Friday, June 29, 2012

Should medical administrators still care for patients?

I have been relatively absent from social media for the past week or so. I have been doing inpatient duties on a general medicine service, and really enjoy working with medical students, interns, residents, pharmacists, and inpatient floor nurses. It has been a wonderful opportunity to experience the day-to-day activities involved in hospital medicine, and of course, to see and care for patients.

The time on the inpatient service is demanding, both physically and emotionally. Managing ill patients, long hours caring for complex patients and updating their families leave little time for my other duties in overseeing a CME office and a residency program. I am trying my best to juggle all of these duties, but for now, the patient care priorities do come first.

As I was arriving one day this week, I saw the chair of another department coming in, and mentioned that I was on service doing inpatient work. He remarked: "So good to hear that you are continuing this great work, and that you are still actively involved in patient care. Keep it up!" That made my day.

So I have been pondering this: should physicians who have major administrative duties and oversee programs, and thus have major time devoted to such activities, still care for patients? Should they still remain clinically active in order to have "street credibility" with their mostly clinical colleagues?

I think the answer to this is "yes." As busy as it is, I still believe that it keeps me fresh. It allows me the opportunity to reflect on why I went into medicine in the first place. It allows me to still remember what it is like to talk with a worried family member about a loved one, to see the gradual changes when a patient improves from hospital admission to discharge. It allows me to also see the trainees doing what we want them to do: learn to care for patients.

The more I become involved in overseeing administrative programs, the less time I can devote to direct patient care. But I still really enjoy doing the day-to-day patient care, and working with trainees as they learn the art and science of medicine. I still haven't forgotten the old adage by Francis Peabody: "The secret in the care of the patient is in caring for the patient."

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

Postinfectious cough

I am not a huge baseball fan to begin with, and when I am, I route for the Nationals. Thus, I pay little attention to the New York Yankees, and was not aware that Yankee player Mark Teixeira had been suffering with a cough for the past month until it the story from the New York Times came through one of my Twitter feeds.

According to the story:
"Mark Teixeira had a battery of tests performed Wednesday to determine the nature of his violent and persistent cough, and he received good news. Teixeira, who has been wracked by the cough for about a month, said he was found to have nothing more serious than severe congestion in his bronchial passageways."

Mr. Teixeira was prescribed prednisone (not something I would recommend for this) and is expected to recover soon. In addition, the doctors at New York-Presbyterian/Columbia hospital in Manhattan performed a CT scan, a lung function tests, blood tests and cultures during their work up (though I am sure the Yankees can afford this). The Times does not mention the diagnosis other than to say that the baseball player had "severe inflammation in my bronchial passageways."

I blog about this because this is one of the most common things I see in the primary care setting. It is often misunderstood and therefore misdiagnosed. It is very easily treated, and there is virtually no research on this disease.

Mr. Teixeira likely has what is known as postinfectious cough. Here's the typical patient presentation: Young healthy patient gets a typical upper respiratory tract infection (URI): cough and congestion, headache, feels ill and low grade fever. URI resolves in a matter of days, but there is a persistent cough that is getting worse, and won't go away. Cough is usually worse at night, and the patient can't exercise because it makes them cough. On occasion the cough is so bad that the patient is winded easily and sometimes the patient thinks they may be wheezing, though they have no history of asthma.

According to the American College of Chest Physicians, which published evidence-based clinical practice guidelines back in 2008, the diagnosis of post infectious cough should be considered when a patient complains of cough that has been present following symptoms of an acute respiratory infection for at least 3 weeks, but not more than 8 weeks.

While the cause of the postinfectious cough is not known, it has been thought to be due to the extensive damage of cells lining the lung and widespread airway inflammation of the upper and/or lower airways.

The good news is that this usually goes away by itself, the bad news is that it can take weeks or even months, and can be quite disruptive to patients' lives; desk jockeys and baseball players alike.

To me one of the most incredible things about this illness is the lack of data on effective treatments. The ACCP review cited above did an extensive review of the literature and found very few studies that looked which treatments worked best. Given the lack of data, here is my take on the appropriate diagnosis and treatment.

Diagnosis can be made without an extensive workup when the clinical presentation is consistent with that described above and there are no other complicating factors that would indicate other possibilities. A chest X-ray may be all that is necessary to rule out any underlying severe disease and is reasonable in a patient who has been coughing for more than two weeks.

Since symptoms are caused primarily by inflammation and hyperresponsiveness/bronchoconstriction in the lungs (which is what we see in asthma), then treatment is likely best with something that treats both inflammation and bronchoconstriction in the lungs, such as an inhaled corticosteroid/long-acting beta agonist like Advair (which is commonly used in asthma).

Of note, Advair (or other ICS/LABA combinations) have not been approved by the FDA for the treatment postinfectious cough and there is no data on the use of ICS/LABA's for the treatment of postinfectious cough. However, this is a common sense approach to the problem based on what we know about the cause, and from clinical experience I can tell you this approach works remarkably well. Use of Advair for postinfectious cough may be the single most common off-label use of any prescription product.

There are two additional important points. First, since inflammation can persist for weeks, it is important that Advair be used for at least 4 weeks. If stopped too soon, before inflammation has completely resolved, symptoms may return. This is very important, because primary care physicians who decide to use ICS/LABA inhalers for postinfectious cough may give patients a medication sample rather than a prescription. Though the drug companies that make these products used to make samples with a month's supply of medication, most inhaler samples today have only 1-2 weeks of therapy.

Secondly, if symptoms have resolved and the patient has taken the inhaler for 4-6 weeks, the patient can safely stop the inhaler. If symptoms return, the patient should be brought back for pulmonary function testing as this may be a new presentation of asthma.

Matthew Mintz, MD, is a Fellow of the American College of Physicians. He is board certified in internal medicine and has been practicing for more than a decade. He is also an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients. This post originally appeared at Dr. Mintz' Blog. Conflict-of-interest disclosures are available here.

QD: News Every Day--Teach med students prevention so they counsel patients later

Preventive medicine isn't being taught until the final year of medical school, which leads to it not occurring more often when these students become doctors, a study concluded.

To examine the way that medical education encourages graduates to practice preventive medicine later on in their careers, medical students at 16 U.S. medical schools completed three questionnaires at the beginning of their first and third years and in their senior year. Topics included 21 preventive medicine topics, the extent of their training about them, and how often they counseled patients about those topics.

Topics included talking to patients about lifestyle choices such as diet, smoking, or taking safety measures, as well as screening tests and exams such as mammography and cholesterol screening.

At the beginning of the third year, self-reported extensive training ranged from 7% to 26% for preventive medicine topics. Topics recommended by the U.S. Preventive Services Task Force received more curricular time (median for topics: 36% if recommended versus 24.5% if not; P less than 0.025), as did topics addressed through testing rather than through more time-consuming discussion with patients (median for topics: 37% for testing and 25% for discussion, P less than 0.005).

"U.S. medical students report receiving little prevention training in their first 2 years and that the training they do remember receiving may not be markedly evidence-based," the authors wrote. "We believe that the low amounts of pre-ward prevention training occur because the first 2 years of American medical school are typically more oriented toward basic sciences than clinical medicine."
Thursday, June 28, 2012

Unjunking ourselves!

The lead story in today's New York Times is that Mayor Bloomberg wants to restrict the size of soft drinks sold in New York City to a maximum of 16 oz. Another way to go might be to restrict them to a minimum of two gallons so you have to be fit enough to carry one if you want to drink it.

Anyway, we'll come back to the mayor's efforts to help us unjunk.

For the moment, let's think about good reasons for unjunking ourselves.

Think about a child or former child you love. This should be pretty easy for any parent, grandparent, aunt, uncle, or just about anybody else who has known a kid or ever been one.

Now, think about that child's growth from year to year and ask yourself: What were they growing out of?

What was the construction material? Matter can't be constructed out of nothing. It comes from somewhere. If a child's head is four inches higher off the floor this year than last year, then that four-inch platform of extra kid was built out of something. What?

Food, and nothing else.

Food is the construction material--the only construction material--for the growing bodies of children we love.

We are, no doubt, all familiar with the expression "you are what you eat," but given how most of us eat, it's quite clear we don't take it very seriously. And for some pretty good reasons. The human machine, and human fuel tank, are stunningly forgiving. We can throw almost anything in the tank, and run reasonably well for decades. We can't build a machine fractionally so accommodating.

And, of course, we don't look like what we eat. We eat donuts, and don't sport big holes through our middles. We eat French fries, and don't sprout French fry antennae.

