Wednesday, February 29, 2012

Think like a doctor, part III

In part I we discussed the history of medicine as a science. In part II we addressed the role of compassion. This is the third part of the series.

In 1994, I first put my hands on a human cadaver. When we first received it, the head and hands were wrapped. The rumor was that this would help us to adjust to the humanity of the thing more gradually. When we did uncover the hands, the nails were painted, giving the meat a sudden, undeniable humanity.

Over the months, my friends and I slowly dissected this person, finding nerves, veins, arteries, muscles. At the same time we learned the microscopic anatomy. We learned how chemistry drove the smallest units of muscles, causing the whole to contract and lift an arm. We learned how specialized channels in the gut could be poisoned, causing cholera patients to dehydrate and die in hours.

We learned how the immune system could be taught to fight influenza; the mechanism by which common antibiotics poisoned cell wall formation in bacteria; the horridly complicated function of the smallest functional unit of the kidney called the nephron. We stood on the shoulders of giants. I loved it.

The first two years of medical school is an intimate visit with the inanimate. Living patients are scarce; the knowledge the human machine is the focus. We stayed in the labs until the middle of the night examining our cadaver, looking into microscopes and comparing what we saw to pictures in books. We traced out biochemical pathways on chalkboards. Never did we see anything corresponding to a meridian or to the four humors, or any other pre-scientific medical ideas. They were clearly a fiction, one dreamed up by our ancestors to explain something insanely complicated.

In the third year, when we did finally see patients regularly, it all came together slowly. It's a medical aphorism that patients don't always read the textbooks. Their diseases may not follow expected patterns. And the addition of real human desires and fears complicates everything.

It takes years to learn how to use medical knowledge to help real people, but you can tell immediately how comforting a word or gesture can be. During that period of perceived incompetence, while you learn how put book knowledge into practice, we reach for things we already hopefully know: how to comfort people.

So-called alternative medicine seems attractive at this point because it purports to focus on the compassion, the relief of symptoms. Let's look into why this is a false compassion.

A patient being treated with acupuncture moxibustion in Nelson, New Zealand by Wonderlane via Flickr and a Creative Commons licenseDuring my third year internal medicine rotation, some of the nurses were practicing "therapeutic touch" on our patients. Since none of us knew what this was, we asked them to stop doing things to patients without an order. Soon after, a remarkable article showed up in the Journal of the American Medical Association. A young girl, with the help of her parents and a well-respected physician, conducted a study on therapeutic touch showing its underlying theory to be fictitious. The alleged energy fields being manipulated by practitioners could not be found to exist.

This was a revelation for me. It brought it all together: the lack of alternative medicine findings in biology or anatomy, the mystical nature of altmed, the claims that the effects could not be measured by "traditional, scientific means." I came to realize that there was no such thing as alternative medicine. There was only medicine shown to work, and everything else.

I did go through my "shruggie" phase--after all, if acupuncture makes my patient feels better, than what's the harm? (In the case of acupuncture, one of the harms may be hepatitis C.)

What I found, though, is whatever good may have come from some altmed practices, it didn't even compare to the harm. Patients were taking buckets of supplements, undergoing potentially harmful procedures, and turning away from medicine proven to work.

This whole process took me years. The rhetoric of alternative medicine is seductive; the truth of real medicine beautiful but messy. How can we teach people to sort out real medicine from everything else? For a layperson, there is no sure way, but here are some hints for laypeople and for doctors who haven't thought much about it:
--If a claim goes against the basic rules of nature, it's probably bunk. Homeopathy, where substances are diluted beyond existence, claims to treat all manner of problems, but for this to be true, we would have to overturn our basic understanding of the universe. Unless the data are close to irrefutable, I'll stick with the model of the universe we already have.
--If a treatment relies on an energy or pathway in the body that cannot be seen in the anatomy lab or detected in some other way, it doesn't exist. So-called energy fields purported to run through the body have never been detected. Meridians of qi have never been detected. Subluxation complexes of chiropractic have never been detected. Therefore, they are unlikely to exist.
--If someone claims that their healing method can't be measured by modern science, they are wrong. It is nonsense on its face. If someone claims an effect, then it is measurable. For example, if someone says that reiki treats a disease, then it should be easy enough to create a study where one group gets fake reiki and the other gets "real" reiki. There. You've measured it. There is no medical intervention that cannot be measured in some way.
--If someone is charging you an exorbitant price for something seemingly simple, it's probably a rip-off. Energy bracelets, crystals, special supplements, sea salts, none of these things contain anything special, nor should they cost a lot of money. Most real doctors prescribe medicines and interventions that they don't directly profit from (directly being the key word). Some specialties, such as dermatology and ophthalmology, may sell items directly related to their practice, but most other specialties do not. As an internist, there is nothing I can think of that I could ethically sell to my patients.
--If a practitioner tells you not to go to regular doctors, then they are trying to kill you, whether they know it or not.
--If a practitioner claims to have special tests that no one else has access to, such as mouth swabs for toxins or special tests for Lyme disease, something is fishy.
--If a practitioner claims there is a grand plot by pharmacy companies or "mainstream medicine" to hide a cure, they are either criminal or crazy. Real doctors want to help people, and real cures are very, very profitable.
--If a practitioner is a "brave maverick," bucking the stodgy power structure of traditional medicine, then he is more likely a dangerous rogue and believes his intuition is smarter than science.
--Older is not better. Just because something is ancient doesn't make it good. In fact, the opposite is usually true, as ancient medical beliefs are usually pre-scientific and fictitious.
--If it sounds too good to be true, it probably is. This is an old rule, but useful. If some drug or procedure really makes you live longer, or cures a horrible disease, it will eventually be available everywhere. Patients and doctors will demand it. But most of these claims never pan out.

This is just a few hints, not a comprehensive list. And certainly, these don't work all the time. A cancer specialty center will probably have new tests that aren't available everywhere, but this is the exception. Web sites like What's the Harm, Quack Watch, and Science-based Medicine have lists of questionable practices and make useful references. But the easiest thing to do is to find a doctor you trust and run things by them. Patients come to me all the time with ads from the paper or printouts from websites. I explain to them what the context is and whether it's worthwhile to follow up on them.

Medicine has spent the last century-and-a-half maturing into a real science. We know that human body is part of the same universe as everything else, made of the same "star stuff." Understanding and improving medicine requires a scientific approach to a real, physical problem. The practice of medicine requires a thorough dedication to science and a deep well of compassion. With either missing, we do our patients a disservice.

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.

NEJM reports on two new drugs for hepatitis C

A recent New England Journal of Medicine delivered an intriguing, imperfect article on a new approach to treating hepatitis C (HCV). The paper's careful title, Preliminary Study of Two Antiviral Agents for Hepatitis C Genotype 1, seems right. The analysis, with 17 authors listed, traces the response of 21 people with hepatitis C (HCV) who got two new anti-viral agents, with or without older drugs, in a clinical trial sponsored by Bristol-Meyers Squibb.

The 21 study participants all had chronic infection by HCV genotype 1, a strain that's common in North America and relatively resistant to standard treatment. All subjects were between 18 and 70 years old, with a measurable level of HCV RNA in the blood, no evidence of cirrhosis, and no response to prior HCV treatment (according to criteria detailed in the paper). In the trial, 11 patients received a combination regimen of daclatasvir (60 mg once daily, by mouth) and asunaprevir (600 mg, twice daily by mouth) alone; the other 10 patients took the experimental drugs along with two older meds for HCV: Peginterferon (Pegasys, an injectible drug by Roche) and Ribavirin (Copegus, a pill, by Roche).

