Friday, March 30, 2012

Public health for nincompoops

Consistency, it is said, is the mark of a true champion. Utter lack of consistency, therefore, must indicate something else entirely. I'll be kind and call it: nincompoopery.

Not my Hat! by cogdoggblog via Flickr and a Creative Commons licenseWhen it comes to public health policy, we are a pack of utter nincompoops. Sorry, but it is what it is.

The timing of this rant is inspired by recent events related to women and matters of family planning. We'll come back to that. For now, let's try this on:

Should medical marijuana be legal everywhere, or not?

You likely had a knee-jerk reaction to the marijuana question. You may feel strongly that marijuana should absolutely be available for medical use. You may feel just as strongly that the idea is outrageous. It's an illegal drug, after all. Or you may feel you don't know enough about medical marijuana to decide.

But I think the best response to the question is another question, a deeper question, a question that gets at the principles--the first principles--that most reasonable people would agree should decide the matter: On what basis is ANY substance approved or disapproved for medical use?

Let's at least agree that trying to answer this about a drug, and never bothering to answer it about all drugs, is inordinately inefficient. It means starting the same debate from scratch every time. Truly silly at best, a formula for inconsistent idiocy at worst. Nincompoopery.

So, on what basis SHOULD any drug be approved or disapproved?

We might think a drug should be disapproved if it's dangerous. But that's clearly not so; drugs far more dangerous than marijuana are used in medicine all the time. A few that spring immediately to mind include nitroprusside, Ketamine, Coumadin and haloperidol.

Perhaps a drug should be disapproved if it's addictive? That's clearly not the case either, since vastly more addictive drugs than marijuana are in routine use, among them the benzodiazepine class of sedatives, home to Valium, that are among the very few habit-forming drugs from which withdrawal can actually be lethal. But then again, alcohol is also potentially habit-forming, and withdrawal can be lethal, and not only is it approved for use, but no prescription is required. And while on the topic, plain old tobacco is more addictive than cannabis.

Well, all right. Perhaps a drug should be disapproved if it's already disapproved! Perhaps we should simply hold the line against medical use of substances that are already illegal. That would be enough to dispatch marijuana.

But it would also be enough to dispatch cocaine and heroin, and here I've got bad news. Cocaine is an approved drug, on hand in virtually every emergency department in the country. It is used, among other things, to control epistaxis, the medial term for severe nosebleeds. During my years as an ER doc, I treated patients with it on a number of occasions. We would soak cotton in a cocaine solution, and into the patient's nose it would go.

As for heroin, it's not legal per se, but Dilaudid is. This is a synthetic opiate painkiller that is, in essence, heroin on steroids. It is many times more potent than heroin or morphine in its narcotic effects.

We could, I think, come up with sound criteria to guide decisions regarding all drugs. They would include such things as: a clear need, clear results of testing, a favorable benefit/risk ratio when used as intended and so on. For what it's worth, medical marijuana almost certainly passes through any such filter, but that's a topic for another time.

What about medically-assisted dying? This is another emotive, provocative topic prone to evoke reflexive answers, but not a lot of reflection. If the goal of medical treatment is to extend life at all costs, the topic is clearly taboo. But then the right question is: What is the goal of medical treatment?

Personally, I think medical treatment is about the patient. I think it serves the patient of sound mind, and the family of sound heart. Admittedly, soundness of mind and heart can at times be hard to judge, but more often than not we can make the call. But this, too, is a debate for another day. My point now is simply that judgments about medically-assisted dying in the absence of judgments about the fundamental objectives of medical care are cart before horse, and tail wagging the dog.

Not to mention (come to think of it, yes to mention) the fact that those elements in our society most opposed to assisted dying seem often to be OK with capital punishment. So sanctity-of-life arguments don't seem to put the issue to bed.

Perhaps we want to oppose all societal actions that aid and abet misguided or objectionable behavior? That is the customary opposition to so-called "harm reduction" strategies, such as needle exchange programs for IV drug users. Such programs have been shown, decisively, to reduce HIV transmission without increasing drug use, but there is a prevailing objection on principle.

But is it a "first" principle, applied consistently? I dare say not! Seat belts and air bags prevent injuries and deaths from car crashes that overwhelmingly would not occur in the first place if people didn't drive while impaired, drive while distracted, drive while texting or exceed the speed limit. So don't seat belts and air bags "aid and abet" speeding, driving under the influence and so on? I leave you to chew on it.

I take a lot of abuse from the "Stop telling us what to do, Katz!" crowd. It doesn't cost me any sleep; it's all part of the gig. But I note it as a fact.

But here's the thing: Those who call me names, many nasty and some profane, for suggesting that we at times need public health policies to protect us--that, at times, the best defense of the human body resides with the body politic--do so on the grounds of defending autonomy. They do so arguing that self-sufficient, self-reliant, reasonably intelligent adults don't need the likes of me, or a big government, telling them what to do.

I might just take this on the chin and live with it (although a counter-argument is not hard to make), were it even remotely consistent. But it's not.

As best I can tell, it's the same "Butt out and let autonomous adults run their own lives" crowd who feels that they/the government absolutely SHOULD tell women when they can and can't get contraceptives, and when they must have ultrasound probes rubbed over them, and perhaps even inserted into them.

In other words, somewhere out there is a pack of hypocritical, occasionally foul-mouthed nincompoops who do NOT object to autonomous adults being bossed around. They simply want to be the ones to do the bossing!

For what it's worth, I think there is a middle path best defined by first principles. I think we could sensibly decide when drugs should be legal or illegal, available by prescription or over the counter. I think we could sensibly decide when regulations are required, and when informing people is enough because knowledge is power. I think we could, but for the most part, we don't.

We hide behind ideology while ignoring epidemiology, and let tales of sound and fury signifying nothing consistent or even sensible wag the dogma.

What we wind up with is public health policy for nincompoops. And if this morass of sloppy thinking and hypocrisy is the best we can do, that's about what we deserve.

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.

Ten pillars of medicine

I've been debating with myself how to break the actual practice of medicine into its essential parts. These, I think, are the basics of what we do every day in the hospital:

I. Care for the ill. Reassure the worried.
II. Know when to start.
III. Know when to stop.
IV. Fluids.
V. Diuretics.
VI. Judicious use of antibiotics.
VII. Appropriate use of steroids and immunosuppression.
VIII. Use the best available evidence and know where to find it.
IX. Use common sense and the 10 equations of physiology for the rest.
X. Listen to the skepticism in your soul but adulterate with a tincture of a hope.

Justin Penn, MD, ACP Associate Member, attended medical school at the University of Washington School of Medicine and trained in internal medicine at the University of Rochester, where he is serving as Chief Resident. This post originally appeared at his blog, Musings of an Internist.

A 4-step primer to fame as a physician

After years of languishing and trying to figure out how to become famous in medicine, I have finally realized the key!

How did I finally reach my epiphany?

Well, one particular doctor (who shall remain nameless) has become famous in my field, as well as moderately famous around the country in the lay press, by promulgating a very specific theory for the last 20 years. Although the theory does have some validity, this doc promotes it as the end-all-be-all of the issue at hand, so much so that the doc now has published a book directed at patients who need help for their problem. When I happened upon the book's website, I noticed a picture of the doc standing together with another physician who has a very famous TV show. (I'll let this doc remain nameless as well, but if you are a wizard you'll figure it out.)

It was then that the light went off about the key to getting famous ...

Promote your agenda by being dogmatic.

Here's how you do that:
Speak in absolutes. Talk in black and white. Never bring up the shades of gray because that might confuse your target audience. Words to avoid include: may, might, could and possibly. Instead choose words like: will, won't, always and definitely.

