Thursday, December 22, 2011

Wal-Mart and the daily special on primary care?

NPR and the Wall Street Journal ran stories this week on Wal-Mart's attempt to re-shape delivery and provision of primary medical care in the U.S. The company is soliciting proposals from vendors that offer products and services designed to deliver efficient and inexpensive primary care to the market place.

Then, in an "Oops" moment, the company's VP for health and wellness issued a statement the next day clarifying his intent: "We are not building a national, integrated, low-cost primary care health care platform." A company spokeswoman said that the request for proposals was "overwritten and incorrect."


Let's start with basics: Wal-Mart is the world's largest retailer. It employs around 2 million people, far more than any other private sector company in the world. It has combined annual sales of over $400 billion.

Wal-Mart's success is in large part due to its massive supply chain and innovative inventory logistics. It knows what its customers want, it negotiates strongly on price, and then stocks the items in huge quantities, passing on the savings to customers.

This strategy has fueled unprecedented growth and changed many communities in which the corporation operates.

This is not without controversy. Wal-Mart pays its employees lower than average hourly wages, and does not offer health insurance to a significant portion of its workforce. The company is said to be responsible for 10% of the total exports of China; one website reports that 80% of Wal-Mart's suppliers are in China.

What's any of that got to do with health care? I find it an interesting question, one that begets further ones:
1) Could Wal-Mart use its strategic and logistical excellence to build a robust and cost-effective primary care network?
2) Would doing any of this improve the company's corporate image? Imagine Wal-Mart working in service to our national goal of "bending the cost curve" on health care spending, and while doing so providing basic health care services not only to its currently neglected employees, but to the population at large.
3) Is 'straightforward' primary care amenable to widget-ization? Certainly most doctors would argue "NO!"

I will be eager to follow the travails of Wal-Mart as they pursue this enterprise. It may be courageous, outlandish, innovative, and special, or it may become Wal-Mart's Waterloo.

I just hope that whatever happens with health care, they do a better job than they did with this Chanukah display that's circulating the Internet.

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--Nearly 9 in 10 doctors stressed on any given day

The vast majority of U.S. physicians are moderately to severely stressed or burned out on an average day, with moderate to dramatic increases in the past three years, according to a survey.

Almost 87% of all respondents reported being moderately to severely stressed and/or burned out on an average day using a 10-point Likert scale, and 37.7% specifying severe stress and/or burnout.

Almost 63% of respondents said they were more stressed and/or burned out than three years ago, using a 5-point Likert scale, compared with just 37.1% who reported feeling the same level of stress. The largest number of respondents (34.3%) identified themselves as "much more stressed" than they were three years ago.

The survey of physicians conducted by Physician Wellness Services, a company specializing in employee assistance and intervention services, and Cejka Search, a recruitment firm, was conducted across the U.S., and across all specialties, in September 2011. Respondents mirrored the AMA 2009 Physician Masterfile, with 2,069 completed surveys representing a 99% confidence level with a +/- 3% margin of error compared to about 750,000 physicians. The survey respondent sample skewed more toward non-primary care practices by 11.1 percentage points, possibly reflecting a younger survey sample and fewer primary care medical school graduates.

The top four external stress factors are the economy (51.6%), health care reform (46.4%), Medicare and Medicaid policies (41.2%), and unemployed and uninsured patients (29.7%). Only 8.6% of respondents reported no external stressors.

The top four work-related stress factors are administrative demands (39.8%), long work hours (33.3%), on-call schedules (26.2%), followed by medical malpractice lawsuits, insurance company interference, conflict or disagreements with administrators, increased complexity of care and electronic health/medical records. Only 1.1% reported no stress from work.

The top three personal life-related factors were not enough leisure time (52.6%), not enough time for exercise or wellness (50.6%), concerns about work/life balance, in general (45.0%), followed by concern about finances or sleep. Only 8.4% of respondents indicated that there was nothing stressing about their personal lives.

The result of the stress is declining job satisfaction (51.2%), a desire to reduce hours (41.2%) and a desire to retire early (29.9%), nearly tied with a desire to leave the practice of medicine entirely for another career (27.6%). The next two were also related to changes in their work situation: desire to switch jobs (21.8%) and desire to switch to a new practice (15.9%). Only 6.9% of survey respondents reported no work-related stress.

Fourteen percent of respondents indicated they had left their practice as a result of stress, among whom 56.7% continued practicing, but in a different setting, 33.3% continued working in medicine, but in a different job or role, and 10 left medicine entirely. Most noted some improvement, with 42.6% each saying leaving improved their stress and burnout.

Not surprisingly, all the stress triggered tiredness (41.4%), sleep problems (36.7%) and general grouchiness (33.9%), personal health problems (24.7%) and conflicts with a spouse or partner (22.6%). But 9.1% of respondents reported no impact on their personal lives due to stress and/or burnout.

Most doctors handle the stress through exercise (62.8%) or time with family and friends (56.9%). The next cluster involved vacation (47.8%), movies or music (44.3%), reading (38%) and getting more sleep (35.8%). Mentoring, yoga, meditation or peer support were not as prevalent, and doctors commented that finding the time and, in some cases, money to do something was, well, stressful.

Nearly one-third of respondents indicated that better work hours/less on-call time and better work/life balance would help to reduce their stress. Nearly two-thirds of respondents said ancillary support would help. This feedback and the growing trend of part-time work schedules for physicians indicate a need for advanced providers such as nurse practitioners and physician assistants who can provide accessible and effective care as physicians scale back their hours in order to pursue better work/life balance, the companies said in a press release.

[Editor's Note: QD--News Every Day will resume publishing on Jan. 3, 2012]
Wednesday, December 21, 2011

Holiday decoration-related ER visits: Are these statistics sending the wrong message?

Yesterday's American College of Emergency Physicians Member Communication e-mail (titled Emergency Medicine Today, in affiliation with BulletinHealthcare) had this as its top story: Injuries Linked to Holiday Decorating on the Rise, from a website called HealthDay News. The reported cites a U.S. Consumer Product Safety Commission press release, crafted with help from Underwriter Laboratories (the wire engineers).

Tangled illumination by Lomo-Cam via Flickr and a Creative Commons licenseThey claim: "In November and December 2010, more than 13,000 people were treated in U.S. emergency departments for injuries involving holiday decorations, up from 10,000 in 2007, and 12,000 in 2008 and 2009, according to the U.S. Consumer Product Safety Commission (CPSC). A well-watered tree, carefully placed candles, and carefully checked holiday light sets will help prevent the joy of the holidays from turning into a trip to the emergency room or the loss of your home," said CPSC chairman Inez Tenenbaum in an agency news release.

Good advice. Though it's been said (many times, many ways. So when it came time for CPSC and UL to raise the topic, did we need the very questionable statistics to justify it?

If you're having trouble wrapping your head around the number of decoration-related emergency department visits, consider this similarly bizarre statistic: 8,000-10,000 kids are injured each year from falling televisions. So, for perspective: in the November to December period, Americans now endure more holiday-decoration-related trauma than an entire year's worth of falling TVs (though, now that I think about it, there may be some overlap, like if while putting up some Christmas lights, Dad knocks over the TV and it lands on Junior's foot. That could be one ED visit logged in both categories.)

Another way to think about it: 13,000 visits over two months spread over the approximately 1,800 EDs in the U.S. translates to about seven holiday-decoration-related visits per ED. Not much, when the average department sees 5.000+ patients a month (and Americans visit the ED 130 million times a year). I'm not even sure it's significantly more than it was a few years ago, when EDs could expect, get ready for it, six (6) visits related to holiday decorating.