But you can't judge what we are made of by what we look like, any more than you can judge a book by its cover or a house by its paint.

Our houses are, often, made mostly of wood, but look nothing like trees. Trees are cut down and, if you will, "digested" in a timber mill to produce wood that is turned into lumber. The lumber is then used to build houses that look nothing like the trees.

But if that lumber is rotten, the house in question may look all right at first, but it will fare quite badly when the first big storm comes along. The quality of a house is rooted in the quality of its construction materials.

Ditto for us. The growing body of a child is built out of food. Nutrients are extracted from food, just as wood is extracted from trees. Rotten wood makes rotten houses. Rotten food makes sick kids. Maybe not right away, but eventually, rotten construction material catches up with us all.

Bodies built out of junk make kids prone to epidemic obesity, to "adult-onset" diabetes. And to much worse.

The kids may look, and even feel, fine for a while. But every cell their bodies build depends on the quality of the available construction material it is offered. Every muscle fiber, every enzyme, every brain cell, every heart cell, every hormone.

No one I know throws any old junk into the tank of a car they hope will run well for the foreseeable future. No one I know willingly builds a home out of junk, or of rotten wood.

Yet as a culture, we act as if "junk food" is an acceptable category. As if it's cute, fun, innocuous and acceptable. As if it's all just a good joke.

But food is the one and only building material for the growing body of a child you love. How's "junk" sounding now?

And, by the way, every one of us adults is turning over literally hundreds of millions of cells daily. These need to be replaced, along with spent enzymes, hormones, neurotransmitters and the like. Where do we get the construction material for this job? Right you are.

My colleagues and I at Turn the Tide think it is past time to unjunk ourselves! Kids and adults alike, but kids in particular.

To some extent, this involves a nation of loving and responsible adults recognizing that "junk" is not a food group. There was no edible junk in the Stone Age, there was just food. There was no edible junk in Mesopotamia at the dawn of agriculture, there was just food! And let's face it, there was no mention of junk in the Garden of Eden, either! We created junk, and the health consequences that come from it.

Time to get rid of it. To that end, we are launching our newest program, the latest sandbag for the anti-obesity, anti-chronic-disease levee: Unjunk Yourself!

The program, which will become a whole library of music videos (with help and support from folks like you!), is aimed at tweens and teens. Like the TRUTH campaign that helped get kids outraged about tobacco, Unjunk Yourself is designed to stir up a bit of righteous indignation. (We have another music video, "The Process," in the works: "We've been processing food, and now we're processing you ...") It will deliver fun, provocative, engaging, health-promoting information in music video format and then provide links to online tools, resources, and programs kids (and their families) can put directly to use. Knowledge, combined with the tools and skills that allow you to USE it, really is power!

And that's what we want to do, empower kids and their families to take health into their own hands.

Mayor Bloomberg's plan to ban large sodas in New York City is already controversial. Some support, and some oppose, the mayor's approach to helping unjunk us. Personally, I think it can be justified, but I much prefer the carrot to the stick. And I prefer for us all to take health into our own hands whenever possible.

Whichever side of the line you are on, perhaps you'll agree that we can and should unjunk ourselves, and our kids in particular. This is not about being food police, health dictators, or nutrition nannies. This is about the fact that to the extent that it is humanly possible, vitality should be the birthright of every child.

This is not about what we take away from kids. It's about we can give them: a better future. Healthy people have more fun. Health is a key ingredient in creating the best and longest life possible. Unjunking ourselves can help us get there. It's among the most valuable, enduring gifts any adult can give a child.

Please watch the video, and help us spread the word. Show it to a kid. And, if possible, please help us grow the music video library.

Today would be a great day to start unjunking a kid you love. And, while you're at it, perhaps you'll want to Unjunk Yourself!

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.

Western meets eastern medicine, or yin meets yang

In today's China, both Eastern and Western medical philosophies and practices exist relatively harmoniously. Patients with minor, usually self-limited problems are treated initially with a seven day course of seven liquid herbal preparations taken each day. If symptoms subside, usually treatment is discontinued. If improved but not resolved, formula may be modified. If worse, regimen can be changed and/or referral to specialists arranged.

There are hospitals that practice purely eastern or only western medicine. But it is becoming more frequent to find hospitals that integrate both disciplines. Chronic conditions, like cancer, tend to be treated with western techniques, with Traditional Chinese Medicine (TCM) used in a supportive or complementary role.

I was somewhat surprised to hear that the two largest cancer problems are breast cancer and liver cancer (mainly the former but not the latter). Before I left, one of my patients had brought an article to my attention about a low incidence of breast cancer in China compared to the West. This may not be the case. Primary liver cancer (hepatocellular carcinoma) has long been the #1 cancer in frequency in the world due to a high incidence of hepatitis, especially in Asia. This results in chronic active hepatitis, cirrhosis and, finally, cancer. Even though we stayed at 5-star hotels, we didn't brush our teeth or rinse our toothbrushes with tap water, and avoided ice. Sanitation, or lack of it, is an issue.

Everywhere in China, especially big cities, there are forests of skyscrapers. Private homes are essentially nonexistent as the government owns all the land. New construction is ubiquitous, so cranes are numerous. Many of these apartment spaces are empty due to high prices, and those that are bought or rented are shared by several families. Same with kitchens and bathrooms. Public bathrooms may lack toilets and simply be holes in the ground.

In some buildings, one bathroom per floor exists. We saw the interiors of three residences. First, the home of one of four of the farmers that first discovered the terra-cotta warriors outside Xi'an. Clean. Very little furniture, as you buy empty spaces which you have to furnish yourselves. But several generations of the family lives there. Second, a more modest quarters of a woman in the old section of Beijing. Bathrooms were down the road apiece. The last was a tiny, single room in what used to be the French Concession section of Shanghai. Five people slept on one cot. No mystery why hepatitis and liver cancers are still issues.

Another surprise is lack of mention of lung cancer. Cars everywhere. Their gridlock is continuous and called "rush days." Mist or fog (mostly pollution) gives a surreal appearance to the landscape of high rises. Seemingly everyone coughs. Lots of spitting. A perfect setup for respiratory problems including lung cancer. There are several hospitals in major cities devoted to respiratory diseases, however.

An excellent article appeared in the Wall Street Journal, Tuesday, April 3, 2012, pg D4, entitled "Chinese Medicine Goes Under the Microscope" by Shirley S. Wang. The main topic is a clinical trial studying a 4 herb combination, called huang qin tang in China and PHY906 in this trial, in combination with chemotherapy to see if effective in reducing side effects of chemo (nausea, vomiting, and diarrhea). If so, patients might be able to tolerate higher doses of chemo with better results. Trial design and quality control are issues when doing studies such as these:

One challenge with using herbal medicines is that the ratio of the chemicals they contain isn't consistent when plants are grown under different conditions. After testing various suppliers, Dr. (Yung-Chi) Cheng ended up creating a biotechnology company sponsored by Yale called PhytoCeutica to carefully monitor growing conditions to ensure plants from different batches were pharmacologically consistent and to continue clinical development of the compound.

Finally, an article that appeared in the China Daily entitled "There's More to Life Than Money" by Cai Hong, a senior writer for the paper, cites the first World Happiness Report released by the Earth Institute last month. Not surprisingly, the top four rated are northern European welfare states: Denmark, Finland, Norway and the Netherlands. China doesn't make the top 100. One of the benchmarks evaluated is health:

"Increased insurance coverage has not yet been effective in reducing patients' financial risks, as both health expenditure and out-of-pocket payments continue to rise rapidly. And there are many reports of disgruntled patients and their relatives attacking the medical staff in hospitals. Reform of public hospitals is essential to control health expenditure because such institutes deliver more than 90% of the country's health services. But Health Minister Chen Zhu said the cost of improving care remains an obstacle, and China is looking to other nations for cost-effective solutions.

This notice appeared in the WSJ this last weekend:

"U.S.-China Pharma: Some big pharmaceutical firms are partnering with Chinese companies in trying to discover the next blockbuster drug. This Philadelphia conference will include venture capitalists and such Western firms as Novartis and Abbott Labs. Wednesday-Thursday, Hub Cira Centre. Regular admission: $1,799.00.

Interesting that both the U.S. and Chinese governments are investigating hospitals for price gouging in the sale of drugs.