Incite fear in people. Tell everyone that if they don't follow your advice something bad will happen to you. Like inflammation or dysfunction, those are hard to disprove. Or maybe malaise, fatigue, depression, or other problems that have a hard time getting better. Then your audience will believe you, because that's probably why they're listening to you anyway.

Never rely on science ("evidence-based medicine"), because only your opinion ("media-based medicine" #mbmed) counts. Studies with valid, patient-oriented outcomes are much harder to do and probably won't prove your point. So why waste the time and money, when being charming and loud is much easier to make sure people know you're right?

Never admit that you don't know. That will just show you are a failure and you will appear less god-like to the people you are trying to reach.

I'm glad that I figured that out. Now I don't have to spend my time trying to understand and study complicated medical issues when I can just make everything fit my agenda. Whew, that's a relief!

Oh, and this is a pretty good way to get elected to political office too.

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

QD: News Every Day--MGMA details academic physician's pay

A new survey details how much less academic professors are making than their private practice peers.

Physician compensation in academic settings continued to trail that of physicians in private practice, as is customary. Family practitioners in academic settings reported median compensation of $173,801, compared with $189,402 in private practice.

Specialists in academic settings also reported median compensation that trailed physician earnings in private practice. Anesthesiologists earned $326,000 in median compensation in academic settings and $407,292 in private practice. General surgeons in academic settings earned $297,260 in median compensation, compared to $343,958 in private practice.

Academic rank is one way to escape this pay gap. Primary care associate professors reported $173,963 in median compensation, but professors reported median compensation of $198,000. Primary care department chairs reported median compensation of $282,296. Specialty care associate professors earned $260,075 and professors earned $280,000. Specialty care department chairs reported median compensation of $506,200.

Chart by MGMA
The MGMA released the salary ranges in its report, Academic Practice Compensation and Production Survey for Faculty and Management: 2012 Report Based on 2011 Data.

Geography also has an influence, the report said. Dermatologists in academic settings reported median compensation of $277,765 in the Midwest and $234,936 in the Western region. General pediatricians in the Eastern section reported $157,289 in median compensation and in the Southern section reported median compensation of $139,410. In the Eastern section, urologists reported $368,401 in median compensation, compared with $300,000 in the Midwest, $336,000 in the Southern section and $445,247 in the Western section.

Compensation in academic settings is les influenced by clinical care reimbursement, the press release explained, and more by research support, educational activity and endowments and philanthropy.
Thursday, March 29, 2012

10 simple questions with complicated answers that people ask their doctors

1. Should I take an aspirin?
2. Should I take a medication for osteoporosis?
3. How often should I get a DEXA scan?
4. Should I see a specialist about this?
5. What's the best test to keep me from getting cancer?
6. Can you write me a prescription for an antibiotic?
7. Can't I just get an MRI?
8. What's the difference between you and a family medicine doctor?
9. What diet can help me live longer?
10. Can't you just order me some baseline bloodwork?

And a bonus:
11. Why is your hospital better than any other?

Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.

Death smells like vanilla

She lay in bed, her breathing erratic; she would breathe in deep and fast, then exhale slowly, as if she'd just hit her first cigarette of the day. In place of a cigarette was a tube, about a quarter of an inch wide. It was stained brown, and every few minutes a bucket attached to the wall would make a hissing sound, and brown sludge would course from the tube into the bucket. Presumably, the tube went down to her stomach. The brown sludge, being contained in tube and bucket, didn't convey a smell or any other hints as to what it might be.

Image via Wikipedia and a Creative Commons Attribution-Share Alike 3.0 Unported licenseAnother tube was in her nose, making a faint, continuous hissing noise. It also had a bit of a brown stain, just on the tips that sat inside her nose. It ran from her nose to another wall outlet, just next to the sludge bucket.

The third tube ran out from under her blanket, across her exposed thigh and over the side of the bed. It ran into a large, thick plastic bag filled with something that looked like urine, but with white flecks forming a cloudy layer at the bottom of the bag. That tube also had spots of brown sludge, but not exclusively, as the oral tube did.

She seemed to produce a lot of brown sludge. A bedside commode had a bit in it, and that one did have an odor, a faintly sweet but strongly fecal smell. More powerful was another bit of sludge on a shelf by the window. In between flowers in various stages of wilt; between cards, some with the neat hand of an older person, some in the large scrawl of a grandchild; next to pictures of someone who must be her, but without tubes and beautiful; on that shelf was a small Styrofoam bowl filled something that looked like cooled beef consomme. It was brown, of course.

From that small bowl, a powerful scent flowed around the dying flowers, past the cards and toward the dying woman. The consomme wasn't beef, but vanilla.

People think of vanilla as subtle; it's synonymous with "bland." But not this vanilla. The hospital-grade vanilla flows thickly through the room, around the sludge bucket, the commode, the still-living body. It attaches itself to other smells, sometimes accenting them, hopefully but rarely overwhelming them. It shares every room filled with brown sludge and grief.

That pleasant scent, the one that defines bland, attaches itself to something else, becoming something else. It becomes part of the smells of dying, of suffering. It becomes cloying, suffocating, insufferable. Outside the woman's room, it may be subtle, but it hints of what is behind the door--tubes, brown sludge, sunken cheeks, uneven breaths.

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--Change in insurance coverage leads to more ER use

People visit the emergency room more often when they shift either direction from insured to noninsured status, a study found.

With so much potential for millions to gain or lose insurance coverage through legislation, court decisions or the still recovering economy, it's worth a look at what might potentially drive emergency room traffic, researchers noted.

They analyzed 159,934 adult respondents to the National Health Interview Survey from 2004 to 2009. The study found 7.8% of the population changed insurance coverage in the past year. Results appeared in the March 26 issue of Archives of Internal Medicine.

Overall, 20.7% of insured adults and 20% of uninsured adults had at least one emergency department visit. The resulting "churning" of insurance coverage was associated with 29.5% of newly insured adults compared with 20.2% of continuously insured adults had at least emergency visit. Similarly, 25.7% of newly uninsured adults compared with 18.6% of continuously uninsured adults had at least one emergency visit.

After adjusting variables, a change in insurance was associated with greater emergency department use for newly insured adults (incidence rate ratio [IRR], 1.32; 95% confidence interval [CI], 1.22 to 1.42 vs. continuously insured adults) and for newly uninsured adults (IRR, 1.39; 95% CI, 1.26 to 1.54 vs. continuously uninsured adults). Among newly insured adults, this association was strongest for Medicaid beneficiaries (IRR, 1.45) but was attenuated for those with private insurance (IRR, 1.24) (P less than .001 for interaction).

An editorialist noted that, as the emergency department is only place in the health care system that cannot refuse treatment, "The newly uninsured likely went to the ED for continuation of whatever treatment they had been receiving. Also, some of the newly uninsured may have lost their insurance because of a new illness, and this group may have used the ED more than the continuously uninsured because they were more ill."
Wednesday, March 28, 2012

The worst case scenario isn't a reason not to take your medicine

Lipitor can destroy your liver.

Back surgery can leave you paralyzed.

People who take Chantix might kill themselves.

You may never wake up from a simple surgery.

These statements are all true. They also are very confusing to many of my patients when I am prescribing drugs or recommending surgery. What should they do when they hear such bad things about drugs, surgeries, or procedures? How much do they risk when they follow my advice?

