Wednesday, November 30, 2011
Do you need to ask your doctor 10 questions?
The blog Shots posted a question primer to prepare patients for medical office visits with their doctors. A reaction to this appeared on Glass Hospital, where John Schumann, MD, FACP, offered his own wry version of the question list. My less wry, and drier response appears below.
While I agree with Shots that education is power, a closer look at the question list demonstrates that the intent to educate may obfuscate instead.
First, the post is entitled, "Ten Questions to Ask Your Doctor," suggesting that patients arrive at their physician's office armed with 10 inquiries spanning a spectrum of medical knowledge and philosophy including medical treatment strategy, physician qualifications, risks of treatment, medical treatment alternatives, choice of hospitals and even how to spell the names of their medications. (I guess Shots believes that spelling counts!)
Some of the questions sound reasonable, but could patients make sense out of the answers? For example, Shots suggests asking, "Which hospital is best for my needs?" Patients often are focused on the choice of hospital, when they should be more interested in which physicians will be caring for them. While the hospital matters, it's much more important who will be performing your surgery, then where it will take place. Are patients equipped to evaluate hospital quality anyway? Is a good reputation or a shiny exterior a true surrogate for medical quality? Patients often have a negative view of a hospital based on an isolated anecdote, which they may not have even experienced first-hand.
Another suggested question is, "How many times have you done this procedure?" Will this provide useful information for patients? I agree that for many medical procedures, a higher case volume means a lower risk of complications. But, will it enlighten a patient to know that the gastroenterologist has performed 2,000 colonoscopies or 5,000 or 10,000? Better questions, which can't be quantitatively answered, would be, "How many times have you done this procedure well, or, how many of your procedures were truly medically necessary?" I object to Shots' version of the "how many" question which simplistically reduces medically quality measurement to a check-off form, paying homage to the deities who gave life to the pay-for-performance beast. What really counts can't be counted. Paradoxically, what can be counted, will count.
In addition, if you bring your doctor the 10-question list, be prepared for some frustration when your office visit ends and you've only covered the first three items on the list. There may not be time left for you to discuss the issue that brought you to see your doctor in the first place. It may take a few visits and a fair amount of dialogue for you to understand your physician's philosophy and style of medical practice. This important information can't be acquired by taking a multiple choice test or answering a series of questions.
The question list on the blog Shots is a guide that needs to be prioritized. You simply can't cover them all in a single visit, and you shouldn't have to. Experienced physicians know that patients often want to cover every last medical concern and we will often begin a visit with a question from our own top ten list--"What are the one or two issues that we need to cover today?"
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.
Annual chest X-rays not useful for lung cancer screening
It's been a disappointing month for proponents of screening.
You remember what screening is? Screening is testing someone for a disease who does not have any signs or symptoms of that disease. In general it means testing a wide population for a specific disease. So if I have a chronic bloody cough and unintentional weight loss, my doctor isn't screening me for lung cancer. He's doing tests to diagnose or rule out lung cancer because I have suggestive symptoms for that disease. Got it?
Lung cancer has long been the number one cancer killer in the U.S. So a screening test that would help save lives from lung cancer is much in demand. In the 1970s studies tested screening for lung cancer with annual chest X-rays. The trials did not find any benefit.
Apparently those 1970s studies had some procedural flaws that made them unconvincing. And X-ray technology has improved in the last 30 years. So it was conceivable that chest X-rays got a bum rap and were actually a valuable screening tool. This prompted the National Cancer Institute to retest chest X-ray screening as part of its Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO), which is a large clinical trial testing various cancer screening tests.
The results of the lung cancer portion of this trial were published in the Journal of the American Medical Association. Over 154,000 people were randomized to either receiving annual chest X-rays or to usual care by their physicians. There was no difference between the two groups in deaths from lung cancer.
So that settles a question I thought was already settled. Healthy people don't benefit from periodic screening chest X-rays.
This finding comes on the heels of other negative news about screening. The ovarian cancer branch of PLCO has also demonstrated that the blood test CA125 is not valuable for ovarian cancer screening. And just two weeks ago the U.S. Preventive Healthcare Task Force's recommended against PSA screening for prostate cancer.
For lung cancer, there is some hope, however. A study in July showed that in a selected population of high-risk smokers screening with spiral CT scans saved lives.
Avoiding unproven tests isn't just a matter of avoiding expense. Unproven tests (or tests proven not to help) cause more harm than good by leading to other invasive unnecessary tests. The informed patient doesn't want to be screened for everything. He wants only what has been proven to help.
Looking For Lung Cancer with A Yearly X-Ray Doesn't Reduce Deaths (Shots, NPR's Health Blog)
X-Rays No Help against Lung Cancer (Wall Street Journal)
Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (National Cancer Institute clinical trial page)
Screening by Chest Radiograph and Lung Cancer Mortality (Journal of the American Medical Association)
Spiral CT Scans Save Lives from Lung Cancer (my post about lung cancer screening with CTs)
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.
QD: News Every Day--Elderly want longevity over quality, but it's tough to predict
Don't assume elderly heart failure patients are assumed to prefer improved quality of life over longevity, study authors noted. The majority of them prefer longevity over quality of life, half expressed a desire for resuscitation if needed, and it was difficult to predict individual preferences.
Researchers looked at patients' willingness to trade survival time for quality-of-life and the preferences for among 622 heart failure patients aged 60 or older participating in the Trial of Intensified vs. Standard Medical Therapy in Elderly Patients with Congestive Heart Failure.
End-of-life preferences were assessed by using a time trade-off tool and one question concerning CPR preference. To assess time trade-off, patients were asked whether they preferred living 2 years in their current state of health or living 1 year in excellent health. If 1 year in excellent health was chosen, the patients were asked whether they would prefer 2 years in their current state of health or 6 months in perfect health. If 2 years in the current state were chosen, then they were asked whether they would prefer 2 years in their current state of health or 18 months in perfect health. The series continued until the choices were the same. This time point subtracted from 24 months derived the number of months of survival time that the patient would be willing to trade.
End-of-life preferences were assessed at baseline, and at 12 and 18 months. In addition, CPR order during last hospitalization was assessed in patients who were included presently after discharge. Patients were divided into four groups: not willing to trade any survival time, willing to trade less than 6 months, 6 to 12 months, and 12 months. Results appeared in the European Heart Journal.
In multivariable analysis, willingness to trade survival time increased with age, female sex, a reduced Duke Activity Status Index, Geriatric Depression Score, and history of gout, exercise intolerance, constipation and edema. But, the authors noted, even combining these variables did not result in reliable prediction. Of 603 (97%) patients who had a resuscitation preference, 51% wanted resuscitation, 39% did not, and 10% were undecided, with little change over time. Resuscitation orders were known in 430 patients, but they differed from patients' preferences 32% of the time.
At baseline, 74% of the patients were not willing to trade any survival time for excellent health. Of the remaining patients, approximately equal groups were willing to trade up to 6 months, 6 months to 1 year, or more than 1 year. Patients aged 75 years and older were slightly more likely to be willing to trade any survival time, the proportion of those not willing to trade would still be 72% (at month 18, 75%).
Patients indicating any willingness to trade survival time for symptom-free living differed in many ways from those unwilling to trade, the authors wrote. They were older, more often female, lived more often on their own and/or were not married, had more signs and symptoms of congestive heart failure and poorer quality of life.
The authors wrote, "Openness and communication about prognosis, trajectories, and realistic treatment possibilities engender hope and allow patients to plan for their future. This applies to various decisions that confront (congestive heart failure) CHF patients, but may be particularly important with respect to (implantable cardioverter-defibrillator) ICD implantation, turning off the device, and treatment with purely symptomatic medical therapy that may even reduce survival."
An editorial commented that patients must receive accurate information about life expectancy in order to make better choice about their end-of-life. This requires open and repeated conversations in a patient-centered environment.
"In patients whose prognosis is grim, the real question we should be asking is 'Given limited quantity of life, how can we maximize quality?'" the editorial stated. "As the end of life nears, the goals of care should also change, and the alleviation of adverse symptoms becomes the most important objective."