The main finding is that the 10 patients assigned to take four drugs all did strikingly well in terms of reducing detectable HCV in their blood over the course of 24 weeks. There was a dramatic response, also, in four of the 11 patients assigned to the new drugs only. An accompanying editorial highlighted the work as a Watershed Moment in the Treatment of Hepatitis C. The medical significance is that they've demonstrated proof of principle: by "hitting" a resistant HCV strain with multiple anti-viral drugs simultaneously, they could reduce it to undetectable levels.

The first question you have to ask about this report is why the NEJM, the most selective of medical journals, would publish findings of an exploratory analysis of two new pills paired with two older drugs for HCV. The best answer, probably, is that the virus infects some 4 million people in the U.S. and approximately 180 million people worldwide, according to the study authors. HCV can cause liver damage, cirrhosis, liver cancer (which is usually fatal) and occasionally blood disorders.

The new drugs derive from some interesting science. This, maybe, also is a factor in why the article was published in the NEJM. Daclatasvir (BMS-790052) blocks a viral protein, NS5A, that's essential for HCV replication. The second new drug, asunaprevir (BMS-650032) inhibits a viral protease, NS3.

I have several concerns about this report. One is that the researchers screened 56 patients for possible registration but enrolled only 21 on the trial; according to a supplementary Figure 1, 35 potential subjects (over half) didn't meet criteria for eligibility. This disparity makes any once-researcher wonder about bias in selecting patients for enrollment. If you're a pharmaceutical company and want to show a new drug or combo is safe, you're going to pick patients for a trial who are least likely to experience or display significant toxicity.

Toxicity seems like it could be problematic. Diarrhea, fatigue and headaches were common among the study subjects. Worrisome is that six patients (of 21, that would be 28.5% of those on the trial) had liver problems manifest by at least one enzyme (the ALT) rising over three times the normal limit.

Further complicating the picture is there's no indication of how these new drugs mesh with the two drugs approved for HCV in 2011: Victrelis (boceprevir) and Incivek (telaprevir).

Given all these limitations, you might wonder about Bristol-Meyers Squibb's influence at the NEJM or, more likely, the manuscript's peer reviewers. The 17 study authors, and the editorialist, separately, disclose a host of industry ties.

What I'm thinking, as much as I'm critical of this research work, is that this is probably the way of the future: smaller, pharma-funded studies of targeted new drugs in complicated combinations. Many will be authored by academics with ties to industry, if not put forth directly by company-employed researchers. These quick-and-promising studies in select patient groups will be routine. And while advocates push for rapid publication of new clinical research in patients with resistant, disabling diseases, it'll be hard for physicians and patients to interpret these kinds of data.

So these particular findings may turn out to be true and life-saving, or not. The bigger concern is this: It would be helpful if the journals would take a really tough stance on full disclosure of authors and editors ties to industry. As Merrill Goozner has emphasized, the Physician Payment Sunshine Act, a small component of the 2010 health care reform legislation, has important implications for academic medicine and reporting of clinical research studies.

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

QD: News Every Day--'Do-not-resuscitate' orders as body art

People have taken to tattooing medical directives on their bodies in case of an emergency.

Lindsay's tattoo by David Sledge via Flickr and a Creative Commons licensePeople undergo tattoos for many reasons, often sentimental ones, but more often than you'd think for medical causes. Patients have received tattoos to cover mastectomy scars, for example, or enhance the appearance of amputations.

Another "tattoo" is actually a skin patch that can monitor vital signs. And scientists have gotten tattoos to celebrate their research, reports internist Toni Brayer, MD, FACP.

Now, people are undergoing tattooing to direct emergency responders in case of an emergency. One pathologist inked "no CPR" on his chest, while others note their status as diabetics or as allergic to peanuts or penicillin, reports the Associated Press.

The AP article outlines how people report that the more common alert bracelets can break or become lost. But, it notes, there's no standardization on how to present tattoos so emergency responders know to look for them, and there's certainly no legal precedent for how a clinician would follow such instructions in the absence of legal documentation.

Endocrinologist Saleh Aldasouqi, MD, FACP, offers case reports from his own files and said that standards are needed for the practice, and that diabetics need to consult with their physicians before undergoing the needle.

Along with tattooing comes body piercing. A review article considers all the issues that surround pierced body parts that primary care physicians should be aware of. Body piercing is on the cusp of entering mainstream acceptance, and a host of issues follow.

One in five piercings become infected, typically with Staphylococcus aureus, group A streptococci and Pseudomonas, but rarely, there's coagulase-negative staphylococci, anaerobic bacteria, or atypical mycobacteria, reports the February issue of the American Journal of Clinical Dermatology. There have even been fatalities associated with them in the absence of any other source of infection.
Tuesday, February 28, 2012

The new subspecialty of clinical informatics: Some (but not all) questions answered

Last fall, the American Board of Medical Specialties (ABMS) approved a medical subspecialty in clinical informatics. The approval of this subspecialty is a recognition of the critical professional role played by clinical informaticians.

As information is so critical to 21st Century medicine, whether in the need for healthcare to be more accountable for its operations or in the coming complexity of clinical decision-making from the data "tsunami" due to advances in genomics and related areas, there will be increasing need for those who work at the interface of medicine and information systems.

Although administered by the American Board of Preventive Medicine (ABPM), the subspecialty will be available to all physicians who have a primary board certification, which is a first for medical subspecialties. The first offering of the examination will likely take place in late 2012 or early 2012 for those who meet the criteria for "grandfathering" of the training requirements.

In the long run, physicians wanting to subspecialize in clinical informatics will need to complete formal fellowship training. The motivation for physician certification in informatics is to recognize the growing stature and need for professional expertise of physicians who spend a significant amount of their time performing informatics-related duties. This includes not only the growing role of the Chief Medical Informatics Officer (CMIO), but other jobs where a physician draws on his or her expertise at the intersection of medicine and informatics.

A great deal of further information is available about this development. The American Medical Informatics Association (AMIA), which spearheaded the effort, has developed a subsite of its website devoted this effort. The site includes a background document, the original press release announcing the ABMS approval, a collection of frequently asked questions (FAQs), and an article by AMIA President Dr. Ted Shortliffe.

I report on this topic periodically in my own blog as well, and an audio report from the iHealthBeat website is also informative.

The "gold standard" for any type of certification of physicians is board certification. There are currently 24 specialty boards (e.g., internal medicine, family medicine, pediatrics, surgery, radiology, preventive medicine, etc.), most of which have subspecialty boards as well (e.g., cardiology, hematology/oncology, and general internal medicine in internal medicine). Some subspecialties, such as geriatrics and palliative medicine, are offered by more than one specialty board. This will be the model for the clinical informatics subspecialty, and in fact it will be offered by all 24 specialty boards.

A comprehensive overview of the rationale and plan for developing the clinical informatics subspecialty was published in early 2010 by Detmer et al.1. This paper described the development of medical specialties and subspecialties generally and in the context of the new proposed subspecialty of clinical informatics. A more recent overview of the status board specialties was published last year and included mention of the proposed one for clinical informatics.2 Papers published in 2009 laid out the details of the core curriculum 3 and training requirements 4 for the subspecialty.

The proposal to establish the clinical informatics subspecialty was developed by the American Medical Informatics Association (AMIA) and submitted to the ABMS in 2010. The lead board submitting the proposal was the American Board of Preventive Medicine (ABPM), which has since been joined by the American Board of Pathology. These two boards will be the administrative home for the subspecialty although as noted above, physicians of all primary specialties will be able to become certified.

Certification in clinical informatics will work like any other multi-board subspecialty. To become certified, a physician will need to meet certain training requirements and then pass a certification exam. In the early years (usually the first five years of a specialty's existence), those with a certain level of experience will be able to "grandfather" in on the training requirements in a "practice track" and certify by passing the exam only.

Those training after the initial practice track period will be required to complete some sort of fellowship in the specialty. The practice track requirements for clinical informatics will be determined after the ABMS approves the subspecialty and will likely apply to those with some defined level of time and depth of experience in clinical informatics settings.