It's a hard world out there, with the attorneys advertising on TV about drugs my patients have taken, with the websites devoted to the harms brought on by a drug or an immunization, with Dr. Oz and other seemingly smart people telling them things that are contrary to my advice, and with friends and neighbors who give dire warnings about the dangers of following my advice. There are so many voices out there competing with mine, that I sometimes spend more time reassuring than I do anything else. A doctor in our practice believes that Dr. Oz ought to issue a statement to doctors whenever he voices another controversial opinion as gospel fact so that we can be ready with our counter-arguments.

What can doctors do? We can't quiet the other voices that speak against us. In truth, those voices have an important role in preventing us from becoming comfortable and dogmatic in our beliefs. So how do I combat such a heavy current against our advice?

By talking about seat belts.

Seat belts can kill you, you know. You can be trapped inside your car by your seat belt and not be able to get out before your car explodes. It's not a fable; it can really happen. You may be sealing your fate to die terribly every time you buckle your seat belt.

When I say this to my patients they instantly get what I am saying. Sure, there is risk putting on a seat belt, but that is overwhelmed with the risk of not wearing it. EMTs will tell you that they rarely unbuckle a dead person.

I love using illustrations like this. I can, with a good illustration, explain a highly complex subject in very little time. They give the patient something they understand as a basis on which to consider their options. In the case of the seat belt, the analogy gives them perspective. It shows them that the people who talk about the bad stuff aren't lying (seat belts really can kill), but they aren't considering the risk of not having the surgery, taking the medicine, or getting the procedure done (seat belts save lives).

There is the risk of over-simplifying something, or leading patients to believe something is lower risk than it really is. That's why I always follow this by talking about how I feel the risk of taking the medicine compares with that of not taking it. I don't argue against those who say Lipitor can destroy your liver, doing so would undermine my credibility because Lipitor can kill your liver; I just simply put that risk in perspective. Analogies alone don't explain things, but they do take difficult to understand concepts and bring them into a world the patient understands. From that point on, the explanation is much easier.

I used the analogy this morning explaining to a mother who was worried about the risk of ear tubes in her baby. I explained that the risk of surgery (wearing the seat belt) was much less than the risk of antibiotic over-use (not wearing the seat belt). She visibly relaxed when I said this. I am not belittling her fear; I am just putting it in perspective.

I use seat belt analogies in other ways too. Today someone told me that they never get flu shots and haven't ever gotten sick. I told them that I could have never worn a seat belt in my life (which is almost 50 years) and I would still be alive talking to them. I've never gotten into a serious accident, so seat belts have been a complete waste of time, right? The patient smiled when I said this. No, I told him, I think it was a good idea to wear them and will continue to do so. People who wear seat belts are more likely to be alive in a year than those who don't. The exact same thing is true for high-risk people and flu shots.

He still didn't get one.

I also talk about the warning labels that seat belts would have if they had to list all of the ways you could be harmed by them. Imagine a seat belt commercial done like a pharmaceutical ad: "Seat belts could choke young children, could trap you in the car and kill you, could cause bruising to the shoulder, pinching to the fingers, lacerations, and abrasions. Seat belts also could be used maliciously by older brothers to torture their younger sister. Call your mechanic if you cannot unfasten your seat belt for more than four hours."

You get the picture. So do my patients.

Buckle up.

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.

What happens in Vegas can be used to teach costs of care

Funded with a grant from the American Board of Internal Medicine Foundation, Costs of Care has partnered with medical educators at Harvard Medical School and the University of Chicago (that would be us!) to start addressing this problem. We are developing a series of web-based medical education videos that use clinical vignettes to illustrate core principles of cost-consideration, including how to communicate with patients about avoiding unnecessary care and reducing overused or misused tests and procedures.

As part of the project launch, we released a new teaser video today called "What if Your Hotel Bill Was Like a Hospital Bill?" The video is a tongue-in-cheek depiction of the challenges patients face in deciphering medical expenses, and their additional confusion when they learn doctors are not trained to consider costs. - Excerpt from Costs of Care Press Release by Dr. Neel Shah.

How does this relate to Vegas?

On a recent trip to Las Vegas with my family for the holidays, I was in the Bellagio lobby admiring the Chihuly glass ceiling. While that was impressive, I was also watching the clerks check in and out the long lines of visitors to the hotel. The staff explained any charges on the bill, confirmed that the bill agrees with the expectations of the patron and then finalized the transaction, printing a copy on the spot for the traveler before they got in the cab to the airport hailed by the bellman.

What a far cry from hospitals, where most of the hospital staff have no idea how much anything costs! After all, doctors are notoriously bad at considering costs in the doctor-patient relationship, as demonstrated by a great piece by Dr. Peter Ubel on his experience with the cost of his own prescription medications. As Paolo (or Paul who works as our research project manager in his day job) from Hotel Hospital highlights, "Our hotel staff specifically focus on the highest quality of care. ... I doubt that they even know how much anything costs here." The rest of the script was easy to write. Shooting was a lot harder since we had to find a spot in the hospital that looked like a hotel, but thanks to some creative camera angles and props from our MergeLab team, we were able to get it done.

Learning about costs of care is critical to taking care of patients. This was especially poignant during my recent inpatient service block at a nearby community hospital, since I cared for many uninsured patients who paid out of pocket for their medications (not to mention their hospital stay).

Our residents were concerned about one patient who was uninsured and would have difficulty paying for Plavix, a critically important drug after his heart procedure. Review of his medications also revealed he was recently put on Lexapro, a nongeneric antidepressant (with a sordid history) that was costing him more than $100 a month when there is a generic alternative for $4 a month, which would help him afford his Plavix.

When physicians do discuss costs, they also get it wrong and perpetuate a medical urban legend such as that patients have to pay when they leave the hospital against medical advice (this is not true!). These are just a few of many examples of why teaching students and residents to bring up costs and arming them with tools to address the issue with their future patients is imperative. Without considering costs of care, we all take a gamble that costs of care are not an issue for patients. Of course, the odds are against that.

Stay tuned for more work from our Teaching Value Project from Costs of Care funded by the ABIM Foundation.

Special thanks to our production team and actors: Mark Saathoff , Andy Levy MS4, Kimberly Beiting, Paul Staisiunas, Jeanne Farnan, and Neel Shah!

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--People who exercise a little but sit a lot still have higher mortality risk

Office workers face a 15% higher mortality risk from all that sitting, but the truly sedentary, those who go home and sit for three more hours, face a 40% higher risk.

Prolonged sitting is a risk factor for all-cause mortality, independent of physical activity. Researchers wanted to put some numbers to this, so they linked survey data from nearly 222,500 individuals 45 years or older from the Medicare registry of New South Wales, Australia, from February 2006 through December 2010.

Results appeared in the March 26 issue of Archives of Internal Medicine.

During nearly 621,700 person-years of follow-up, more than 5,400 deaths occurred. Compared with less than 4 hours per day sitting, adjusting for physical activity and other confounders, all-cause mortality hazard ratios were:
--4 to less than 8 hours sitting, 1.02 (95% CI, 0.95 to 1.09),
--8 to less than 11 hours sitting, 1.15 (95% CI, 1.06 to 1.25), and
--11 or more hours sitting, 1.40 (95% CI, 1.27 to 1.55).

The association was consistent after accounting sex, age, body-mass index (BMI) and physical activity, as well as between healthy participants and those with cardiovascular disease or diabetes. There was a clear dose-response relationship for sitting time and physical activity that persisted even among those with relatively high levels of physical activity.

Researchers pointed to prolonged sitting's effect on metabolism, including increased plasma triglycerides, decreased high-density lipoproteins and decreased insulin sensitivity, as well as changes to carbohydrate metabolism.

"Our findings suggested not only an association between sitting and all-cause mortality that was independent of physical activity but, because the findings persisted after adjustment and stratification for BMI, one that also appears to be independent of BMI," the researchers wrote.