Tuesday, November 29, 2011
HIPAA inhibits medical education through case studies
It was an interesting tweet that referenced a soon-to-be-published case report from the Annals of Emergency Medicine (via @EmergencyDocs) that piqued my interest: "Thrilling case study: emergency doc cracked chest to save 42 y/o woman in cardiac tamponade after ablation therapy. http://bit.ly/umnydc"
Details about the case are quite specific and the case report heralds from a town in Minnesota. It describes, in very specific detail, the management of a patient who presented to the emergency room in shock from cardiac tamponade after a catheter ablation procedure for right ventricular outflow tract tachycardia.
Is this unique case report HIPAA compliant?
I would say, according to our current definition of HIPAA's "personal health information," such a case report is not HIPAA compliant. Nor could such a case be mentioned on a blog, for that matter, even though it presents important information for people dealing with these patients.
There is an important quality-of-care role in telling these clinical stories. In fact, HIPAA states there are just "18 little rules" that doctors are supposed to follow when they report important clinical cases. But details about cases may need to be very specific. Specific case reports can bring important specific clinical details to the attention of the medical community. For instance, if doctors had not been willing to describe several cases of pulmonary vein stenosis or two cases of esophageal perforation in a major medical journal years ago, how many more people might have been injured as a result?
But there's problem giving such details about clinical details about patient cases: "the small cell problem": "Clinicians should be sensitive to the 'small cell problem': the existence of individuals with such unique or unusual diagnoses or illnesses, that it might be possible for others (or patients and families themselves) to identify the individuals in case reports or medical text books based upon limited information, such as state or city of residence, age and diagnosis."
The "small cell" problem violates HIPAA and HIPAA means business: millions of dollars of business that gets released in press releases from the Department of Health and Human Services when they catch their prey.
But doctors should not be afraid of publishing case reports especially since there are good reasons for them clinically. Further, when doctors make good faith efforts to conceal patient's personal information in those reports, they should not be subject to threats of HIPAA's "small cell" problem. Simply put: the "small cell" problem is HIPAA's, not the doctors'. Extending the definition of personal health information as defined by HIPAA to include "any other unique identifying characteristic" about a patient's case limits doctors' ability to improve care to our patients while greatly increasing our legal culpability for that effort.
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.
A pox on your house? How fighting one disease brought back another
[Editor's note: This post was originally published November 5, 2009.]
Some were surprised to read that after a pro basketball player swatted a bat out of the air, he had to have rabies vaccinations.
This is not a surprise to many medical folks who have had to give rabies prophylaxis after bat exposures. Most of the few human rabies cases in the U.S. are transmitted by bats, although raccoons are more often diagnosed with the disease.
Because rabies is fairly easy to transmit and nearly always fatal to humans, we are very aggressive about prevention. Rabid wild animals can have unusually aggressive behavior and can transmit rabies to humans and to their pets. With human populations mixing more and more freely with wild animal populations, the risk of rabies exposures increases. We're obviously not about to hold down every wild raccoon and vaccinate them, but humans, being rather clever animals, have found a way to vaccinate animals in high-risk areas.
One program aims to create a "vaccine barrier" in the Appalachians by dropping oral rabies vaccines into these areas either by plane or by hand. The program is aimed primarily at raccoons but other animals are affected as well. The vaccine itself is fiendishly clever, but, as the CDC reports, is not without some unintended results.
The vaccine was created by taking a glycoprotein antigen from the rabies virus and inserting it into Vaccinia virus, the same one used for smallpox inoculation. Further explanation requires a historical digression.
Smallpox killed and disfigured millions of people around the world until its eradication in 1979 through a massive vaccination program. It is unclear when parts of Asia and Asia Minor began using immunotherapy to prevent smallpox deaths, but in the early 18th century, Lady Mary Worthley Montagu, an English aristocrat stationed in Istanbul, made note of the practice and brought it back to England.
In these pre-vaccination days, smallpox pustules would be lanced, and their contents inserted into the skin of healthy people, producing a (hopefully) minor, localized infection which would then protect people from severe smallpox infection. Smallpox inoculation saved many lives but was not without risk. Later in the century, Edward Jenner developed the practice that ultimately replaced it: vaccination. This practice was based on the observation that milkmaids previously infected with cowpox ("vaccinia"), a usually-minor infection in humans, were relatively safe from smallpox. Two hundred years later, smallpox was gone.
Vaccinia is not one of the safer vaccines. In people with defective immune systems, the normally mild infection can be severe, so eradicating smallpox not only saved people from smallpox but from needing the vaccine (it is still used in specialized settings such as the military). But vaccinia has not outlived its usefulness.
How do you vaccinate millions of wild animals? Most vaccines must be injected, but there are exceptions, such as the human oral polio vaccine. In this case, a little genetic engineering convinced vaccinia to produce an important rabies antigen. When eaten, the virus in taken up in the lymphatic tissue in the throat, and immunity to rabies develops. The vaccinia infection caused by the vaccine is usually mild and transient.
So in areas where it's needed, little ketchup package-shaped vaccines are dropped from planes or spread by hand. They are wrapped in tasty fishmeal, and animals readily bite into them. But raccoons aren't the only curious animals out there. Dogs are pretty curious, too. Because this vaccine contains a live virus, the CDC maintains a surveillance system to watch for human infections. They found one.
A woman in Pennsylvania was out picking berries when her dog brought her a vaccine packet it had found. Some of the vaccine material dripped on to her hands which had been abraded by the berry brambles. She was perfectly inoculated by the special vaccinia virus. In most people, this would only be of passing interest, but the woman suffers from inflammatory bowel disease and takes powerful drugs to suppress her immune system. Within four days of exposure, she had pox on her hand.
She sought help even before she developed the rash so doctors were able to track her disease carefully. Unlike normal patients, she did not develop antibodies to fight her infection, and it started to spread. Her immunosuppressive medications were stopped, and she was treated with specific immunoglobulin treatments and recovered without lasting ill effects.
This case of human vaccinia infection is notable for it's rarity. Only one other person has ever developed an infection from the vaccine. The rabies problem is real, and this is a fascinating solution, but as the CDC points out, education needs to improve in areas where the vaccine is used.
This one case walks us from Lady Worthley Montagu's 18th century observations, to Jenner's discovery, the eradication of smallpox, and the co-opting of the same organism via recombinant DNA techniques to help fight an entirely different disease. Science doesn't get any more interesting than this.
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.
The doctor and the orthodontist
I took my daughter to the orthodontist last week to get braces. (She chose purple.)
There's a lot about the process that seems better than when I was a kid. Mostly, it's that instead of having to slide brackets around each of your teeth (yishk!) the orthodontist just paints a special glue on the enamel and places the brace on the front of each tooth. Kids get to pick the color of their braces now, introducing some degree of choice (and therefore control) into what amounts to a victimization of one's oral cavity.
What really stunned me, though, was the way that her orthodontist organized his practice.
I've written before about the concept of patient-centered medical homes," [PCMH] a high-minded concept in which patients see a doctor or her associates whenever necessary, and all information is seamlessly inside a electronic medical record so any and all providers are able to deliver timely, safe, effective, high-quality care.
It's an idea that is central to health care reform, and seen as a way in which we can contain costs. [Of course one of the big problems with this concept is that patients often don't understand the name. Survey data shows that there are loads of misconceptions about what a PCMH actually is. Here is one funny look at this phenomenon.]
My daughter's orthodontist is part of a three-person practice. But for each orthodontist, there are three hygienist/techs and at least one office staff member handling billing, care coordination, and administrative issues like computers.
This sounds pretty personnel-heavy, but let me assure you there was constant motion and therefore constant productivity.
In the hour that it took for my daughter to have her braces applied, there were four different patients seen in the chair next to her, by three different techs and two of the orthodontists.
The examining suite was arranged with eight chairs in a semicircle, and each chair had a computer screen next to it so that the patient's parents could see their kids' X-rays, projections of what their jaws/teeth would look like during and after treatment, and get educational material. Of course, the techs and orthodontists used the system for entering patient data as well.
In the center of the circle, tech/hygienists were troubleshooting, preparing trays for subsequent patients, discussing aspects of care, etc.
