Tuesday, July 31, 2012

The problem with transformation

Eric Topol wrote a post recently put up on The Health Care Blog where he looks to a future enabled by emerging technology.

Just as the little mobile wireless devices radically transformed our day-to-day lives, so will such devices have a seismic impact on the future of health care. It's already taking off at a pace that parallels the explosion of another unanticipated digital force: social networks.

Take your electrocardiogram on your smartphone and send it to your doctor. Or to pre-empt the need for a consult, opt for the computer-read version with a rapid text response. Having trouble with your vision? Get the $2 add-on to your smartphone and get your eyes refracted with a text to get your new eyeglasses or contact lenses made. Have a suspicious skin lesion that might be cancer? Just take a picture with your smartphone and you can get a quick text back in minutes with a determination of whether you need to get a biopsy or not. Does your child have an ear infection? Just get the scope attachment to your smartphone and get a 10x magnified high-resolution view of your child's eardrums and send them for automatic detection of whether antibiotics will be needed.

Now, I am the first to confess my infatuation with technology. I am also a very big believer in patient empowerment, which could be the one force strong enough to overcome the partisan politicians and corporate lobbyists resisting any positive change. But there are several problems I see with this kind of empowerment with technology.

First off, the goal is not to find technologies that simply transform, but ones that move care to a better place. Right now our system is running aground for one reason: We spend too much money. Patient empowerment that improves efficiency of care is good, while empowerment that increases consumption or decreases efficiency is to be avoided if at all possible.

The technology mentioned in the article is predominantly data-gathering technology, increasing the amount of information moving from patient to physician. The hope is that this will enable faster and better informed decisions, and perhaps some of it will. But I can see harm coming out of this as well.

The example of parents checking their children's ears is a good one for me, as it hits close to home. I am certain that by giving this tool to parents we will diagnose many more ear infections than we do now, but for what end? Most ear infections will go away if left untreated, and the push has been (for quite a long time, actually) to resist the urge to give antibiotics for ear infections in children. Doctors have had a very hard time resisting this, as it is in our medical DNA to intervene when we find a problem, but we have caused many problems because of this addiction to intervention. A large number, if not the majority, of ear infections are undiagnosed and clear on their own at home without intervention. Now add to this a technology which gives us the ability to see all of those undiagnosed ear infections, and we have to muster even more willpower to resist the urge to treat them all. This is the same problem as we have encountered with PSA testing: Be careful gathering data you don't know how to handle.

But even without considering this important objection to improved data-gathering, there is another problem which stands in the way of this type of technology: reimbursement. It sounds great to enable people to avoid visits to the doctor's office by having tools that previously were only accessible at an office visit. It sounds like a very good way to save money and wasted time spent in waiting rooms with outdated magazines. But this technology presumes that doctors will be willing to act on this information without seeing the patient in the office. It presumes we will be willing to offer free care. If the time I spend sifting through patient-collected data rises exponentially, the payment I get for that time cannot remain at the present level: zero.

If our goal (as it should be) is to spend less money on unnecessary care, we will get to it much faster if we somehow give proper incentive. Our encounter-based payment system stands in the way of any progress in this area. The only way most of us get paid is to see people and deal with problems. This makes doctors reluctant to offer any care outside of this setting, and puts undue pressure on intervention (to justify the encounter to the payors). Until our system puts more value on avoiding unnecessary treatment and keeping people well we will be stuck in this struggle between patients who want to avoid seeing the doctor and doctors who can't afford to let patients do that.

This is a major pity, as life would be much better for my patients if they could stay out of the office, and life would be much better for me if I could encourage them to do so. The "transformative technologies" are hobbled before they get out of the gate by these obstacles, ones that must be addressed if we really want things to change.

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.

QD: News Every Day--Putting numbers on the next decade's doctor shortage

One-third of doctors intend to leave medicine in the next decade, while in the past year alone one in eight went part-time, retired or left practice, according to a survey by a health care staffing company.

The physician shortage itself has been well-documented, while the latest news and numbers contrasting the increasing demand by newly insured millions of people expected to seek service as a result of health care reform.

Add the demands of baby boomers into the mix--their volume as they enter into old age as well as their unique demands for health--and it's the perfect storm.

56% of doctors cited economic factors for retiring or leaving medicine in 2012, while 51% cited health reform. (The survey was conducted before the U.S. Supreme Court upheld the Affordable Care Act.)

Younger doctors also said they were considering leaving medicine this year. Of those who said they would leave the practice or are strongly considering so by the end of 2012, 55% were less than 55. Those doctors also reported that the cost of running a practice was too high and that they didn't want to practice medicine in the era of health reform.