An editorialst wrote that even people who exercise a half hour a day can be sedentary for the other 15.5 waking hours. "To put this in perspective, 30 minutes of physical activity is as protective an exposure as 10 hours of sitting is a harmful one."
Tuesday, March 27, 2012

Save the date for social mission and medicine

In 2010, a group led by Fitzhugh Mullan compiled a provocative ranking of medical schools based on a "social mission score." The criteria used in calculating the index for medical schools were:
--output of primary care physicians,
--doctor-graduates serving in underserved areas, and
--number of minority physicians trained.

This was a through-the-looking-glass approach to ranking medical schools, since it practically inverted the traditional rankings. The schools usually at the top of the U.S. News & World Report rankings (based on research dollars and reputations, among myriad other factors) were all near the bottom of Mullan’s list.

The article caused a stir in both the media and in academic medical circles. It was nice recognition for state schools and historically black medical colleges that emphasize training primary care doctors to serve in their communities. The schools at the bottom of the list were forced to explain why their missions, although different, still made a social impact.

If the world didn’t actually change, it was at least a good thing because it forced academics and the public to think a little differently, if even for a short time.

If any of this story moves or interests you, then I’m happy to tell you of an upcoming conference at which this conversation will continue. Movers and shakers in the worlds of social justice and medical education will come to Tulsa to brainstorm how we can better serve the needs of our country in the 21st Century.

[Beyond Flexner refers to the 100th anniversary of the Flexner Report, a 1912 white paper commissioned by the Carnegie Foundation that had an enormous impact on how medical education was structured and delivered in the 20th century.]

Info on the conference:
Beyond Flexner: Social Mission in Medical Education will feature the work of a recently completed study on examples of "post-Flexnerian" medical schools, as well as innovations in medical education related to the social determinants of health, public health, and social accountability in an era of market and legislative driven health reform.

Beyond Flexner: The Social Mission of Medical Education
May 15-17, 2012 - Tulsa, Oklahoma
David Satcher, MD, MPH
H. Jack Geiger, MD
Gerard Clancy, MD
Additional details will be available soon, so stay tuned!

Questions? Email

This post by John H. Schumann, MD, 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.

Notes on Kalydeco, the new cystic fibrosis drug

I thought it worthwhile to learn a bit about Kalydeco, the new drug for cystic fibrosis. It's the first "smart" medication approved by the FDA for some patients with this condition. According to BusinessWeek and other sources, the annual cost of this oral treatment, manufactured by Vertex Pharmaceuticals, will be nearly $300,000.

Cystic fibrosis is an inherited disease that affects the lungs, sweat glands and, in males, the vas deferens, the tube that carries sperm from the testes. Patients are prone to infection (especially pneumonia), overheating, infertility and other problems.

Most symptoms arise from defects in transport of ions, like chloride, through membranes. Cystic fibrosis is often disabling and, typically, life-shortening. In 1989, Francis Collins and Lap-Chee Tsu reported in Science they'd discovered the gene responsible.

Now, there's a wealth of information about the Cystic Fibrosis Transmembrane Regulator (CFTR) gene. It's located on human chromosome 7 at q (long arm) 31.2, and encodes an ABC (ATP-binding cassette) type ion transporter protein. According to an analysis in Nature this week, scientists have identified over 1,500 CFTR mutations.

Kalydeco goes by the generic name ivacaftor and has been tested published reports as VX08-770–102. This compound targets the defect caused by one mutation, termed G551D. Only 4% of cystic fibrosis patients have this genetic variant. Over 90% have a different mutation, F508del. These distinct mutations alter the protein distinctly.

From Nature News: "... In patients with the G551D mutation, the channel fails to open properly, so ions are unable to pass through. About 90% of people with cystic fibrosis have a different mutation, called F508del, which results in proteins that do not fold into their proper shape and so get targeted for degradation, reducing the number of channels ..."

Drugs in the pipeline will target the more common F508del mutation. Meanwhile, it's easy to envision more than a few eager parents, patients and optimistic pediatricians wanting to prescribe the new drug for their cystic fibrosis patients who don't have the G551D mutation. The number of people living with cystic fibrosis in the U.S. is 30,000, according to the Cystic Fibrosis Foundation, so the FDA's approval applies to approximately 1,200 individuals, the 4% who carry the G551D mutation.

This seems a perfect example of a new, expensive drug that may really help just a few people, and for which there's a clear genetic marker. Now, if we could only assume the assay for the mutation will be done correctly in each case ...

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--Coronary artery calcium the new risk marker that matters most

Coronary artery calcium scores offered the most statistically and clinically significant value to Framingham Risk Score predictions among 12 coronary heart disease risk markers, a study found.

Coronary artery calcium (CAC) measurement may be the only newer coronary risk factor to add meaningful information to standard risks, such as smoking and diabetes, noted editors of Annals of Internal Medicine, in which the research appeared on March 20. But measuring coronary artery calcium is expensive and exposes individuals to radiation, so its use for coronary risk assessment requires further evaluation.

To assess whether newer risk markers for coronary heart disease risk prediction and stratification improve Framingham predictions, researchers conducted a prospective, population-based study among 5,933 asymptomatic, community-dwelling participants from The Rotterdam Study in the Netherlands.

The research measured traditional coronary heart disease risk factors used in the Framingham score (age, sex, systolic blood pressure, treatment of hypertension, total and high-density lipoprotein cholesterol levels, smoking, and diabetes) and newer risk factors (N-terminal fragment of prohormone B-type natriuretic peptide levels (NT-proBNP), von Willebrand factor antigen levels, fibrinogen levels, chronic kidney disease (CKD), leukocyte count, C-reactive protein (CRP) levels, homocysteine levels, uric acid levels, coronary artery calcium scores, carotid intima-media thickness (cIMT), peripheral arterial disease and pulse wave velocity).

Adding coronary artery calcium scores to the Framingham score improved the accuracy of risk predictions (c-statistic increase, 0.05; 95% confidence interval [CI], 0.02 to 0.06; net reclassification index, 19.3% overall [39.3% in those at intermediate risk, by Framingham]). Levels of NT-proBNP also improved risk predictions but to a lesser extent (c-statistic increase, 0.02; 95% CI, 0.01 to 0.04; net reclassification index, 7.6% overall [33.0% in those at intermediate risk, by Framingham score]). Improvements in predictions with other newer markers were marginal.

Improvements in coronary heart disease risk prediction with other newer risk markers, including cIMT, ankle-brachial index, and pulse wave velocity, which have been shown to be strong predictors of coronary heart disease in other studies, were modest, the authors reported. NT-proBNP may be more useful for coronary heart disease risk prediction at older ages. Although other biomarkers such as fibrinogen levels, CKD, leukocyte count, CRP levels, and homocysteine levels, were independently associated with the risk for later coronary events, their incremental value beyond traditional risk factors was marginal.

"The better performance of CAC score compared with other vascular measures of atherosclerosis probably reflects the disparity in contribution of various vascular beds in the disease process," the authors wrote. "However, because of variations across studies in the number of risk categories and thresholds and in clinical outcomes of interest, it is difficult to make direct comparisons of our findings with those of other population studies."
Monday, March 26, 2012

Bewildering insurance policies and how they play out in reality

A woman goes to her urologist. She has a known stone that was partially removed through a cystoscopy a month ago. She has been having residual colicky pain for the past month that has been getting increasingly worse. Her urologist recommends a CT scan to see if there is evidence of obstruction. Her insurance denies the scan.