Now that the ABMS proposal has been approved, the ABPM will begin development of a certification exam, which will likely become available in the fall of 2012 for those meeting the practice track requirements. The next step will be to define the requirements for clinical fellowships in clinical informatics and their accreditation by the Accreditation Committee for Graduate Medical Education (ACGME), which accredits residency and specialty fellowship training programs.

Even though the process for establishing the subspecialty is well-defined, a number of questions remain. One question is how many health care organizations and others will require their physician-informatician practitioners to be certified. Another question, very critical to academic informatics units, is what will be the role for formal didactic education, especially that offered by distance learning.

Programs such as ours at OHSU have been a popular vehicle for physicians and others to become informatics practitioners. The distance learning aspect has been especially valuable, as many clinicians enter informatics careers after they have established their clinical careers.

The graduate-level education approach has been validated by the strong uptake of these programs as well as the more recent funding for them though the Office of National Coordinator for Health Information Technology (ONC) University-Based Training (UBT) Program, including the program I direct at Oregon Health & Science University (OHSU).

I am hopeful that ACGME will adopt flexibility in the clinical informatics fellowship program educational programs, including possibly allowing organizations like OHSU to provide the coursework portion of the training requirements in settings where a large educational infrastructure is not available.

Although there are a number of details still forthcoming, this new development is an exciting one for the informatics field. AMIA is also developing other pathways for comparable certification not only for physicians who are not eligible for ABMS certification but also for informatics professionals of other backgrounds, both clinical and non-clinical. All of these will contribute to the critical role that informatics plays in the 21st Century health care system.

[1] Detmer, D., Munger, B., et al. (2010). Clinical informatics board certification: history, current status, and predicted impact on the medical informatics workforce. Applied Clinical Informatics, 1: 11-18.
[2] Cassel, C. and Reuben, D. (2011). Specialization, subspecialization, and subsubspecialization in internal medicine. N Engl Journ Med, 364: 1169-1173.
[3] Gardner, R., Overhage, J., et al. (2009). Core content for the subspecialty of clinical informatics. JAMA, 16: 153-157.
[4] Safran, C., Shabot, M., et al. (2009). ACGME program requirements for fellowship education in the subspecialty of clinical informatics. JAMIA, 16: 158-166.

This post by William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, originally appeared at his blog Informatics Professor, where he posts his thoughts on various topics related to biomedical and health informatics.

16 words that can make a drug rep go quiet

Drug reps come to our office fairly regularly, but not as often as they used to. Some of them look like regular folks, but many still look a lot like Barbie and Ken. These guys have a tough job. It's hard to cultivate relationships when you can't pay off physicians with free trips or offers of remuneration for serving as a "consultant." Remember "dine and dash?"

Mining at Broken Hill by State Records NSW via Flickr and a Creative Commons licenseDespite these prior excesses, I do not disparage pharma reps, many of whom are ethical professionals who have developed vertical knowledge on a narrow niche of medicine. I have learned from them, but I remember that they are salesmen. Caveat emptor.

Drug reps face other challenges beyond the ban on ballgame and theater tickets. We physicians are often constrained by insurance company formularies that dictate what we can prescribe. The insurance companies would balk at that statement and would offer a lawyerly response that, of course, we physicians can prescribe any drug that we believe best serves the patient's medical interest, but that this selection may not be a covered benefit. Get the idea?

One tool that pharmaceutical companies have relied on for years is to purchase individual physician's prescription data from pharmacies. This data mining gives pharmaceutical companies lists of physicians by name and the drugs prescribed by each doctor. In other words, the Nexium rep can learn how much or how little of the drug I prescribe compared to its competitors. (No patient identifying data is included.) Drug reps can be given sales goals based on this data.

Memo to Barbie and Ken
Kirsch is prescribing too much Prevacid, which is giving the corporate folks heartburn. More aggressive sales techniques required. Launch OperationBURYPREV ASAP.

Physicians have always hated this open secret in the pharmaceutical industry. It's open because we all know it is practiced and it's secret because drug folks won't talk about it. Doctors, test this the next time a drug rep wanders into your office. Use the following ice breaker as a guide.

"Yo rep, can I see my individual prescribing data that your company has mined on me?"

At that moment, you will be amazed at the stillness of the lips and larynx that are facing you. An orifice that is usually a portal for endless chatter becomes a hollow cavern. It's almost a miracle.

The Supreme Court ruled in a 6-3 vote at the end of their term last year that data mining by pharmaceutical companies is constitutional. Vermont had previously passed a law restricting this practice, which the Court has struck down.

I respect the decision because the Supreme Court's responsibility is to determine if an action is legal, not to make policy. The court did so to protect free speech. Drug reps, however, won't be speaking freely on this to physicians. I wonder how they and their bosses would feel if we mined their data. Would they agree that free speech goes both ways?

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--Move over kids, and let grandma have the game controller

Being offered video games that encouraged physical activity didn't help children, but one inactive game did help their grandparents' cognitive skills, two separate studies found.

In the first study, researchers offered a new video game system to children 9 to 12 years of age, with a body-mass index between 50th and 99th percentile. The children were randomized to receiving two active or two inactive video games. Physical activity was monitored with accelerometers for 5 weeks over the course of a 13-week experiment, as well as diaries and machine-recorded gaming sessions.

Results appeared at Pediatrics. There was no evidence that children receiving the active video games were more active in general, or at any time, for that matter, than the children who received inactive video games.

"[A]lthough children can do moderate or vigorous [physical activity] with active video games in laboratory settings, they either did not elect to play the provided games at that level of intensity, or compensated for the increased intensity by being less active at other times in the day," the authors noted.

Move over, sonny. Grandpa wants to take a crack at the game controller. A different set of researchers reported that playing World of Warcraft boosted cognitive functioning for older adults, particularly for those who had scored poorly on cognitive ability tests before playing the game.

WoWScrnShot_121606_220132 by Jemimus via Flickr and a Creative Commons licenseThe researchers said in a press release that they chose World of Warcraft because it is cognitively challenging, socially interactive and offers new situations during game play. World of Warcraft is an expansive, immersive environment that lets millions of players in a virtual world populated by creatures, characters and towns, and even offers an in-game economy and other complex features.

The researchers note on their website that, "Unlike the video games used in many of previous studies, playing WoW relies upon the simultaneous use of multiple cognitive abilities and does so within a dynamic social environment." (If you're not among the more than 10 million World of Warcraft account holders, you can get the gist of the game here.)

Researchers first tested the cognitive functioning of study participants, aged 60 to 77, to set a baseline for cognitive abilities including spatial ability, memory and how well participants could focus their attention. The experimental group of study participants then played World of Warcraft on their home computers for approximately 14 hours over the course of two weeks, before being re-tested. A control group of study participants did not play World of Warcraft, but were also re-tested after two weeks.

Results appeared at Computers in Human Behavior.

The group that played World of Warcraft saw a much greater increase in cognitive functioning, though the effect varied according to each participant’s baseline score. Among participants who scored well on baseline cognitive functioning tests, there was no significant improvement after playing World of Warcraft. Researchers recorded significant improvement in both spatial ability and focus for participants who scored low on the initial baseline tests, but no memory improvement.

The people who needed it most, those who performed the worst on the initial testing, saw the most improvement, the researchers noted.
Monday, February 27, 2012

Some construction on the medical home

"Get busy." That was the message from Richard Baron, MD, MACP, to primary care physicians attending National Medical Home Summit, held in Philadelphia today and tomorrow. Dr. Baron is a primary care physician himself (so he knows well how very busy docs already are), but he's now working at the Medicare-Medicaid Innovations Center. The agency's got a number of innovations involving the medical home and primary care physicians up its sleeve, from what Dr. Baron had to say.