This post by Richard Just, MD, ACP Member, originally appeared at, a joint publication of Richard Just, MD, aka @chemosabe1 on Twitter and Gregg Masters, MPH, aka @2healthguru on Twitter. Dr. Just has 36 years in clinical practice of hematology and medical oncology.

QD: News Every Day--Painkiller abuse rises in young men, declines in teens

Young men saw a 105% increase in painkiller abuse in the past decade, paralleling the increases in death and treatment admissions seen in this time period.

To determine if those using painkillers recreationally had had increased since 2002, a researcher applied data from the National Survey on Drug Use and Health, an annual survey of the noninstitutionalized, civilian population 12 years and older, for years 2002-2003 and 2009-2010.

Frequency of abuse of pain relievers was categorized into the time spans of 1 to 29 days, 30 to 99 days, 100 to 199 days, and 200 to 365 days.

Results appeared in a research letter in Archives of Internal Medicine.

Annual average rates of painkiller abuse of the time span of 200 to 365 days increased 105% among male respondents between 2002-2003 and 2009-2010.

Rates of 200 to 365 days of painkiller abuse increased significantly among those ages 18 to 25 (77.6%), 26 to 34 (81%), and 35 to 49 (134.6%).

However, any abuse of painkillers among people ages 12 to 17 decreased by 15%.

The authors noted that the findings parallel increases in overdose deaths and treatment admissions associated with opioid pain relievers in recent years.

"The finding that nearly 0.4% of people 12 years and older, almost 1 million people, reported using pain relievers nonmedically for 200 days or more in 2009-2010 and roughly 2%, or 4.6 million people, used them for 30 days or more is concerning," the author wrote. Each of the 257 million opioid prescriptions dispensed in the United States annually contributes on average to more than 2 days of opioid abuse.

Internists aren't often confident when prescribing opioids, or that they detect and manage abuse. But clear-cut and easy guidelines can help internists achieve the best outcomes for preventing abuse, confronting patients about it and, when needed, ending opioid prescribing among abusers.
Wednesday, June 27, 2012

Avoiding the unintended consequences of the new work hours

This letter from residents appears in Academic Medicine, Unintended Consequences of Duty Hours Regulation.

"Prior to this year, 30-hour call shifts were the norm for many residents in our hospital and nationally. The rigor of these shifts taught us to maintain professionalism and compassion amidst life-and-death stakes. Overnight calls, despite the unavoidable fatigue, were training grounds for independent decision making and some of the most exhilarating times of residency. These shifts were often the best opportunities to watch the evolution of disease away from the pages of a textbook and to experience the transition from trainee to doctor under appropriate supervision. Most important, the extended hospital shifts were the time for residents and patients to bond--developing the critical doctor-patient relationship and designing a collaborative plan of care.

"No amount of shift-design or fatigue-mitigation strategies can replace such important experiences--from a medical and humanistic standpoint. The decrease in daily continuity has whittled away the interactions on which the patient-doctor relationship depends. Electronic cross-cover lists have replaced personal interactions as residents' primary source of information. On the whole, the changes have established a norm of perpetual patient transfers from one team to the next, with diminished opportunities for any one team to develop responsibility for a patient. As a result, we residents are losing 'our' patients."

While I empathize with these residents, I will argue that we can provide excellent training. Our family medicine residency in Huntsville, Ala. developed a call schedule that minimizes the negatives and maximizes the positives. The key is responsibility. All interns and residents work a maximum of 14 hour shifts. When you admit a patient, you "own" that patient. They emphasize continuity. Hand-offs occur during rounds with the night and day residents rounding together first thing in the morning with the attending physician.

While I do believe that the old schedule made great physicians, perhaps we can still succeed, if we do design our call systems around principles rather than hours. When we emphasize the patient and the physician patient relationship, then we may even do better.

But then everyone knows that I am a lifelong optimist.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.

Better patient satisfaction, which model to follow?

Patient satisfaction is an important element of medical care. It was always important, but it has taken on a new significance since hospitals and physicians will be graded on their bedside manners. And, these grades count for cash. Money motivates.

Who believes that a leopard can't change its spots? Throw a leopard into the pay-for -performance arena, define spots as inferior quality, and watch what happens. We would all witness a Darwinian tour de force as leopards would become spotless in just a few generations.

Recently, I was exposed to two models of customer service. First, I endured the experience of setting up cable service for TV and wireless internet. Sounds easy, but I would not advise this task for anyone who has a heart condition. What should have been easily accomplished in one phone call took multiple calls to screw it all up. Of course, every single call 'was important to them' and required a generous amount of waiting time for me.

With one exception, every customer service agent I reached was located in another continent. I am not railing against outsourcing here. Companies make products and hire workers abroad because it is in their economic interest to do so. However, since my specific and simple question was best answered by one of their local folks in Cleveland, none of the reps in India or the Philippines could answer it.

Try also explaining to them that it is hard for a working person to be home to greet the local installer when you are not given a specific time of their arrival.

I can't wait when I need to contact these guys when the system is malfunctioning. I don't yet have coronary disease, but I might pop a nitro under the tongue then just in case. The headache the pill might give me will nothing compared to the throbbing migraine the phone calls will cause.

In addition, different reps offered entirely different advice, which I think were total guesses. This is always fun for the customer. See excerpt: --Rep #1: I recommend that you do this
--Rep #2: I recommend that you do not do this.
--Rep #3: I recommend that you contact Rep #4.

I tried to beg or bribe them for a local Cleveland phone number to contact, but this classified information was on a 'need to know basis', and my need to know didn't cross the threshold.

And then, there's the Apple Store. My beloved iPhone unexpectedly suffered a cardiac arrest, a total meltdown without warning. Cruised over to Apple and was immediately greeted by an affable rep who actually seemed to care about my misfortune. I was siphoned over to another rep who in a few minutes recognized that my iPhone's soul had already ascended to heaven and would no longer enjoy an earthly existence. He provided me immediately with a new device and waited by my side until he could verify that it was operational.

I've been to this store on other occasions and am always impressed with the courtesy, efficiency and competence that their outstanding staff show to their customers. It reminds every time me how inadequate and undervalued customer service is in the marketplace.

Is Apple simply doing what all companies should do, or is this standard unreasonable? Do other companies make it tough on us on purpose to discourage us from complaining or asking for refunds or rebates? How many gazillions of dollars to insurance companies reap because we simply give up seeking relatively small amounts of money that we believe we are entitled to?

Which model of customer service do we physicians use with our own patients? Do we emulate the airline industry? Or, do we look to a group of young and energetic geeky types for guidance?

Remember the adage, an apple a day keeps the doctor away? I suggest that we doctors keep an apple on our desk to remind us why we come to work.

If you are inclined, leave a comment below. I assure you that 'your comment is important to us.' You comment may be monitored for quality assurance.

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--Medicare cuts cause most unease among medical practices

Potential Medicare cuts are the top challenge to running a practice, according to a survey.

According to 1,252 respondents to MGMA-ACMPE's "Medical Practice Today: What members have to say" research, the top five challenges of running a group practice are:
--managing finances with the uncertainty of Medicare reimbursement rates,
--preparing for reimbursement models that place a greater share of financial risk on the practice,
--preparing for the transition to ICD-10 diagnosis coding,
--dealing with rising operating costs, and
--participating in the Centers for Medicare & Medicaid Services' EHR meaningful use incentive program.

"The threat of a significant cut in Medicare reimbursement continues to plague physician practices and severely hinders their ability to properly plan and assess their financial situations," said Susan Turney, MD, MS, FACP, president and CEO of MGMA-ACMPE, in a press release. "The increased regulatory burden brought on by unfunded federal mandates only exacerbates this uncertainly caused by the flawed Medicare Sustainable Growth Rate physician payment formula."

Medical practice professionals in hospital- or IDS-owned medical groups found preparing for the ICD-10 diagnosis codes more challenging than those in physician-owned groups. Managing finances, implementing and/or optimizing a patient-centered medical home (PCMH), and dealing with the commercial-payer physician credentialing process were also cited as a greater challenge for hospital-owned groups.

"The healthcare environment is increasingly complex to navigate," Dr. Turney added. "It's more important than ever for professional practice administrators, especially those who are board certified in medical practice management, to assist their practices in adapting to the arduous processes and regulations that govern our industry."

The survey invited members by e-mail to participate in a web-based questionnaire about 54 issues, using a five-point scale for each one.
Tuesday, June 26, 2012


The story about Dr. Spitzer's late-life recanting of the 'gay cure' got me to thinking.