Still, I've yet to see my first mistletoe-hanging trauma. I have seen more than my share of frankincense and/or angel dust intoxication lately, but I don't think that counts as a decoration-related ED visit.

In fact, I handle a lot of statistics and analysis for our ED, and I could not tell you how many holiday decoration injuries we've seen this year, or last. To really do it right (i.e., publication-quality data that could stand up to peer review or Joint Commission scrutiny) we'd have to build a query to retrospectively through the text of all patient notes, looking for mentions of menorah fires or tree-felling injuries, then do a chart review. Or we could code a checkbox and ask our triage nurses to prospectively screen for this, along with suicidality, domestic violence, and HIV.

Probably what CPSC is doing, instead, is drawing from a few statewide databases or surveys like NHAMCS and generalizing broadly (certainly, there are no scholarly papers on holiday decoration emergencies; the literature on falling TVs is much more robust).

Survey data is fine for identifying new threats to the population, or changes in abuse patterns, but it's hardly precise and when I see dozens of headlines about the rise in ED visits from holiday injuries (Google news counts 291 stories at the time of this writing) it makes me cringe. If next year's holiday decoration visits fall back down to 10,000, does that mean we've turned a corner on educating the public about the menace of holiday decorations? And so we won't need to be so vigilant anymore? Or is it just a statistical blip, well within the margin of error, not at all worthy of a headline?

And on that note, I must break off to do some holiday-related shopping, confident (but somewhat disturbed) in the knowledge I've now spent more time mulling this over than anyone involved in writing or selecting that press release for inclusion in ACEP's daily email.

This post by Nicholas Genes, MD, PhD, 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.

Zetia: still crazy after all these years

The role of cholesterol in coronary heart disease has been known for decades, and the discovery of drugs that lower cholesterol has prevented millions of heart attacks and strokes, and saved countless lives. The primary class of drugs, HMG-CoA reductase inhibitors, or "statins," have been particularly effective, and their benefit seems to extend beyond their effect on cholesterol levels.

This "added benefit" of statins has been a bit frustrating for drug researchers. Isolating this non-cholesterol-lowering effect has been an elusive goal. Rather than search for a biological mystery, drug companies have invested resources in finding other drugs that lower cholesterol. Some of these early compounds, such as fibric acid derivatives, have been shown to be effective at lowering heart disease mortality, but they are not as potent as statins, and are more difficult to tolerate (some are powders or are available as very large pills, for example).

In the first decade of the 21st Century, an new cholesterol-lowering compound was discovered. Called ezetimibe (Zetia), it prevents absorption of cholesterol in the intestine, and is effective in lowering levels of LDL cholesterol. But it doesn't seem to prevent heart attacks or deaths. If lowering cholesterol doesn't improve important outcomes, then cholesterol is just a number.

We know that statins lower cholesterol, heart attacks and death, and this reduction is proportional to cholesterol level. Apparently, Zetia, which effectively lowers cholesterol, doesn't have the sine qua non that gives statins the ability to save lives.

Zetia's manufacturer, Merck, came up with a very clever marketing strategy. In addition to marketing ezetimibeto lower cholesterol, they marketed another drug, Vytorin, which contains both ezetimibe and simvastatin, a statin with proven efficacy. Vytorin was supposed to give that little extra something, that little extra bump needed to help patients achieve their cholesterol goals. But Merck never showed that Zetia had the same magic as statins, and it wasn't clear that Vytorin had any advantage over simvastatin alone (except to Merck: Vytorin costs about $130 per month, simvstatin only $10).

Merck has invested a lot in ezetimibe, and is still trying to find a clinical home for it. This year The Lancet published a new ezetimibe study. This one looked at patients with chronic kidney disease (CKD). CKD patients have a higher risk for heart attack, although the cause isn't completely clear. Neither is this study. Rather than picking the most important outcomes, heart attack and death, they chose "major athersclerotic events," a much broader category.

Of course they found that Zetia reduces this outcome in these patients, but not by much. They failed to find a significant reduction in cardiac death, heart attacks, or death (despite the linguistic acrobatics in the Discussion section).

If the failure to prevent important outcomes wasn't enough, the study design had a basic, fundamental flaw. Rather than comparing Vytorin (or in this case two tablets, Zetia plus simvastatin) to a statin alone, they compared it to placebo. There is no way of separating out the effect of the Zetia and the simvastatin. The only conclusion that can be drawn from the study is that using a statin plus ezetimibe improved outcomes. For all we know, these outcomes would have been just as good without the ezetimibe.

The study design seems to me to be completely dishonest, perhaps unethical. Their justification for the design was curious: "To achieve an average reduction in LDL cholesterol of about 1 mmol/L without the use of high statin doses (which are associated with an increased risk of myopathy, especially in patients with impaired renal function), a low dose of a statin (simvastatin 20 mg daily) was combined with a cholesterol-absorption inhibitor (ezetimibe 10 mg daily)."

So they are using the ezetimibe under the assumption that these patients would either not benefit from a low-dose statin, or would have side-effects on a higher dose statin. Curious indeed.

More curious, though, is the fact that the study began with three groups: simvastatin, simva plus ezetimibe, and placebo: "Patients entering SHARP were initially randomised three ways between simvastatin 20 mg plus ezetimibe 10 mg daily,simvastatin 20 mg daily, and placebo to assess the safety of adding ezetimibe to simvastatin during the first year (with no safety concerns identified and those initially allocated simvastatin alone were then rerandomised to simvastatin 20 mg plus ezetimibe 10 mg daily versus placebo after 1 year ..."

Wait ... what? What happened to the statin-only group? Why did they drop it? Why don't we get to see those results?

I can see no raison d'etre for this study other than as a marketing tool for ezetimibe.

Scandinavian simvastatin survival study group . (1994). Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S) The Lancet, 344 (8934) DOI: 10.1016/S0140-6736(94)90566-5

Baigent C, Landray M, Reith C, et al. (2011). The effects of lowering LDL cholesterol with simvastatin plus ezetimibe in patients with chronic kidney disease (Study of Heart and Renal Protection): a randomised placebo-controlled trial The Lancet, 377 (9784), 2181-2192 DOI: 10.1016/S0140-6736(11)60739-3

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.

QD: News Every Day--Update shows 1 in 3 overweight, 1 in 3 obese, for $300 billion in costs

A highly popular and widely cited update on America's cardiovascular health shows that one-third of children and adults are overweight and one-third are obese (body-mass index greater than 30 kg/m2).

Results of the annual Heart Disease and Stroke Statistical Update appeared Dec. 15 at Circulation. The updates have been cited in the literature more than 8,700 times since since 1999 and about 1,600 times in 2010 alone.

Among the other factoids:
--The rate of death from cardiovascular disease fell 30.6% from 1998 to 2008. It still accounted for almost one in three deaths in 2008, more than 2,200 each day, or an average of 1 every 39 seconds.
--One third of deaths from cardiovascular disease occurred among younger than 75. The average life expectancy is 77.9 years.
--One-third of adults older than 20 have hypertension. Eight in 10 know it, seven in 10 take a pill for it, and nearly five in 10 have it controlled.
--15% have total serum cholesterol levels greater than 240 mg/dL.
--Metabolic syndrome affects one-third of the population.
--Direct and indirect costs of cardiovascular diseases are approaching $300 billion, more than any other diagnostic group. For comparison, cancer is $228 billion.
Tuesday, December 20, 2011

Research suggests more damaging effects of endurance exercise on the heart

Dear Endurance Athletes,

Accept an apology in advance. You have endured so much from me.