One of the most intriguing was the Comprehensive Primary Care Initiative. Eventually this program will pay practices about $20 per Medicare beneficiary per month (on top of fee-for-service) to provide really coordinated, comprehensive primary care. After some time, that payment will be reduced and practices will be given a share of the savings that are expected to result from this improved primary care.

Sound good? Want to know where you sign up? Nowhere yet. Right now, CMS is shopping the idea to insurers, because the agency wants them to run concurrent similar deals with the practices so they're not revamping their services only for Medicare patients. After a good number of insurers in a particular region are on board (and so far the response has been strong, according to Dr. Baron), local practices will be recruited. The program will be looking for practices that are well-equipped to provide this higher-quality care, which is why Dr. Baron is encouraging his colleagues to "get busy" becoming high-functioning medical homes.

QD: News Every Day--Mindfulness in palliative care

Palliative care is an emotionally tough field for physicians and even more so for pediatricians. One coping mechanism is mindfulness, a way of remaining involved and aware of interacting with patients, yet detached just enough to allow for proper decision-making.

The goal of mindfulness is to act and be aware of acting at the same time, which creates a slight mental space that allows the physician to choose how he or she responds, instead of reacting, judging or lashing out.

This video comes from Stephen Liben, MD, a self-described "Buddh-ish" pediatric palliative care doctor, and an Associate Professor in the Faculty of Medicine of McGill University and Director of the Montreal Children's Hospital Pediatric Palliative Care Program. It comes via Canadian Virtual Hospice's YouTube channel.

Dr. Liben's take-home message is that mindfulness helps physicians cope with burnout and other side effects of becoming emotionally invested with patients. More learning mindfulness for internists is available here.

Public health and the illusion of your autonomy: Kill the umpire?

I watched this year's Sugar Bowl with particular interest, given my daughter's graduation from the University of Michigan last year. So, I was happy with the outcome. Regarding the wild and wooly play, I can say only: Thank goodness there were referees! And that is the real point of this tale.

Dave Trembley by Keith Allison via Flickr and a Creative Commons licenseYou may be one of those stopping by here because you tend to agree with me, or at least find what I have to say interesting. If so, thank you. I like being liked as much as the next guy!

But, I fully appreciate that you may just as well be one of those stopping by here because you almost never agree with me, and are looking for the next opportunity to put me back in my place or pick a fight. If so, I'm game. This one's (mostly) for you.

What you probably like least about me and my left-leaning inclinations is my penchant for so-called nannyisms (a conclusion I derive from innumerable less-than-complimentary comments in response to my columns). I realize I am by no means the quintessential nanny. You probably like many of my friends and colleagues such as Mike Jacobson, Marion Nestle, Kelly Brownell, Michael Pollan even less. But let's talk about me.

Yes, I think food marketing to children should be regulated; I don't think a Madison Avenue marketing executive vs. the average 6-year-old is a fair matchup. I think nutrition guidance systems should be devised independently of the companies selling the food, should convey overall nutritional quality, and should correspond to health effects. I think a soda tax is perfectly reasonable, although I favor a nutrition-based system of financial incentives. I think tobacco should be banned. And what the hell, let's really go for it: I believe in gun control. Nannyisms, all.

But not so fast. Let's look at this from a different quarter altogether, such as the fourth quarter of the Sugar Bowl.

For that matter, pick a sport, any sport, preferably one you like to watch and/or play. With very rare exception (bowling comes to mind), that sport up to its highest levels is supervised by some kind of ... well ... nannies.

Baseball has umpires. Football, basketball, soccer and hockey have referees. So does boxing. Tennis and the Olympics have judges.

Should we kill the umpire, and all the rest?

That inclination does take over when the calls go against our guys. But chances are, we don't really mean it.

We don't mean it, because in the absence of an umpire or referee, any game becomes a no-holds-barred affair.

Of course, it might all run sweetly in accord with the honor system. But if you believe that, it's time to talk about my moonlighting as a bridge salesman. I've got a doozy for you.

No, what tends to happen in the real world when we've killed off all the umpires and referees is that the less scrupulous team prevails. Cheaters prosper in a world of no accountability.

What's that you say? You can look after yourself? You are, after all, a fully autonomous adult?

Well, alrighty then. You and your team can indeed fight fire with fire. The other guys throw low blows, or lob pitches at the batters' heads, and your team can do the same. But that rapidly evolves into an arms race, and devolves into a debacle. Such a contest ends either when someone wins, or when a whole lot of people get very seriously hurt and everyone loses.

Viewed through an uncompromising "We're all adults who can look out for ourselves" lens, umpires and referees are unneeded, unwelcome nannies who wantonly trample the autonomy of the players.

But viewed through a lens I suspect most of us might be more inclined to use, they simply make sure the rules of engagement are reasonable, equitable and enforced. They prevent cheaters from prospering. They prevent an arms race. They prevent the outcome where whoever actually plays by the rules gets clobbered.

I won't speak for my friends and colleagues in public health, although I suspect they feel the same; I'll just speak for myself. I am nobody's nanny. But as you play with the military-industrial establishment with your health on the line, I don't mind being a referee.

You may feel you don't need one. But just like the basketball player who believes he doesn't need no stinkin' refs just before taking an elbow in the kidney. You are wrong. With all due respect, and meaning no offense, you are dead wrong.

I find that often my job in public health is not about telling people things they never knew -- it's about telling them things they never knew they never knew. Nutritious food does NOT need to cost more. "Organic" and "natural" do not reliably mean organic and natural, let alone better for you. "Zero grams trans fat" doesn't really mean zero.

If you have diabetes and are advised to control your sugar intake, beware pasta sauce, which at times contains more added sugar than ice cream topping. If you have hypertension and are advised to watch your sodium intake, beware breakfast cereals, which are, as a matter of routine, more concentrated sources of added salt than potato chips.

"Multigrain" doesn't mean whole grain. "Fat-reduced" does not mean more nutritious. Sugar may appear divided up into ten different aliases in an ingredient list so it doesn't have to be listed as the first ingredient. Physical activity during the school day does not interfere with academics, but often tends to enhance them. A slice of pizza is NOT a vegetable. And so on.

You may think you are defending your autonomy by opposing a ban on toys in Happy Meals. But while you are resisting the tyranny of public health, you are playing right into the hands of a large and rich corporation that is far more concerned with its profits than the health of your child. Did they consult you about putting the toy in, or did they hold a closed-door session where highly-paid marketing executives told them how to manipulate you by manipulating your children?

You may not need your hand held in the supermarket, because you can make sense out of things all on your own. But which is better for you, the unfortified breakfast cereal made from whole grain, or the highly fortified cereal made from stripped down grains with added fiber? Which is better for you, the whole grain bread which may or may not contain partially hydrogenated oil, or the bread made with less whole grain and canola oil? Do vitamins and minerals truly "enhance" water?

If you think you know the answers, I think you're wrong. I've devoted 20 years of my career and nine years of post-graduate education to these issues, and I find them challenging. I've written two editions of a textbook on nutrition, and still think this stuff is hard to sort out. What isn't hard to sort out is how the front-of-pack messaging is designed to take advantage of your confusion, and influence what you buy.

That you can even attempt to make informed decisions about nutrition (even if often failing in the attempt) is because products carry a nutrition facts panel and ingredient list mandated by that pack of nannies in the federal government. Absent that nannyism, none of us would have a clue what's in our food. I think we can, and should, do a whole lot better than a long list of factoids the average shopper and most experts can't readily assemble into a summative measure of overall nutritional quality but that's a discussion for another day.

Perhaps you have such faith in your autonomy that you believe you can outwit Ph.D.s in marketing paid large sums to outwit you. Perhaps your autonomy is the equal to the collaboration of food scientists, nutritional biochemists, and neuro-physiologists who have used functional MRI scans to determine what combinations of flavors and ingredients make it a virtual certainty that you can't eat just one!