Specialists showing the greatest propensity to leave the profession in the next decade, according to the survey:

--Oncologists and hematologists, 57%
--Otolaryngologists, 49%
--General surgeons, 49%
--Cardiologists, 45%
--Urologists, 42%

The survey was conducted online from April 19 to April 27 by e-mail with 2,218 respondents. The error range for this survey at the 95% confidence level is +/- 2.1%.
Monday, July 30, 2012

QD: News Every Day--Yoga may help balance in stroke survivors

Yoga may help patients improve their balance after stroke, according to a new pilot study.

Researchers performed a small randomized study of yoga-based rehab in patients who had suffered an acute stroke. Thirty-seven patients who did yoga were compared with a control group of 10 patients who were on a waiting list and receiving usual care. A registered yoga therapist taught the yoga sessions, which were held twice a week for eight weeks. The sessions involved relaxation and meditation, along with seated, standing and floor yoga postures.

Outcome measures were balance, balance self-efficacy, fear of falling and quality of life. The study results were published online July 26 by Stroke.

At eight weeks, no significant difference was noted between waiting-list controls and yoga patients in baseline or follow-up scores. However, in within-group comparisons, yoga patients had statistically significant improvement in both balance, assessed by the Berg Balance Scale, and fear of falling, assessed by using a "yes/no" question. The authors noted that their study was small and unblinded, but concluded that a yoga-based intervention could be helpful in patients recovering from stroke.

"The improvement in balance is statistically significant and clinically meaningful and is larger than previously reported in other poststroke exercise trials," they wrote. "Group yoga should be further studied as a possible feasible and effective intervention to improve balance, [quality of life], and participation poststroke."

What's the right way to supplement with calcium?

Many patients who have been advised to supplement with calcium (especially women for bone protection) were thrown for a loop by the study in the British Medical Journal that linked calcium supplements to heart attack. Here is what the researchers found:

They studied 24,000 German and European patients ages 35-64. Using questionnaires, they quizzed them about their vitamin and mineral supplements. They also tracked their health for 11 years, looking at heart attacks, strokes and death. (These studies can be easily done in countries with socialized medicine because everyone has health coverage and electronic records!!!)

They found that the intake of calcium supplements did not affect the risk of stroke, either protection or causation. But the people who took calcium supplements daily were 86% more likely to have a heart attack than those who didn't use any supplements. Dietary calcium caused no problem, it was just the supplements.

What should we make of this study? Dietary calcium is a good thing and calcium from food actually lowered the risk of heart attack. So eating foods with calcium is just fine. But we have relied too much on supplements that are increasingly being found to be worthless in preventing disease and even harmful when taken in large doses.

The average person should not take calcium supplements. They can increase the risk of kidney stones, cause gastrointestinal problems and even heart attacks. It is now becoming clear that recommending vitamin supplements can be harmful and they do not replace good, balanced diets.

Foods with calcium include low fat dairy, yogurt, cheese, collards, spinach, potatoes, soybeans, and turnips.

This post originally appeared at Everything Health. Toni Brayer, MD, 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.
Friday, July 27, 2012

How to deliver a cancer diagnosis to patients

When I see patients in the office, I try to guess their occupations from their demeanor and mannerisms.

Salesmen are the easiest to ID. In general, they are gregarious males with manly handshakes. They laugh loudly and like to tell jokes. Teachers are more reserved and often give their narrative in a logical and chronological order, as would be expected. Another clue that the patient is an educator is that their appointments are usually in late afternoons. I have a solid record picking out the engineers and scientists. (For physician readers, I estimate that with regard to engineers, my sensitivity and specificity are 60% and 90% respectively.)

Engineers can be tough patients for gastroenterologists to treat. They operate in a computational universe, where numbers add up and problems have concrete solutions. Doctors, particularly gastroenterologists, function in an entirely different milieu. Our world is nebulous. Engineers see mathematical truths, while GI physicians see fog. When they see us with chronic nausea and abdominal pain, they are frustrated when we cannot provide them with a satisfying diagnosis.

I recall an engineer I saw some time ago. He was neatly attired and related his ominous symptoms in an intellectual manner, as if he were giving traffic directions. He was having trouble swallowing his food and was steadily losing weight, a presentation that generates the highest level of physician concern.

I scheduled him for a scope examination of the esophagus, and found the expected cancer. Afterward, he was seated with his wife as they awaited the news of my findings.