Let's at least start by agreeing that I can't control the data.

Yes, you guessed it. There is unfortunately more bad news pertaining to the deleterious effects of endurance exercise on the human heart.

Again, I am sorry. Maybe re-phrasing the previous sentence will soften the blow. How about this: "Yet another study on endurance athletes suggests that exercise, like everything else in life, has an upper limit."

Here goes, buckle up.

The study titled, "Exercise-induced right ventricular dysfunction and structural remodeling in endurance athletes" was published last week in the European Heart Journal.

Researchers from Belgium and Australia enrolled 40 long-term endurance athletes in a study looking at heart function after an endurance race. All subjects were long-term exercisers and were accomplished athletes with above average fitness. They were elite.

By measuring cardiac enzymes (heart injury) and taking ultrasounds (directly seeing heart function) immediately after four different length races (marathon through 'ultra-triathlon'), researchers were able to measure the acute effects of extreme exercise on the heart. MRI scans performed a week later assessed for cardiac scar tissue. (The presence of scar in heart muscle portends trouble because it disrupts electrical signals.)

The main findings:
--Compared to pre-race measures, right ventricular (RV) function diminished post-race, whereas LV function remained normal.
--Blood levels of cardiac enzymes increased post race and these rises correlated with the amount of RV impairment.
--The degree to which RV function decreased correlated with increasing race length and an athletes' VO2 max.
--12% of athletes had scar detected on MRI scans at one- week post-race. Those with scar reported greater cumulative exposure to exercise and had more RV abnormalities post race.


The authors rightly conclude: "Intense exercise causes dysfunction of the RV, but not the LV. Although short-term recovery appears complete, chronic changes may remain in many of the most practiced athletes."

My take:

I'm not an alarmist, but this study scares me.

First, there are (general) rules in medicine. One in cardiology, electrophysiology in particular, holds that RV damage is not good. Diseases that affect the RV tend to cause electrical instability that may increase the risk of sudden death. (Medical people call such a process, arrhythmo-genic.)

I'm not saying that exercise-related stunning of the heart and scar formation causes sudden death. I'm just pointing out that things that mess with the RV should not be called meek. If I was writing an academic piece, it would read, "The findings of this well-done study are hypothesis-generating and warrant further prospective investigation."

Second, the data fits a pattern: Longer races and fitter athletes (who are able to sustain higher outputs longer) release more cardiac enzymes and sustain greater RV dysfunction. Those with the greatest exercise history and those who sustain post race RV damage are at greatest risk of developing scar. More was worse.

Third, the findings fit nicely with prior studies. Marathon rats who ran themselves silly, like the subjects in this study, showed similar scar patterns. Also, numerous prior studies in humans (published in peer-reviewed journals) have shown similar patterns of heart injury immediately post race. Other more recent MRI-imaging trials also confirm the presence of scar tissue in the hearts of endurance athletes.

Fourth, and most frightening, in the discussion section the researchers comment on the possibility that heart damage accumulated from long-term exercise may persist even after de-training.


Exercise remains the most effective and safest means to prevent and treat heart disease. The overwhelming majority exercise far too little. In fact, I believe the U.S. suffers from severe exercise-deficiency.

That said, however, accumulating data suggest at least the possibility of an upper limit of what the human heart can sustain.

Each study on extreme exercise has its limitations. This one is small. It's not randomized. And, studying exercise is tough because of the many confounding variables: genetic make-up of individuals, the presence of underlying diseases, and self-reporting of exercise amounts are just a few of many examples. But when taken together en bloc, these ominous trials grow harder for the naysayers to dismantle.

All this is reassuring to masters of the obvious. As it looks like optimal health is born and nurtured through balance.

And there's little about running marathons or slogging through Ironmans that could be called balanced. Fun maybe, for some.

Balanced? Heart-healthy? No way.

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

Using GoAnimate to create case scenarios

Case scenarios are critical in medical education. They make the content more real and applicable to work and thus add value. This point was borne out during a recent course I co-directed on the use of technology in medical education. As a part of the course, physicians worked in teams to create eLearning modules.

Four out of the five teams chose to use an animated video to introduce their module. One of these team chose Xtranormal for their video but the three other teams chose GoAnimate. Physicians found it relatively easy to use these tools.

One of the most striking examples of these videos was one to help introduce the importance of describing a skin lesion.

Besides priming the learner for clinical content, these videos can be used as lead ins for training on communication skills or focused history taking. Here is a link to an animated video to lead in to a discussion on communicating with an angry patient.

Education technology folks working with faculty in medical schools or with residency programs should consider introducing these educators to use of animated videos in their teaching.

Summary of advantages of animated videos for medical education:
1) Relatively easy to create
2) Can be embedded or linked from any eLearning content or Learning Management System
3) Makes the course content more real and thus adds value
4) Makes eLearning more fun
5) Can you used as basis for a face to face discussion with learners
6) No HIPAA issues
7) Easy to share/disseminate

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

Yoga or stretching helps chronic back pain

Everyone hates stress, and for good reason. Stress makes us miserable. Perhaps for that reason, stress is blamed for virtually every disease for which the cause is still unknown. Later, when we discover the true cause, we find that it is unrelated to stress. We thought stress causes stomach ulcers before discovering the bacterium that is the true culprit. We thought stress caused heart attacks before a study comparing high-stress to low-stress individuals showed that this wasn't true. Stress causes gray hair? Nope. Genes cause gray hair. Irritable bowel syndrome is probably the next disease on this list. We're close to sorting out what causes it, and when we do, we can stop blaming stress.

Cat Pose by joeyogaportland via Flickr and a Creative Commons licenseSo stress causes misery, which is bad enough, but we should be careful not to scapegoat it for other ills.

A study in the Archives of Internal Medicine last month adds another illnesses for which stress may not be relevant.

Chronic back pain is common and has no universally effective treatment. Lots of patients swear by yoga, and for many with chronic back pain it seems to improve their symptoms. Is this simply because the exercises stretch their backs and legs, or is the breathing and meditative component also helpful? After all, countless people attest to the stress-lowering properties of yoga. Shouldn't less stress decrease chronic pain?

To test this question, researchers enrolled over 200 patients with chronic back pain and randomized them to three groups. One group attended weekly yoga classes. A second group attended weekly stretching classes. A third group was given a self-care book teaching exercises for low back pain and was asked to follow the book's instructions independently. All the patients had their functional status and pain levels measured by periodic questionnaires.

As expected, the yoga group did better than the self-care group. But surprisingly, the yoga group did no better than the stretching group. This suggests that the benefit for back pain from yoga is entirely related to the stretching, with no additional improvement from the meditation and breathing exercises.

That's not to say that the breathing exercises and the meditation don't feel good, which might be reason enough to do them.

So chronic back pain may be another illness that doesn't have as much to do with stress as we thought. But stress makes us unhappy and strains our relationships. That's reason enough to find ways of managing stress.

The holidays are around the corner, which for some of us are particularly stressful. So when you're feeling very anxious and want to tell a loved one who is annoying you "You're giving me an ulcer," remember that he's not. Take a deep breath and say something like "You're not giving me an ulcer, a heart attack, or gray hair, but I wish you'd stop anyway."

Learn more:
Yoga, stretching both ease chronic back pain: U.S. study (Reuters)
Yoga May Help Low Back Pain. Mental Effects? Not So Much (Wall Street Journal)
A Randomized Trial Comparing Yoga, Stretching, and a Self-care Book for Chronic Low Back Pain (Archives of Internal Medicine)

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--5 steps for flu prevention should include mandates for health care workers

Health care facilities should consider mandatory flu vaccinations for their employees if other attempts don't increase rates to 90%, a draft statement from a U.S. Department of Health and Human Services (HHS) working group stated.