The orthodontists (two present while I was there) literally sat on office chairs and swiveled from patient to patient, washing up copiously between each encounter, and leaving plenty of time to communicate with parents, and work phone calls in between patients.
It was a tour de force.
I was overwhelmed by the efficiency of it all, the professional nature of the encounter(s), and my daughter entering a rite of passage (and how brave she was!) in no particular order.
How much does it cost?
Well, like health insurance, our employee-benefit dental insurance defrayed a significant portion of the upfront cost. What our insurance didn't cover, we could have financed. We chose to pay the remainder in a lump sum so as not to incur interest on the debt.
But like a capitation model, we've paid for the treatment. Under the contract we've signed, our daughter can visit the orthodontist 12 times, 24 times or more, however many it takes to get her teeth straight. I'm certain that at a practice like this one they know their business well enough that even with some unexpected hiccups, they will make money on most patients in the long run.
And I'm OK with that. They are providing real value for our money. It goes beyond the "product." It encompasses the feeling that I got by participating in my daughter's care and seeing how the operation worked. Literally.
Our experience there made me wonder why medicine can't be practiced this way.
Medicine is too complicated. Our costs are too variable. Our practice flows are less predictable. We're not just focusing on one part of the body.
But what's to stop us from, say, asking our patients with diabetes to come to group visits? They could be seen en masse for education and testing, and see the doctor for quick individual consultations about medication adjustment or the need for further consultation. All the providers (physicians, nurses, medical assistants, physician assistants, nurse practitioners, dietitians, etc.) could be practicing at the top of our licenses.
At the orthodontist's office, the hygienists and techs all were involved in lab work, preparation, and direct patient care. No one's talents were going to waste by locking into one repetitive job description. I spoke with one hygienist, and she told me that she enjoyed the different roles in her job. And she felt empowered to make change or to let the orthodontists know if something wasn't working well. All in all, it seemed a pleasant work place with a real team atmosphere.
I guess seeing it firsthand makes me realize that achieving a medical home model can be done in primary care. We just need our medical homes to be more like our orthodontic homes.
Just ask my daughter. Luckily for her, with modern methods, there's no need for headgear anymore. (I never smiled when I had to wear this trap.)
This post by John H. Schumann, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.
QD: News Every Day--Scientists probe restrooms to quantify their ickiness
Public restrooms are disgusting. You knew this. You didn't need science to tell you this. Science is telling you anyway.
To clarify exactly how gross a public restroom is, scientists wanted to learn exactly what's germinating in them and where the worst surfaces are. They sampled 10 surfaces: door handles into and out of the restroom, handles into and out of restroom stalls, faucet handles, soap dispensers, toilet seats, toilet flush handles, the floors around the toilets and floors around the sinks in six male and six female restrooms on the University of Colorado at Boulder campus were sampled on a single day in November 2010.
To determine the potential sources of bacteria on restroom surfaces and how the importance of different sources varied across the sampled locations, they used a software package, SourceTracker, which estimates the proportions of sources for each surface. Results were published at PLoS One.
Using high-throughput barcoded pyrosequencing of the 16 S rRNA gene, they found 19 total bacteria, most belonging to Actinobacteria, Bacteriodetes, Firmicutes and Proteobacteria. Communities clustered into three areas: the toilets, the restroom floor, and those found on surfaces routinely touched with hands.
On toilet surfaces, gut-associated taxa were more prevalent, suggesting fecal contamination of these surfaces. Floor surfaces were the most diverse of all communities and contained several taxa commonly found in soils. Skin-associated bacteria, especially Propionibacteriaceae, dominated surfaces routinely touched with hands. Vagina-associated Lactobacillaceae were widely distributed in female restrooms, likely from urine contamination, the authors wrote.
The authors noted that college students aren't the most likely bunch to wash their hands, which is the key to avoiding germs. But, even worse than bathrooms? The TV remote control.
Monday, November 28, 2011
Keep the big picture in focus
People should be admitted to the hospital because they are sick enough to have an increased chance of dying relative to those going home. My overall patient-by-patient "mission statement" is: Find the diagnoses and offer treatment options that decrease acute mortality and chronic morbidity through efficient and high quality care. Offer palliative care options when such treatment is medically futile or does not provide significant gains in the quantity to quality of life balance. The patient needs to be looked at as a gestalt of both data and intuition regarding the level of acute injury inflicted on the substrate of a certain level of chronically damaged protoplasm.
I have to explain to my patient and their circle that based on what I think is going on, will the treatment options available improve their lives and do those benefits outweigh the risks of that treatment. If not, pursuing aggressive treatment of the untreatable is a study in futility, and palliative care options should be introduced.
Understanding the worst case scenarios, is in my opinion, more valuable to both provider and patient than painting a rosy picture of the future. It is important to foresee negative outcomes to know what to test for and what you may need to treat, but without either you or the patient losing sight or hope of positive outcomes. Positive outcomes do not necessarily mean a cure, it may mean pain control, dignity, and even a peaceful death.
Sweat the details
A good internist is a scared internist: worried about what has happened, concerned about why the current state of their patient is different from before, wondering how complications can occur in the future. We take a microscope to abnormalities, trying to tease out if this is incidentally benign or malignant, wondering if this is evidence of disease or simply a normal perturbation.
Hospitalists must be the diagnostic laser, making light-speed decisions about what to pursue and what to defer as well as carefully convey to outpatient follow-up. We must carefully dissect subjective complaints and objective data using the scalpel of evidence-based criteria and a wealth of subspecialty guidelines.
We must thin out the electronic medical record of redundant or inaccurate diagnoses while updating it with new history. The patient's medication list is not simply the medications they are prescribed but those they are actually taking and when they are taking them. A hospitalized patient demands an agent, their hospitalist, who manages nutrition, hydration, electrolytes, medications, and ancillary therapist evaluations while requesting appropriate specialist consultation and preventing adverse events such as deep vein thrombosis, falls, and delirium. We must take a collection of prior documentation to weave a history, amalgamate in-patient events, tests, and consults as daily progress notes, and then meticulously sift all of this into a timely, complete discharge summary.
Achieving hemodynamic homeostasis
I consider "vitals" to be an acronym for Verify If They Are Living Still. In general most hemodynamically regular people are euthermic with a heart rate between 60 and 90 beats per minute, breathing 8-16 times per minute, have a systolic blood pressure greater than 100 mm Hg and less than 160 mm Hg, and saturate greater 92% on room air. If they don't they are either (1) acutely sick with a physiological response, (2) chronically sick and at their (albeit abnormal for the majority of the human population) baseline, or (3) weird.
Acutely ill humans should have a positive response to appropriate therapy, that is there vital signs approach normal, and negative one to inappropriate therapy. That being said, people die even despite the most optimal of treatment decisions, and people live despite our best unintentional attempts at killing them. You have to determine whether the population mean abnormal vital sign(s) are an indicator of acute pathology or simply evidence of chronic but stable disease.
Returning the patient to basal levels lab result rubor
People are often admitted because of the density of red (abnormal) test results they have. Although abnormals should be recognized they should also be placed within the context of their chronicity and severity.
Some patients have bloody diagnostic tests at baseline. An elevated white blood cell count can be due to chronic lymphocytic leukemia, dehydration, stress, or infection. No matter what we as physicians do, it is unlikely that no matter what we do acutely we cannot change the leukocytosis of CLL. Antibiotics do not treat dehydration or stress, but not treating a pneumonia with its associated leukocytosis is tantamount to medical crime.
Similarly a volume depleted patient may have a CBC in the black, volume contraction hiding their basal anemia, just because they are less in the red, doesn't mean they are any less sick. An elevated creatine in a patient on dialysis has an impressive crimson hue but generates little therapeutic inertia compared to the same value in someone without previous kidney disease.
No matter what intervention is undertaken, the patient with end-stage renal disease will never be in the black when it comes to creatinine, if we waited for this value to normalize before discharging the patient, they would serve a life sentence. As hospitalists we must find with the intent to treat the scarlet letter of abnormal but accept the chronic unchangeable crimson that will show up on some diagnostic tests. We can only attempt to restore our patient to the baseline they had before and hope to prevent the next decompensation as best we can.