First I imagined all the jobs that the steady progress of innovation and technology have eliminated:

Ice men, telegraph operators, lamplighters, copy boys, milkmen, typesetters. These are only a few.

Travel agents have become an endangered species, too, as people can book their own trips online through dozens of different websites. [Though a recent article claims a comeback of sorts for travel agents.]

I guess now we can add therapists practicing the 'gay cure' to the list of outmoded professions. No doubt there will be holdouts for a while.

Dr. Spitzer was a giant in his field. He was a main contributor to the third and fourth revisions of the Diagnostic and Statistical Manual of Mental Disorders, the bible of psychiatry.

Ironically, as a young academic, he had been instrumental in de-listing homosexuality as a disorder (1973), seeing psychopathy related to sexual orientation as mere "sexual orientation disturbance," i.e. anxiety caused by issues of orientation, gay or straight.

As an iconoclast, Dr. Spitzer was always looking to speak truth to power. Yet he became the power. So when he decided to study a group of former gays claiming to have been 'cured,' he was swimming in dangerous waters. His poorly-conceived study gave validity to a pseudoscience that mainstream psychiatry and psychology viewed with disdain.

And now, with homosexuality again big news, Dr. Spitzer realized that it was time to publicly acknowledge his mistake and recant. He typed a letter to the journal that had published his 2001 study. Here's the final paragraph:

"I believe I owe the gay community an apology for my study making unproven claims of the efficacy of reparative therapy ['gay cure' therapy--ed.] I also apologize to any gay person who wasted time and energy undergoing some form of reparative therapy because they believed that I had proven that reparative therapy works with some 'highly motivated' individuals."

Commentary about Dr. Spitzer's letter was voluminous. Many appreciated his courage and honesty. Others angrily wrote him off as a sick old man [he suffers from Parkinson's and is near 80] trying to curry favor or seek the spotlight again.

My own view is that as a man of principle he did what he felt he had to do to promote truth in a contentious world. His apology reads sincerely to me, and he acknowledges that he caused harm, something no honest physician ever desires.

It's quite a story.

Dr. Spitzer caused me to think about other famous 'recantations.' Galileo immediately sprang to mind. In 1633 he was found by an Inquisition of the Church to be "vehemently suspect of heresy."

Talk about harsh. He was required to "abjure, curse, and detest" his written opinions that the Sun, and not Earth, was at the center of our solar system [heliocentrism]. He lived under house arrest for the remainder of his life.

Popular legend holds that at the end of his trial he muttered "and yet it moves," referring to Earth.

There the comparison ends. Dr. Spitzer won't be muttering anything of the sort.

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.

What to make of medical dogs

For thousands of years we have guided the evolution of dogs to fulfill our needs for work and companionship. Service dogs are pretty remarkable. I love to watch herd dogs mimicking the dance of predator and prey. When you see a guide dog help someone navigate a building or street, you can't help but to be impressed by the dog's "devotion" and "skill."

It seems there is a new canine skill in the news every day. Now, in addition to the traditional roles guiding the blind and deaf and helping the physically disabled, dogs are claimed to be able to calm autistic children, detect blood pressure changes and seizures, and find cancers. Dogs have been used in the bed bug epidemic to find the critters (with little scientific evidence of success).

Humans and dogs have co-evolved successfully to create strong owner-dog attachments (to the point of pit bull owners defending their dogs rather than acknowledging a dog's danger to humans).

It seems intuitive, and is quite plausible, that dogs can calm us, can help lead us in ways analogous to their roles in nature (if "natural" can even be applied to dogs). It's easy to see how herding behavior can be adapted into guide dog behavior, or hunting behavior into chemical detection.

What's less clear is whether any of these roles are based on fact rather than intuition.

What raised my interest this week was a dog featured on ABC News. The show followed a young woman with a "rare heart condition" that goes unnamed. It shows her dog alerting her to an impending fainting spell.

The film itself is useless as data. It simply shows the dog nudging the patient and the patient responding by lying down. But even assuming that the family has seen "successful" alerts of fainting, there is no evidence in the literature to suggest dogs can actually do this in any context.

It is likely that the dog improves the woman's sense of security and well-being (something the literature supports in human-service dog relationships) but there is no way to know if the dog is "sensing" changes in blood pressure as claimed.

One of the most interesting medical claims for dogs is an ability to detect cancers in humans, perhaps before conventional testing might.

While anecdotes abound, there is scant literature to support this ability. One unimpressive pilot study looked at dogs' potential ability to detect bladder cancers from urine samples. The idea behind cancer dogs is that there may be volatile compounds produced in cancer patients that dogs can detect by scent. In these studies, the compounds are not identified, not tested for, not named. There are many confounders, for example, in the few samples used, there may be other differences being detected by the dogs.

In the other study (I found very few) dogs were "trained" to detect lung and breast cancers in humans. The methodology of breath sampling is not validated as far as I can see, and once again, the putative compounds in breath are not identified. Statistically, the efficacy is marginal at best.

Another controversial use medical use of dogs is for seizure detection. So-called "seizure alert dogs" are purported to warn their masters of impending seizures, and to stay with them during the event. It doesn't take a bucket of skepticism to wonder what this actually means.

Many seizures are preceded by marked changes in behavior as the patient experiences an aura, something anyone/any dog should be able to notice. Staying by a bonded human isn't too unusual either. I do wonder how the humans know what the dog does, as many true seizures are accompanied by a period of confusion and memory loss. An objective witness would be needed to note the behavior.

And some case studies have done just that. There aren't a lot of data, but one patient monitored in a seizure unit experienced nine seizures, one of which was "sensed" by her dog. In another, the dog sensed a "pseudo-seizure", that is a fit that is not, neurologically-speaking, a seizure but a non-seizure set of behaviors, often precipitated by stress.

That dogs can be trained to help humans is pretty clear; we've bred them for this. But these abilities must necessarily have limits, limits set by biology. If a behavior seems implausible, the evidence for it must (from a Bayesian standpoint) be pretty damned solid.

I don't doubt the social and emotional value of dogs as companions, and as active helpers in many circumstances. But beyond this, the evidence is wanting.

Allen K, Shykoff BE, & Izzo JL Jr (2001). Pet ownership, but not ace inhibitor therapy, blunts home blood pressure responses to mental stress. Hypertension, 38 (4), 815-20 PMID: 11641292
Lane, D., McNicholas, J., & Collis, G. (1998). Dogs for the disabled: benefits to recipients and welfare of the dog. Applied Animal Behaviour Science, 59 (1-3), 49-60 DOI: 10.1016/S0168-1591(98)00120-8
Willis, C. (2004). Olfactory detection of human bladder cancer by dogs: proof of principle study BMJ, 329 (7468) DOI: 10.1136/bmj.329.7468.712
McCulloch, M. (2006). Diagnostic Accuracy of Canine Scent Detection in Early- and Late-Stage Lung and Breast Cancers. Integrative Cancer Therapies, 5 (1), 30-39 DOI: 10.1177/1534735405285096
Dalziel DJ, Uthman BM, Mcgorray SP, & Reep RL (2003). Seizure-alert dogs: a review and preliminary study. Seizure : the journal of the British Epilepsy Association, 12 (2), 115-20 PMID: 12566236
Strong V, Brown S, Huyton M, & Coyle H (2002). Effect of trained Seizure Alert Dogs on frequency of tonic-clonic seizures. Seizure : the journal of the British Epilepsy Association, 11 (6), 402-5 PMID: 12160671
Doherty, M., & Haltiner, A. (2007). Wag the dog: Skepticism on seizure alert canines Neurology, 68 (4), 309-309 DOI: 10.1212/01.wnl.0000252369.82956.a3

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--The 10 most desirable medical schools are ...

U.S. News & World Report calculated a list of the 10 most popular medical schools, as calculated by those able to enroll the highest percentages of accepted students.

110 ranked medical schools provided acceptance and enrollment data for the 2011-2012 school year to create the list:
1) Oklahoma State University Center for Health Sciences

2) University of Kansas Medical Center

3) University of New Mexico School of Medicine

4) University of Oklahoma College of Medicine

5) Medical University of South Carolina

6) University of Washington School of Medicine

7) University of North Dakota School of Medicine and Health Sciences

8) University of South Dakota Sanford School of Medicine

9) University of Nevada-Reno School of Medicine

10) Harvard Medical School

U.S. News surveyed more than 140 medical schools as part of its larger series ranking best colleges and graduate schools.
Monday, June 25, 2012

High health care costs does not equal quality

The new buzzword in Medicine these days is "value based purchasing." It's not a new concept. Everyone wants to get their money's worth, whether it is a new car, a meal at a fancy restaurant or the best medical care. Without clear information on quality, however, many patients assume that more expensive care is better care.