If so, you probably don't want rules for airline safety checks either. No matter what the financial pressures, we can surely just count on the airline industry to avoid any corner-cutting, can't we? Airplane safety inspections and maintenance are endeavors overseen by aviation nannies.

Or maybe they are just referees. Objective third parties with a priority other than which team wins. Umpires who are committed to making sure the game is fair.

I don't think we're surrendering our autonomy by acknowledging a role for referees. In their absence, the team with more resources and fewer scruples will, indeed, win.

We needn't wade into the weeds about scruples, but let's acknowledge the resource inequity in public health. The companies and industries my fellow referees and I work to constrain have hundreds of millions of dollars to spend; you don't. They have access to every doctoral-level expert money can buy; you don't. They have proprietary data about the details of what makes customers like you tick. They've got the ear of Congress. All you've got is caveat emptor. You're going down!

Which is where I come in. Not as a nanny, but as a referee.

I realize I may still make calls you don't like. There may be times you want to kill the umpire. But perhaps we can agree that unlike a nanny, an umpire is not here to curtail anyone's autonomy. The job is to do the best one can to make sure the contest is fair.

After that, it's up to you. Play ball!

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.
Friday, February 24, 2012

Our broken system example #2: Fat cats

We have a cat. He's fat. His name is Zander, but we call him "Cat," "Kitty," "Loaf of Bread" (because that's what he looks like when he lies down and his fat spreads), lard butt, and "Fatso Catso." In the picture above he is sitting on a puzzle because ... well, because he's a cat.

There are two main reasons he is fat:
1. He always wants to eat.
2. We feed him too much.

Lest you think that we are bad cat servants (which is what you call people who own cats ... I mean, people who live in the cat's house), let me paint a picture. It's 6 a.m. and I go downstairs. The cat immediately meows continuously until I feed him. Then I go upstairs and do my normal morning routine. While I am up in the shower, my wife comes downstairs and is met by meowing and an empty bowl. We've learned that the cat's desperation for food is not indicative of his eating history, but my wife's natural reaction is to assume I did not feed the cat, and so give him a second bowl. He will do this every morning, sometimes tricking us into feeding him three times.

The same routine happens in the afternoon (we feed him at 6 p.m.). Around 3 o'clock, the cat begins his campaign of meow assaults on whomever he can bother. If you walk to the door of the garage, he rushes to it, knowing that behind that door is his food. Naturally, the only reason we would walk to the door is to feed him, right?

You get the picture. He is deceptive and is difficult (if not impossible) to satiate. We've gotten better at regulating his weight, but only at the cost of the persistent meowing which serenades 50% of our waking hours.

What does this have to do with our broken system? Just change the food to money, and then think of all of the people who profit off of health care.

The second broken thing in our system is the fat cat. A fat cat is a person, group of people, or company that gorges off of the money in our system. Not everyone making money in health care are fat cats, most are simply getting money they earned from providing goods or services. But there are a number of fat cats in health care who are being given all the food they meow for. Here are a few examples:

Drug companies. Why are drugs so expensive? Because they can be. If government and private insurers were not paying for most of the drug costs, who could afford $200/month for Lipitor? People wouldn't buy most medications if they had to pay full price; the full price is impossibly high. Even many generics are over $100 per month. Despite this fact, the prices continue to be high and drugs continue to sell. Why? Because someone else picks up the tab.

It's as if the auto industry charged $500,000 for a new car. Since nobody can afford this, the government mandates car insurance to cover most of the cost. This brings the cost down to $20,000 to $50,000 for car buyers. Or if bananas cost $100 per bunch, but food insurance brought the cost down to $4. If you sold cars or bananas, would you resist this model? Would you trade a $500,000 payment from the government for a $20,000 check from the consumer? No more than my cat would turn down the third bowl of cat food.

Hospitals. Stents 'R Us hospital in our town just built a large cardiology wing costing 600 gazillion dollars. They did this using money from a procedure that has not been shown to prolong life or save lives. Sure, stents make a lot of sense logically (opening a blockage is a good thing, one would think), but it is, as of now, an unproven thing. But the marble lobby and the spiral staircase bear witness to the fact that they are not only paid for, they are paid for quite handsomely. Eat up, kitty.

Ancillary services. Why does a CT scan in India cost a fraction of the cost in the U.S.? Are scanners more expensive in the country in which they are made? Are the companies that sell the CT scanners warmhearted toward the people of India? No, CT scans are expensive in the U.S. because they can be. Again, it's the fact that the third-party payers shield consumers from the exorbitant amounts charged that makes it reasonable to price CT scans out of the realm of affordability. So what do the payers do about these high costs? They pass them on to the taxpayers or raise the rates of the insurance policies. It doesn't hurt them to pay so much, so they just keep feeding the kitty.

Doctors. Yes, we doctors are not immune to eating the cat food. Some docs pile up the number of appointments, giving less time for care so they can make more money. We primary care docs are stuck with a decision between money and quality of care. It's a terrible decision to have to make, and many decide that money is the most important thing. Other primary care providers just order a lot of tests from their own labs or X-ray facilities. We did this for a while, and the seductiveness of the dollar sign was too much for us, and we got rid of our X-ray equipment.

Then there are the highly-paid specialists. A banker friend of mine recently told me about a specialist who was complaining about how horrible reimbursement is, and how bad medicine is now. Then he found out that this doctor earns over $750,000 per year. Why do docs see so many patients that they can't offer good care, and why do other docs feel entitled to incredibly large salaries? Because they can. Someone keeps filling the bowl.

I think that the biggest cause of this gluttony is the third-party payer system which hides the cost from the consumer and gets us all used to the idea of paying for all that cat food. How many people are getting rich off of medicine? How many professions wouldn't exist without this all-you-can-eat buffet of cat chow? How many companies are rewarding investors with huge profits because their devices or drugs are paid far above their cost of manufacture?

All of this money is thrown at care, and what does it get us? Does it get us better care? Does it get us longer lives? Does it get us happier patients, or satisfied doctors?

No, it just gets us a bunch of lard-butt kitties meowing for more to eat.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

How med students should spend their final free summer

The summer between first year and second year of medical school is sometimes referred to as the "last summer" since it is the last time students can travel or take off before they start the journey towards USMLE Step 1 and then their third year clerkships. With the angst building, first year medical students are actively deciding in the dead of winter what they will do over the summer.

Sunglasses taking a sunbath by Andres Rueda via Flickr and a Creative Commons licenseOne popular decision is to do research. This is not uncommon since residency programs are increasingly competitive and look for students who have a commitment to scholarly work. However, there are a plethora of other things students could do as well. As tonight is our "Intro to our Summer Research Program" for Pritzker medical students, I thought I would share some of the most common questions I get about the "Last Summer."

Should I do research in a competitive field? The answer here is to do substantive research that you are interested in with a "CAPE" mentor (Capable, Available, Project interests you, Easy to get along with). As my premed advisor once told me, "Mickey Mouse" research is not going to look good to anyone (no offense Mickey).

The key is to find something you are passionate about. After all, you have to tell this story on your interview trail of why you choose to do this and the answer "because I wanted to go into ortho" is not really that captivating to anyone (even to an orthopedic surgeon). Instead, if you do something you are passionate about, like community health work, you can always tie it back to your chosen field.

Most residency program directors don't expect you arrived in medical school with laser-like focus towards their field anyway and expect to hear some type of journey or a-ha moment that drew you to their field. Because competitive specialties are often reimbursed for clinical work and tend to be smaller departments, they depth of research opportunities may be more limited. But, don't forget that neuroscience research is relevant to neurosurgery. Any oncology research on head and neck cancer is still relevant for ear nose and throat doctors, and so forth.