All public health services, HHS staff and Federally Qualified Health Centers should follow suit, stated the Health Care Personnel Influenza Vaccination Subgroup in draft recommendations.

The working group released five steps to boost vaccination rates:
--Employers should establish comprehensive flu infection prevention programs as recommended by the Centers for Disease Control and Prevention (CDC) to achieve the Healthy People 2020 influenza vaccine coverage goal of 90%.
--Employers should integrate flu vaccination programs into their existing infection prevention programs.
--HHS should encourage CDC and the Centers for Medicare and Medicaid Services to standardize the methodology used to measure health workers' flu vaccination rates, as well implement incentives, penalties or requirements that facilitate adoption.
--Employers and facilities that still can't achieve 90% flu vaccination rates among workers after following the three previous steps should strongly consider an employer requirement.
--HHS should encourage developing new and improved vaccines and vaccine technologies, including support for research, development and licensure of vaccines with better immunogenicity and duration.

According to the Advisory Committee on Immunization Practices, annual vaccination is the most effective flu prevention strategy. Immunizing health care workers protects them, keeps them at work during flu season and protects coworkers and patients.

The report notes that while vaccination is the best-documented and most effective intervention to prevent the flu, it's tough to definitively measure. Outcomes for patients varied widely between the studies considered by the working group.
Monday, December 19, 2011

Do doctors feel that they need permission to share ideas?

Let's say you're a doctor and you have an idea, opinion, or a new way of doing things. What do you do with it?

It used to be that the only place we could share ideas was in a medical journal or from the podium of a national meeting. Both require that your idea pass through someone's filter. As physicians we've been raised to seek approval before approaching the microphone.

This is unfortunate. When I think about the doctors around me, I think about the remarkable mindshare that exists. Each is unique in the way they think. Each sees disease and the human condition differently. But for many their brilliance and wisdom is stored away deep inside. They are human silos of unique experience and perspective. They are of a generation when someone else decided if their ideas were worthy of discussion. They are of a generation when it was understood that few ideas are worthy of discussion. They are the medical generation of information isolation.

I spoke with a couple of students recently about medical education reform. And as I often like to do, we discussed what was needed to prepare doctors for life in 2050. I picked up on the most remarkable ideas and suggested that they publish their views as a position paper or editorial. They looked puzzled, and for good reason. They believe that the simple expression of their brilliance is not their responsibility or even their right. It's that of some national professional body or editor. You need the keys to the kingdom to be heard. You need permission. You need to be invited.

In Poke the Box, Seth Godin calls this the tyranny of the picked: Waiting and hoping "acknowledges the power of the system and passes responsibility to someone else to initiate."

But the way the world communicates is changing. The barrier to publish is effectively non-existent. The democratization of media has given every physician a platform to the world. But the physicians have yet to speak up. We're preoccupied with how our voices will sound. We pine over what someone might think. We're too concerned with how we'll look and not concerned enough with how our thoughts, ideas and passions could be an instrument for the world.

If the 20th century was marked by the physician-as-silo, the 21st century will be marked by the dissolution of barriers and the emergence of new ways of collaboration and thinking. This will be a generation marked by information and networks. The institutions that existed to organize us will give way to social structures compatible with the way we communicate. Tools for sharing and drawing from collective intelligence will capture our restrained wisdom. And I suspect that we'll see the most amazing things emerge.

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

Medical malpractice reform losing physician support

With regard to physicians' support for medical malpractice reform, "The times they are a changin'." These iconic words of Bob Dylan, who has now reached his eighth decade of life, apply to the medical liability crisis that traditionally has been a unifying issue for physicians.

The New York Times reported that physicians in Maine are going soft on this issue, but I suspect this conversion is not limited to the Pine Tree State. Heretofore, it was assumed that physicians as a group loathed the medical malpractice system and demanded tort reform. The system, we argued, was unfair, arbitrary and expensive. It missed most cases of true medical negligence. It lit the fuse that exploded the practice of defensive medicine. Rising premiums drove good doctors out of town or out of practice.

What happened? The medical malpractice system is as unfair as ever. Tort reform proposals are still regarded as experimental by the reigning Democrats in Congress and in the White House. The reason that this issue has slipped in priority for physicians is because our jobs have changed. Private practice is drying up across the country for the same reasons that family owned hardware and appliance stores are vanishing.

Look what has happened to independent bookstores? If you want to find one in your neighborhood, you may need to hire a private investigator. Private physician offices are being squeezed out by surrounding medical institutions that, using Ross Perot's famous phrase uttered in the 1992 presidential campaign, have created a "giant sucking sound" as it vacuums up patients from private doctors' waiting rooms.

This is only half of the story. Sure, the medical behemoths that employ doctors have cut deeply into private physicians' patient bases. But, increasingly, physicians are joining these enterprises willingly becoming employees of hospitals and large multispecialty clinics.

Understandably, these physicians who are entering their careers do not want the lifestyles of their predecessors. They want time off and a decent family life. They want hospitalists to admit their office patients who need in-patient care. They don't want to spend hours of uncompensated time each week on paperwork that doesn't help patients or improve their medical skills. They don't want the stress of making payroll, hustling for patients or engaging in the fun pastime of trying to convince insurance companies to pay them what they are owed. You get the idea here. They are shifting to a shift work culture, and I certainly understand why.

Can these doctors still get sued? They can, and they will. But, they are not paying their own medical malpractice premiums. Some of the larger medical institutions that employ them are self-insured. Since these physicians are not paying the bill--or any bills--they don't have the same stake in the game that we private practitioners do. Medical malpractice reform is still on their radar screen, but the blips occur at a higher orbit. They are focused on other issues.

What this means that one of tort reform's most unified and vocal constituencies will lose interest in the medical liability issue. The crop of physicians entering the profession in the next decade just won't view medical malpractice reform as a religion. Of course, they will reel when they are unfairly sued, as we do, but it won't be an issue that commands much of their attention in between lawsuits.

Folk music is prophetic. Where have all the doctors gone? Long time past seen. Will medical malpractice reform ever really happen or will it continue to be just blowin' in the wind?

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.

Electronic health records, quality and safety take the fore at Pritzker IHI open school

A classroom at the University of Chicago's Pritzker School of Medicine was packed earlier this month with both medical students and students in the Graduate Program in Health Administration and Policy (GPHAP) interested in learning more about the IHI and quality improvement. Dr. Chad Whelan, a hospitalist and institutional leader on quality improvement, facilitated an open discussion about some of the challenges in using electronic health records to improve quality of care and encourage physicians to practice more evidence-based medicine.

Some of the topics covered included the unintended consequences of using electronic records, the benefits of an electronic record from an administrative standpoint, and issues surrounding the quality of documentation. The meeting was organized by students in Pritzker's Quality and Safety Track with guidance from Laura Botwinick, Director of GPHAP. During a lively and interactive question and answer session, here are just a few of the questions that were raised by students and the discussion that ensued.

How interoperable are the record systems? Why aren't we using one single interoperable system?
While interoperability is a focus of "meaningful use" that is part of American Recovery and Reinvestment Act of 2009, electronic health records industry is also a marketplace with vendors competing for market share. Because of that, interoperability may not have been achieved earlier.

For larger healthcare systems such as the VA, the implementation of CPRS represents an example of an interoperable system across many hospitals nationwide. Since academic medical centers often have several teaching hospital affiliates, physicians and trainees have to learn to work in several different systems, some of which may not even talk to each other. While many urban medical centers have adopted electronic health records, a recent study demonstrated only 17% of hospitals capital investments.