The Agency for Healthcare Research and Quality (AHRQ) has funded a study to look at this. A team of researchers studied how various presentations of cost and quality influenced the choices of patients. They found that many people perceived low cost clinicians to be substandard and avoided them. It didn't matter if they were paying out of pocket for care or if they had insurance that covered the service. They still associated higher cost with higher quality care.

When patients were given information in the form of easy to understand data about care quality they were more likely to make choices that didn't cost more. It mattered how the data was presented.

Americans spend more on their health care than citizens of 12 other developed nations, but the quality of that care (as measured in outcomes, accessibility, preventive care) lags far behind. It is difficult for a patient to know what "quality" care is. According to Peter Lee, the former chief executive of the Pacific Business Group on Health, "For most consumers, the fact that there is no connection between quality and cost is one of the dirty secrets of medicine."

Most people don't have the time or expertise to delve into finding out if their doctor, hospital or surgeon can deliver "value" for the cost. There are a number of websites that compare hospital outcomes for surgeries, infections and treatments but they are cumbersome and the data can be two or more years old. Essentially they are useless for the patient.

Until we can:
--define quality,
--provide transparent data that is easy to understand, and
--provide pricing and costs that are easy to understand,

we will never be able to bring the escalating cost of health care under control. Until that time, patients are flying blind and hoping that their high cost care delivers something in return that they can value.

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.

Remembering a warm-hearted patient

When I was a resident I worked in a general medicine clinic. One afternoon each week, I'd get more dressed than usual and split off from my inpatient team around noon to go see patients in another building, outside of the hospital.

Today, I'm reminded of a man I saw there and treated for two years. His name was Mr. Sunshine. (The patient's name was not Mr. Sunshine, but it was equally evocative of his disposition.) The first time I met him, it was in the midst of a noisy, crowded and windowless waiting room.

"Mr. Sunshine?" I called out, as loudly as I could from the receptionists' desk. I'd skimmed through his chart including partial notes of a recent hospitalization. It was 1988, long before we stopped calling patients by their names in public areas. He stood up and greeted me with a broad smile. He shook my hand before I guided him to a smaller, quieter windowless room for his examination. He carried a medium-sized suitcase.

Mr. Sunshine had heart disease, kidney disease, diabetes, and peripheral vascular disease. He'd had a heart attack or two, and possibly a stroke. He was a large man. As I recall, he came from North Carolina but had lived most of his life in Brooklyn. After some brief, standard but sincere chit-chat about who we each were, I asked him why he was there in the clinic. "I'm sick," he said. "I think maybe I should be in the hospital." That was, essentially, his chief complaint.

Being the diligent resident that I was, I attempted to get through a review of systems, the drill by which doctors run through a lot of questions as fast as possible, starting like this: "Do you get headaches, earaches, have trouble hearing, double vision, blurred vision, sinus congestion, a runny nose, frequent sore throats, swollen glands, cough, pain on swallowing ..."

Keep in mind, this was before most doctors had sheets for patients to answer these questions in advance, on a checklist, or nurse practitioners to ask the questions for them. If you were lucky, and smooth, and the patient wasn't "difficult" or really sick, you could get through a complete review of systems in less than 1.5 minutes.

Mr. Sunshine said he was tired and short of breath most of the time. He pulled from his suitcase a crumpled, large brown bag with more than 20 medication vials and vitamins. There was a set of pajamas inside, and other stuff including a toothbrush.

I didn't admit Mr. Sunshine to the hospital that day, but we bonded. He stayed as my patient in the clinic for two years, always treating me with respect while I adjusted and tried to reduce his meds.

Once he asked me if he might ask me a question.

"Sure," I told him.

"Are you Jewish?" he asked.

"Yes, I am."

He nodded. I lacked the nerve to ask him why he wanted to know. He told me he sang at his church.

When I moved on to become a fellow in hematology and oncology, Mr. Sunshine asked if he could still be my patient. I told him that in my new position I'd be working in another clinic, and only with patients who had either cancer or serious blood disease. He didn't have cancer, or sickle cell anemia, or anything like that.

"If I get leukemia, will you be my doctor?" he asked me.

"Yes," I told him. "But it's a good thing you don't have that now," I said, adding: "I wish you the best, Mr. Sunshine."

I've been thinking lately, what makes you recall some patients. I hope he's doing OK, wherever he is now. Same for all my patients, really. I wish I could tell them.

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.
Friday, June 22, 2012

What do you take home from medical conferences?

I attended a local conference today sponsored by our Department of Pediatrics and Riley Hospital for Children. Many of our residency graduates, especially those who live and work locally, return for this meeting. It really is great to see our graduates and what they are up to. I enjoy hearing about how they have transitioned to practice, and learning about their own successes and challenges.

This particular year, I was not a presenter, nor did I run any workshop. I went to this conference strictly to learn. It was simply wonderful to do so. The day started off with a dynamic visiting speaker reflecting on the state of well child visits and potential innovations around how to be more effective with these, especially given the changes in medicine that are occurring and will continue to occur.

One might think that this topic is not all that interesting (which the speaker himself even acknowledged). Plain and simple, I was inspired! It brought me back to why I chose to go into medicine in the first place: to make a difference. Other extremely well-presented sessions reminded me of things I should be doing when encountering patients with specific conditions. A lunchtime talk on mentoring solidified a successful day for me (and that was only halfway through the day!). Other great "high-yield" topics in the afternoon piqued my interest as well.

When some people come back from conferences similar to this one, they realize that while the conference was wonderful, there is still a stack of paperwork that needs to be completed, that there is more work to be done, patients need to be seen, and e-mails must be answered. I also have all of those things looming over me. But I also gained a sense of purpose, connectedness, and excitement for the future of medicine from the conference. In addition, I learned some new things, was reminded of things I should already know, and also heard about changes coming in the future.

What do you get out of going to conferences besides the acquisition of information? What other "informal curriculum" things get you jazzed up, and how can conference organizers effectively capture that for other attendees? I am curious if others see this similarly or differently.

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

Why I won't have a PSA test when I turn 50

Generations of patients and doctors have been steeped in the myth that any kind of cancer should be found as soon as possible and when found, removed. The image of a gray-haired doctor on television telling the frightened patient "If only we had caught it sooner ..." has convinced us all that cancer must be diagnosed ASAP.

But it turns out that diagnosing prostate cancer sooner hurts more than it helps. For the last two decades many men over 50 have been regularly screened for prostate cancer with a blood test called PSA (prostate specific antigen) despite the fact that there was never any evidence that this test saves lives.

Last October the U.S. Preventive Services Task Force (USPSTF) reviewed the available studies about screening for prostate cancer. Their preliminary recommendation was against routine screening of men at any age for prostate cancer. (I wrote about their recommendations at the time.) The USPSTF, after considering public responses to their recommendations released their final recommendations, which are essentially unchanged. The USPSTF recommends against PSA screening for prostate cancer as it concludes that the benefits from screening are small or nonexistent and do not exceed the known harms of screening.

How is that possible? There is no question that many more prostate cancers have been diagnosed since the advent of PSA testing and also no question that the cancers diagnosed are at a much earlier stage than those found before PSA testing was routine. How can diagnosing prostate cancer more frequently and earlier not help?

To understand that we have to understand that prostate cancer is very common but rarely harmful. Prostate cancer increases in incidence with age, and grows very slowly. Prostate cancer frequently takes a decade or longer before it causes patients any harm. So many men with prostate cancer never develop any symptoms from it and die from some other cause at a ripe old age. Unfortunately, some men develop aggressive metastatic prostate cancer which cuts their life short, but we have no accurate way to distinguish which prostate cancer will remain indolent and which will be aggressive.

A consequence of this slow-growing but very common cancer that afflicts older men is that it's very hard to show that early detection and early treatment actually helps anyone. The studies reviewed by the USPSTF showed that the life-saving benefit of PSA screening is either nonexistent or very small.

If 1,000 men are screened for a decade with PSA testing, this will lead (many years later) to between zero and one life saved from prostate cancer. But much harm will befall those thousand men because of the testing. 150 to 200 of them will undergo prostate biopsies because of an abnormal PSA. One third of the men having biopsies will experience a significant adverse symptom as a complication of their biopsy, and one or two will require hospitalization because of a biopsy complication.