These minutes when we physicians know the bad news, and the patient doesn't, are ponderous. We wish we could hold on to the secret and spare patients from the knowledge that will change their lives so brutally and irrevocably. Subconsciously, we stall. During those minutes, hours or sometimes days, physicians are in a different dimension, a medical twilight zone. Once we relate the news, however, we are hurled back to earth. Once the patient knows, then we are enveloped by an aura of cold reality.

How should physicians give bad news to our patients? Should we be blunt? Do we front load the heavy news or lead to it after several introductory sentences? Should we use euphemisms like 'growth,' when cancer is the right word? Should we spin the information with hope and optimism, even if the medical facts contradict this assessment? Do we tend to sugarcoat for our own benefit as well as to soothe the patient? Should serious medical news ever be delivered on the telephone? How do we respond if the patient asks, "Am I going to die?"

There is no standard strategy of how to do this right. In addition, patients are distinct human beings and must be approached individually. See First, a blog that emphasizes the importance of communication between physicians and patients, writes that false hope for patients may be the wrong prescription. Medrants, an academic physician and thoughtful blogger, speaks for all physicians when he writes, "Breaking bad news may be the most difficult and important part of our profession."

I have spent 4 years in medical school, 3 years in an internal medicine residency followed by 2 years of fellowship training in gastroenterology. During those 9 years, I don't recall a single lecture on how to deliver bad news to patients. Yet, I remember memorizing biochemical equations, the names of minute nerves and muscles, the function of microscopic components of cells, hundreds of medications and the natural history of arcane diseases that I have never seen in my career.

The astute medical interns and residents I admired were those who could spew off the dozen or so medical explanations for an elevated calcium blood level. I wonder if medical training, at least in my day, had proper priorities for training physicians. Doc Gurley, a physician and folksy and irreverent blogger, recalls a single lecture she heard as a medical student on how to deliver bad news to patients. It impacts her practice to this day, two decades later.

Delivering bad news is a very difficult and unavoidable responsibility of a physician. Do I do it well? I think so, but I'm not really sure. I gave the news to my patient and his wife after I had made arrangements for him to see the necessary consultants in the coming days. I think that patients' stress in these situations is eased when there is a plan that we physicians put in place. He listened without demonstrating emotion, and thanked me for my time. He then left with his worried wife. The news was still in his analytical left brain, where he stores his facts, figures and formulae. What happens when it crosses the Rubicon over to the other side?

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.
Thursday, July 26, 2012

Remember where you started

Have you noticed that too many physicians develop the "big head"? These physicians start to believe that they are as good as the flattery they receive.

Our position in society is very seductive. We receive almost instant respect. And too often we believe that we are special.

But many physicians escape this trap. I can only speculate why some physicians resist temptation.

I think they remember from where they came. They remember who they were as kids. They remember how hard they worked to achieve academic success. They remember being medical students and striving to learn medicine so that they could help patients.

Even "big head" physicians usually work to help patients, but they become jerks other than when with their patients.

Physicians are not unique. The same thing happens to many other successful people. But this blog is about medicine.

So I hope medical students and residents are reading this rant. You have already met the "big head" physicians. You probably have told yourself that you will not turn out like them.

So work hard to keep yourself grounded. Remember your roots. Keep your friends from before medical school, and hopefully they will treat you like the same goofball you were prior to medical school. Remember your inner goofball.

Remember how lucky we are to become physicians. Remember that we are regular people who are doing a very special job, but that does not give us the right to become jerks.

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.
Wednesday, July 25, 2012

Cannabis for chronic pain: Are we there yet?

Marijuana is pretty popular stuff, and for good reason. It is a potent drug, capable of both making someone feel good and of reinforcing dependence pathways in the brain. Cannabis has been lauded for its ability to treat nearly any unpleasant symptom (except perhaps dry mouth), but so far evidence other than the anecdotal has been meager.

One of the areas where research has been a bit promising is in the treatment of certain types of nerve pain. Small studies have shown some possible benefit in certain groups of patients, but robust studies are lacking. In the U.S., this is certainly due at least in part to restrictions on cannabis research, but only in part.

Still, chronic nerve pain is an important problem, with imperfect treatments. Opiates such as morphine are effective but come with significant side-effects. Some anti-seizure medications such as gabapentin and pregabalin have shown some promise, but they are relatively expensive (although the price on gabapentin is dropping) and only somewhat effective. Finding effective drugs, to be used either alone or in combinations, would help people suffering from a frustrating and sometimes disabling problem.

