasn't come up with anything, his most interesting point was on his vision of the future health care team.

He made the usual scary statements about the shortage of physicians and the growing elderly population, but unlike yesterday's speakers, he didn't see midlevels as the solution, since there might not be enough of them either. He suggested that regular people, with the assistance of technology, will have to take on the extra workload. Those care coordination teams that everyone's so fired up about should include not just clinicians, but patients, their families, and their neighbors. Yes, he said neighbors. (Which is a little worrying, given that I've recently learned that no Gen Xer ever bothers to meet her neighbors. And you probably thought I had finally written a whole blog post without bringing the generation gap up.) This idea of self-care came up in the hospital of the future article that I wrote recently, too, so I'm starting to see a theme here.

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Is meaningful use the right incentive to get physicians to use EMRs?

Before I took over one of the classes that now teach at the medical school, I asked students why the value of that class was so low. One of the reasons they gave was that it was so hard to do well in the class, and there were so many other things to study, students only put in enough effort to pass. In other words, incentives are only good if they are both valued and attainable.

As this related to electronic medical records (EMRs), achieving meaningful use is not easy. The technology for clinical decision support (a requirement) is not quite ready for prime time. Nor is there an easy way to share parts of the EMR with patients. In a study of almost 600 docs who had been using EMRs, most were confident that they would qualify for meaningful use and get bonuses for doing so. However, the survey also found that the majority of these physicians would not meet some of the criteria. Thus, though the financial incentive seems nice, the path to getting these incentives may be so unattainable that physicians won't waste the effort or expense.

More importantly, some of the "stuff" that's meaningful in meaningful use may not have value for physicians. Policy makers that developed these criteria were understandably thinking on a population level (lowering blood sugar in a population of diabetics). However, physicians are used to dealing with patients one on one.

A recent survey of EMR using physicians was done over at Software Advice regarding the advantages of using EMRs. Granted 50 respondents may not accurately generalize to most physicians; however, some of the results are telling. What do doctors like about EMRs? Greater accessibility of charts, easier to read notes, more accurate patient information, and improved coordination of care by having the ability to share data. As a user of EMRs for well over a decade, I would concur with these findings. EMRs are far from perfect, but based on these advantages, I could never go back to paper. What "benefits" of EMRs did doctors not see as readily? Improving preventative care, opportunity to participate in pay for performance, improving clinical decision making, and reducing errors/improving patient safety.

Thus, under the current plan to increase EMR use by physicians, the financial incentives may be too hard to achieve and the purported benefits may not be easily perceived. This combination does not bode well for the adoption of EMRs by most physicians. Instead, policy makers might want to consider a different approach. First, rather than create a financial carrot that will be too difficult to achieve for most, use that money to reduce barriers to adopting EMRs in the first place. Second, instead of focusing on the benefits important to policy makers, focus on benefits that are important to physicians, such as making our work easier and more productive. This is important because EMR vendors design their products on what they believe will meet their customer's needs. The first EMR platforms focused on improvements in billing and coding to capture more revenue. Now, vendors are focused on helping physicians achieve meaningful use. If vendors focused on making a physicians work easier and more productive (and policy maker made it easier to adopt these tools), EMR adoption would be much greater than it is now.

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.

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QD: News Every Day--Physicians need more training when adopting EHRs

Physicians need at least three to five days of training on new electronic health record (EHR) systems to achieve the highest level of overall satisfaction, but nearly half of new users get three or fewer days of training, according to a survey.

AmericanEHR Partners surveyed physicians' experiences with EHRs to achieve some meaningful use requirements. (The group is a web-based resource for EHR system selection/implementation developed by the American College of Physicians and Cientis Technologies).

AmericanEHR Partners used a 139-question online survey to collect data form physicians, nurse practitioners and physician assistants about their use and satisfaction with EHRs and health information technology. Survey data from more than 2,300 physicians in conjunction with five different professional societies was collected from April 2010 to July 2011. Results appeared at the group's website.