Many of these biopsies will turn out negative (because PSAs are so inaccurate) but some others will diagnose prostate cancer. Those patients diagnosed with prostate cancer will undergo treatment, frequently surgery, radiation, or both. Surgical complications will cause one of the men to develop a dangerous blood clot and two of the men to have heart attacks. Forty of the men will become impotent or incontinent because of their radiation or surgery. That's a lot of harm for very little, very uncertain benefit.

The specialists who (presumably with the best of intentions) have been making a living causing all this harm were indignant. The American Urological Association was "outraged", but perhaps their outrage will lessen when they ponder how much their members have been paid to make tens of thousands of men impotent. An editorialist in the Annals of Internal Medicine who wrote in support of the USPSTF recommendations quoted Upton Sinclair, who said, "It is difficult to get a man to understand something, when his salary depends on his not understanding it."

So I will start explaining to my male patients the known harms and the unproven benefits of PSA screening. For many patients this will be a slow and difficult psychological shift. Many patients will still request the test out of habit or simply because they don't yet believe the new recommendations. That's fine. They're the boss. I only give advice.

In six years I will turn 50. I tell all my patients that I'll celebrate by undergoing a colonoscopy for colon cancer screening. I will certainly not have my PSA checked.

What we urgently need is a new test that discriminates aggressive prostate cancer from the more common harmless prostate cancer, and we need less harmful treatment options. I have six years to wait for such advances. Meanwhile, a very nice man who has been my patient for over a decade is scheduling his prostatectomy in the next few weeks. I hope he does well.

Learn more:
All Routine PSA Tests For Prostate Cancer Should End, Task Force Says (Shots, NPR's health blog)
Government task force discourages routine testing for prostate cancer (Washington Post)
Men Should Skip Common Prostate Test, Panel Says (Wall Street Journal)
Screening for Prostate Cancer: U.S. Preventive Services Task Force Recommendation Statement
USPSTF author insight video
Prostate Cancer Screening: What We Know, Don't Know, and Believe (Annals of Internal Medicine editorial)
What the U.S. Preventive Services Task Force Missed in Its Prostate Cancer Screening Recommendation (Annals of Internal Medicine editorial)
National Panel Advises Against Prostate Cancer Screening (my post last year about the USPSTF PSA recommendations)

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.
Thursday, June 21, 2012

The prostate screening predicament: What's a guy to do?

The U.S. Preventive Services Task Force has moved on from ambivalence about prostate cancer screening with the PSA test, and inveighed decisively against it. As is ever the case with guidance about cancer screening, this recommendation is apt to stoke the flames of competing passions, and generate a whole lot of heat but altogether too little light.

To defend against that, let's try to keep our passions in check and appraise the relevant elements of this recommendation analytically and see where we land. Those elements include: (1) the nature of the USPSTF and its work, (2) the nature of prostate cancer, (3) the nature of screening tests in general, (4) the nature of evidence, and finally, (5) the nature of the nature/nurture debate and its pertinence to prostate cancer screening.

(1) The USPSTF can certainly be trusted. This is a multidisciplinary group of experts in preventive medicine, evidence review, clinical medicine, and public health practice. They are convened by federal agencies, notably the Agency for Healthcare Research and Quality (AHRQ), but are independent of them. The sole job of the task force is to review the current evidence, and reach conclusions about it.

A unique feature of this group is that while they do have skin in the game of evidence-based recommendations, they have no skin in the game of clinical care that ensues. In other words, members of the task force don't lose or win if we do, or don't, screen for prostate cancer. They have no stake in the use of any particular test or technology.

That is not true of the many groups that often respond critically to task force recommendations for doing less. Cardiologists have a stake in echocardiograms. Gastroenterologists have a stake in endoscopy. And cancer societies have a stake in doing more, not less, about cancer.

Often, those groups are the ones who use the test or technology in question, and doubtless believe in it--and profit from it. The American Urological Association was quick to point out the liabilities in the task force process, and the fallacies in its conclusion. But the urologists have skin in this game, and thus a conflict that the task force lacks.

What the task force lacks, though is wiggle room. They are boxed in by the high standards of their evidence review, and really have no allowance for informed conjecture about how things might be done better. They evaluate what we are doing, based on studies already completed. Where that can fall short is addressed in point number four, below.

(2) Prostate cancer is unpredictable. Most men who die after age 80 die with it, but not of it. Finding those cases that are destined to remain localized and inconsequential, and not recognizing them as such, will tend to result in a "cure" far worse than the indolent disease. But, of course, other cases do progress, spread, and can prove lethal. The unpredictability of prostate cancer and the limits of our current prognostic abilities make it tough to confer consistent benefit when disease is found early.

(3) Screening is applied to the general population and is, literally, looking for trouble. To find it whenever it's there, you need a test that is very sensitive, but such tests tend to produce false positives. If you want to avoid a lot of false positives, you need a test that's very specific, but then you tend to miss some cases of actual disease. For these reasons, screening is not invariably a good idea; just because we can, doesn't mean we should. The test performance, predictability of the disease, prevalence of the condition, and capacity to intervene effectively when disease is found early all factor in.

(4) Evidence is one of those areas where, to quote Mick Jagger, you can't always get what you want. We are often awaiting more data, better studies, longer follow-up. While waiting, the task force often concludes it cannot conclude anything, and recommends neither for nor against a particular test. In the case of PSA testing, they are recommending against its use based on the evidence we have now, which is, in turn, based on the kind of screening we now do. This does not mean there aren't ways to screen for prostate cancer that would confer net benefit; it just means we haven't settled on them yet. Maybe they aren't worked out; maybe they are too expensive. In the case of our current methods, we have evidence of absence of a beneficial effect. In terms of alternative approaches to screening that are in development, we have something very different: absence of evidence. That means recommendations can, and should, be revisited as new evidence comes in. A task force recommendation is for now, not forever.

(5) And finally, there's the issue of what we can do while we are not being screened for prostate cancer. Here, I think it's important to recall that screening does not prevent cancer; it just finds it early, which may help prevent it from advancing. Preventing it outright is better.

And we do have evidence that a short list of lifestyle factors can help prevent prostate cancer, and prevent it from progressing once it has developed. A 2008 study, for example, showed that a lifestyle program incorporating the usual elements, avoidance of toxins like tobacco, an optimal mostly-plant-based diet, regular physical activity, stress management, adequate sleep, good social interactions (I call these "feet, forks, fingers, sleep, stress & love") dramatically down-regulated cancer promoter genes, and up-regulated cancer suppressor genes in men with early-stage prostate cancer.

We can do better than just watch and wait during the period of "watchful waiting." We can nurture nature, and change the inner world of our genes.

There will no doubt be better ways to screen for prostate cancer in the future, ways that meet the USPSTF standard. While waiting for the advent of better methods, I am a 49-year-old male, and do not get screened. In contrast, I certainly will get colonoscopy next year, for which the evidence is decisively good.

But I am not just leaving the fate of my prostate to chance while hoping better screening methods come along. I am using the power of lifestyle to nurture whatever predispositions nature dealt me, and reshuffle the deck in my favor. You don't need an invitation from the USPSTF to do likewise.

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.

Synthesis in medical education

Mimi presented to the emergency room because of excruciating chest pain.

The seven of us delved deep into the case starting with the patient interview. We started with the generic, "Why are you here today?" and maneuvered our way toward the history of her present illness. She had been lifting boxes at home when the pain started. After probing for more details on her symptoms, she noted that, "It felt like something tearing in my chest."

We all had that keyword ingrained in our minds, it meant an aortic dissection.

After completing the rest of the pertinent medical history, we started a physical examination. We palpated the precordium and the abdominal area. We noted that the intensity of the point of maximum impulse was increased, suggesting a thickened left heart. Importantly, there was evidence of a dilated pulsatile mass in area of the abdominal aorta. It all made sense.

We wanted to visualize what we were working with, so we ordered a chest X-ray. The widened mediastinum and prominent descending thoracic aorta was more fuel for the fire. We ordered an echo to check on the heart and surrounding vessels. It confirmed our suspicion about the hypertrophic left heart and even revealed an intimal tear within the descending thoracic aorta. Everything fit together perfectly.

Following a few more labs and tests, we generated a problem list, submitted a diagnosis and suggested a management plan for Mimi. Then we joined the other six groups to debrief on the case.

[If you haven't guessed yet, Mimi is a computer-simulated patient. This would be a blatant HIPAA violation if she wasn't.]