The best research is often interdisciplinary and crosses department boundaries so you should not be afraid to, either. It's also important to remember that as a first year student, it's hard to even know if you will be competitive for radiation oncology or associated competitive specialties. You will need killer board scores, and great clinical grades. So, while you may think securing the research with the department chair will give you an extra edge, nothing and no one can make up for a poor performance on high stakes exams or clinical rotations. So, don't forget to study!
I want to go to country X? How can I get a global health rotation there? Well, certainly the urge to travel is strong in anyone (including me). But, you need to separate your travel bug from a genuine interest in global health. Most global health rotations are not a vacation, and may not be what you think of as "tourist" destination (despite the short-lived popularity of Off the Map).

Maybe your stars are aligned and your school or a nearby affiliate you know has a program near your hot spot of interest. Usually, however, it is not that easy and you should consider how strong your affinity is for a specific country or location versus your interest in getting the best global health experience possible. Global health programs that fund medical students are not easy to come by. So, if you are genuinely interested in global health, it is always better to go with an established program and mentor to get the most substantive experience even if it's not in the exact country you are interested in.

The other thing to remember is while this may be your last summer for a while; it is not your last vacation! You will have time to plan a vacation to your designated hot spot if you can't work it in this summer.

Do I have to do anything? The answer here is easy. No, you don't have to do anything per se with your time off. Many students find themselves on the hamster wheel of endless extracurricular activities. The real question is what is your goal? If it is to go home and see family and friends, there is nothing wrong with that! The key is to ensure that you are doing something with your time off that will make you feel ready to face the second year of medical school.

It is easy to forget that there is a lot of time to participate in extracurricular activities at various other points in your medical school career. The key is that if you will regret not spending time with your friends or family this summer, then you need to make time to do that.

What if I want to do everything because I don't want to close any doors? This is not an uncommon feeling for medical students. However, it's important to remember that your summer work is not choosing a specialty! There is essentially nothing you can do over the summer that will close a door. There may be some things that allow you to put your foot further into the doorway, but that does not mean another door will close. The only doors you close are the ones in your mind.

Most students decide on their specialty after their third year rotations and will often fine-tune their experiences in research in that area in the fourth year. Another thing to consider is to do research in a cross-cutting area like ethics that could apply to everything.

Sometimes the angst you may be feeling is about making a choice that is wrong for you. However, the truth is that as long as you are genuinely interested in the opportunity, you cannot make a wrong choice since it will be an easy story to tell no matter what you do. Since everyone is different, it is always good to get individualized advice from a faculty advisor at your school who can comment on your specific career and research goals.

Finally, no matter what you do with your last summer, don't forget to make sure you enjoy it!

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--Meaningful use adoption sparse as CMS previews stage 2

Physicians adopting electronic health records (EHR) are still spurning meaning use criteria, two industry surveys showed, even as the government has released details on expanding the criteria.

Physicians in groups of 10 or more are more likely to have adopted EHRs, even while remaining unfamiliar with regulatory issues, meaningful use criteria, and ICD-10 requirements, for example, according to a survey by the Deloitte Center for Health Solutions.

The company surveyed 501 physicians online (acknowledging this might bias responses to technology users). Because practice size might significantly impact results, the initial respondents were resampled, and 307 responded.

Nearly two-thirds said use an EHR, more among large practices (78% of 10 or more practitioners, 68% of 2 to 9 practitioners, 54% of solo practitioners). Solo practitioners are also unlikely to have plans to implement them (45% vs. 15% of group practices).

While physicians largely agree that EHRs are valuable in improving quality (84%) and important to managing patient care (79%), more than six of 10 physicians state that EHR use has not improved diagnosis accuracy or treatment planning, the report said.

It continued that while two-thirds of physicians agree that HIT can improve quality of care in the long run, two-thirds also believe that "the hospital-physician relationship will suffer as physician privileges are put at risk to comply with hospital standards for meaningful use," the report states. "Nearly 90% of all physicians believe that hospitals are more advanced in HIT than their own offices; more than three-quarters of physicians view HIT as a reason to collaborate with hospitals."

Reasons for not adopting EHRs included upfront financial investment (66%), operational disruptions (54%), privacy concerns (22%), vendor selection challenges (15%), and lack of incentives (13%).

Another survey concluded that while 42% of health care providers in all settings use EHRs, 39% have no plans to implement stage 1 of meaningful use. IVANS, Inc., a national health information exchange, announced the results in a press release.

Of that 39% with no plans to implement meaningful use, 26% of them are providers in hospitals and private practices that are eligible for incentives for doing so.

According to the company, 33% of providers surveyed said budgetary concerns are their biggest challenges, while 21% cited technology requirements. The survey was conducted electronically among 700 health care providers from across the U.S.

In stark contrast, the Centers for Medicare and Medicaid Services (CMS) are moving ahead with stage 2, the agency announced yesterday.

CMS announced that In Stage 1, providers and hospitals must meet or qualify for an exclusion to all of the core objectives and 5 out of the 10 menu measures in order to qualify for an EHR incentive payment.

CMS proposes for stage 2 that providers must meet or qualify for an exclusion to 17 core objectives and 3 of 5 menu objectives. Hospitals must meet or qualify for an exclusion to 16 core objectives and 2 of 4 menu objectives.

Other requirements optional in stage 1 but required in stage 2 include:
--changes to the denominator of computerized provider order entry,
--changes to the age limitations for vital signs
--elimination of the "exchange of key clinical information" core objective from stage 1 in favor of a "transitions of care" core objective that requires electronic exchange of summary of care documents, and
--replacing "provide patients with an electronic copy of their health information" objective with a "view online, download and transmit" core objective.

Even though there's been limited adoption of stage 1, there are some easy ways to achieve meaningful use criteria using an EHR. And, Farzad Mostashari, MD, the government's national coordinator for health information technology, spoke specifically to his fellow internists how they can best serve their patients and take advantage of incentives.

And, AmericanEHR Partners, a collaboration that include the American College of Physicians, reported last year that at least one week of training correlated with improvement in the reported usability of advanced EHR features (e.g. checking patient formulary, importing medication lists, and medication reconciliation). The full report, "The Correlation of Training Duration With EHR Usability and Satisfaction: Implications For Meaningful Use," and a corresponding chart pack can be downloaded.

ACP also make meaningful use resources available on its website.
Thursday, February 23, 2012

This doctor's 'complex' patients aren't who you think they are

The government, academics and policy wonks are always in the process of "redesigning" health care. Patients with increased health care needs are considered "complex" and these patients consume the major health resources (translate: "money").

In fact, 65% of total health care expenditures are directed toward the 25% of patients with multiple chronic conditions. Eighty percent of Medicare spending is on patients with four or more chronic diseases. For the first time a study has been done and published in Annals of Internal Medicine that actually asks primary care physicians (PCPs) what defines patient complexity. Who better than the treating doctor to answer this question?

The researchers asked 40 primary care physicians to rate the complexity of 120 of their own patients and to document the characteristics associated with complexity. Over one-fourth of patients were described by the doctors as "complex." The doctors were not told what defined "complexity," but instead were asked to describe it in their view. Once a patient was described as "complex," the doctor was given five domains to choose from, developed from previously published concepts. The five domains were:
--medical decision making (cognitive effort needed to make appropriate diagnoses and therapeutic decisions),
--coordination of care (overseeing care involving others and for making sure that the medical system is working for the patient),
--patient's personal characteristics (challenging patients),
--patient's mental health issues (includes substance abuse), and
--patient's socioeconomic circumstances (home and work issues, inability to afford medication).

Some characteristics of PCP-defined complex patients stood out. They were more likely to be over age 60 and women. They were more likely to have government insurance (Medicare/Medicaid) than commercial insurance. They were more likely to be undereducated and had many office visits. They took more than twice as many prescribed medications.