There were 4,280 responses, an average response rate of 8.5%, though rates differed across professional societies. Of those who responded to the survey, 2,384 (54%) had an EHR system and completed the entire survey, and 69% of the surveys were received from physicians in practices of 10 or fewer clinicians.

Other key findings from the report include:
--Overall satisfaction with an EHR highly correlated with whether the respondent was involved in choosing the system.
--Ratings on ease of use for basic EHR functions required for meaningful use continued to improve with more than two weeks of training.
--Training of at least one week correlated with improvement in the reported usability of advanced EHR features such as checking patient formularies, importing medication lists and medication reconciliation.

The authors, which include staff from the American College of Physicians, wrote, "We were surprised to find that almost 50% of respondents received three or fewer days of training given the complexity of current EHR systems and the pressure to achieve [meaningful use]. The percentage of respondents reporting this low level of training was highest for individuals in practices of 11+ clinicians. It is possible that larger practices deploy other methods of ensuring clinicians receive appropriate EHR guidance, such as placement of coaches alongside clinicians after implementation in lieu of additional pre-implementation training."

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Monday, October 24, 2011

Make that three.

Moderators at the primary care "hot topics" forum let the audience select the topics of discussion. And what did they go off on first? Yup, again, it was the work ethic of my generation. "How do you get their productivity up to the same level as older doctors?" and "Where is this mindset of the younger generation coming from?" attendees asked. One offered a solution to these crazy young docs who want to leave work at 5: "Choose a different profession!" Um, folks, I get that you're frustrated, but that's not gonna help with the primary care shortage.

The group did discuss solutions to the shortage, and there seemed to be a general consensus that midlevels are the most promising one, although some attendees have found that older patients (there's that generation gap again) were reluctant to see NPs instead of MDs.

Naturally, since these are the money folks, the conversation eventually moved along to how to make money off primary care. Ancillaries, the managers said-- DEXA scans, skin clinics and physical therapy.

And the money shortage is likely only to get worse, since the consensus in the group was that some kind of Medicare cut is coming, although a show of hands and some discussion indicated that managers expect a reduction under 15% rather than the 20+% that's currently set to take effect.

Then we all went to the Strip to drink away our sorrows. (And for those tracking the Gen X work ethic, that was after 5 pm!)

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Why're they always picking on us?

I've heard two lectures so far this conference and both of them picked on my generation's work ethic. In a session that was mostly about compensation plans (more on that later sometime probably), consultant Jeffrey Milburn cracked this one: "The older physicians live to work. Others work to live. The younger ones say, 'What, me work?'"

But he made up for it by teasing internists as a whole, in his explanation on how to determine the appropriate payment for call coverage. Give a bunch of internists a piece of paper and then ask, "How much for you to take an extra night of call?" They'll come up with big numbers, he said. Then ask, "How much would you pay somebody to take a night of your call?" The average of those two numbers might give you the market rate.

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Patients have generations, too.

Surely you've read before (perhaps even in our publication) about the challenges of Boomers and younger generations working together. You know the drill-- these young'uns are good with computers but they're all hung up on this idea that they should get to have a life. But Cam Marston, the opening speaker at MGMA put a new spin on the concept-- addressing how generational differences can affect the way that you attract, and treat, patients.

A lot of it is pretty obvious. Millennials (those born between 1980 and 2000) like getting information by text, Boomers not so much. Younger patients do a lot more of their own internet research.

But some of the advice on how to act on these generations' well-known differences was useful. To get the attention of those self-absorbed Generation X and Millennial patients (yes, it is sometimes an embarrassment to be part of this group), talk to them about how things will affect them individually in the future. And offer information, but share decisionmaking with them-- unlike their parents, they're not going to accept pronouncements from on high (I totally plead guilty to that one).

The good news is that if they like you, they'll update their Facebook status and all of their friends will become your patients too. "Their word of mouth referrals to each other are golden," Marston said. "They're more likely to trust a friend's Facebook post on a stock buy than an investment expert."

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What's right with these pictures?

I'm covering the Medical Group Management Association's annual meeting for the next couple days, and the fun started even before the meeting did. Can you guess where it's being held from these shots of the exhibit hall? Who wants to join me in the "Bring Internal Medicine 2016 to Vegas" movement?