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.
Advocate to preserve residency funding despite 'supercommittee' failure
So, you have probably heard about the supercommittee (gang of 12) and the need to brace for massive cuts to control federal spending. But, do you know that the chief target is residency training? That is right. Funding for residency largely comes from Medicare, and the general concern is that they are paying too much and not getting their money's worth.
Of course, this comes at a time when there is a shortage of residency spots given the expansion of U.S. medical schools, and a dire need for physicians, especially in primary care, to meet the needs of health care reform.
So, in this perfect storm, 40 medical groups (yes, there was that much consensus) sent a letter to the supercommittee pleading with them not to cut Graduate Medical Education funding. Now the situation is dire enough that the Association of American Medical Colleges advocacy leaders are in high gear encouraging those in graduate medical education to encourage their residents to write to their Congressman. (And yes, if you live in a supercommittee state, it's even more important for you to do this).
So if you are a resident or future resident or can sympathize with the need to have future physicians, now is the time to take action. For my fellow medical educators out there, you don't need to be left out. The American College of Physicians has a very broad (don't need to be an internist) easy-to-use advocacy website to shoot of a quick note to your Representative and Senator about the need to preserve GME funding.
Medical educators have actually started a dialogue about the role of advocacy in medical education. Specifically, the Editor of Academic Medicine has challenged us to come up with how advocacy should properly be integrated into medical training. I can think of no other way than advocating for preserving funding for the system by which we train our nation's future physicians.
Vineet Arora, MD, FACP
(AAMC e-mail encouraging residents to take action)
I encourage you to take a few minutes to visit the AAMC Legislative Action Center (http://capwiz.com/aamc/home/), select "Residents", and send an electronic letter opposing cuts in Medicare funds that support residency programs. With the zip code you enter, the letter will be sent automatically to your Senators and Representatives urging them to oppose GME cuts as part of deficit reduction. PLEASE USE YOUR PERSONAL EMAIL ADDRESS (eg, gmail.com), AND NOT YOUR INSTITUTIONAL EMAIL ADDRESS.
Congress is discussing a deficit reduction proposal that would cut funding by as much as 60%, or $60 billion, for Graduate Medical Education (GME) and jeopardize residency training programs across the country. Given the current and growing shortage of physicians, GME cuts will reduce access to health care and threaten the well-being of all Americans.
It is most important that residents enrolled in programs in Arizona, California, Washington State, Massachusetts, Ohio, Pennsylvania, Montana, Michigan, Maryland, Texas, or South Carolina, voice your concerns. You are represented by members of the "Super Committee" that will finalize the deficit reduction plan.
Thank you for your help.
Atul Grover, M.D.
Chief Advocacy Officer
Vineet Arora, MD, is a Fellow of the American College of Physicians. She is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist, supervising internal medicine residents and students caring for general medicine patients, and serves as a career advisor and mentor for several medical students and residents, and directs the NIH-sponsored Training Early Achievers for Careers in Health (TEACH) Research program, which prepares and inspires talented diverse Chicago high school students to enter medical research careers. This post originally appeared on her blog, FutureDocs.
QD: News Every Day--Too much vitamin D can trigger afib
Too much vitamin D can lead to 2.5 times the risk of atrial fibrillation, researchers found.
To determine if there is a correlation between too much vitamin D and increased heart risk, researchers examined blood tests from 132,000 patients in the Intermountain Healthcare Center database. Results were presented at the American Heart Association Scientific Sessions in November, and appeared at the Intermountain website.
Patients did not have any known history of atrial fibrillation, and all had previously received a vitamin D assessment as part of their routine care. Patients were then placed into categories to compare levels of vitamin D: low (less than 20 ng/dL), low/normal (21-40 ng/dL), normal (41-80 ng/dL), high/normal (81-100 ng/dL), and excess (more than 100 ng/dL).
Patients with low, low-normal, normal and high-normal levels of vitamin D had no increased risk of atrial fibrillation. However, atrial fibrillation risk was 2.5 times greater in patients with excess levels of vitamin D compared to those with normal levels.
The Institute of Medicine currently advises that healthy adults should be able to take as much as 4,000 IU (international units) of vitamin D daily. But the exact amount of vitamin D to achieve normal levels is unknown and usage varies in different regions and communities, which can cause problems, said the researchers.
They encouraged physicians to ask patients about all vitamins and supplements, and that checking blood levels of vitamin D in patients who develop atrial fibrillation may help uncover the cause of the abnormal heart rhythm.
Wednesday, November 23, 2011
Doctors resist changes of new cancer screening guidelines
Cancer. Just the word is scary. Actually, that's the problem. Once you say that word, the average American will do anything, ANYTHING!, to just get it out of their body. Whether or not they have it, whatever the actual numerical chances of their ever developing it, no chance for detecting or treating it should ever be neglected. EVER!
Ask any med-mal lawyer. Better, ask any 12 average people off the street (i.e., the ones who are going to wind up on a jury). "The doctor didn't do every possible test/procedure, and now the patient has CANCER? String him up!"
Hence we have the new guidelines for prostate-specific antigen (PSA) testing. (Given that many patients with prostate cancer have normal PSAs and lots of patients with high PSAs don't have prostate cancer, it doesn't seem semantically correct to call it "prostate cancer screening".) Surprise! Turns out that not only does PSA testing not save lives, but that urologists don't really care. Certainly not enough to stop recommending PSAs to just about everyone they can get their hands on.
Nor do breast surgeons have any intention of modifying their recommendations, not only in light of new understandings of the limitations of mammography, but even as their own treatment recommendations contract, becoming ever more targeted and less invasive.
I recently heard a local surgeon speak about the progression from radical mastectomies to partial mastectomies to lumpectomies; from axillary node dissections to sentinel node sampling; from whole-breast radiation to intra-cavitary seeds. Listening to him, breast cancer therapy is becoming downright minimalist. Yet at the end of the talk, when asked about the new recommendations for biennial mammography, his response was, "Every woman should have an annual mammogram starting at age 40. I mean, there are no downsides to mammography."
Never mind the psychological stress of extra views, ultrasounds, and false positives, not to mention the bruising and even skin tearing that I see far more often than I'd like. "No downsides"? Not for him, that's for sure. When will they realize that mammography catches slower-growing cancers that would be treated just as easily if they were found a year later? Women die of aggressive tumors that pop up between annual mammograms, which by definition would not be detected by standard screening.
The gynecologists are no better. They all still insist on annual visits for Pap smears to find cancers that take 10 years to grow (and then only in the presence of human papillomavirus) and pelvic exams that detect, well, nothing. Whether driven by legal concerns or patient insistence, scientifically unnecessary medical care is running rampant in this country, playing a pivotal role in bankrupting us in the Orwellian name of "the best medical care in the world."
What to do, though?
First, stop asking the foxes what they think of the new hen house alarm system. What do you think a urologist is going to say about PSAs? Why would a surgeon ever recommend against a mammogram? And whatever you do, don't even think about questioning the need for an annual gynecological exam. Goodness. What's a poor doctor to do without providing all that care? Starve?
Actually, you might be able to get an appointment with a urologist in less than six weeks for a kidney stone if they weren't so booked up with annual rectal exams and PSAs on every asymptomatic man over 50. Think about getting in to see a gynecologist for heavy bleeding in less than three months. Not only would the care be more appropriate, but those same specialists worrying about their empty appointment books would probably be making more money by seeing patients who actually need their specialized skills and procedures.
So if you shouldn't ask the specialists about screening guidelines, to whom should patients turn? How about me? Why not discuss these complex issues with your family doctor, who doesn't make any money off your PSA or your Pap or your mammogram. Believe me, my schedule is plenty full with sick people and the worried well (defined as those patients I cannot talk out of all those inappropriate interventions. Yes, they're out there. Yes, I try to explain it to them. Am I always successful? Of course not, though it's not for lack of trying.)