I find it fascinating that most of the PCP identified complex patients were not considered high risk by the Medicare model and other known models. The algorithms that guide payment and other policy decisions didn't hold up. The patients identified as complex by PCPs affect their workday and time, yet the known models would not have called them complex. More than co-morbidity and other case-mix definitions, factors like inadequate insurance, alcohol related problems, prescriptions for anxiety and other mental health issues were all associated with increased complexity per the physicians. These patients generated more visits, more high cost procedures and more need for mental health services.

The fact that doctors are finally being asked about their work is promising. It is predicted that 32 million uninsured Americans will come into the primary care system with the passage of the Patient Protection and Affordable Care Act. This, at a time when fewer medical school graduates are entering primary care and many PCPs are leaving clinical practice due to work related stress and decreased job satisfaction.

These results actually provide insight that should be considered in designing a health care system that works for patients and care-givers. It should influence payment mechanisms, office support and allow the extra time it takes to care for complex patients. These changes would go a long way to increasing the work satisfaction for PCPs. The fact that this was the first study that actually defined complexity from the PCP perspective is amazing. Let's hope it is the start of something that will ultimately improve the health care system for patients and PCPs.

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--Hospital staff worried about culture of reporting mistakes

Hospital staff fee like hospitals support patient safety, yet hold reporting mistakes against the staff, reports the Agency for Healthcare Research and Quality (AHRQ).

The agency reported the results of its "Hospital Survey on Patient Safety Culture: 2012 User Comparative Database Report."

In tallying specific responses to questions, staff responded in the negative (such as "disagree" or "strongly disagree") with statements that detailed nonpunitive responses to errors. Three questions included like their mistakes are held against them (50%), the person is being written up instead of the problem (46%), or staff worry that mistake are kept in their personnel files (35%).

Other areas included handoffs and transitions. Respondents reported (again, percentages reflect negative responses such as "disagree" or "strongly disagree") that things fall between the cracks when patients transfer across units (41%) or that information gets lost among shift changes (51%).

On the positive side, however, respondents agreed with statements that hospital management provides a work climate that promotes patient safety (81%) and that their actions show that safety is a priority (75%).

In comparison, office-based staffers reported in an AHRQ survey from 2010 that office processes were good at preventing mistakes (79%). In other questions, they responded in the negative (again, a response such as "disagree" or "strongly disagree") that mistakes happen more often than they should (70%), it's just by chance that more mistakes don't happen (74%) and getting more work done is more important than quality of care (73%).

The 2012 user comparative database report displays results from 1,128 hospitals and 567,703 hospital staff respondents. It was designed to assess hospital staff opinions about patient safety issues, medical errors, and event reporting. The survey includes 42 items that measure 12 areas of patient safety culture. AHRQ also conducts surveys for physician practices and nursing homes.
Wednesday, February 22, 2012

Osteoarthritis at the base of the thumb has a 15-33% prevalence in adults

What is it?

Patients with osteoarthritis of the thumb carpometacarpal joint, or base of the thumb, commonly seek help for their symptoms. Arthritis at the base of the thumb causes functional disability and pain, particularly with "pinching" actions.

How common is osteoarthritis of the thumb?

The prevalence of this condition increases with age and is greatest in postmenopausal women. It ranges between 15% prevalence in adults in Finland and a 33% prevalence in postmenopausal women. This is likely to increase as populations age and people stay active for longer.

How to diagnose it?

Pain reproduced on the axial grind test localizes pathology to the base of the thumb.

Trapeziometacarpal and scaphotrapeziotrapezoid joints should be assessed with plain radiographs (X-rays) that typically show degenerative changes. However, X-rays may underestimate the extent of the disease.

What to do?

Non-operative treatments can ameliorate symptoms and delay surgery in most patients with osteoarthritis of the thumb:

--behavior modification
--pain relief
--corticosteroid injections

No single operative procedure has been shown to be superior:
--Simple trapeziectomy has the lowest complication rate; and
--Arthrodesis may be the best option for patients who value pain relief and reliable strength and stability more than mobility (such as younger manual workers).

Piano lesson: Rachmaninov had big hands.


Osteoarthritis at the base of the thumb. BMJ 2011.

Ves Dimov, MD, ACP Member, is an allergist/immunologist and Assistant Professor of Medicine and Pediatrics at the University of Chicago, where he evaluates and treats both pediatric and adult patients. He is double board-certified in Allergy/Immunology (ABAI, a conjoint board of Medicine and Pediatrics) and Internal Medicine (ABIM). This post originally appeared at CasesBlog, his daily update of medical news.

QD: News Every Day--FDA announces two new suppliers for scare cancer drugs

The U.S. Food and Drug Administration will import one cancer drug and has approved a new manufacturer for another one to respond to serious shortages.

The cancer drug Doxil will temporarily be replaced by Lipodox (doxorubicin hydrochloride liposome injection), which is expected to end the shortage and fully meet patient needs in the coming weeks, the agency said in a press release.

Doxil is used to treat ovarian cancer after failure of platinum-based chemotherapy, and for AIDS-related Kaposi's sarcoma and multiple myeloma. FDA anticipates that the incoming supply of Lipodox will fully meet demand. The import is a temporary, limited arrangement specific to the drug's manufacturer and distributor.

And, FDA offered expedited review to a preservative-free methotrexate used for intrathecal treatment of children with acute lymphocytic leukemia and for the high-dose therapy of osteosarcoma. The generic drug is made by APP Pharmaceuticals. It will become available in March and continue indefinitely. Second, drug-maker Hospira released 31,000 vials of new product, enough for more than one month's worth of demand. Other drug makers increasing production are Mylan and Sandoz Pharmaceuticals.

"A drug shortage can be a frightening prospect for patients and President Obama made it clear that preventing these shortages from happening is a top priority of his administration," said FDA Commissioner Margaret A. Hamburg, MD, FACP. "Through the collaborative work of FDA, industry, and other stakeholders, patients and families waiting for these products or anxious about their availability should now be able to get the medication they need."

The agency's website offers more on the wide range of drug shortages that are occurring across the U.S.

How often should you check your bone mineral density?

Breaking a bone is frequently a catastrophic injury for an older patient. A hip fracture or a vertebral fracture frequently leads to a permanent decrease in mobility, which starts an inexorable decline in health and independence. For that reason, fracture prevention is a critical part of the care of older people.

Osteoporosis, which is severely decreased bone density, is a major risk factor for fractures, especially in women over 65. Osteoporosis is also treatable, and there is good evidence that treating osteoporosis with bisphosphonates (a family of medicines which includes Fosamax, Actonel and Boniva) prevents fractures.

So we know that testing bone density is important in women over 65. But we don’t know how frequently we should be recommending the test. Medicare pays for the test every two years, and in the absence of scientific information about how frequently the test is valuable, that has become the accepted default.

This week’s New England Journal of Medicine published a study that helps shed some light on the question. Almost 5,000 women 67 years of age older who did not have osteoporosis at the beginning of the study were enrolled. The women had periodic bone density studies for up to 15 years. The goal of the study was to find the length of time between tests that would safely detect most cases of osteoporosis before a fracture occurred.

Not surprisingly the safe testing interval depends a lot on the initial bone density. For women with advanced osteopenia*, a testing interval of only 1 year was required to detect osteoporosis in time. For women with moderate osteopenia, retesting in 4 years was adequate. Women with mild osteopenia or normal bone density could wait 15 years before the next test. The intervals also varied with the age of the women, with younger women losing bone density more slowly than older women.

These findings should be validated in large studies before put to use. But if the general theme is right, women in their 60s with normal bone density can safely defer their next test for a decade.