The Canadian Medical Association Journal recently released a study on cannabis. The study focused on smoked cannabis in a subset of patients with chronic nerve pain. Cannabis and its active ingredients are available in many forms, including oral mixtures of cannabis extract and THC alone. The authors don't give a specific justification for the use of traditional pot-smoking, but the editorial that accompanies the piece suggests that: "It's good to see the trial of smoked cannabis in neuropathic pain reported by Ware and colleagues because smoking is the most common way in which patients try this drug."

I hope that this isn't the justification intended by the authors. This may be obvious to most readers, but choosing a route of delivery based on "what they do on the street" is not a terribly clever thing to do. Even raw cannabis can be delivered by (probably) safer inhaled means such as vaporization (and they do mention vaporization at the end of the paper).

In any case, the study was, in some respects, well-designed. They appeared to have a good placebo control, which is no small feat in a study of smoked cannabis. And they did find some modest improvement in pain scores, and noted that this reduction was dose-dependent. The more potent the weed, the lower the post-treatment pain score. But in total, the evidence isn't terribly convincing.

The study was very small, and the authors admit that their results were modest, especially when compared to already-available medications. They attempt to minimize this by noting that the patients chosen had already failed conventional therapy, although the study design does not suggest this to be strictly the case.

While this study gives us reason to continue to look at cannabis, it does not give convincing evidence that cannabis improves upon currently available drugs in regards to safety and efficacy.


Mark A. Ware MBBS, Tongtong Wang PhD, Stan Shapiro PhD, Ann Robinson RN, Thierry Ducruet MSc, & Thao Huynh MD, Ann Gamsa PhD, Gary J. Bennett PhD, Jean-Paul Collet MD PhD (2010). Smoked cannabis for chronic neuropathic pain: a randomized controlled trial (Early e-release) Canadian Medical Association Journal: 10.1503/cmaj.091414

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.

Who do ya trust?

A reporter emailed me last week to ask my opinion about a publication from the United States Preventive Services Task Force about obesity. I e-mailed back something bland. I found the recommendations eminently reasonable but was unsure if they could be applicable in the everyday clinical environment.

But of course I was going to be in general agreement; the manuscript came with the imprimatur of the USPSTF. Far be it from me to second-guess a manuscript that's authored by folks who have immersed themselves in the field, actually read and thought about the 15 or 20 references, and responded to comments by the lay public ranging from thoughtful to nutso.

Why did the reporter want my opinion? Because I'm a poly-diploma'd doctor at a fancy medical school who has his name on scientific papers and is interested in evaluating evidence in a careful way. Not because I'm more expert on obesity than your average academic internist.

So the question rears its head: how can a non-expert evaluate the work of an expert? A healthy dose of skepticism is needed. Or even more, we need experts who point out that most experts are wrong.

But we need the other side of the coin too. We need to be able to trust, because we can't check everything ourselves. This isn't just a question of epistemology (How can we know something we can't see with our own eyes?) but a question of emotional reliance. Sure we can't trust everyone. People bought and paid for by Big Pharma, for example, why should we trust them?

But if structures are in place to ensure some trustworthiness, we can believe. There is a balance to be struck between radical skepticism on the one end and drooling credulity on the other. Otherwise we could never make any decision at all.

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.
Tuesday, July 24, 2012

Learning how to interpret statistics from an epidemiologist

Early on in Between the Lines , a breezy new book on medical statistics by Dr. Marya Zilberberg, the author encourages her readers to "write, underline, highlight, dog-ear and leave sticky notes." I did just that. Well, with one exception; I didn't use a highlighter. That's partially due to my fear of chemicals, but mainly because we had none in my home.

I enjoyed reading this book, perhaps more than I'd anticipated. Maybe that's because I find the subject of analyzing quantitative data, in itself, dull. But this proves an easy read: it's short and not boring. The author avoids minutia. Although I'm wary of simplified approaches, because as she points out, the devil is often in the details of any study, this tact serves the reader who might otherwise drop off this topic. Her style is informal. The examples she chooses to illustrate points on medical studies are relevant to what you might find in a current journal or newspaper this morning.

Over the past year or two, I have gotten to know Dr. Zilberberg, just a bit, as a blogging colleague and on-line associate. This book gave me the chance to understand her perspective. Now, I can better "see" where she's coming from.

There's a lot anyone with an early high school math background, or a much higher level of education, might take away from this work. For doctors who've attended four-year med schools and, of course, know their stats well (I'm joking, to be clear), this book provides an eminently readable review of basic concepts: sensitivity, specificity, types of evidence, types of trials, Type II errors, etc. For those, perhaps pharmacy student, journalists and others, looking for an accessible source of information on terms like "accuracy" or HTE (heterogeneous treatment effect), Between the Lines will fill you in.