Now from a health economics perspective, this is where it gets interesting. She is so disgruntled that she goes to the local emergency room where she racks up a hefty ED bill, has the scan done, and gets admitted. They don't have a hospital bed for her at this particular hospital but they do at the sister hospital across town, so they send her over by ambulance and she is admitted to a medical floor for two days.

If you were the insurance company wouldn't you be kicking yourself right about now for not just getting a CT scan from her urologist's office. Maybe the outcome would have been the same, but then again maybe it wouldn't. Waste anyone?


Justin Penn, MD, ACP Associate Member, attended medical school at the University of Washington School of Medicine and trained in internal medicine at the University of Rochester, where he is serving as Chief Resident. This post originally appeared at his blog, Musings of an Internist.

Honesty in medical practice: Do doctors always (sometimes) tell the truth?

"... resolve to be honest at all events; and if in your own judgment you cannot be an honest lawyer, resolve to be honest without being a lawyer."

Lincoln Memorial at night by rjv541 via Flickr and a Creative Commons licenseNo need to identify the authorship of the above quotation, which should be known by all discerning readers, such as those who feast on the weekly Whistleblower offering. For those who have suffered a cognitive lapse, I will provide four identity clues. Take a guess after each clue. If after the fourth clue, you are still clueless, then politely request a fifth and sixth clue in the comments section, and they will be provided to you.

1) He had a high pitched voice.
2) He was prone to depression and melancholy.
3) He was an ambitious and successful attorney.
4) He was known as "the rail-splitter."

Honesty in medicine is a fundamental pillar of our profession. However, physicians and scientific investigators have the same moral failings as the rest of our species. While we have moved beyond the atrocities of the Tuskegee syphilis "research," we are actively combating plagiarism, fraud, corporate misconduct and ethical erosion.

Most of us believe that our physician's exam room is a sanctuary from dishonesty. Our own doctor, while imperfect, is honest and would not knowingly give false information to us. A recent survey published in Health Affairs challenges this assumption and suggests that a new battlefront against medical dishonesty needs to be waged.

Nearly 20% of about 1,800 physicians surveyed did not soundly reject that patients should never be told a falsehood. About 10% admitted to having done so themselves.

We don't know the specifics of their truth-stretching, which may have been well meaning massaging of medical facts or sanitizing a prognosis. Nearly a third of physicians did not agree that medical errors should be disclosed to patients. Keep in mind that while patients have a right be informed about medical mistakes, the current medical malpractice system is a major impediment blocking physicians from admitting error. It's a little tougher for a doctor to tell a patient he messed up when this admission will be used as a legal cudgel against him.

I think that honesty is an absolute virtue, and not an elastic concept that can be stretched over questionable behaviors. How would I measure up? Here are examples of advice that I've given patients over the years:
--recommended fiber as a treatment for irritable bowel syndrome, although there is no scientific basis for this,
--ordered CAT scan for defensive purposes to minimize my legal vulnerability,
--placed feeding tubes in patients at the request of attending physicians when the medical benefit of this intervention is questionable,
--kept silent when patients were being subjected to overtreatment by me or my colleagues.

How do I reconcile my view that I am honest with the above examples? Are my honesty standards too high or is my performance too low? Although my level of honesty may be sufficient to practice medicine, according to the unnamed author of the quote that begins this post, it would surely disqualify me from the practice of law.

This post by Michael Kirsch, MD, 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--Medical boards issue real punishments for online conduct

QD: News Every Day--Medical boards issue real punishments for online conduct
Most U.S. medical licensing authorities have handed down punishments, sometimes severe ones, for unprofessional conduct online, a survey found.

Researchers surveyed the executive directors of all 68 medical and osteopathic boards about violations of online professionalism and subsequent actions taken. This study was done in partnership with the Federation of State Medical Boards (which does not track online violations; hence, the survey).

The research letter was published at the Journal of the American Medical Association.

Directors of 48 boards responded, representing about 88% of the approximately 850,000 physicians in the Federation's database, of whom 44 of 48 (92%) reported receiving at least one online professionalism violation. The most common ones were inappropriate patient communication online, such as sexual misconduct (33 of 48; 69%) for one or more violations); use of the Internet for inappropriate practice, such as online prescribing without an established clinical relationship (30 of 48; 63%); and online misrepresentation of credentials (29 of 48; 60%).

In response, 34 of 48 (71%) of boards held disciplinary proceedings, including formal disciplinary hearings 24 of 48 (50%) and issuing consent orders 19 of 48 (40%). In addition, 19 of 48 (40%) of boards issued informal warnings and 12 of 48 (25%) reported at least one instance in which no action was taken.

Serious disciplinary outcomes such as license restriction, suspension or revocation occurred at 27 of 48 (56%) of the boards.

"[T]hese violations also may be important online manifestations of serious and common violations offline, including substance abuse, sexual misconduct, and abuse of prescription privileges," the researchers wrote. "In addition, these incidents are highly problematic in their own right because they reflect poorly on physicians' values to the public."

The history of online misbehavior has been documented before, for example, by 60% of medical students.

ACP issued guidance for online behavior as part of its ethics manual.
Friday, March 23, 2012

Brown fat: Of smoke and (maybe) fire

Brown fat is hot, figuratively and perhaps literally. It is the focus of two recent research papers, one in mice and one in men, and the marquee item in a recent New York Times article, along with other media attention. Brown fat is hot, because it may help keep us warm, burn calories and help keep us thin.

Smoke and Fire by whiteforge via Flickr and a Creative Commons licenseBut how hot is it? Proverbs tell us where there's smoke like this, there's fire. But sometimes where there's smoke, there's just smoke, and a whole lot of hot air!

That was my impression when brown fat first started heating up in 2009. In the April 9 issue of the New England Journal of Medicine that year, three articles (1, 2, 3) and an editorial highlighted the potential, and apparently overlooked, importance of brown fat in human weight regulation.

I was surprised at that time that we were surprised to be learning that brown fat played a role in human temperature regulation and metabolism. I thought that we were taught just that in medical school (mid-1980s in my case). I somehow managed not to get the memo indicating that I didn't know what I thought I knew, and thus failed to be surprised in 2009.

Be that as it may, the New York Times jumped on the brown fat band-wagon then, suggesting that these "new" findings might offer a "cool way to lose weight," namely, by using some yet-to-be-discovered wonder drug to reset the human thermostat. Or, in the interim, turning down the thermostat in our homes.

The heat has been turned up rather than down on the topic, however, with the advent of the two new brown fat studies. One, in mice, published in the prestigious journal Nature, purports to establish the existence of a new hormone, irisin, which is integral (in exercising mice, at least) to the process of converting garden-variety white fat into its hottie counterpart, brown fat. Irisin exists in humans as well as in rodents.

The excitement over this is summed up concisely by the authors: "Increased irisin levels in the blood cause an increase in energy expenditure in mice with no changes in movement or food intake. This results in improvements in obesity and glucose homeostasis. Irisin could be therapeutic for human metabolic disease and other disorders that are improved with exercise."

In other words, if irisin does in people just what it does in mice, and if we can develop irisin to give people, it might cause them to burn more calories without needing to exercise. Of course, amphetamines do that already, and they're not really a terrific idea. But I don't want to get ahead of myself.

The second new study, and in some ways the more provocative of the two if only because the participants were human (six healthy men, to be exact), demonstrated that cold can induce brown fat to burn white fat. Body temperature is maintained with cold exposure by the combustion of the body's stored fuel (i.e., white fat) by the body's newly discovered (sort of) stove (i.e., brown fat). If the body gets even colder, shivering ensues and the muscle activity of shivering helps restore a normal temperature. Only when all of these defenses are overcome does hypothermia occur.