What are the reasons behind the findings in the literature that mortality and errors sometimes increase when an EHR is installed?
Medicine is a complex system and sometimes changing one thing without changing another will yield unexpected outcomes. Furthermore, if bad processes are automated, errors can happen much more quickly and systematically if they were being made in the first place. That is why it is important to use QI tools to improve systems before an EHR is laid over them.

For example, during a QI intervention for pressure ulcers, the implementation of EHR for nursing documentation actually led to a decrease in the physician recording of pressure ulcers since they did not know where to access nursing notes.

How much training do practicing physicians get when an EHR is deployed?
Training is definitely part of the EHR implementation strategy. One commonly used approach is to actively train early adopters who can champion it for the late adapters and laggards. At our hospital, that training included several hours of classroom time plus watching online video trainings at home with practice tutorials. However, as the faculty and others present agreed, the learning curve is steep and learning is an ongoing process. Anecdotally, there is often "reverse mentoring" with many of the residents who learn on the job are able to teach the attendings tricks of the trade.

What can be done to avoid the cut and paste problems that have emerged?
Interestingly, hospitals often have the choice whether to disable cut and paste or keep it active. By disabling it however, the ability of EHRs to make doctors more efficient is sacrificed. However, enabling cut and paste creates the risk that the information is out of date or inaccurate.

While many egregious examples have been described in the literature, there are some novel experiments being tried around the country include trying to use different colors for pasted information or creating patient records like wikis so multiple people are updating. In a handoff curriculum for residents, we do highlight avoiding CoPaGA syndrome (Copy and Paste Gone Amok) by highlighting that it is allowed to cut and paste but their responsibility is to cut, paste and update.

Are medical students getting trained on electronic health records?
Most learning at present is orientation to a specific system and on-the-job training. Principles of effective practice with EHR need to be translated into medical education as it is an important core skill that all medical graduates will need. While medical informatics is covered by in some form in many medical schools, recent debates highlight that more robust teaching on electronic health records needs to evolve and expand. Moreover, the EHR can be used to actually advance medical education by providing a record of what types of patients a resident sees and assist in performance evaluation of patient care.

--Anthony Aspesi, MS2 (with Laura Botwinick and Vineet Arora)

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: Santa Claus showing off a slimmer physique

Santa Claus is showing off a slimmer physique following hundreds of years of obesity and severe morbidity.

Image from Wikimedia CommonsSanta has been slimmer in the past, specifically, as St. Nicolas, before literature from the 19th century began to note a more "jolly" side to Santa. By the early 20th century, a Coca-Cola campaign illustrated him at his heavier weight (perhaps from drinking too much soda from the 1930s onward).

Efforts to lose weight were demanded from Santa's employer, Walmart, which required him to lose weight or face increased insurance premiums. (You're not really surprised he was working for the retail giant, were you?)

Santa underwent the transformation using advice from his internist, but was so confident he could lose weight, he actually put money on the effort. He turned to a company that gambles on whether subject can lose a set amount of weight in a given amount of time. The company places bets on how much weight people can lose. (It profits because only one in four people collect.)
Friday, December 16, 2011

Follow up on 1991 Gulf War veterans

Remember the 1991 Gulf War between the United States and Iraq (aka: "Operation Desert Storm")? A new study has been published in the American Journal of Epidemiology that assessed the health status of 5,469 deployed Gulf War veterans compared to 3,353 non-deployed veterans. At 10 year follow up, the deployed veterans were more likely to report persistent poor health. The measures were functional impairment, limitation of activities, repeated clinic visits, recurrent hospitalization, perception of health as fair or poor, chronic fatigue syndrome illness and post-traumatic stress disorder (PTSD).

From 1995 to 2005, the health of these veterans worsened in comparison to the veterans who did not deploy to the Persian Gulf. A study done in the United Kingdom that compared Gulf War veterans to UN peacekeepers who served in Bosnia and other non-deployed Gulf War soldiers found the same thing. The deployed veterans had significantly worse health in all realms.

This was a longitudinal study and the veterans self reported their health status. Over time the deployed veterans reported new conditions that persisted or worsened with time.

The authors note that the health problems cannot be proven to be due to the effects of the military service in the Gulf War. But previous studies also found a higher prevalence of PTSD and other mental disorders among deployed Gulf War soldiers. This study also showed high rates of PSTD (14.4% compared to non-deployed, 4%).

There are numerous animal experiments that show exposure to repeated stress disrupts the blood-brain barrier and increases neurotoxicity induced by chemicals in many cerebral areas. Gulf War soldiers were exposed to organosphosphate chemical warfare agents. Even low level exposure to nerve agents can have a negative effect on brain structure years later. In another study of Gulf War veterans, they found the soldiers with fatigue, mood or cognitive complaints demonstrated impaired immune function.

There is no doubt that our war veterans return home with significant health risks, even if they are not visibly wounded in battle. These young men and women deserve not only our respect and praise, but the best mental and physical health care that we can provide.

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

QD: News Every Day--Obese women earn measurably less

Obesity impacts income, especially among women, according to a report from The George Washington University School of Public Health and Health Services' Department of Health Policy.

In 2004, wages among the obese were $8,666 less for females and $4,772 lower for males. In 2008, wages were $5,826 less for obese females, a 14.6% penalty over normal weight females, the researchers concluded after examining years 2004 and 2008 in the Bureau of Labor Statistics' National Longitudinal Survey of Youth.

The research shows that there are significant differences in wages dependent upon race that couldn't be accounted for by measuring pre-recession (2004) and recession (2008) measures. In 2004, Hispanic women who were obese earned $6,618 less than those who were normal weight. In 2008, the differential doubled for Hispanic men who were obese to earnings of $8,394 less than normal weight counterparts, while for women the gap narrowed slightly.

Other key findings from the report include:
--Men and women who were obese experienced reduced wages compared to their normal weight counterparts;
--Except Hispanic men, the wage differential narrowed between 2004 and 2008, despite the economy worsening;
--White obese women experienced a wage penalty in both 2004 and 2008 while white men only experienced a differential in 2004;
--Obese Hispanic women experienced a wage differential in both 2004 and 2008; obese Hispanic men only experienced a wage differential in 2008;
--Obese black men's wages were higher than their normal weight counterparts in 2004 and 2008, while black women's wages were similar between those who were obese and those who were normal weight.

The research builds upon previous research that focused on the overall, tangible, annual costs of being obese based on indirect costs, including lost productivity, and direct costs, such as obesity-related medical expenditures. On average, those costs are $4,879 for an obese woman and $2,646 for an obese man.

The implication for clinicians involves moving beyond just the direct costs and into the indirect--yet unclear--relationship between obesity, health and socio-economics, the report concluded.
Thursday, December 15, 2011

Is the adderall shortage a harbinger of future drug supply problems?

Today, most if not all doctor's offices are strained by the shortage of some prescription medication or vaccine. A month ago, President Obama signed his executive order directing the FDA to take steps to reduce drug shortages as the White House stated that drug shortages have nearly tripled over the past five years, reaching the stunning number of 178 in 2010. These shortages make regular news: Cancer patients without the chemotherapy needed to keep them alive, antibiotics unavailable to treat life-threatening infections, or intravenous nutrition to support the critically ill fighting to live while medical teams and families search for elusive remedies.