I'm more interested in seeing that the care you get is medically and scientifically appropriate, especially when deciding which screening interventions to forgo. "Watching and waiting" is often as viable a strategy for cancer as it is for lesser ailments. Let us family physicians educate you, our patients, so that you don't end up with irreparable harm from treatments intended to cure something that would never have killed you. Sometimes "just getting it out of my body" leaves you much worse off than leaving well enough alone.
This post by Lucy Hornstein, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.
Health and wellness programs: medicine or marketing?
There's a new term that has entered the medical lexicon. The word is wellness. Hospitals and medical offices are incorporating this term into their mission statements, corporate names, business cards, medical conferences and other marketing materials. The Cleveland Clinic Foundation has appointed a Chief Wellness Officer, an intriguing fluffy title that does not clearly denote this individual's role and function. This is deliberate, as the word wellness is designed to communicate a feel good emotion, not a specific medical service.
Just a click or two on Google will lead you into the wellness universe. Here's a sampling.
--Institute of Sleep and Wellness
--Wellness Institute of America
--National Wellness Institute
--Physicians Health and Wellness Center
--Physicians Wellness Group
There's even a sponsored ad on Google where one can search for physicians, presumably trained in the medical specialty of wellness. I was dismayed that my name didn't appear in a wellness search of the Cleveland, Ohio region. Does this mean that I don't offer my patients health and wellness?
Where is all of this wellness coming from?
It's coming from marketing departments who understand the public mood. While conventional physicians view complimentary medicine warily, the public can't swallow it fast enough. Patients want a softening of the medical profession and are willing to accept new genres of care based on promises, testimonials and faith.
I admit that much of what my colleagues and I prescribe and recommend is based on scant medical evidence. I don't have satisfying treatments for irritable bowel syndrome or chronic abdominal pain. I understand why such patients look beyond me and my colleagues for healing and relief. They are spending billions of dollars on herbs, colonic hydrotherapy, Reiki, massotherapy, holistic medicine, naturopathy, aromatherapy, biomagnetism, guided imagery, medication and homeopathy.
Hospital and medical marketers may not know how to cure disease, but they sure can count. The vast majority of Americans have pursued alternative medicine for one reason or another. The medical establishment has expanded its healing mission to gain access to this huge and growing market. Conventional hospitals, where cardiac catheterizations and colonoscopies are performed, now offer a variety of wellness programming to extend their branding into the surrounding communities.
I think that we are risking a wellness overdose, and there is no antidote. My concern is that it confuses the public between ways to improve their lifestyles and state of mind and actual medical care and treatment. I concede that many alternative medical treatments make folks feel better, but I'm not sure they cure disease.
There's a danger in medicine when faith overtakes reason. An extreme example is when cancer patients were spending precious time and resources for shark cartilage or other high-cost alternatives that have no scientific basis. These opportunities exploit desperate people who have no way out. They shouldn't have to spend money to pray for a miracle. They can do that for free, and they should.
I know there is spirited belief and support for unconventional medicine to complement traditional medicine's failings. If they want to turn skeptics like me into believers, then they'll have to pursue a more conventional approach. Test your treatments in high-quality clinical trials. If scientific studies determine that these treatments, or any therapies, offer no benefit, then abandon them rather than assail them as flawed and biased studies.
I'm in favor of any intervention that makes people feel good, provided it is safe and doesn't exploit folks. Just because the word medicine is in the label, doesn't make it so.
This post by Michael Kirsch, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
QD: News Every Day--Canadian task force recommends fewer mammographies
The Canadian Task Force on Preventive Health Care suggested fewer mammographies in a set of recommendations that mirrored those of the U.S. and U.K.
Key recommendations include:
--no routine mammography for women in their 40s because the risk of cancer is low in this group while the risk of false-positive results and overdiagnosis and overtreatment is higher
--routine screening with mammography every two to three years for women ages 50 to 74
--no MRIs to screen average-risk women, and
--no routine clinical breast exams or breast self-exam.
The full set of recommendations appear in CMAJ, the Canadian Medical Association's journal. One-page information pieces are available for both physicians and patients on the task force's website.
In the study, the Canadian task force noted the number needed to screen to prevent one death from breast cancer for women ages 40 to 49 years is 2,108. But the risk of a false-positive result from mammography is higher for women in their 40s. Screening 2,100 women in this age group once every two to three years for about 11 years would prevent a single death from breast cancer, but it would also result in about 690 women having a false-positive result on a mammogram, leading to unnecessary follow-up testing, and 75 women having an unnecessary breast biopsy.
The number needed to screen to prevent one death from breast cancer for women ages 50 to 69 years is 721. Screening 720 women in this age group once every 2–3 years for about 11 years would prevent a single death from breast cancer, but it would also result in about 204 women having a false-positive result on a mammogram and 26 women having an unnecessary breast biopsy.
Screening about 450 women ages 70 to 74 years once every 2–3 years for about 11 years would prevent one death from breast cancer, but it would also result in about 96 women having a false-positive result on a mammogram and 11 women having an unnecessary breast biopsy. No recommendation was made for women older than 74 because of a lack of data.
"There was no evidence that screening with mammography reduces the risk of all-cause mortality," state the authors. "Although screening might permit surgery for breast cancer at an earlier stage than diagnosis of clinically evident cancer (thus permitting the use of less invasive procedures for some women), available trial data suggest that the overall risk of mastectomy is significantly increased among recipients of screening compared with women who have not undergone screening."
An editorialist commented, "[T]hese guidelines are more balanced and more in accordance with the evidence than any previous recommendations."
The editorial continued that diagnosis of cancers that would otherwise be undetected leads to life-shortening treatments and mastectomies.
"The main effect of screening is to produce patients with breast cancer from among healthy women who would have remained free of breast disease for the rest of their lives had they not undergone screening," it continued.
"The best method we have to reduce the risk of breast cancer is to stop the screening program," it concluded. "This could reduce the risk by one-third in the screened age group, as the level of overdiagnosis in countries with organized screening programs is about 50%."
J. Leonard Lichtenfeld, MD, MACP, the Deputy Chief Medical Officer for the American Cancer Society, wrote that no screening takes it too far.
He wrote, "I say that such a position may not take us back to the 1960's, but not far from that. We will have more women having more mastectomies because the cancers are larger. And more women will have chest wall invasion, and more women will have lymph node involvement and our use of radiation and post-operative adjuvant chemotherapy will not get us back to baseline. Not to mention that the decline in breast cancer death rates in the United States that we have seen year over year since the early 1990's would likely stop at some point over the next 10 years."
Tuesday, November 22, 2011
The fixation on a flawed cancer screening test
In the face of accumulating evidence and a U.S. Preventive Services Task Force finding that prostate-specific antigen (PSA) screening for prostate cancer does more harm than good, the most frequent response I hear from physicians who continue to defend the test is that PSA is all we have, and that until a better test is developed, it would be "unethical" to not offer men some way to detect prostate cancer at an asymptomatic stage. (However, these physicians for the most part don't question the ethics of not offering women screening for ovarian cancer, which a recent randomized trial concluded provides no mortality benefit but causes considerable harms from diagnosis and treatment.)
I'm currently reading historian Stephen Ambrose's dual biography of Oglala Sioux leader Crazy Horse and Civil War cavalry general George Armstrong Custer, whose troops were routed by the Sioux at the famous Battle of Little Bighorn in 1876. One premise of the book is that the same aggressive instincts that served Custer so well during the Civil War, to always attack, even when the strength and disposition of his enemy was unknown, became fatal flaws when he became an "Indian fighter."
For most of his post-Civil War career, Custer and his men blundered around the Great Plains looking for someone to fight, and not particularly caring if the Indians he engaged in battle were actually at war with the U.S. Army. In one telling description of Custer's first major Western engagement, Ambrose writes: "Here was audacity indeed. ... Custer had no idea in the world how many Indians were below him, who they were, or where he was. His men and horses were exhausted. ... He was going to attack at dawn from four directions at once. He had made no reconnaissance, held nothing back in reserve, was miles away from his wagon train, and had ordered the most complex maneuver in military affairs, a four-pronged simultaneous attack. It was foolish at best, crazy at worst, but it was also magnificent and it was pure Custer."