The new study was also noteworthy for the magnitude of the observed effect. By making the participants cold up to but not past the point of shivering, metabolic rate was reportedly increased by some 80%, resulting in the expenditure of an extra 250 calories or so over 3 hours. That's not an unimpressive figure, but a brisk walk for one hour would do the same.

That's why brown fat, or at least brown fat combined with cold, is hot.

One opportunity to which this research points is weight management by toughing out the cold. This seems to me a perfectly good and perfectly improbable recommendation. We already have good cause to turn our thermostats down and accept a nominal degree of perennial discomfort: We could save money, and help save the planet. Maybe the incentive of keeping last year's belt relevant this year will get us over the hump of habitual hypothermia, but I'm thinking not. Being cold all the time is in, a word, uncomfortable. If people were willing to be uncomfortable to control weight, a whole lot more of us would exercise!

The second opportunity related in particular to the mouse study is to increase the generation of calorie-burning brown fat by exercising. But this is really just another way of saying if you exercise more, you are apt to weigh less, and almost certain to be healthier. Those arguments haven't carried the day with most members of our population thus far, and it's not obvious that the added bonus of "and you'll have a bit more brown fat, too" will clinch the deal. In essence, this simply clarifies one mechanism by which exercise may do what we already know it does.

Which brings us to the last great opportunity: a new wonder drug. Irisin, or something like it, in a capsule or syringe.

I suppose we might devise a wonder drug for weight control and insights into the secret life of brown fat could be how we get there. But I am extremely dubious.

Insights into the secret life of our endocannabinoid system gave us rimonabant, the most promising weight control drug to come along in just about forever. It causes weight loss, and improves a wide variety of metabolic parameters, too.

But it does so by tinkering with native neural pathways, and unintended consequences abound. For rimonabant, the most salient of those was a dramatic enough increase in the rate of suicide for the drug to be approved and then withdrawn in Europe, and never approved in the first place in the U.S.

I do not think we will find a drug to fix obesity. I invoke Nathaniel Hawthorne to help me make the case.

In Hawthorne's short story, "The Birthmark," a physician is married to a beautiful woman. She is, in fact, so beautiful that by all accounts, her beauty is nearly perfect. But her beauty is only NEARLY perfect. It is marred, ever so slightly, by a small birthmark on her cheek.

The physician hears so many times of his wife's "near perfect" beauty that he becomes seduced by the concept of perfect beauty. He thinks to himself: "After all, I'm a physician! I have the power; I can do this."

Then the story slowly builds toward an ominous crescendo as the physician prepares an elixir and prepares his wife for a procedure. When at last all is ready, the physician stretches his wife out on a bed and administers his elixir to her. And lo and behold! The birthmark disappears, and her beauty is flawless.

But, alas. Hawthorne was writing for the religious sensibilities of his time, and this story was a moral parable about the unattainable conceit of human perfection. And so this birthmark was no superficial blemish. Rather, it was the mark of the woman's inescapably imperfect humanity. The elixir removed the birthmark from her skin, but traced its remedial effects from her skin to the very core of her to her heart and rendered her beauty perfect, even as it killed her.

What the hell has this got to do with brown fat? More than you might think.

Like Hawthorne's hapless heroine, we, too, are "marked" by the fundamentals of the human condition. We are all offspring of predecessors who lived in a world where calories were relatively scarce and hard to get, and physical activity constant, arduous and unavoidable.

We now live in a world where physical activity is scarce and hard to get, and calories constant, effortless and unavoidable. Is it any wonder we have epidemic obesity?

But the solutions reside in fixing the havoc we have wrought in our environment and lifestyle, not tinkering with human metabolism. If we pollute the oceans and fish start to die off, a drug that will let fish live on land seems far less plausible than cleaning up the oceans.

Do you recall the news flashes about obesity genes? Newly-discovered hormones that control hunger? Brown fat is the hot topic du jour.

We have numerous, intricate, overlapping layers of metabolic defense against starvatio, the threat that has stalked the heels of Homo sapiens from time immemorial. We have no native defenses against caloric excess because we never needed those before.

An effort to use a drug, any drug, to rework the fundamentals of human metabolism so that we don't turn a surplus of calories into an energy reserve in burgeoning adipose tissue seems to me an enterprise fraught with no less peril than Hawthorne's elixir. I don't believe we will ever devise such a drug, and if ever we do, I shudder to think what its unintended consequences may be.

I am also tempted to wonder if I am the only one recollecting that obesity is now epidemic in children. Are we thinking to use drugs to regulate the thermostats of growing children? Does anyone have even a clue what that might do to growth and development? As a parent, are you at all comfortable with the notion? The defense of doubt rests.

Like everyone else, I hope the new studies of brown fat provide insights we may eventually exploit to improve the human condition. I am, I confess, a bit less inclined to give the whole topic the cold shoulder than I was in 2009.

But I am cool on the concept of weight control through pharmacology, whether by beckoning to our brown fat, or by any other mechanism. Obesity is no superficial blemish to be medicated away; it's the birthmark of a people living in a world all too often at odds with the fundamentals of health, and certainly--and profoundly--at odds with healthful weight control. I contend, as I always have, that we will win or lose the war of weight control with our feet and our forks, not pharmacotherapy.

So by all means, stay tuned to the smoke signals about brown fat. But I urge you to keep other irons in the fire.

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--Limiting anesthesia during endoscopy eyed as potential source of savings

General anesthesia for endoscopy in low-risk patients has risen considerably, and an estimated $1.1 billion spent on the practice presents a target for health care cost-savings, researchers concluded.

Researchers conducted a retrospective analysis of claims data for samples of 1.1 million Medicare fee-for-service patients and 5.5 million commercially insured patients who had upper or lower endoscopy between 2003 and 2009.

Results appeared in the March 21 issue of the Journal of the American Medical Association.

Overall, 26.6% of Medicare patients and 28.6% of commercially insured patients received anesthesia. These represent 2.2 million gastroenterology procedures performed on Medicare beneficiaries and 7 million gastroenterology procedures performed on commercially insured patients.

Anesthesia services delivered to low-risk patients (American Society of Anesthesiologists physical status level of 1 or 2) fell from 78.6% in 2003 to 64.1% in 2009 among Medicare patients, whereas it remained constant in the commercially insured patients, from 86.5% in 2003 to 83.9% in 200).

Annual payments for anesthesia services among Medicare patients almost doubled in real terms, from $2.2 million in 2003 to $4.2 million in 2009 per 1 million enrollees, the authors noted. Annual payments per 1 million commercially insured patients increased more than 4-fold from 2003 ($1.9 million) to 2009 ($8.4 million).

Meanwhile, per-procedure cost for anesthesia services remained stable in real terms for Medicare patients ($147.20 in 2003 and $150.20 in 2009) and increased by 13.6% for commercially insured patients ($447.10 in 2003 and $508.70 in 2009). Wide regional variations indicated that some of this practice is discretionary, and randomized trials have shown no difference in results or satisfaction whether sedation is done by an anesthesiologist or a nurse under the endoscopist's supervision, the authors noted.

This increased use of anesthesia services is partly due to the benefits of propofol, which requires training in general anesthesia, as well as insurers' payment policies and marketing by the anesthesiology community.

"Use of anesthesia services for low-risk patients during gastrointestinal endoscopies may have increased steadily to more than $1.1 billion per year and presents a target for health care savings," the authors wrote.

And editorialist noted that deep sedation or general anesthesia potentially allow for more complete exams that can be done in a shorter amount of time, although no randomized trials prove this. And, patients might prefer it.

Furthermore, medical malpractice drives this, because using an anesthesiologist transfers liability, doesn't lower reimbursement and lets endoscopists treat more patients per day.