The work reads as a skinny, statistical guidebook with commentary. It includes a few handy tables: on false positives and false negatives (Chapter 3), types of medical studies (Chapter 14), and relative risk (Chapter 19). There's considered discussion of bias, sources of bias, hypothesis testing and observational studies. In the third chapter the author uses lung cancer screening scenarios to effectively explain terms like accuracy, sensitivity and specificity in diagnostic testing, and the concept of positive predictive value.

Though short, this is a thoughtful, non-trivial work with insights. In a segment on hierarchies of evidence, for example, the author admits "affection for observational data." This runs counter to some epidemiologists' views. But Zilberberg defends it, based on the value of observational data in describing some disease frequencies, exposures, and long-term studies of populations. In the same chapter, she emphasizes knowing and stating the limits of knowledge (p. 37): "... I do think we (and the press) do a disservice to patients, and to ourselves, and to the science if we are not upfront about just how uncertain much of what we think we know is ..."

Mammography is, not surprisingly, one of few areas about which I'd take issue with some of the author's statements. For purposes of this post and mini-review, I'll leave it at that, because I think this is a helpful book overall and in many particulars.

Dr. Zilberberg cites a range of other sources on statistics, medical studies and epistemology. One of my favorite quotes appears early on, from the author directly. She considers the current, "layered" system of disseminating medical information through translators, who would be mainly physicians, to patients, and journalists, to the public. She writes: "I believe that every educated person must at the very least understand how these interpreters of medical knowledge examine, or should examine, it to arrive at the conclusions."

This book sets the stage for richer, future discussions of clinical trials, cancer screening, evidence-based medicine, informed consent and more. It's a contribution that can help move these dialogues forward. I look ahead to a continued, lasting and valuable conversation.

This post originally 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.

Specialist roulette

"I want you to get me a new doctor," she told me, a bit of disgust coming out in the sharp tone in her voice.

"What happened?" I asked.

"He asked me if I was nauseated, and I told him no, I was just vomiting. Then he asked if I was feeling pain in my stomach, and again I told him no, it was just vomiting. He then told his nurse to write down nausea and abdominal pain. When I objected, he just gave me a bad expression and walked out of the room."

I tried to come up with a plausible explanation for his action, but there was none. "I'm sorry," I said. "There are a lot of people who come back from him feeling really happy and listened-to. It's obvious that you saw none of that from him."

"I asked his nurses if he always acted this way," she continued, "and they just shrugged and told me that he sometimes did."

"I'm happy to send you to a different doctor," I said, shaking my head.

I hate it when this happens.

I send people to specialists for two main reasons:
--I am not qualified to offer the treatment or procedures the specialist can give.
--The specialist has far more experience with the problem, and so can offer better care.

But there is one thing I am not doing: giving over care of the patient. Patients are more than just diseases or problems to be solved. Patients are more than a single organ system. It is my job as a primary care provider to orchestrate and oversee the care my patients get as a whole, including those areas also managed by other physicians. I am, in essence, borrowing the specialist for their experience and skill to help me take care of my patient.

So when I have a patient come back from an encounter like this one, it not only bothers me for the sake of the patient, I feel a personal sense of being let down by the other doctor. I need help, and the person I chose to help my patient didn't do the job I need them to do. Were they just too lazy to listen? Were they just having a bad day? Do they understand the question I was asking them to answer? Did the patient somehow come across in the wrong way?

I am never quite sure for the reasons for these bad experiences, but I hate playing specialist roulette every time I send people to another doctor. It's not only a waste of time and money, it also undermines the person's trust in me for choosing the specialist, and often hurts their overall view of my profession. Why bother going to the doctor and pay lots of money only to be patronized, trivialized, or simply ignored, while not seeing their problems get better?

I get the same sinking feeling when I send a patient to the ER. When I have a person come to the office with problems that need immediate attention, it is often quickest to send them to the emergency room, where they can get labs, X-rays, and specialty consults in a very short period of time. There are times when I call the ER physician to explain my rationale for sending the patient, especially when I think the reason may not be apparent to someone seeing them for the first time, but there are other times when it is glaringly obvious to me what's going on and what needs to be done. Yet, again it feels like a game of roulette, never knowing if the doctor will see what I see and do the proper workup, or if the patient will call the next day saying nothing was done in the ER.

From my perspective, the big problem is one of information. I am working with much more information than the other doctors. I've often seen the person for many years and in many circumstances, knowing how significant it is when this particular person comes to my office complaining of pain. I actually had a physician come to me with an acute appendicitis, and even my staff knew how serious a problem it must be for a physician to want to be seen immediately.