As this new reality plays out in hospitals and homes the media is provided a steady stream of drama for our morning paper or evening news. Meanwhile, time and focus is repeatedly stolen from physicians, patients, and parents in a myriad of ways. Currently, my medical practice in primary care internal medicine has been negatively affected by the shortage of Adderall, a medication used to treat attention deficit hyperactivity disorder (ADHD). What this medical condition may lack in dramatic news worthiness it more than makes up for in sheer numbers, with an estimated 4.5 million Americans living with this condition today.

I had my first inkling several months ago of the affect the Adderall shortage would have on my practice after one of my patients called frustrated that their pharmacy did not have their Adderall at the prescribed dosage. By calling several pharmacies I was able to find their medication at a smaller dose. Advising my patient to "double-up," I wrote another prescription and had to direct my patient to return to my office to pick up the rewritten prescription, a time-consuming process that doctors and patients can ill afford to repeat on a regular basis.

Unfortunately, this scenario, initially thought an exception, has now become the rule, monopolizing my own time while draining the daily resources of my staff, nurse and medical partner. Most ironically though, it forces a population of patients unable to concentrate without medication to focus on precisely the type of task that would challenge them the most in order to obtain their medication, a classic "Catch-22".

Last week, I had the opportunity to attend the Capitol Hill forum, "Is ADHD Ailing our Economy," in the Rayburn office building. From a panel of experts I heard evidence regarding the prevalence of ADHD in our country as well as the economic impact ADHD has on our nation's economy. I had previously thought in economic terms limited to drug costs alone, but during this forum I heard compelling evidence of the economic impact of untreated ADHD, such as the cost last year somewhere between $87 billion and $138 billion dollars in lost productivity or the expense of $3 billion dollars in burden to the judicial system in 2010 alone.

Against this backdrop of economic impact my curiosity as to the cause of the Adderall shortage was piqued. If the economic impact of untreated ADHD is so expensive, then how can we allow the shortage of Adderall to continue? I spoke with a representative for Shire pharmaceuticals, makers of Adderall XR, and was assured that the shortage did not extend to their product line, as the shortage was limited to the generic rapid release version of Adderall. He stated that the actual cause of the shortage was complicated, but Shire's quarterly report dated Mach 31, 2011 stated that "Shire's ability to supply this product is limited by quota restrictions that the U.S. DEA places on amphetamine use."

The FDA blames increased demand (legal and illegal), while the DEA has not released any official statement on the shortage, but does offer a "Drug Fact Sheet" comparing Adderall to cocaine and crack. Further confusing the reasons for this shortage are lawsuits filed over the last two years by Teva pharmaceuticals and Impax Laboratories, makers of generic Adderall, against Shire regarding shortages of the parent compounds in making Adderall as Shire is under contract to provide the parent compound to both of these companies.

While the specific reasons for the Adderall shortage remain elusive and the finger pointing continues, I fear this shortage will continue unchecked for many more months before a solution is found. Adderall is but one of many drugs now difficult to find and I am most worried that these shortages are a symptom of a growing dysfunction between government and the medical industry. Today's shortages may pale in comparison to tomorrow's deficiencies.

Dr. Simmons' travel and participation in the Capitol Hill briefing was made possible by sponsorship from Shire Pharmaceuticals.

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

Medical Skepticism, vol. 5

Tip of the cap to the St. Louis Cardinals for their inspired comeback and World Series victory.

I offer an even bigger hat tip to famous Alabama orthopedic surgeon Dr. James Andrews for his robust medical skepticism.

Those of you that are sports fans have no doubt heard of Dr. Andrews. He is to pitchers' elbows, shoulders and knees what Andy Warhol was to Campbell's Soup.

The New York Times trendspotted the following big medical news: Doctors order too many MRIs.

Shocker, right?

You may have read something like this before; here the difference is that it's the folks most likely to benefit from the superfluous imaging tests that are decrying their overuse.

Orthopedic surgeons generally only earn income when they perform operations. So it comes as big news when the best and the brightest of the bunch tell us we don't need the tests that lead them to do operations.

In fact, the technology in the MRI is so good that it defies our understanding of what to actually do with the information it provides.

Here are some key points from the Times article that will save you the trouble of clicking over there:
1) The details in an MRI are such that a radiologist almost never interprets a study as "normal."
2) The irregularities that make an MRI "abnormal" seldom correlate to physical symptoms (more on this below).
3) As an example: when a healthy runner goes for a jog, she'll have evidence of "abnormal" fluid noted in her knee capsule on an MRI scan immediately afterward. But there is no injury.
Dr. Andrews, in a gutsy move, obtained MRIs on the shoulders of 31 professional baseball pitchers. To quote the article: "The pitchers were not injured and had no pain. But the MRIs found abnormal shoulder cartilage in 90% of them and abnormal rotator cuff tendons in 87%. "If you want an excuse to operate on a pitcher's throwing shoulder, just get an MRI.," Dr. Andrews says."

In training, I was taught about a study in which 100 consecutive healthy volunteers received MRIs of their low back. Even though none of the subjects had symptomatic back pain, 33 of them had abnormalities on their MRIs, things like disc "herniations" and "protrusions."

What do we do with that information? Should we offer the volunteers surgery that they don't need?

Dr. Andrews and his orthopedic colleagues are asking themselves the same questions about their patient-athletes.

A take home point: don't demand an MRI from your doctor if you have a musculoskeletal athletic injury. Time itself heals many wounds.

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.

Mice, men, and the measure of resveratrol

Based on a small, brief, but nonetheless profound and compelling study in the current issue of the highly regarded scientific journal, Cell Metabolism, I intend to start taking resveratrol.

Rarely is anything that comes in a capsule or pill worth comparing to the power over medical destiny exerted by living well, good use of feet and forks in particular. Lifestyle can do what no pill can do. That will doubtless prove true of resveratrol as well, but thus far its promise looks all but unprecedented to me. The study in Cell Metabolism did, in fact, compare this particular pill to the power of lifestyle, and the pill measured up.

And rarely is it prudent to make a leap of faith from mice to men. Rodent studies often suggest benefits that fail to materialize when therapies are tested in humans. But having shown early promise in mice, resveratrol has nimbly made the leap to men (with, presumably, the same implications for women) in the new study.

The study in question assigned 11 obese but otherwise healthy men to 30 days of placebo and 30 days of 150 mg of resveratrol daily in random order. The study was double-blinded, meaning neither the participants nor the researchers knew who was taking what when. The fundamental study hypothesis, based on prior work in animals, was that resveratrol supplementation would mimic the effects of calorie restriction.

Calorie restriction has long shown promise for extending lifespan. Studies in a number of species have shown clear gains in longevity with administration of a nutritionally adequate, but calorically restricted diet (roughly 30% fewer calories than would be considered a "normal" level for maintenance of healthy weight). There have been no such studies in humans, for some fairly obvious reasons, salient among them the fact that if such an intervention worked, it would take longer than the researcher's lifespan to find out!

That said, the metabolic effects of calorie restriction in humans suggest opportunities for both health promotion, and life extension. But there are also some jokes attached to the notion of extending survival by practicing a state of carefully controlled, semi-starvation. Among the better ones: You may live forever, or maybe it will just feel that way. Or: It may well extend your life, but you'll keep wishing you would die!

Of course, adherents to so-called caloric restriction deny the downside, and report feeling vital while anticipating a long life. They intend to have the last laugh. Whether or not they get it, I wish them well.

But I also recognize that no matter what the benefits of calorie restriction, most people will not practice it. After all, we know there are profound benefits of controlling weight just by eating the recommended level of calories, and we can't get most people to do that! So 30% less? Fuggedaboutit.

Enter resveratrol.