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Stay away from chiropractic neck manipulation

From time to time I answer questions from reporters about alternative medicine. In general, the coverage given my comments has been accurate and fair. One such accurate a fair representation of my words appeared recently in Readers Digest: "Over the years, a number of my patients have had strokes after chiropractic neck manipulation. It can cause something called vertebral artery dissection, where the main artery leading to the back of the brain actually splits. Now I tell patients, if you want to see a chiropractor, fine, but never let him touch your neck."

Shortly after this was published, I began to receive phone calls and letters from chiropractors around the country. They were not happy. Here's a typical example: "Dear [Dr Pal],

"Really! You really felt the need to outright lie in a national publication. 'Over the years, a number of my patients have had strokes after chiropractic neck manipulation.' A number of your patient's [sic], you lie. I am willing to bet you have never had a case of stroke caused by chiropractic among your patients. This issue of stroke and chiropractic has been studied and studied. It's been proven that the odds of a stroke after a chiropractic adjustment are infinitesimally small yet you lied.

"I was going to quote the studies conducted by the Canadian government and NIH and give you statistics from my malpractice carrier, the largest insurer of chiropractors in the United States to prove you wrong, but you already know you lied. I don't have to prove it to you.

"Watch next month's issue of
Reader's Digest to the publication having to correct its outrageous error in printing your lie.

"I don't know what your motivation was and I really don't care. I just wanted you to know that 'we' as a profession know you lied and the majority of the public who have benefitted [sic] from safe chiropractic care know your profession has a history of failure and safety that will always surpass my profession by a high margin."


Unfortunately, most of the mail has been about this quality, with statements such as "you lie" and "I would give you safety statistics but I don't want to."

I am sure there are better defenders of chiropractic neck manipulation out there, but so far I haven't heard from them. The letter basically consists of multiple accusations of lying. Of course, he has no way to know if I'm lying or not, and if he knows anything about confidentiality, he knows that it would be unwise for me to give him specific numbers of patients. I can tell you that the number isn't large, but is certainly greater than one. I certainly cannot show him charts to prove anything.

And of course, correlation does not prove causation. It may be that these patients, who had vertebral artery dissections shortly after chiropractic neck manipulation represent coincidences. Plausibility and the medical literature suggest causation however.

He apparently also has an ax to grind with real doctors about our "history of failure and safety." That's an old saw from altmed folks that I've addressed many, many times, and I'll leave it to the archives for now.

The evidence in the literature is quite clear. Vertebral artery dissection (VAD), a type of stroke, is associated with chiropractic neck manipulation. It is not a common outcome, perhaps 1.5/100,000 manipulations, but it happens. What's left is a somewhat subjective decision regarding the risks vs. benefits of the procedure.

VAD is an uncommon type of stroke that affects the back of the brain. Rather than go into the details, I think we can all agree that strokes are a bad outcome, and that if a procedure carries that risk, it better have a lot of benefit. For example, coronary artery bypass surgery carries a definite risk of stroke, but the benefits are strong: bypass helps people with heart disease live better and longer, and in many cases saves lives. The risk of stroke is often less than the risk of not having surgery.

The best literature has failed to show a significant benefit of chiropractic neck manipulation vs. more conservative therapy for the treatment of neck pain.

What we have here is an intervention that carries a small but real risk of a catastrophic complication, whose benefits are unclear at best. While I don't recommend chiropractic treatment to my patients, for those who use it I give them this information. I succinctly tell them that they should not let a chiropractor manipulate their neck. It's just not worth it. I do the same for "mainstream" medical therapies whose risk benefit ratios are not favorable. It's just good medicine.