If readers of American Indian descent will kindly forgive my making this analogy with their 19th Century ancestors, this passage is strikingly similar to the way we diagnose and manage prostate cancer. The vast majority of American Indians by this time had either signed peace treaties or were content to leave settlers alone. Under pressure to "do something" about a few troublesome tribes, however, the U.S. Army sent the overaggressive Custer out to do battle with whatever "warriors" he could find, assuming that in the process he would either kill, capture, or scare off those who aimed to do them harm.
That's pretty much what we do by deploying the PSA test to screen for prostate cancer. We cast as wide a net as possible, doing harm at every step of the way: false positives, adverse effects of prostate biopsies, and overdiagnosis and overtreatment of abnormal-appearing cells that we identify , usually inaccurately, as potentially lethal. For every man whose life may be extended by treatment, 30 to 50 will be treated for no benefit, and 10 to 20 will sustain permanent physical harm. And our continuing obsession with this flawed screening test not only flies in the face of evidence, it's pure Custer.
This post by Kenny Lin, 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.
Ovarian cancer screening has no value
If you want to create an outcry of indignation, just inform people that certain screening tests are of no value and do not increase time on this earth. People love the idea that if they do all the right things and get all the medical tests at the right time, they can prevent disease (... Uh ... no, tests don't prevent anything.) or catch cancer early and cure it.
The furor over the lack of benefit for men of the screening Prostate Specific Antigen test (PSA) is still being heard. It seems everyone knows someone who was "saved" by getting a PSA and don't try to tell me there is evidence to suggest otherwise, dammit!
There is a new report in the Journal of the American Medical Association (JAMA) that confirms previous studies and shows there is no benefit for women to obtaining screening ultrasounds and Ca125 for ovarian cancer. This is bad news because every year over 21,000 women are diagnosed with ovarian cancer. Most of them are diagnosed in advanced stages and the five-year survival rate is only 30%. Of course we want a safe, effective screening test that can detect abnormalities early.
Ca125 (blood test) and transvaginal ultrasounds should work, but they don't. The 13-year-old study confirmed a prior report that the predictive value of these tests was low and additionally it confirmed there was no difference in mortality in women who underwent screening compared with those who did not. Additionally they found a high number of false positive tests and 15% of women with false positives suffered serious complications of surgery.
The discouraging findings may be because ovarian tumors are aggressive and annual screening is ineffective. The serious complications associated with false positive tests also makes it a bad screening test for the population.
Someday we will find good tests to detect these cancers. Right now patients and doctors should just say, "No."
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.
Help wanted: DIY medicine
First there were contractors. Then came Home Depot.
Once we had accountants. Along came TurboTax.
Printers? Soon we had Kinkos, er, FedEx.
Even venerable old lawyers are being outsourced and replaced by do-it-yourself manuals and online services.
Which brings me to my profession. Medicine.
I'm researching a new frontier in health care: do-it-yourself medicine. As more information is available online, patients are empowered like never before.
The rise of the e-patient movement is one such example. But now, with direct-to-consumer lab testing and radiology, people are able to access medical services and consume them like any other commodity.
I'm interested in learning about people that obtain these services without the consultation of a medical professional.
Caveat: a lot has been written about cyberchondria, Google-itis, and patients advocating for themselves and their loved ones with their doctors.
I'm looking for people out there that self-diagnose and treat but make every effort to steer clear of the medical establishment.
Are you such a person? Do you know one?
All information and stories will be held in strictest confidence. We're trying to gauge the prevalence of this phenomenon in the world.
Comment on the blog or send tips/inquiries to GlassHospital [at] gmail [dot] com.
This post by John H. Schumann, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.
QD: News Every Day--Insurance status affects length of stay for some hospitalized patients
Patients without insurance have shorter lengths of stay when admitted to for-profit hospitals for preventable illnesses, researchers found.
Researchers analyzed length of stay for insured and uninsured patients by for- and non-profit hospital status. The study applied data from the National Hospital Discharge Survey (NHDS) from 2003 to 2007 for patients ages 18 to 64 years. The analysis included those who were hospitalized with both ambulatory care-sensitive conditions (ACSCs), which were considered to be preventable, and non-ACSCs.
Ambulatory care-sensitive conditions were defined as those conditions for which hospitalizations are thought to be avoidable through preventative care and early disease management: seizures; ear, nose and throat infections; chronic obstructive pulmonary disease; bacterial pneumonia; asthma; congestive heart failure; hypertension; angina; cellulitis; diabetes; hypoglycemia; gastroenteritis and dehydration; and kidney and urinary infections. Non-ACSCs were also studied for comparison. Hospitalizations were excluded if patients left against medical advice.
Results appeared in the November/December issue of the Annals of Family Medicine.
After controlling for comorbidities; age, sex, and race/ethnicity; and hospitalizations with either an ACSC or non-ACSC diagnosis, patients without insurance tended to have a significantly shorter length of stay across all hospital types (2.77 days) than for those with either private insurance (2.89 days, P=.04) or Medicaid (3.19, P less than .01). In-hospital mortality rates were not significantly different among types of insurance, the researchers noted.
Across all hospital types, the length of stay for those without insurance was shorter in an adjusted analysis of ACSCs. ACSCs treated in government hospitals showed no significant difference in length of stay regardless of whether the patient had insurance, other than Medicaid or was not insured, researchers noted.
The authors wrote, "Because of the nature of ACSCs, we would expect that individuals who lack access to health care as a result of no insurance would arrive at a hospital with a more severe illness. Instead, our study found that length of stay for patients with ACSC diagnoses was shorter for those without insurance, results similar to those for non-ACSC diagnoses."
Monday, November 21, 2011
The role of touch when talking to patients
My wife has two world-class oncologists who help her manage her Stage 4 lung cancer. Both are excellent clinicians. Yet their skills differ in one very important way. Her radiation oncologist physically touches her a lot (in a good way of course). There are the touches on her arm, a hand on the shoulder, hugs, and of course a thorough hands-on physician exam. Her medical oncologist, not so much.
We all recognize the therapeutic value of touch. Abraham Verghese, MD, a Stanford physician and professor, at the 2011 Med2.0 Conference, described the power of touch associated with the physical exam. In the following scenario he describes an interaction with a chronic fatigue patient who came to him after being seen by many other physicians: "The patient was very voluble and kept talking as I began the physical. I always begin my routine, my ritual with the patient's hands ... it seems natural to hold the hands. I slip my finger to the radial pulse and then examine the fingers looking for cyanosis and clubbing ... As I began my routine, this talkative patient began to quiet down. I had an eerie sense that the patient and I had slipped back into a primitive ritual ... one in which I had a role and the patient had a role.
"When I was done the patient said to me with some awe ... I have never been examined like this before. If this were true that was unfortunate since this patient had been examined by other physicians many times before. Following the exam, I told the patient the same thing he had been told by other physicians, I don't know what the problem is ... but here's what we will do. I had earned the right to tell the patient this because of the examination."
Dr. Verghese believed that, unlike the other physicians seen by the patient, he had earned the right to diagnose the patient and expect the patient to accept and act on his findings. Why? Because of the patient trust he had earned in part through the power of touch.
Turns out that there is scientific research to back up Dr. Verghese's claim. According to researchers, people are able to more accurately discern a wider range of feelings and emotion from touch than from gestures, expressions, and sometimes even words. That's because touch is the first language we learn. Tiffany Field, PhD, of the Touch Research Institute in Miami has found that benefits of touch seem to stem largely from its ability to reduce levels of cortisol, a stress hormone manufactured by the body.
Given the high degree of personal stress associated with a trip to the doctor, a lab test, or hospital visit, I suspect we could use a whole lot more touching, not less as is the trend. Dr. Verghese has a name for this trend. You know, where clinicians gather around the computer and not the patient. He calls it iMedicine, and it's not a good thing.
That's my opinion. What's yours?
Keltner, D. Born To Be Good: The Science of a Meaningful Life" (Norton, 2009)
This post by Steven Wilkins, MPH, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.
'Thank you for your consult ...'