Options such as bundled fees may change medical practice but might have unintended consequences on patients adherence to screening guidelines, the editorialist noted.

"Careful implementation of new policies regarding 'potentially' discretionary services need to incorporate the patient and clinician perspective while continuing to implement change that bends the cost curve," the editorial said. "This may require all parties, including patients, clinicians, and facilities, to have a greater stake in the financial consequences of their action."
Thursday, March 22, 2012


I have the room to myself. I really like the breakfast bar and the high-backed leather benches my wife found at Value City. We set up the Mac down here where we can see kiddo using it and where I can easily fill a glass of water or get some pretzels.

I wrote a post yesterday that took something out of me, like removing a splinter. I can't write directly about my patients so I put together scenes, impressions, words collected over the years into sketches that help me make sense of what I see every day.

The hard work, the work I'm always learning is the quotidian, the tedious. Following paper from one place to the next, learning the technocratic side of medicine has been hard, but my teachers excellent. As good as my pathology professor was, my partners are month by month helping me learn the minutiae and the big picture of the behind-the-scenes work.

But it's still the exam room that I love, that I find easy, natural. I don't know what the hell a doctor is. Am I a scientist? A shaman? I know that life is terribly contingent. These contingencies are the gaps in the blinds, letting in a cloying darkness.

My wife asked my why cancer patients look like cancer patients. I gave some sort of lame answer about cancer cachexia, temporal wasting, but it's really the gaps in the blinds. A young person you recognized in decades of photos suddenly looks very different, and that difference says "sick." The patient may not see it, the family may not see it as they take pictures they hope show hope and happiness, but I can see it. It's a glimpse of what is to be (or not to be, right?)

I refuse to believe it's all narcissism, that we see only ourselves in our sick friends, or that we see our opposite. We may identify, and we also know that it cannot be us--ever. We're protected from these contingencies. But there is something more empathic, a more real connection. In the exam room the Kleenex box isn't just for the patients. We try to build a Chinese wall, but when you tell someone you've known for ten years that you're unlikely to share an eleventh, you can see the wall for what it really is--old, crumbling, fallen in places. The feelings seep through, and so does the sense of your own precariousness.

Whether the metaphor is a blind or a wall, it's imperfect and porous. Clinical terms can lend a distance, a sharpness. The sharpness can cause us to pull back suddenly as the pain of the wound reaches the brain. But it can draw us into the story, sometimes deeply. You may start to fantasize about making a house call or insinuating yourself even more into the bruising scrum.

There are no really good comparisons to be made. No metaphor captures the conflict, the emotions that are real, and distant, and intrusive.

I'm not a shaman. I'm not a scientist. I'm a human being immersed in the life of other human beings, bringing knowledge to their sometimes-disrupted lives, sometimes phoning it in, sometimes delivering a eulogy for the living.

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.

Untreatable gonorrhea, the next infectious threat

Our old nemesis, the clap, is in the news again this month.

Gonorrhea is the second most common sexually transmitted disease in the US, with more than 600,000 cases annually. In men it usually causes pain on urination, penile discharge, or sore throat. In women it may not cause symptoms or may cause painful urination, vaginal discharge, or sore throat. If untreated, gonorrhea can spread to the fallopian tubes, joints, and heart valves. I know that most readers simply can't hear enough about penile discharge (especially if they're reading this over lunch), so to the right I've included a microscopic image of exactly that. The gonorrhea bacteria are visible as the small dark dots.

With the discovery of penicillin in the 1940s the treatment of gonorrhea was revolutionized. But ever since that major victory gonorrhea has won several important battles. Gonorrhea developed resistance to sulfanilamide in the 1940s and to penicillins and tetracyclines in the 1980s. When I trained in internal medicine in the mid 1990s, Cipro (an antibiotic in the family called fluoroquinolones) was the preferred treatment for gonorrhea. In the 2000s some fluoroquinolone-resistant strains of gonorrhea appeared and by 2007 resistance was widespread.

Third generation cephalosporins are now the last antibiotic family to which gonorrhea is susceptible. But, as a decade ago with fluoroquinolones, sensitivity to cephalosporins is slowly decreasing, especially in the western US. Though no strain in the US has become resistant yet, a strain isolated from a patient in Japan in 2009 was highly resistant to cephalosporins.

The downward creeping cephalosporin sensitivity of gonorrhea prompted CDC researchers to sound the alarm in an editorial in the New England Journal of Medicine. The editorial warns that if the early signs of decreasing sensitivity are analogous to what we observed with fluoroquinolones in the '90s, then we may be only a few years away from strains of gonorrhea that are untreatable by any antibiotics.

The authors make sound recommendations to accelerate development of new antibiotics and increase surveillance of gonorrhea antibiotic sensitivity. But it's entirely possible that these efforts will fail, and that the only defense against gonorrhea will be from a vaccine which is not expected any time soon.

I've written before about the emerging problem of bacterial antibiotic resistance. Our grandchildren may study the period from the 1940s to the 2040s as the antibiotic century. Unless antibiotic development stays a step ahead of the wily microorganisms we may reach a time when sexually transmitted infections are managed the way they were a hundred years ago – promoting the use of condoms and corny public health posters encouraging men to keep their flies zipped.

Learn more:
CDC warns untreatable gonorrhea is on the way (Chicago Tribune)
Gonorrhea could join growing list of untreatable diseases (Scientific American)
Antibiotic-resistant gonorrhea (Centers for Disease Control and Prevention)
The emerging threat of untreatable gonococcal infection (New England Journal of Medicine)
Gonorrhea (U.S. National Library of 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--Marfan syndrome eludes primary care diagnoses

Primary care doctors are only catching one in four cases of Marfan syndrome, and 12% of patients are diagnosed only after the death of a family member.

The National Marfan Foundation surveyed 1,369 Marfan syndrome patients in February to better understand the diagnosis patterns of people with Marfan syndrome.

Early diagnosis, along with new drugs and surgeries, have led to longer life expectancies, but physicians may still rely on decades-old medical school training to spot the symptoms, the chair of the Foundation's professional advisory board said in a press release.

There's a distinct knowledge gap, since the Foundation pointed out that nearly 70% of Marfan's patients report that they were diagnosed before the age of 20. But 18% of respondents said it took an aortic dissection to raise clinical suspicion.

One survey participant explained that, even though the child had a parent with Marfan syndrome and the parents noted that the child had Marfan features, a pediatrician attributed the symptoms to other benign causes. A kindergarten vision exam resulted in a visit to the ophthalmologist, who then sent him to the cardiologist, who confirmed the diagnosis.

The three signs that most often raised the suspicion of Marfan syndrome were long limbs (73%), long, flexible fingers (68%) and height (64%), while indented or protruding chest bone (45%) and scoliosis (33%) were also mentioned.

One-third of respondents (33%) responded that ectopia lentis was the first feature to raise a suspicion of Marfan syndrome. Eye care providers were the first to suspect Marfan syndrome in nearly 20% of cases.

4% of respondents said that a doctor in the emergency department was the first to suspect Marfan syndrome, while in 8%, a relative was the first to suspect the condition.

Simplified diagnostic criteria appeared in the The Journal of Medical Genetics in 2010. This includes a systemic score that assigns Marfan features a numeric value that culminate in a total score. Three significant changes include:
--Aortic root dilatation/dissection and ectopia lentis are weighted more heavily than other characteristics;
--There is a more precise role for molecular testing; and
--Less specific manifestations of Marfan syndrome are either removed or given much less weight in the evaluation process.

Before, evaluation of features were called major or minor.