References

Reuter, U., Hamling, M., Kavuk, I., Einhaupl, K., Schielke, E. (2006). Vertebral artery dissections after chiropractic neck manipulation in Germany over three years. Journal of Neurology, 253 (6), 724-730 DOI: 10.1007/s00415-006-0099-x

Norris JW, Beletsky V, & Nadareishvili ZG (2000). Sudden neck movement and cervical artery dissection. The Canadian Stroke Consortium. Canadian Medical Association Journal, 163 (1), 38-40 PMID: 10920729

Rothwell DM, Bondy SJ, & Williams JI (2001). Chiropractic manipulation and stroke: a population-based case-control study. Stroke, a journal of cerebral circulation, 32 (5), 1054-60 PMID: 11340209

Ernst, E. (2003). Chiropractic spinal manipulation for neck pain: a systematic review. The Journal of Pain, 4 (8), 417-421 DOI: 10.1067/S1526-5900(03)00735-1

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog, White Coat Underground. The blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.

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QD: News Every Day--Patients benefit knowing death is imminent

Providing information of imminent death to cancer patients does not increase pain or anxiety, but is associated with improved care and to increase the likelihood of fulfilling the principles of a good death, a Swedish study found.

Informed patients significantly more often had parenteral drugs prescribed as needed, died in his or her preferred place, and had an informed family who were offered bereavement support. There was no difference between informed and uninformed patients in control of pain, anxiety, nausea, and respiratory tract secretions, although there was a difference in management of confusion. Results appeared at the Journal of Clinical Oncology.

Since 2000, there has been an increasing focus on palliative care in Sweden, the study authors wrote. In 2001, the Swedish Government identified breakpoints for transitioning to palliative care at the end of life and starting communications when that breakpoint was reached. Adoption increased in the ensuing years, and a national quality register was established, the Swedish Register for Palliative Care, in 2005.

Data about the care delivered during the last week of life were collected from a Web-based questionnaire completed by the physician and/or nurse responsible for the patient's care during the last week of life, The questionnaire is based on the 11 principles constituting good death as defined by the British Geriatrics Society, with eight of 25 overall questions covering topics such as autonomy, information about imminent death, symptom control, parenteral prescriptions as needed, and preferred location at time of death.

This study included all cancer deaths between 2006 and 2008 for which the patient did not lose his or her decision-making capacities until hours or days before death (n=13,818, 20% of all cancer deaths in Sweden during the study period). The majority of the patients (91% (n=12,609) had been given information about imminent death; 9% (n=1,209) had not.

A matching procedure created a comparison of 1,191 informed and 1,191 uniformed patients. Symptoms of pain, anxiety, confusion, nausea, dyspnea, and respiratory tract secretions were reported as being relieved in 80% to 96% of the patients during the last week of life in both groups. There were no significant differences between the informed and uninformed groups except for the symptom of confusion. Confusion was reported as not completely relieved in 60 patients (5%) in the informed group and in 87 patients (7%) in the uninformed group.

Significantly more patients in the informed group (70%) than in the uninformed group (39%) died at their preferred location. Staff knowledge of the preferred place of death was significantly higher among the informed patients than among the uninformed patients (25% who did not know among informed, compared to 55% among uninformed patients). If a patient had been informed of possible imminent death, family members were significantly more likely to have been offered bereavement support (83% vs. 78%), the authors found.

The authors concluded, "To give information about imminent death is a conscious act that involves awareness of the fact that the patient is dying, an awareness that also implies preparedness of the [health care provider]. Such preparedness should increase the probability of a more proactive approach with respect to prescribing palliative drugs and addressing patient and family wishes and needs during the last days of life (i.e., a concept of total care)."

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Friday, October 21, 2011

There's always something new to learn

There they were, little maroon flags outside three patient exam room doors. You could almost hear the game show host ask the question:

Will it be Door #1, Door #2, or Door #3?"

So I asked the medical assistant, "Who's next?" and she pointed me to Door #2.

It was a new patient with a familiar problem, one I've seen probably a thousand times before. Another day, another case. Bada bing, bada boom. Nothing to it. You would think that all cases, and all people are the same in some ways. Certainly, those managing our health care system of the future would like us to believe it's so simple: just another case of heart failure (what can go wrong?) or supraventricular tachycardia (love that one, there's NOTHING hard about that!) or maybe a few PVCs (Check). Another day, another dollar.