I also have all of the previous workup on a problem, a history of previous problems, and I know the family, home, and psychological landscape in which the person lives. When the person goes to the specialist, the other doctor has only what I send them and what the patient tells them. What seems obvious to me may not be the same for someone seeing them without my information. But I do expect them to consider not only the patient's motivation for wanting to be seen, but my motivation for sending them.

It comes down to a single thing: respect. Patients deserve to be treated with respect, and I am angry when my patients get otherwise.

Beyond that, I deserve to be respected by my colleague for having put thought into my decision to ask for help. The visit my patient described was not just insulting to her, it was insulting to me.

I try to give other doctors the benefit of the doubt, as sometimes personalities don't work together, and everyone has moments where they drop the ball. Encounters like this one go into my database when I decide who I will ask when my patients need more than I can offer. My lack of consults to certain providers, especially after I had been using them in the past, should send a message to them about my opinion of their care. I've had several physicians ask me why I wasn't sending them as many consults as I was doing previously. My universal answer is this: My patients had bad experiences at your office.

They are my patients, and I expect them to be treated well.

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.
Monday, July 23, 2012

Risks overstated for antidepressants and suicides

When the U.S. Food and Drug Administration issues a black box warning, it is usually to alert physicians of a serious side effect of a drug. That warning is highlighted in all of the package material of the pharmaceutical and is a big deal. For years, the SSRI antidepressants have carried a black box warning that the drug might cause suicide in children and adults. This warning was there despite the fact that no actual suicides occurred during the drug trials, but patients did experience suicidal thoughts and behavior. I remember hearing about lawsuits against psychiatrists when medication was prescribed and it was thought to have contributed to suicide attempts.

A new meta-analysis study has been published in the Archives of General Psychiatry that analyzed 9,185 patients who took Fluoxetine (Prozac) and Venlafaxine (Effexor). These included 7,517 adults, 960 geriatric patients and 708 youths. Contrary to the black box warning, they found that these medications decreased suicidal thoughts and behavior in adults compared to placebo. No differences were found for youths. In all age groups, severity of depression improved with medication and was significantly related to suicidal thoughts. There were no suicides that were attributed to the medication.

This study is important because some clinicians may not prescribe and some patients may be afraid to take antidepressants that could significantly help their quality of life. Major depressive disorders are life threatening and SSRI medication has been an amazing modern breakthrough to help people get back on track.

If you Google this topic you get lots of scary anecdotal information about antidepressants causing suicide and violence along with the usual conspiracy stories and pharmaceutical bashing. When you consider that 70% of people who commit suicide did not see a psychiatrist within the last year, you realize how serious depression is.

Antidepressants do not cure life problems, but they bring significant relief and save significant lives in millions of humans.

This post originally appeared at Everything Health. Toni Brayer, MD, 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.

Tucking in for a good night's rest (doctor included)

In the era of shifts rather than calls, the art of "tucking in" a patient is being neglected.

In the past this generated pages to wake you up but now it generates unneeded business for your colleague who is covering for you. When the "night float," "nocturnist" or "nocturnalist" is getting paged for a sleeping pill, acetaminophen or a laxative you are getting a reputation of being lazy, short sighted and a person who wastes clinical temporal resources. While your therapeutic regimen may treat the patient, their symptoms do not spontaneously alleviate as soon as the medications hit the blood stream, there is a temporal lag. In addition, your patient may develop new complaints only peripherally related to their presenting diagnosis.

Imagine, if you will, being a traveler trapped in a hotel room, that you forgot your luggage and you have to call the front desk for permission to get up to use the lavatory. This is the powerlessness experienced by patients, who may need trivialities to feel better but have to have a doctor's order to get them. It is critical to see to the diagnosis and intervene but it is a necessity to see to your patient's comfort as well. By nature, "tucking in" a patient uses adjunctive measures, medications that the benefits of comfort do not outweigh the risks of side effects, adverse reactions, or worsening the hemodynamic status of the patient.

Rate-controlled unidirectional gastrointestinal motility
People don't like vomiting, nurses like it less than anyone else. People also like a semblance of bowel regularity and consistency, too much and too little are both subject to complaint, a complaint that is geometrically proportional with age. Symptomatically treating nausea, vomiting, diarrhea, and/or constipation does not solve the problem; your diagnostic inquiry and therapeutic intervention must still proceed.

Where I trained, ondansetron was the front line antiemetic of choice, however it can only be given twice in one day. Therefore a breakthrough or back-up agent such as prochlorperazine, promethazine or metoclopramide is a good idea.