A mobile website features a summary of the new diagnostic criteria, including seven simple formulae for diagnosing Marfan syndrome, an interactive Systemic Score Calculator, a Z-score calculator used to determine the size of the aorta compared to body surface area, and key points about the role of genetic testing and family history.
Wednesday, March 21, 2012

Two things to read today

The first comes from Portland internist Devan Kansagara, MD, MCR, in an eloquent piece for Annals (usually "medical humanities" is not dignified by an actual human style). (This comes on the heels of a first-author systematic review in JAMA.)

Dr. Kansagara writes: "I have cared for several patients over the years whose palpable loneliness still shocks me. And this is not loneliness that 5 minutes of handholding or a visit from the volunteer dog can fix. This is institutionalized loneliness, refractory loneliness, the end stage of a life that has somehow not gone as planned. It is mixed with the memory of poor choices and their residual regret. I am sometimes witness to tragedy that I cannot define, diagnose, manage, or cure. I am increasingly aware of the tragedy of social isolation, but I have a hard time understanding it. The mechanism of disease--if one can call it that--is too overwhelming, too multifaceted. Social isolation is not a medical illness in the way that I was taught to think about illness, but it is often the ubiquitous fact that envelops every medical decision and even haunts the way I think about a patient's terminal illness.

"I have never asked a patient why he or she and society had parted ways, but in quiet moments, I occasionally think about it. Sometimes clues present themselves: an offhand remark about an accident, a history of incarceration or drug abuse, or a financial dispute with a family member. Roman, however, did not offer many clues. The next-of-kin information in his chart was blank. He had a daughter, but they had not spoken in years. I don't know why. Sometimes it's better not to know--sometimes too much history can corrupt empathy."

The second comes from "The Oracle of East Baltimore," an article from Urbanite:

"Weaver holds an endowed chair as alumnae professor of English at Simmons College, editing and translating poetry and prose both into and from modern Mandarin. In 2004 and 2008, he organized international conferences of Chinese poets at Simmons, the first held outside China.

"In a telling anecdote on the mindset of the average Baltimorean, he recalls family members refusing to believe that he could speak the language of Yao Ming. To which he replied: 'How would you know that anything I said wasn't Chinese?'"

Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.

Patient handout for offering advance directives

One of the big changes recently in my practice has been the addition of preventive care visits for Medicare patients (more on this later). Of the greatest benefits has been the opportunity to talk about advance directives. Because of this opportunity, I have talked about it far more than ever before.

But because I am somewhat lazy, and I don't want to give the same talk 1,000 more times, I wrote my own handout about advance directives for my patients.

I've decided that I will publish any handouts I write to my blog so that I can get comments from readers, and so that others can use what I have written for their own practice.

Advance Directives: Living Wills and Health Care Power of Attorney
Nobody likes to think about them, but these two things are very important documents for people as they grow older.

What is a living will?
A Living Will answers the question: If I am incapacitated and can't give my opinion, what do I want done if:
1) My heart stops beating. Do I want them to shock it to bring it back to beating?
2) My breathing fails. Do I want to be assisted in breathing using a ventilator?
3) My blood pressure drops. Do I want to get chemicals to raise my blood pressure?

For most people, the answers to these questions is, "Yes, as long as I won't get stuck on a machine, and as long as things don't get hopeless." In fact, this is the answer that doctors use if there is no living will at all. Doctors aren't forced to do everything at all cost to save a person, but they will do everything up to the point when it becomes clear that things are "hopeless."

When is a living will important?
There are two circumstances when living will is most important:
1) When a person doesn't want any or all of the three things on the list done.
2) When a person does want them done when other people might think they don't.

These are often the case when people are elderly or have serious diseases that make life difficult.

Common Mistakes
1) Not having a living will when it's needed. This is bad, as it forces family to guess at what you would have wanted.
2) Not understanding life-saving measures. Many people believe that being put on a "breathing machine" is a bad thing, and should always be avoided. In truth, most people put on ventilators come off of them easily. These are the same machines used to assist breathing during surgery, allowing deeper anesthesia.
3) Not talking to family about this. People don't like to talk about death, but avoiding this topic can turn a difficult situation into something that tears apart a family.

What is "Health care power of attorney?"
This is actually the more important decision to make, answering the question: "If I can't make decisions about my health care, who should do it in my stead?" If a person does not have this issue addressed, the law will assign people the task based on how close they are to the person. The progression goes like this:
1) Spouse (or parents, for an unmarried minor)
2) Adult children
3) Other next of kin, including adult grandchildren and siblings.

The problems happen when more than one person fits one of these categories. If, for example, the spouse is not living or not available, all of the children will have equal rights to have their wishes followed. In other words, the very difficult questions about a parent's life and death are left to a committee of siblings, which can and has torn families apart.

How is it done?
Health care power of attorney is a designation of who you think will most keep with your wishes, and who will work best with the other family members. It is a legal designation, and so should be overseen by an attorney if at all possible. The process is as follows:
1) Choose family member(s) that you feel confident with. Choose a single person to have this responsibility and another (if possible) to take the role if the first can't do it.
2) Let them know that you are doing this and what your wishes are.
3) Get the documentation (from an attorney or online. The AARP is a good resource for this kind of thing) and get it filled out, with proper witnesses and notarizing if needed.

Put the documents in a place that is safe and is known to all involved

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.

Physicians butt heads about overuse of stents

One of my patients is in the hospital in another city (where he lives part of the year) after suffering a GI bleed. He had a black stool, had lost blood, was quite anemic and experienced weakness and chest tightening before he came to the ER.

In the emergency room his cardiologist was called and admitted him under the cardiology service. When I called the cardiologist to identify myself as his internist, he told me the patient was getting a transfusion and he wanted to do an angiogram to see if his prior stents were open, and possibly put in more stents.

What? Stop right there.

The patient has chronic renal failure, has low blood counts, was quite stable with no symptoms, was receiving a transfusion and the cardiologist wants to put in stents? There are so many things wrong with this story I wanted to scream.

First of all, the workup should first zero in on the GI tract and find out why the patient had lost blood. He was not experiencing any chest pain or tightness once he received blood and was feeling quite normal. The cardiologist didn't even seem to be considering what the cause of the anemia was and had not called in a GI consultant.

Additionally, with compromised kidney function, an angiogram could put him into acute renal failure: "Contrast nephropathy is a recognized complication after coronary angiography and intervention that has been associated with prolonged hospitalization and adverse clinical outcomes," writes lead study author Jay Kay, MBBS, MRCP, from the University of Hong Kong in Aberdeen, and colleagues.

Not only was the workup and plan completely wrong, but I wanted to ask the cardiologist if he was even aware of the COURAGE study that has rocked the medical world. This large trial was published in the New England Journal of Medicine and presented at the 2007 Scientific Session of the American College of Cardiology. The results showed there was no difference in the outcome (death or new non-fatal heart attack) between patients with stable angina who received cardiac stents and those who did not. Every patient is different and large trials like COURAGE give us information with which to make decisions.

Most patients think stents save their lives. Most patients have never heard of these trials and still depend upon their physician to make the decision about what is needed. In this case, the cardiologist was making a really bad decision for my patient.

As the internist, I am looking at the entire picture and trying to be the quarterback. I respect the roles of the receiver, the halfback and the guards, but each of them are looking only at one part of the play, while I am viewing the entire field. In this case a patient with a GI bleed (later found to be an ulcer), no signs of unstable angina and chronic renal failure should not have an angiogram or any invasive cardiac procedure.

I advised my patient to "Just say no". When he did, the cardiologist replied, "Don't blame me if you go home tomorrow and have a heart attack."

Just jaw dropping.

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.