I suppose it would be easy to classify patients that way, after all, I'm now just a "proceduralist for the heart electrical system" in the eyes of many these days. But there is something that I always find myself looking for with each new patient I see: The Question.

The Question is the query that irreversibly connects you with the patient. It's not the details of the history of present illness or the past medical or surgical history, rather, it's The Question that makes the patient look at you in a slightly different way. It's The Question that makes them realize you're human. It's The Question that lets them know you're interested. It's The Question that is outside the rubric of medical history taking. It's The Question that keeps you coming back for more, day in and day out.

The cool thing about The Question is it's usually different for every patient. In fact, it is invariably unique to a given patient. The challenge for every doctor is finding it. And the weird thing is, you might not know you found it at first. But when someone asks you about the patient, it's invariably The Question and its answer that you recall alongside their health issue. It might be a simple, "What kind of work do (did) you do?" or "What's your son doing now?" or even "Nice shirt. Where did you get that?" Nothing complicated, mind you. You hear about the job, the kids, the passions: people being people, not just an algorithm.

And the best part?

There's always (and I mean always) something new to learn.

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

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NEJM review on breast cancer screening gets to the nitty-gritty of false positives

With little fanfare, the New England Journal of Medicine published a feature on breast cancer screening in its Sept. 15 issue. The article, like other vignettes in the NEJM, opens with a clinical scenario. This time, it's a 42-year-old woman who is considering first-time mammography.

The author, Ellen Warner, MD, an oncologist at the University of Toronto, takes opportunity to review updated evidence and recommendations for screening women at average risk for the disease. She outlines the problem: "Worldwide, breast cancer is now the most common cancer diagnosed in women and is the leading cause of deaths from cancer among women, with approximately 1.3 million new cases and an estimated 458,000 deaths reported in 2008.(1)

On screening: "The decision to screen either a particular population or a specific patient for a disease involves weighing benefits against costs. In the case of breast-cancer screening, the most important benefits are a reduction in the risk of death and the number of life-years gained ..."

She breaks down the data for mammography by age groups: "For women between the ages of 50 to 69 the evidence is clear, she says. For those over 70, there are little data to support breast cancer screening. There's a consensus that screening isn't appropriate for women with serious coexisting illnesses and a life expectancy of less than 5-10 years."

For those between the ages of 40-49, Warner challenges the revised 2009 USPSTF recommendations on several counts. She critiques those authors' weighting of data from the Age trial of 161,000 women, emphasizing the use of an antiquated (single view) mammography technique and flawed statistics. She considers: "... However, this change in remains highly controversial,22, 23 especially because of the greater number of years of life expectancy gained from preventing death from breast cancer in younger women. According to statistical modeling,19 screening initiated at the age of 40 years rather than 50 years would avert one additional death from breast cancer per 1000 women screened, resulting in 33 life-years gained."

What I like about Warner's analysis, besides its extreme attention to details in the data, is that she's not afraid to, at least implicitly, assign value to a procedure that impacts a young person's life expectancy relative to that of an older person.

She goes on to consider digital mammography and the Digital Imaging Screening Trial (DMIST [NCT00008346]) results. For women under 50 years, digital mammography was significantly more sensitive than film (78% vs. 51%).

The article is long and detailed; I recommend the full read including some helpful tables, with references to the major studies, and charts.

In concluding, the author, who admits receiving grant support from Amersham Health (a GE subsidiary), consulting fees from Bayer and lecture fees from AstraZeneca, returns to the hypothetical patient, and what might be said to a woman in her 40s who lacks an outstanding risk (such as a genetic disposition or strong family history): "... Mammography screening every 2 years will find two out of every three cancers in women her age, reduce her risk of death from breast cancer by 15%. There's about a 40% chance that further imaging (such as a sonogram) will be recommended, and a 3% chance for biopsy with a benign finding ..."

In my opinion, this is key, that the chances of a false positive leading to biopsy are only 3% for a woman in her 40s. If those biopsies are done in the radiology suite with a core needle, every 2 years for women of average risk, the costs of false positives can be minimized.

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

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Blog log

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Other blogs of note:

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

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

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

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

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

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