Until recently, there was a financial difference between performing a "Consultation" and a "New Patient Visit" for office visits (Medicare stopped paying for Consultations at a higher rate than New Patient Visits in 2010). I won't get into the ins-and-outs of what the criteria for a consultation were, why payment for the codes were eliminated for Medicare patients, etc. (If you want to read more about the difference, click here). The long and short is: in specialists' offices, patients often get/got billed for the more expensive "consults" when in fact the visit was not a consultation at all. Let's just use this understanding as the brief background for what I'm about to say.
I work at an academic medical center. My patient base is quite different from that of a typical gastroenterologist in that I often get asked to consult on (i.e. render an opinion about treatment for) patients by other gastroenterologists. Because I see patients from all over the state, patients often come from several hours away and do not expect to get their routine GI care where I work. Patients frequently return to their referring gastroenterologist for their care after I have rendered my opinion or helped them through their situations. This is the way tertiary care medicine is supposed to be. When a patient returns to their gastroenterologist, they are closing the circle of the consultation.
How then should I feel when a referring physician sends me a note on a patient, originally sent to me by him, that says something to the effect of: "John Doe is being seen in consultation at the request of Dr. Ryan Madanick for a history of colon polyps." ?
Here are my issues with this:
I didn't send the patient to him in consultation. I know how to take care of patients with a history of colon polyps. As a matter of fact, I DO perform colonoscopy. The patient returned to his care because he was the patient's referring doctor in the first place, not because I wasn't certain about the best option for this patient's care.
The patient is returning to the original referring physician. The visit shouldn't even be billed as a New Patient Visit. It is an Established Patient Visit (which pays a lot less).
If the patient's insurance covers Consultation codes at a higher billing level, we are all losing (well, except for the payee). The patient probably wouldn't see any difference. However, if this happens time and time again, the payment system would break down (or wait, maybe it already did.)
Let's get this straight. I know the referring doctor well, and I think he practices good medicine. Still, we know why the note was documented this way. And this is exactly the type of fraudulent billing practice that got the Consultation codes removed by Medicare.
I'll end by making a plea: Please don't bill a patient and their insurance for a consultation when it is just a visit.
Ryan Madanick, MD, is an ACP Member, a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain. This post originally appeared at his blog, Gut Check.
QD: News Every Day--Dementia inpatients must be shifted away from hospitals, back to nursing homes
Sending dementia patients to the hospital could overwhelm the health care system and not offer them any better care at the end of life, researchers noted.
The researchers obtained data on all hospitalizations involving a dementia diagnosis for the 85 years and older group between years 2000 and 2008 from the nationally representative Nationwide Inpatient Sample database, a part of the Agency for Healthcare Research and Quality Healthcare Costs and Utilization Project.
Annual hospitalization data came from the U.S. Census Bureau. They projected the future volume of hospitalizations involving a dementia diagnosis in the 85 years and older group two ways, with and without allowing for population growth, to compute the absolute minimum potential growth and then to account for population growth and 7 the observed historic increase in the age-adjusted incidence of dementia hospitalizations between years 2000 and 2008.
The research letter appeared in the Nov. 14 issue of Archives of Internal Medicine.
Researchers noted that between 2000 and 2008, patients 85 years and older comprised less than 2% of the total U.S. population, they represented more than 40% of all annual hospitalizations associated with dementia. The actual absolute volume growth from 700,000 to 1.2 million hospitalizations among patients with a dementia diagnosis between 2000 and 2008 equated to population incidence increase from 16,398 to 21,088 cases per 100,000 population.
The estimated 2050 volume of dementia hospitalizations in the 85 years and older group may be between 3 and 7 million, depending upon accounting for population growth, or a potential a 10-fold growth in the volume of these hospitalizations.
Even at its minimum, the absolute growth in hospitalizations involving a dementia diagnosis could overwhelm the health care system, the authors noted.
"In addition, humanistic considerations dictate that this degree of aggressive care may be inappropriate for many patients with dementia," the authors wrote. "For example, it has been reported that patients with advanced-stage disease have a prognosis comparable to metastatic breast cancer or stage IV heart failure. Although our data are unable to convey the severity of the observed dementia diagnoses, a recent study noted that 18.7% of nursing home residents with advanced dementia were hospitalized near the end of life, even though the most frequently stated goal of care was comfort. For such patients, hospitalizations represent more of an intrusive burden than a desirable intervention."
Commenters told Reuters that the burden will have to shift back to nursing homes to care for non-life threatening illnesses such as pneumonia, in order to lower acute-care hospitalization costs and provide more comfortable care.
Friday, November 18, 2011
Patients need teamwork in medicine
Atul Gawande, MD, says that we're used to doctors working like "cowboys," rugged individualists who are responsible for making sure your care gets done right. We don't need cowboys, he says. We need "pit crews," teams of doctors working together toward a common goal, with each playing their own role.
It's an appealing idea. Pit crew-like teams work, and work well, in trauma units across the country.
But there's a problem: if you haven't just been airlifted to a hospital after a horrible accident, you're not going to be treated by a pit crew. You're going to be on your own, shuffled from one 15-minute specialist visit to the next, likely with no one person in charge of your care.
Dr. Gawande knows this, and he picks a heck of an example of the problem:
"But you can't hold all the information in your head any longer, and you can't master all the skills. No one person can work up a patient's back pain, run the immunoassay, do the physical therapy, protocol the MRI, and direct the treatment of the unexpected cancer found growing in the spine. I don't even know what it means to 'protocol' the MRI."
Why is that such a good example? Because it's exactly what happened to my brother at one of the leading medical centers in the country. He had a person directing the work up of his back pain and all the rest, including deciding on the right treatment for the "unexpected cancer found growing in his spine." It all worked well ... except that he didn't have cancer at all. In fact, had he been treated for cancer, he might not be with us today.
The truth is when you get sick, there is no pit crew rushing out to help you make your way through the system. There are overburdened, time-pressed doctors making decisions based on fragmented and often incomplete information. Scientific studies showing diagnoses are inaccurate more than 20% of the time are a clear warning sign and a symptom of this public health crisis.
If you're sick, you don't have time for the system to change. And so while we may not want our doctors to be cowboys, as a patient, you better learn how to be one. Be self-reliant, demand answers, and, above all, know this: the person with the greatest stake in getting your care right isn't your doctor, it's you.
This post by Evan Falchuk, JD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.
QD: News Every Day--Mental illness sparks creativity among sufferers and their families
People with schizophrenia or bipolar disorder and their first-degree relatives more frequently work in creative professions, suggesting some truth to the long-mythologized link between artists and madness. The way the link plays out along family lines suggests a genetic cause, researchers reported.
While smaller studies have looked specifically at small groups of creative populations such as artist's workshops and their rates of mental illness, researchers in Sweden conducted a population-based study of how often mental illness occurs among people and their relatives, and its association with creative and non-creative professions.
The researchers performed a nested, case- control study using longitudinal Swedish total population registers and compared it with occupational census data. Creative professions included visual artists such as photographers and non-visual artists such as performers and writers, as well as members of the scientific professions among university academics. Accountants and auditors acted as a control group.
Results appeared in The British Journal of Psychiatry. Overall, the registries reported 54,042 people (29,479 men and 24,563 women) with schizophrenia, 29,644 people (11,910 men and 17,734 women) with bipolar disorder and 217,771 people (84,352 men and 133,419 women) with unipolar depression.
Compared with the control group, those with schizophrenia demonstrated no difference in having a creative profession (odds ratio [OR]=0.98; 95% confidence interval [CI], 0.88 to 1.08) but were significantly less likely to be scientists (OR=0.63; 95% CI, 0.51 to 0.79), researchers reported. They were significantly more likely to be an artist, (OR=1.14; 95% CI, 1.01 to 1.28), mainly because of a trend in the visual arts (OR=1.30; 95% CI, 1.13 to 1.49).
Parents and siblings of people with schizophrenia were significantly more likely to hold a creative profession across all domains compared with the control group (parents OR=1.55; 95% CI, 1.43 to 1.67; siblings OR=1.36; 95% CI 1.26 to 1.48). Offspring were not more likely to be in a creative profession overall, but were more likely to be in the visual arts (OR=1.38; 95% CI 1.18 to 1.62), a finding that is in line with the individuals with schizophrenia, the authors noted.