If their nausea and emesis is due to a systemic response to ischemia or infection, management of the cause will fix their symptoms, the time delay in improving cardiac perfusion and treating that urinary tract infection will be covered by anti-emetics. If the nausea and vomiting are due to obstruction or ileus you will be better served with a nasogastric tube to low intermittent suction than just anti-emetics, alleviating the distention and pain which may or may not help the actual problem does help their symptoms, without hiding that massive amount of intestinal content that is just waiting to be ejected when their vomiting centers come back on-line.

Lastly, look the side effects of analgesia, opioids are notorious for causing nausea and vomiting, sometimes simply switching your analgesic regimen will help.

On the back end, people like a "normal" bowel routine. Once the rate, composition and volume changes they get concerned and want action. Constipation must be excluded from ileus or obstruction. In constipation you still have gas and no other symptoms aside from the abdominal discomfort. Physicians are the leading cause of in-hospital constipation. We make people take their iron supplement and proton pump inhibitors, and we fluid-restrict them. We address their pain needs without looking out for opiate-induced bowel dysfunction. Once you're sure it's constipation and not its malevolent cousins ileus or obstruction, you can always work on their bowels with bisacodyl, milk of magnesium (MOM), magnesium citrate, or enemas. If they have kidney disease, avoid the magnesium and phosphorus and try lactulose.

Feed me
I just waxed poetic about this the other day.

"Oh Dr. Sandman, bring me a dream ..."
Sleep is a valuable therapeutic tool. People want to be "knocked out" a la the late Michael Jackson to get that good nights' rest and get better. However the layman does not understand that the medications we use as sleep aids can easily push one over into respiratory depression and failure.

On the flip side, a little sleep deprivation can move the recalcitrant patient toward discharge because they sleep better at home. Hospitals are loud, obnoxious places. You have a new, equally ill roommate, an open door to a lit corridor, you often times have things stuck to or in your body, you're probably tethered to some who's-is-what-is-it, you have apnea, telemetry, and bed alarms going off, and vital signs being checked at all hours of the night and labs drawn at other times. IV pumps are loud and voices carry in the halls of healing.

Patients are not allowed to rest and do not feel in control. This leads to an upset person when you preround at the crack of dawn. Thus sleeping aids, which don't actually improve sleep but do make people forget that they woke, may be of benefit. However only use them when you are sure that there is no other reason keeping the patient awake such as pain, anxiety, or delirium and that by giving them a respiratory depressant you will not precipitate respiratory failure.

First trim tethers such as IV fluids, Foley's, and NG-tubes. Also get rid of alarms you don't need, like the telemetry and apnea alarm on your comfort care patient. Eliminate unneeded lab draws and foster communication between nurses and patients so that evening vitals can be done before the patient decides to go to bed. Consider non-chemical adjuncts to foster sleep such as no naps and increased activity during the day, turning the television off at bedtime, switching their phones off, or finding them some boring reading material. Limit caffeine intake in the later part of the day. Controlling pain can help with sleep, so make sure you have an adequate analgesic regimen in place.

Where I trained, our formulary advocated zolpidem. This is the pill that one of my nurses referred to as "the pill that turns my sweet 80+ year old patient into a psychotic nudist." Benzodiazepines can also be used, either long or short acting, but benzos are known to cause delirium, more so than zolpidem. Diphenhydramine can also be used but is also deliriogenic.

Generally, if a patient is on benzodiazepines and not sedated I continue them to prevent withdrawal. If the patient insists that diphenhydramine is the only thing they can take for sleep, give a small dose a try. But neither of these medications are "go to" drugs for the sleeping aid naive. Haloperidol is a good choice if their insomnia is due to hyperactive delirium.

ACP Member Mike Aref, MD, PhD, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging. This post originally appeared at his blog, I'm dok.
Friday, July 20, 2012

Bloomberg soda ban ignites controversy. What's next?

I'm a gastroenterologist and I should be against obesity. I should counsel patients who have reached a designated rung on the body-mass index ladder on the risks of carrying excessive poundage and the benefits of achieving a more streamlined silhouette. I should encourage them to pursue a regular pattern of exercise and to choose food and beverage items wisely. I should advocate that the optimal tactic to achieve and maintain weight loss is to adopt a sustainable lifestyle change, rather than engage in a short distance sprint.

Any controversy so far? I doubt it. While I want my patients, and indeed everyone, to make wise choices in life, I won't make them do it. Doctors advise and patients decide. Intelligent folks who know the risks of their choices are entitled to make them freely.