This was our first case in our Synthesis course. I imagine this is what problem-based learning is like [if you have PBL at your school, do share about the experience!] and overall, I'm impressed by the modality.

I like that we are working in a larger group than in TBL [we had 5 members for TBL, 7 now in Synthesis] because it is a better representation of a health care setting. I like that we are given the opportunity to work through all the nitty-gritty details of the case at our own leisurely pace. And I enjoyed the debriefing discussion [Dr. Misra led it--she's wonderful!]. However, because we are forced to discuss and dissect every single detail, the session seemed to move slowly.

I suppose it's important to start slow and make sure you've covered all of your bases rather than delve straight into an algorithmic approach, but since there weren't any huge curveballs thrown into the mix we knew the diagnosis within ten minutes due to her report of "tearing" chest pain.

Finally, the feedback portion of the program was valuable because it pointed out where we were on-track with our interview, physical exam and tests but also listed other important aspects that we missed. Although we had the diagnosis from extremely early on, we still missed a couple of smaller steps that would have been important to report. Regardless of the things we missed, I'd say that our group did a relatively good job investigating our first patient.

Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich. She has a Bachelor of Science in Engineering [Biomedical Engineering] and Master of Science in Engineering [Biomedical Engineering, again] from the University of Michigan. This post originally appeared at her blog, "And Thus, It Begins," which chronicles her journey through medical training from day 1 of medical school.
Wednesday, June 20, 2012

Why do we expect productivity from physicians?

"Let's Be Less Productive," from the New York Times

When I first joined the faculty in 1980, no one used the terms productivity. The concept of relative value units (RVUs) had not yet arrived. I believe it was a better time.

Productivity does not just plague physicians. Tim Jackson has authored a brilliant piece about productivity.

"At first, this may sound crazy; we've become so conditioned by the language of efficiency. But there are sectors of the economy where chasing productivity growth doesn't make sense at all. Certain kinds of tasks rely inherently on the allocation of people's time and attention. The caring professions are a good example: medicine, social work, education. Expanding our economies in these directions has all sorts of advantages.

"In the first place, the time spent by these professions directly improves the quality of our lives. Making them more and more efficient is not, after a certain point, actually desirable. What sense does it make to ask our teachers to teach ever bigger classes? Our doctors to treat more and more patients per hour? The Royal College of Nursing in Britain warned recently that front-line staff members in the National Health Service are now being "stretched to breaking point," in the wake of staffing cuts, while a study earlier this year in the Journal of Professional Nursing revealed a worrying decline in empathy among student nurses coping with time targets and efficiency pressures. Instead of imposing meaningless productivity targets, we should be aiming to enhance and protect not only the value of the care but also the experience of the caregiver.

"The care and concern of one human being for another is a peculiar "commodity." It can't be stockpiled. It becomes degraded through trade. It isn't delivered by machines. Its quality rests entirely on the attention paid by one person to another. Even to speak of reducing the time involved is to misunderstand its value."

What unintended consequences have productivity and RVUs wrought? We have encouraged physicians to spend less time with patients, do procedures more quickly, avoid telephone calls and emails (no RVU points here) and generally worry more about volumes than individual patients. Now I know that I use hyperbole in these statements, but while we rarely are as cold as the previous sentence, the concepts do influence us. Anyone who can remember medical practice prior to these concepts can explain how practice has changed because of these phrases.

Patient visits are not widgets. Patients expect and deserve our full attention without concern for the clock. Patients have questions that we need to answer. History and physical examinations take time. Considering multiple diagnoses takes time. Sometimes we need to stop and read while the patient is in the room. We need time to do our job properly.

I hope others will take up the call. We should banish productivity as a descriptor. The concept has diminished our profession and thus we should reject it.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.

Dead people don't get bronchitis, or antibiotic resistance

It was during my residency that the first indication of heart toxicity of antibiotics affected me personally. The threat was related to the use of the first of the non-drowsy antihistamines, Seldane, in combination with macrolide antibiotics, such as Erythromycin causing a potentially fatal heart arrhythmia.

I remember the expressions fear from other residents, as we had used this combination of medications often. Were we killing people when we treated their bronchitis? We had no idea, but we were consoled by the fact that the people who had gotten our arrhythmia-provoking combo were largely anonymous to us (ER patients).

Fast forward to 2012 and the study (published in the holy writings of the New England Journal of Medicine) that Zithromax is associated with more dead people than no Zithromax. Here's the headline-provoking conclusion:

During 5 days of therapy, patients taking azithromycin, as compared with those who took no antibiotics, had an increased risk of cardiovascular death (hazard ratio, 2.88; 95% confidence interval [CI], 1.79 to 4.63; P less than 0.001) and death from any cause (hazard ratio, 1.85; 95% CI, 1.25 to 2.75; P=0.002). Patients who took amoxicillin had no increase in the risk of death during this period. Relative to amoxicillin, azithromycin was associated with an increased risk of cardiovascular death (hazard ratio, 2.49; 95% CI, 1.38 to 4.50; P=0.002) and death from any cause (hazard ratio, 2.02; 95% CI, 1.24 to 3.30; P=0.005), with an estimated 47 additional cardiovascular deaths per 1 million courses; patients in the highest decile of risk for cardiovascular disease had an estimated 245 additional cardiovascular deaths per 1 million courses. (Emphasis Mine).

It turns out that they also indicted Levofloxacin, another commonly-used antibiotic as being roughly as risky as Zithromax.

While this is good fodder for the headlines, it hits me right where I live. I constantly have patients coming into the office with symptoms that make them feel they need an antibiotic, many of whom have gotten Zithromax. I wrote an early post on the subject of the temptation to give a Z-Pak in the gift basket we give our patients for walking into our office:

Which brings me back to the Z-Pak. Zithromax (Azithromycin) is truly a great drug, and the friend of many doctors. It treats strep throat, skin infections, sexually transmitted disease, whooping cough, and certain kinds of, yes, bronchitis. It is very easy to take, requiring a total of 5 doses over 5 days, and it comes in a handy-dandy pack with a catchy name. When a patient tells their friends and family, "I got a Z-Pak," they are much more impressed than if they say, "I got an antibiotic."

I ended with a warning:

So, when you have a cough and go to the doctor, get the diagnosis of bronchitis, and get a Z-Pak think of me. You may want to ask if you really need the antibiotic, or if you can wait to see if it will go away without it. In many, if not most cases, you might just as well meditate with the word "Zithromax" as your mantra, or burn the pills in a sacrifice to the Greek god Z-pacchus.

God bless America, land of the Z.

I even wrote a poem for it:

Six little pills at the patients' insistence
Six little pills should we now keep our distance?
Six little pills we'll rue your existence
If Six little pills are paths to resistance.

Oh Zithromax, Zithromax!
You make us desirous
Against our best judgment to cover a virus
Oh Zithromax, Zithromax!
Your pills in a pack
So oft make the best doctor act like a quack.

Yet there are good reasons to use antibiotics like Zithromax, so I am left with the dilemma of how to interpret the results. Is this a real problem, or is it simply a retrospective study by a bunch of scientists wanting to make a splash?

I have to answer this question because I have to decide whether or not I am going to write a prescription for this medication, risking a "is my doctor trying to kill me?" look from my patients. I have to prescribe antibiotics, but in doing so do I feed the fortunes of personal injury attorneys who realize the two following things:

1) Doctors prescribe Zithromax by the bucket
2) Every one of the patients who get a Zithromax prescription will die.

I give it 2 weeks before we see a commercial soliciting business for people who have loved ones who took Zithromax and then had heart attacks.

To figure out how to deal with this dilemma, I went to some of the experts among the med blogger community. Marya Zilberberg is an epidemiologist at the University of Massachusetts and author of the blog, Healthcare, etc. She even wrote a book about how to properly read medical literature (a book that I need to read, actually). In short, she's brainy. She wrote a post entitled, Why I have the propensity to believe the azythromycin data (I told you she was brainy), in which she states the following:

But there is a second, possibly more important reason that I am inclined to believe the data. The reason is called succinctly "propensity scoring." This is the technique that the investigators used to adjust away as much as feasible the possibility that factors other than the exposure to the drug caused the observed effect.

She then quotes a part of her book (which I definitely need to read) about propensity scoring. Tying this to the Zithromax study:

And if you are able to access Table 1 of the paper, you will see that their propensity matching was spectacularly successful. So, although it does not eliminate the possibility that something unobserved or unmeasured is causing this increase in deaths, the meticulous methods used lower the probability of this.