Those with bipolar disorder were significantly overrepresented in creative professions compared with the control group (OR=1.35; 95% CI 1.22 to 1.48). There was an increased likelihood of both visual (OR=1.42; 95% CI 1.23 to 1.64) and non-visual (OR=1.44; 95% CI 1.20 to 1.73) artistic occupations, researchers reported. First-degree relatives of those with bipolar disorder were more likely than those in the control group to hold a creative profession in general, with higher odds ratios for scientific than artistic occupations.
Individuals with unipolar depression were not more likely to be involved in creative professions (OR=0.94; 95% CI, 0.90 to 0.99). Those with bipolar disorder and their first-degree relatives were not more likely to become auditors or accountants, and those with schizophrenia or unipolar depression and their first-degree relatives were significantly less likely to do so.
"This Swedish total population case-control study is several magnitudes larger than previous studies and demonstrates an increased likelihood for both people with schizophrenia and bipolar disorder, as well as for their respective relatives, to work in a creative occupation, compared with controls," the authors wrote.
They continued, "Even though the present study does not explain what mechanisms may underlie the observed association between mental disorder and creative occupations, it is noteworthy that the likelihood of creative occupations in relatives of those in the case group was highest among healthy first-degree relatives and this gradually decreased with increasing familial distance to these individuals. Additionally, there were no significant differences between the maternal and paternal half-siblings. These results hence suggest a genetic rather than environmental explanation."
The study did not control for the more open environment found in many creative professions, which might allow those with mental illnesses to function successfully, compared to the more structured, 9-to-5 atmosphere found in auditing and accounting careers. The study's lead author, Simon Kyaga, told ACP Internist "Generally traits associated with creative behavior are openness, non-conformity, contrarianism, sensitivity, etc. that are unlikely to go hand in hand with 9-to-5 atmosphere."
He continued, "Two important aspects of creativity are divergent thinking and motivation. It is likely that these aspects will be present to a differing degree in patients with different psychiatric disorders. Studies have for instance shown patients with schizophrenia being able to 'think outside of the box' or actually less restrained by common sense, while patients with bipolar disorder have been shown to be more ambitious than the general population."
An editorial commented that mental illness is counterintuitive to be linked with creative success because of symptoms, including impaired concentration, short-term memory deficits and impaired executive function.
But, the editorial noted, other symptoms boost the creative mind. Elevated mood and rapidity of thought often facilitate creativity. Mania and hypomania increase the types of thought important in creativity. Bipolar illness can lead to risk-taking, grandiosity, restlessness and discontent. Illness-induced introspection and a need to make meaning of or ameliorate suffering inspire imagination and creativity as well, the editorialist wrote.
Thursday, November 17, 2011
Medicine's next-generation doctors have different priorities
Doctors are, famously, workaholics. That's just the way it's been forever, at least as far back as my memory goes. You work crazy hours in residency, you graduate and work like a dog to establish your practice or to become a partner in your practice, and then you live out your career working long hours because there just aren't enough hours in the day to do everything that needs to be done. I remember, growing up in the '80s, that my friends whose parents were doctors were latchkey kids whose dad (usually the dad, then) was never at home when we were hanging out in the rec room playing Atari.
Yeah, Atari. Look it up, kids.
Not much had changed by the time I went to medical school. There was recognition of the fact that burnout was an issue, that divorces, alcohol abuse and suicides were more common among physicians than in other professions. The unspoken implication was that being a doctor was difficult and stressful, which increased the risk of these consequences of an over-burdened professional life.
These stresses were accepted as part of the turf, as a necessary part of "being a doctor." It wasn't optional, and indeed, most physician teachers that addressed the matter chose to sublimate it into a mark of nobility. Being a physician was a calling and a duty, and a physician must gladly subordinate his or her own happiness and well-being to the service of their flock.
But things have changed, or at least a slow shift is in progress. It was probably ongoing when I was in training, though I was pretty oblivious at the time. I see it more and more clearly as time goes on. Young physicians have different priorities now, and they are making career decisions based on a more self-centered set of values.
For example, a study in American Medical News, cited by @Skepticscalpel, revealed that graduating residents place "free time" and "lifestyle" as their top priorities in choosing a position, above even financial considerations. Young doctors are opting for large multispecialty practices and for hospital employment in droves, stable and predictable practice environments, and the practice model of small group or independent practitioners withers on the vine. At the same time, driven by slightly different motives, residency hours are being restricted.
This has provoked a chorus of curmudgeonly disapproval from many, especially from within the surgical specialties. Skeptical Scalpel himself mused: "Does all this bother anyone else? I wonder what people expected? Did they not know that being a doctor involves commitment and self-sacrifice?"
One commenter was rather more direct: "Being a doctor is not a job like being a banker or contractor. It is a life. The decision to become a doctor should carry as much weight as the decision to enter the priesthood. Medicine is not a dilettante's profession. Make the commitment or get out."
Which, I think, aptly summarizes the position of the "old guard," the guys who paid their dues and expect the next generation to do the same. But we (and I still include myself in this group) who are younger don't agree, at least not entirely. It seems like the demands of this profession are, in part, not intrinsic to the job but rather culturally and institutionally generated, and thus, subject to change.
Why should I spend my entire career working 60 hours a week? Is that necessary to maintain my skills? Is it worth the cost to my family and my personal life? Is it more important to me that I be a "good doctor" than it is that I be a good father and a good husband? I don't think so, and in fact, personally, I identify myself more as a father than a doctor.
Note that I am referring to a career, not to training, where there is some argument in favor of intense experience. That is a different topic.
So I am entirely in favor of the movement towards more humane and livable practice environments for physicians. And I do not think this movement is going to reverse itself, but rather, will become the new standard going forward. The phenomenon of cohort replacement, or "the replacement of old guards of organizational members and leaders with newer cohorts who have different beliefs, opinions, and values," will likely slowly but inexorably change the culture of medicine towards one in which the accepted, default position is that physicians have robust extra-professional lives.
John Mandrola, an electrophysiologist, is cautiously supportive of this transition, but poses the unsettled question of whether this is good or bad for patients.
To some degree, it's a clear win for patients. A well-rested surgeon performs better. An ER doc who is suffering from burnout is not the one you want treating your child. An internist who retires at age 50 because the office life is too demanding represents "brain drain" as the most experienced and valuable docs flee the workforce.
The surgical and procedural-based specialists seem to have the most resistance to this change, and they do have some valid points. There is a correlation between how many times you do a procedure and how well you do it. You can learn to do a lap chole in residency, but you may not be really good at them until you have done a few hundred in the first few years of your practice. Further, surgeons have a different relationship with their patients, usually shorter duration but much more intense. This makes it harder to place boundaries on intrusion of their practice into their personal lives.
However, these hurdles are logistical barriers which can be overcome, at least in part. The use of trained and experienced physician extenders can greatly streamline the non-operative elements of care and allow the surgeon to focus his or her time where it carries the most value: in the OR and at the bedside.
The greater question of whether this is good for patients relates to the looming physician shortage. If physicians, as a group, are cutting back on their time at work, this will require a larger workforce to deliver the same amount of care. There are some efficiencies that can be gained, especially through the use of PAs and NPs, which may mitigate the matter. However, it's hard to escape the conclusion that the trend towards a firmer life-work boundary for doctors will exacerbate the physician shortage.
I don't think that's an argument against greater work-life balance in medicine. That's still good policy. The consequences need to be acknowledged and addressed, and it's worrisome because little is being done to address the physician shortage in the first place. But it doesn't change the fact that the ability of doctors to have stable and fulfilling extraprofessional lives is good for both doctors and the patients we serve.
And in any case, the argument of whether this is a good thing or a bad thing is about as important as a debate over the tides. It's happening, as the result of thousands of individual docs all making the same personal choices, and it's very unlikely to change. So we had best recognize it and make plans to deal with it.
This post by Liam Yore, 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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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.
Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).
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Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.
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Technology in (Medical)
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.
Peter A. Lipson,
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.
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Other blogs of note:
American Journal of
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.
The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.