Uva en Paterna (Valencia) by Herbolario Allium via Flickr and a Creative Commons licenseResveratrol is a compound concentrated in grape skin, and thus red wine. Early studies suggested it functioned as a potent antioxidant. While that might be of health benefit on its own, the history of isolated antioxidant supplements is one of perennial disappointment. Our high hopes for clear health benefits with supplements of vitamin C, beta-carotene, vitamin E, lycopene, and combinations have been consistently dashed. Meta-analyses of antioxidant trials suggest no benefit, and potential harm, serving up a starkly precautionary message.

But resveratrol is not just an antioxidant. It influences mitochondrial function and energy metabolism. And most importantly, resveratrol is a gene modifier. It influences the activity of a gene complex called SIRT1, which influences a wide array of metabolic activity, is considered a regulator of the "health span," and is the very gene complex influenced by calorie restriction.

The new study was published in Cell Metabolism for a reason, it reports changes in biochemical measures and cell biology and is thus a bit dense in its details. But the take-away message was clear enough. Daily dosing of resveratrol for a month mimicked most effects of calorie restriction, improving energy metabolism in muscle, improving insulin sensitivity, lowering blood pressure, and apparently enhancing fitness. There were no adverse effects of resveratrol.

Of course, there is much we don't know. The beneficial effects of resveratrol might wear off in time, or be too modest to matter. Or perhaps adverse effects might show up late. Calorie restriction, for instance, is associated with reduced fertility, and reduced libido. I count myself among those who would consider the latter of those effects too high a price to pay for any metabolic benefits. We don't know if resveratrol can facilitate weight loss, although that looks promising. We don't know, and won't for a very long time, if it can extend the human life span.

But we do have the first clear evidence that a natural compound can exert the same profound effects on metabolism, weight and genes, in humans, as calorie restriction. There is at least reason to hope a meaningful anti-aging effect could be appreciated as well.

Resveratrol has made the leap from mice to men. It will take some time to ascertain the true medical measure of this compound. While it is certainly premature to declare it a "wonder drug," I find myself wondering about that possibility. It's the best contender for a profound medical advance in a pill I have seen in a long time.

And so, I intend to try it for the next six months or so to see what effects I discern (less, of course, if I discern any I don't like). I can't yet recommend resveratrol to you with any great conviction, but I can share my excitement about its apparent promise, and I promise to share the results of my personal experience with it. Stay tuned!

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

QD: News Every Day--5 steps for preventing provider fatigue

Health care facilities should take five steps to ensure staff aren't becoming sleep fatigued, according to a Sentinel Event Alert from The Joint Commission.

Shift length and work schedules impact job performance, and in health care, that means patient safety, the alert stated. A study of 393 nurses over more than 5,300 shifts showed that nurses who work shifts of 12.5 hours or longer are three times more likely to make an error in patient care.

Furthermore, residents who work traditional schedules with recurrent 24-hour shifts:
--make 36 percent more serious preventable adverse events than individuals who work fewer than 16 consecutive hours,
--make five times as many serious diagnostic errors,
--have twice as many on-the-job attentional failures at night,
--experience 61% more needlestick and other sharps injuries after their 20th consecutive hour of work,
--experience a 1.5 to 2 standard deviation deterioration in performance relative to baseline rested performance on both clinical and non-clinical tasks, and
--make 300% more fatigue-related preventable adverse events that led to a patient’s death.

The Joint Commission recommended five specific steps to take:
1. Assess fatigue-related risks, including those for off-shift hours and consecutive shift work.
2. Assess hand-off processes and procedures to ensure that they adequately protect patients against mistakes due to fatigue.
3. Invite staff input into designing work schedules to minimize the potential for fatigue.
4. Create and implement a fatigue management plan that includes scientific strategies for fighting fatigue. These strategies can include: engaging in conversations with others (not just listening and nodding); doing something that involves physical action (even if it is just stretching); avoiding caffeine when already alert or when nearing bedtime); taking short naps (less than 45 minutes).
5. Educate staff about sleep hygiene and the effects of fatigue on patient safety.

"We have a culture of working long hours, and the impact of fatigue has not been a part of our consciousness," said one physician, a sleep expert and author of several research studies on sleep's effects on providers and patient safety, in the report. "Most are unaware of sleep and circadian biology and the degree that it affects performance. And, most do not realize how much research supports the need to make changes."
Wednesday, December 14, 2011

QD: News Every Day--E-cigarettes should require third-party health and safety reviews

Modified risk tobacco product manufacturers should consider using FDA-approved, independent third parties to oversee health and safety research on their products, according to an Institute of Medicine report.

Such studies should look at each product's composition and addiction potential; the amount of human exposure to harmful components; perceptions about the product's effects and likelihood of addiction; and effects on human health, the report continued.

Studies should be reflect the entire population and should also include current and former smokers, beginning smokers and teens, and groups at high risk for tobacco use.

"Independent oversight would ensure that the data submitted to FDA are reliable and credible, and it could help re-engage the mainstream scientific community in research," the Institute of Medicine said in a release. "Because of the tobacco industry's well-documented history of improper conduct, many institutions and scientists currently refuse to conduct or publish research supported by the tobacco industry."

Cigarette use is 20.6% among adults and 19.5% in youth, rates that have been static since the late 1990s, the report said. Of the 46 million adult smokers in the United States, an estimated 70% want to stop. While 45% try to stop during the course of a year, only 6% succeed for one month or more.

Modified risk tobacco products such as e-cigarettes and lozenges could be one part of a comprehensive strategy, especially among the most reluctant to quit, but too little is known about the products' health effects and whether they pose less risk than traditional tobacco products.

The Family Smoking Prevention and Tobacco Control Act of 2009 requires that modified-risk tobacco products undergo a pre-market approval process similar to drugs and devices. According to the act, a company that wants to market a lower-risk tobacco product in the U.S. must offer scientific proof to the FDA that the product will not only reduce harm to individuals, but also benefit the population as a whole.

While the companies usually do their own FDA safety studies, the tobacco industry lacks the capacity and expertise to do so, the report says. And, the industry's history of improper manipulation of data undermined its credibility and isolated it from the mainstream scientific community, the IoM release said. Many major universities won't accept tobacco funding, and many high-impact scientific and medical journals won't accept manuscripts supported by the tobacco industry.

Transparency would also build trust, the IoM said. Making data publicly available will also build public trust and will allow for independent analysis of data and methods, the report says. FDA should require sponsors of modified risk tobacco products to place all data generated during a product's development and marketing in a public repository selected by the agency.

FDA should also require that studies offered in support of an application to market modified risk tobacco products conform to established standards of good research governance, including appropriately qualified investigators, transparency, independent institutional review board or ethical review, and adherence to federal regulations that ensure the protection of human participants in biomedical research.

Thoughts on getting my photo taken at a medical appointment

A funny thing happened at my doctor's appointment on Friday. I checked in, and after confirming that my address and insurance hadn't changed since last year, waited for approximately 10 minutes. A worker of some sort, likely a med-tech, called me to "take my vitals."

SiPix camera by Hello, I am Bruce via Flickr and a Creative Commons licenseShe took my blood pressure with a cuff that made my germ-phobic self run for self-regulation, i.e. I stayed quiet and didn't express my concern about the fact that it looked like it hadn't been washed in years. I value this doctor among others in my care, and I didn't want to complain about anything. Then the woman took my weight. And then she asked if she could take my picture, "for the hospital record."

I couldn't contain my wondering self. "What is the purpose of the picture?" I asked.

"It's for the record," she explained. "For security."