Learn more:
Patients With Normal Bone Density Can Delay Retests, Study Suggests (NY Times)
Many Older Women May Not Need Frequent Bone Scans (Shots, NPR’s health blog)
How Often Should Women Be Screened for Osteoporosis? (Wall Street Journal health blog)
Bone-Density Testing Interval and Transition to Osteoporosis in Older Women (New England Journal of Medicine article)
Medications for Osteoporosis (my summary in 2008)

* Definition of various levels of bone density according to T score
Bone Density / T score
Normal / greater than -1
Mild osteopenia / between -1 and -1.5
Moderate osteopenia / between -1.5 and -2
Advanced osteopenia / between -2 and -2.5
Osteoporosis / less than -2.5

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.
Tuesday, February 21, 2012

Think like a doctor, part II

In part I we discussed the history of medicine as a science. This is part II in a series.

It is during a surgery rotation when a medical student perhaps feels least competent. Not only is there an enormous amount of book learning, there are the physical skills that take years to develop. Most of the time you pull on a retractor and answer questions, record vitals and pull out drains. My instructor, who in the OR hurled Spanish invectives like scalpels and called every med student, "Pullgoddamyou," was gentle as a kitten with conscious patients.

When I was in his office an elderly woman came in for a superficial biopsy. He had treated her for years and she trusted him. After spending time talking to her and calming her, he numbed up the area and went to work. But the patient was tearful, from the pain and also from the knowledge that the biopsy was not going to give her good news. I reached up and took her hand, then quickly released it, uncomfortable with my spontaneous act of intimacy. Dr. Gruff looked at me and said, "No! Hold her hand! That is compassion; that is being a doctor!"

Compassion can be learned, or at least a simulacrum of it. Hopefully it comes naturally to most doctors, but for those who it does not, and cannot be taught, there are specialties that don't involve much patient care. Radiology, pathology, and a few others involve very little patient interaction, but are essential to the modern practice of medicine. While the surgeon waits, hands folded in the OR, the pathologist quickly prepares slides and calls up with an answer that can be the difference between a small biopsy or a radical cancer surgery. Sitting in the barber's chair one day, the barber asked me to take a bottle of wine to a radiologist. His wife had gone in for minor surgery and the radiologist had discovered an early cancer on a routine X-ray, saving the woman's life.

I'd guess that most people, when thinking of a doctor, think of their own doctor, a primary care physician or an OB/GYN. Hopefully this is someone they've come to trust, someone who can give them the tools to stay as healthy as possible and to treat them with compassion when they fall ill. This part of medicine: this rapport, this compassion, is essential to good patient care. A patient who likes you, and who you in turn like, is more likely to trust in and benefit from your advice.

But compassion is not enough. In medicine, compassion unguided by science can be dangerous. When you have strep throat, do you seek out a compassionate clergy or friend with no medical knowledge, or a doctor? The doctor knows that untreated, strep can lead to abscesses, rheumatic fever, and can (but does not usually) cause permanent damage. She knows that strep is easily killed by certain antibiotics and not by others. She knows when the sore throat is more likely to be a virus and should be treated with hot tea and chicken soup rather than drugs.

Physicians are daily witnesses to the power of compassion, and like any power, compassion can corrupt. A compassionate act often has immediate and satisfying results. Treating hypertension gives neither the physician nor the patient immediate satisfaction. It is the reduction of the risk of heart attack and stroke, a benefit that accrues over time, that makes treatment worthwhile. But doctors like anyone else would love to see an immediate reaction, something unlikely in a patient with a disease without symptoms. Patients are rightly skeptical about treating a disease which causes no discomfort. It is up to the physician to work with the patient to help them understand the importance of treatment, to use their rapport to help the patient understand the benefit.

Sometimes the doctor and the patient unconsciously conspire to gain immediate satisfaction where none should medically exist. Of the two, the physician should know better. When doctors recommend unproven or implausible treatments with the idea that it may make the patient feel better, they enter a folie a deux. We know how to treat high blood pressure with diet, exercise, and medication. It might not make you feel better immediately but it will save your life. Compassion will help bring the patient around.

But how about adding on some hypnosis or acupuncture? These feel more "real" to the doctor and the patient, but are no more real than a sugar pill. If there is any benefit to these, it is through the same mechanism the doctor uses in the exam room: a hand on the shoulder, a cocked ear, a smile. It is compassion without the benefit of actually treating the disease.

There is nothing wrong with compassion. In fact it is necessary to get the most benefit out of the patient-doctor collaboration. But it is not, in itself, powerful enough to cure infection, to prevent strokes and heart attacks. Compassion plus medical science is good doctoring. Compassion plus no science is charlatanism.

In part III, I'll examine how to spot the difference.

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.

Concierge and boutique practices are another form of defensive medicine

Some time ago, I rented a car during a visit to another city. I chose among the various categories of vehicles which are listed from the last expensive to the most costly. Here were my choices:
Bentley Continental attracting wealth famous drivers by Auswandern Malaysia via Flickr and a Creative Commons license--economy
--full Size

As I have pointed out on this blog with regard to medical care, people spend other people's money much more easily than they spend their own. This is why I have argued that patients need to have some skin in the game to serve as a brake on profligate medical spending. There may be other effective brakes to consider, but diagnostic and therapeutic restraint demanded by patients is a potent and reasonable option.

In the rental car case, I was not on someone else's expense account, but was handing over Kirsch cash. I chose a standard sized vehicle. Of course, I could have saved money by driving off in an economy vehicle, but rental cars are priced like movie popcorn. For a few dollars more per day, you can drive a bigger car. It is a brilliant pricing strategy that encourages the consumer to upgrade.

Here's the point. I ordered and paid for a standard sized car. I cannot expect that I will be presented with a luxury automobile when I arrive at the rental car lot. Of course, I can upgrade to a higher category, but I will have to pay more. Isn't this fair? If you are paying for a Chevy, don't expect to drive away in a Cadillac.

This concept relates to the practice of concierge medicine, also known by the even more derogatory description of boutique medicine. In these practices, patients pay a premium to the physician in return for higher level medical services. These physicians can earn the same income, or more, while caring for much fewer patients.

Why do insured patients pay more for concierge care?
--same day appointments,
--on time office visits that last as long as needed,
--direct access to the physician's cell phone,
--physicians accompanying patients to specialists' offices,
--comprehensive annual physical examinations and health review,
--emphasis on preventive medicine, nutrition and wellness, and
--posh waiting rooms with New Age soothing music.

Concierge medicine criticisms:
--It's not fair;
--Insured patients should be getting these services anyway;
--It's elitist; and
--It siphons primary care physicians away from those who can't afford concierge care.

Concierge medicine didn't emerge in a vacuum. It was not concocted by greedy physicians who were seeking to provide Cadillac care so they could continue to drive Cadillacs.

Boutique medical practices have become popular because private practice primary care physicians faced three mounting challenges:
--financial pressure with declining reimbursements and rising overhead,
--declining quality of care from seeing higher volume of patients, and

Concierge medicine is a response to this reality. Concierge practices are financially solvent and provide premier quality medical care to a smaller group of patients. This is not exclusively a benefit for the wealthy. Many average income folks have decided that spending $100 each month for superior medical services is worth it for them and their families. How much do you spend each month on your cell phone? Is concierge medical care more important to you than an iPad, a smart phone or joining a pricey gym? We all make choices in how we spend our money.

For those who want this higher level service for their families, they may need to cut back on other expenses. What kind of car are you driving now? Full size? Luxury? Sports Car? Hybrid? Perhaps, it is worth downsizing your wheels and upgrading your medical care.

I realize that many folks don't have this option right now, particularly under current economic conditions. We all wish that they, and everyone, could receive concierge level medical care, but this is not how our society works.

Concierge medicine isn't the avaricious aggressor here. It's self-defense.

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.