So by this I am led to believe the data have some beef behind them. I am also much more likely to use the word "propensity," as it may make me sound as brainy as Marya.

On the counterpoint is Dr. Wes, one of the old guard bloggers (who I've drunk beer with), who has been blogging since the internet was run by carrier pigeon. Dr. Wes is a cardiologist who specializes in heart rhythm problems, the kind of problems that presumably killed the people in the NEJM study. He wrote an article, How Bad is Azithromycin's Cardiovascular Risk? in which he admits the potential risk of this kind of antibiotics, but questions the data methods of the study:

What was far scarier to me, though, was how the authors of this week's paper reached their estimates of the magnitude of azithromycin's cardiovascular risk.

Welcome to the underworld of Big Data Medicine.

He minces no words as he continues:

To think that despite all of the confounding factors that the authors had the balls to state that "as compared with amoxacillin that there were 47 additional deaths per 1 million courses of azithromycin therapy; for patients with the highest decile of baseline risk of cardiovascular disease, there were 245 additional cardiovascular deaths per 1 million courses" is ridiculous. Seriously, after all the manipulation of data, they are capable of defining a magnitude to three significant digits out of a million of anything?

His conclusion is that this study is basically a bunch of sensationalized data meant to get headlines (which it did). I think he needs a beer. Call me, Wes.

So I am left to sift through these two opinions of two people I respect, and do so in the backdrop of patients wanting antibiotics and lawyers dreaming of big yachts. What do I think? I think we can't tell what the truth really is. Yes, the folks who wrote the study are probably gunning for headlines (as is the NEJM), but it is also a fact that antibiotics can be dangerous, and all drugs come with some sort of a price.

I come back to advice I gave in an earlier post: When all else fails, do nothing. Don't give an antibiotic unless it's needed, and don't ask for one if you don't need it.

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.
Tuesday, June 19, 2012

Disruptive innovation coming to higher education? The role of massive open online courses

The notion of disruptive innovation was popularized by Clayton Christensen [1, 2], and is described as change, usually technological, that causes upheaval of an entire industry sector. We have seen plenty of disruptive innovations in the modern digital era, as the marketplace for products such as books, newspapers, photography, banking, and travel has undergone profound change. Who takes pictures using film or regularly walks into a bank anymore? Who does not spend at least part of their reading time doing so on electronic devices, increasingly those held in the hand, such as smartphones or tablets?

There is a certain irony for those of us who work in academic biomedical and health informatics. On the one hand, we are immersed in the technologies that have caused so much disruptive innovation, i.e., computers, the Internet, and the World Wide Web. On the other hand, those of us in academic informatics apply our work at the intersection of two fields that may be the lone remaining holdouts for disruptive innovation, namely healthcare and education.

We can debate in another post whether disruptive innovation will ever come to healthcare. There are some signs, but I am not holding my breath. Recent developments in higher education, however, potentially portend profound change coming. Being in higher education for a livelihood, I naturally have great interest in the consequences of disruptive innovation within it.

This potential disruptive innovation in higher education comes in the form of what some call massive open online courses (MOOCs). This area has received a great deal of attention lately with the foray of some of the leading U.S. universities into this area, namely Stanford, Harvard and Massachusetts Institute of Technology (MIT). It has garnered attention in the popular media [3-6].

As most readers of this blog know, I have great enthusiasm for online learning. A good deal of my work in the last decade has focused on the fusion of educational technology with biomedical and health informatics [7-10]. However, the result has mostly been education based on the traditional model of the professor teaching and interacting with a relatively modest number of students.

MOOCs change the calculus of online learning in a much more profound way. Stanford computer science professors Andrew Ng and Daphne Koller have been at the forefront, adapting and delivering their courses to massive audiences [4, 6]. They are part of a new technology venture led by Stanford and including several other big-name US universities called Coursera. Not to be left out, Harvard and Massachusetts Institute of Technology have also launched a similar initiative.

Despite their high profiles, these are not the first such initiatives to disseminate high-quality higher education content via the Web. Two other initiatives, Udacity and the Khan Academy, have been doing this for several years. Resources like the University of Pittsburgh Epidemiology Supercourse have been in existence even longer.

Will these MOOCs lead to disruption in higher education? The cynic in me notes that Ng and Koller are not changing the core Stanford product, where a small number of highly smart students pay a substantial amount of money in the form of Stanford tuition for the privilege of being on the Palo Alto campus and getting a degree from Stanford. I also note that these courses are mostly basic courses, and not the more advanced knowledge that might help someone apply this information. The content is "open" in the sense of being available to anyone, but not in the "wiki" sense of being improved upon in a massive way.

But the optimist in me with the goal of spreading knowledge via technology cannot help but be impressed at the uptake and reach of these courses. I certainly enjoy the global interaction I have through the various educational activities in which I take part in on the Internet. Even Facebook can sometimes be a platform for disseminating knowledge and doing what I enjoy most as an educator, which is getting people to both delve into deeper layers of fact as well as apply them in larger contexts and intellectually principled ways.

As is often the case, the ultimate reality will likely fall somewhere in the middle. Clearly the Web provides an unprecedented vehicle for knowledge dissemination. But education is so much more than a student absorbing knowledge. There is also the in-depth application of that knowledge for real-world purposes. I cannot help but wonder, for example, whether the Coursera natural language processing (NLP) course will enable a student to be able to implement a system that can detail with all the nuances of the narrative text generated by clinicians in the electronic health record. One thing that clinical informatics has taught us is the lack of predictability of technological interventions in healthcare settings.

Of course we have shown to our satisfaction at Oregon Health & Science University (OHSU) that pretty much all types of learning can be delivered online. But we have also learned that an education involves more than learning. Early on in our foray into distance learning, I was struck how we had developed, without deliberately trying to do so, a virtual community. When students join our program, they not only get access to our courses, but also our faculty, their student colleagues, and our connections to the larger informatics world, including our connections to industry. Even the staff in our office provide a conduit for their new journey into careers and other activities in the field.

But I am also, in a sense, part of this MOOC world, due to the Office of the National Coordinator for Health IT (ONC) Curriculum Project that has absorbed a great deal of my professional time, effort, and passion over the last couple years. All of this potential for disruptive innovation of informatics education therefore comes at a time of critical juncture for our field. We have been fortunate to have, for the first time in the history of our field, substantial federal investment, not only in the form of subsidized education for students, but also in the development of the ONC curricular materials. The verdict is still out on what impact the curricular materials will have on informatics education and training in the long run. But with the ARRA funding for them winding down, we are at a critical juncture in finding ways to sustain them (if we believe they are important) once the grant for them ends at the end of 2012.

In conclusion, I view the potential for disruptive innovation in higher education as a challenge and an opportunity. While I am not worried it will make my world dissipate like camera film or bank tellers, I do know the ride will be bumpy. But in the end, I am confident that education will be improved and possibly more cost-effective. I am also confident of the continued role I will play in advising students and others about directions and opportunities for our field. And if things ever do settle down, we can move on to the real challenge for disruptive innovation, which is the healthcare industry!

[1] Christensen, C. (1997). The Innovator's Dilemma: When New Technologies Cause Great Firms to Fail. Boston, MA. Harvard Business School Press.
[2] Christensen, C. (2012). Disruptive Innovation, in Soegaard, M. and Dam, R., eds. Encyclopedia of Human-Computer Interaction. Aarhus, Denmark. The Foundation.
[3] Lewin, T. (2012). Instruction for Masses Knocks Down Campus Walls. New York Times. March 4, 2012.
[4] Markoff, J. (2012). Online Education Venture Lures Cash Infusion and Deals With 5 Top Universities. New York Times. April 18, 2012.
[5] Brooks, D. (2012). The Campus Tsunami. New York Times. May 3, 2012.
[6] Friedman, T. (2012). Come the Revolution. New York Times. May 15, 2012.
[7] Hersh, W., Junium, K., et al. (2001). Implementation and evaluation of a medical informatics distance education program. Journal of the American Medical Informatics Association, 8: 570-584.
[8] Hersh, W. and Williamson, J. (2007). Educating 10,000 informaticians by 2010: the AMIA 10×10 program. International Journal of Medical Informatics, 76: 377-382.
[9] Hersh, W. (2007). The full spectrum of biomedical informatics education at Oregon Health & Science University. Methods of Information in Medicine, 46: 80-83.
[10] Hersh, W. (2010). The health information technology workforce: estimations of demands and a framework for requirements. Applied Clinical Informatics, 1: 197-212.

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