I thought about it. My picture is pretty much public domain at this point in my life, a decision I made upon deciding not to blog anonymously. Besides, most everyone at the medical center used to know me, including the receptionists, janitors, cafeteria cashiers, nurses' aides, social workers, deans, full professors, geneticists, fellows in surgery and old-time voluntary physicians, among others who work there. So why didn't I want this unidentified woman who works in my oncologist's office to take my picture?

It made me uncomfortable, and here's the reason: My picture is a reminder that, without it, I might be like any other patient in the system. They (administrators, nurses, other docs, maybe even my future doctors) will need or want the picture to recall and be certain who Elaine Schattner is.

Don't get me wrong. I agreed to the photo after all of maybe 20 seconds deliberating. (And my doctor was, I soon learned, duly informed I'd "had an issue" with it. Was that for just asking the reason?) The unidentified med-tech person used an oddly small, ordinary pink camera to complete her task.

When I met with my doctor, she explained that the photo is for security and, essentially, to reduce the likelihood of errors. The hospital has records of so many thousands of patients, many who have similar or identical names. There are good reasons to make sure that your notes on "Sally Smith" are entered into the chart of "Sally Smith" who is your patient.

It's understandable. I remember when at the nurses' station there'd be a sign (on "our" side) saying something like "CAREFUL: Anna Gonzalez in 202, Alma Gonzalez in 204b," or something like that.

Patients blur.

It's hard, veritably impossible, for most doctors and nurses to keep mental track of all of the patients they've ever seen and examined. There's utility in the new system. Yes, it's a good idea for a doctor, say upon receiving a call from a woman she hasn't seen in 3 or 6 or 9 years, to see her picture in the chart, as a reminder.

But I hope my doctors know who I am, and not just what I look like in the image.

This post originally appeared at Medical Lessons, written by Elaine Schattner, ACP Member, a nonpracticing hematologist and oncologist who teaches at Weill Cornell Medical College, where she is a Clinical Associate Professor of Medicine. She shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology and as a patient who's had breast cancer.
Tuesday, December 13, 2011

Medicare ramps up rationing of cardiac and orthopedic care

With the announcement that the Center for Medicare and Medicaid Services (CMS) will begin auditing 100% of expensive cardiovascular and orthopedic procedures in certain states earlier this week, we see their final transformation from the beneficent health care funding bosom for seniors to health care rationer:

"The Center for Medicare and Medicaid Services will require pre-payment audits on hospital stays for cardiac care, joint replacements and spinal fusion procedures, according to the American College of Cardiology in a letter to members. Shares in both industries fell with Tenet Healthcare Corp., the Dallas-based hospital operator, plunging 11% to $4.18, the most among Standard & Poor's 500 stocks. Medtronic Inc., the largest U.S. maker of heart devices, dropped 6% to $34.61.

The program means hospitals won't receive payment for stays that involve cardiac care or orthopedic treatment until auditors have examined the patient records and confirmed that the care was appropriate, Jerold Saef, the reimbursement chair for the Florida chapter of the American College of Cardiology, wrote in a Nov. 21 letter to members. The review process is expected to take 30 days to 60 days, beginning January 1, Saef said."

This is not at all unexpected. In fact, in our field of cardiac electrophysiology, we have known this day would be coming; our expensive, life-saving gadgets and gizmos are easy targets upon which the government can cut its rationing teeth. And so as it will go for us at first, and then for many other areas of health care.

But the government has no idea how to do this, really. They don't have the data, the cerebral wattage, acceptable information systems, nor manpower. So, the government will grow further to offset its shortcomings in order to assure they can "save money" for our health care system.

But CMS, like the U.S. Post Office, has a dirty little secret: they don't pay very well. To offset their low pay, they have to offer some pretty nice benefits to attract their best and brightest. And because the government is now going to bite off trying to manage an entire country's medical procedure rationing during a limited eight-hour government workday, they are going to be flooded with calls, many of which will be frustrated, angry calls that have been on hold a very, very long time.

And so they'll hire more people to improve services.

And pretty soon it will dawn on them: this is expensive to do. It will just be a matter of time when, like the Post Office that was affected by their inability to keep up with pension and health care costs, they'll surrender and turn over their efforts to private enterprise.

That's because health care is local. Health care is complicated and needs lots of data, systems, and capable facile people to make decisions on data the government wants but knows it doesn't have. (Remember when the Department of Justice had to "consult" with the Heart Rhythm Society to "understand" defibrillator implant practices by tapping into their NCDR database?) Further, because the government moves slowly, can print money when it runs short, and must work through politics, government rarely works under budget. (In fact, when money runs out in government, they just shut down – not a great idea when working in health care.)

Of course the insurers don't want this. They already know it's too damn expensive to take on the risk of our paying for the health care of our aging seniors. (They were one of the main proponents of health care reform, remember?) So the government will have to have their back somehow. (Those details still have to be worked out, but it'll happen because politically, it must).

And the final transformation of our health care system of the future will be complete.


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.

Difficult to digest carbohydrates implicated in irritable bowel syndrome

Irritable bowel syndrome (IBS) is a chronic condition marked by abdominal pain, bloating, and alternating constipation and diarrhea. There is no specific test for IBS and other more serious diseases like celiac disease and inflammatory bowel disease can cause similar symptoms. The good news is that when a doctor has ruled out these more serious diseases and diagnosed IBS the patient can be assured that her illness is chronic but not progressive or life-threatening. The bad news is that IBS symptoms can be quite miserable, and at their worst can interfere with work and life activities.

Myriad treatments are used for IBS, and as with any disease with myriad treatments, that means that none of them are consistently effective. I wrote five years ago about a trial that showed modest success using antibiotics for IBS but even that trial did not show an improvement in the majority of patients.

A new theory proposed by researchers in Australia holds that IBS is caused by certain sugars that are difficult to digest. These sugars pass undigested through the small intestine and are fermented by bacteria in the colon. This releases carbon dioxide which causes bloating and pain, and draws water into the colon which causes diarrhea.

These carbohydrates are called FODMAPs, which stands for Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols, which just means small sugars that can undergo fermentation.

FODMAPs are present in lots of foods. (This Wall Street Journal article has a handy table with a list of foods high in FODMAPs and low in FODMAPs.) So eliminating them entirely requires some drastic dietary changes. Nevertheless, the Australian researches published a study in last month's issue of the Journal of Human Nutrition and Dietetics in which patients were randomized to standard care or to a FODMAP-free diet. About half of the patients in the standard group had symptom improvement, compared to about three quarters of those on a FODMAP-free diet.

Gastroenterologists who are promoting this theory recommend that patients try a FODMAP-free diet for six to eight weeks and then slowly reintroduce FODMAP-containing foods to determine what quantities they can tolerate. Unlike food allergies, complete abstinence is not necessary. It's just a matter of reducing the FODMAPs below whatever threshold causes misery.

Some caveats are necessary. The study was quite small, and it was not blinded since it's impossible not to know whether your diet is being restricted radically. So the results should be treated as suggestive but preliminary. Still, for those with severe IBS symptoms a FODMAP-free diet may be worth a try. It may be inconvenient but it's certainly safe and the worst that could happen is that it won't work.

Learn more:
When Everyday Foods Are Hard to Digest (Wall Street Journal)
Very Restricted Diet May Reduce Symptoms of IBS (WebMD)
Irritable Bowel Syndrome (National Library of Medicine information page)
An Oral Antibiotic Reduces the Symptoms of Irritable Bowel Syndrome (my post in 2006)
Comparison of symptom response following advice for a diet low in fermentable carbohydrates (FODMAPs) versus standard dietary advice in patients with irritable bowel syndrome (Journal of Human Nutrition and Dietetics)

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.