Mayor Michael Bloomberg, a RINO (Republican in name only), has recently issued a citywide sugary drink ban that has made news across the country and beyond. While there are loopholes that will allow some of the sugary spirits to pass through, the ban is still far reaching and will leave many New Yorkers parched. Did the governor choose wisely here?

There's a conflict between an individual's right to make personal choices and the state's obligation to create sound public policies to serve the greater good. The governor and his acolytes argue that the millions of excessive pounds that are weighing down the Big Apple are costing the city gazillions of dollars in lost productivity and medical expenses. Opponents reel from another governmental edict controlling their personal lives.

If you agree with Bloomberg, then how far can and should the government go to control our behaviors? Who makes the decisions on what activities we engage in, us or the government? Who decides if an activity is meritorious or injurious?

If you support the soda ban, explain why you wouldn't support the following proposals:
--Ice cream and candy will now be available only by a doctor's prescription.
--Any individual who is 10 pounds over ideal body weight, as defined by the government, will be terminated from their jobs.
--Cigarette use will now be criminalized and convicts confined until they are rehabilitated to protect their health and the rest of us from the scourge of second hand smoke.
--Car owners of gasoline engines will be taxed heavily to encourage electric car use. Society is entitled to clean air and polluters must pay a price.
--Those who selfishly won't exercise and are at risk for medical complications that the rest of us have to pay for, will have a percentage of their wages garnished.
--Every Monday the government will choose a designated food item that it deems to be not healthful and it will be banned for the entire week. Restaurants, grocery stores and food trucks will delight in wondering when their number will come up. The government can set up a lottery where the public can wager on which ingestible item will be that week's contraband. Revenue can be used to fund the special cigarette police who will be working in 3 shifts rounding up inhalers.

Every day, diet soda and other caffeinated liquids slide down my gullet. Does this promote better health? Probably not, but I want the choice of what I can eat and drink.

Let's have some perspective here. I'm not asking for the right to drive 90 miles per hour on the highway, which threatens the state's interest much more than it would protect my right to speed on the open road. Banning soda and other sweet elixirs doesn't meet this test. Indeed, if government encroachment continues, it may drive many of us to drink. See you at happy hour.

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.

Public health and personal responsibilities

We are never alone. If you would, please hold that thought.

Politics, it seems, at least the variety practiced and prevailing in the U.S. nowadays, endeavors to make morons of us all. It gives us a contrived reality where there is no middle ground between the nanny who wants to tell us all what to have for breakfast, and the ninny who actually believes that big corporations won't exploit us in a world of no regulation or oversight. It implies to us that if ever we acknowledge the strength in unity, if ever we ask for, or offer, a hand up, we must be card-carrying members of the Karl Marx fan club. Anybody that concedes some value to the body politic is labeled a socialist.

What a load of festering rubbish! And as fate would have it, festering rubbish holds the key to our enlightenment on these muddled topics.

By and large, it's bacteria that cause rubbish, or anything, to fester. Sometimes it's other kinds of microorganisms, but let's not split cilia. Bacteria will do.

Bacteria, or their cousins, the archaea, were almost certainly the first life form on the planet. They are our distant ancestors. And, astonishing but true, they differ more from one another than all other forms of life differ from each other, or from them. Bacteria are the incubator of biodiversity on our planet. There is more fundamental genetic variation among varieties of bacteria than there is separating penguin from pine tree, orange from ocelot. I kid you not.

But I do digress. Let's get back to politics, or rather, the body politic. We are one, even when we're alone. We are, in fact, never alone.

Within our own skin, we are sufficiently in the minority to qualify as a potential rounding error. Bacteria outnumber our cells by 10 to 1 at least. The total population of the so-called microbiome totals roughly 90 trillion.

These germs, and although they are a vital part of us, they are, in fact, germs, contribute to a wide array of critical body functions. Their importance has turned them into New Age media stars as well, with coverage even A-list celebrities might envy. These bugs are big news.

Long known, though ever better studied, is the profound contribution of intestinal organisms to digestion. There is a growing body of evidence to suggest that disruptions to the normal flora of our GI tract may be implicated in a wide array of gastrointestinal disorders, and may be of particular importance in irritable bowel syndrome. There is a corresponding body of evidence, fast growing, that replenishing normal flora with probiotic supplements may confer benefit in such circumstances.

There is growing recognition that disruptions in gastrointestinal flora may be a factor, or in unusual but not truly rare cases of weight loss resistance, perhaps even the factor, conspiring to cause obesity. There is some early evidence that reconstituting healthy intestinal flora through the easy expediency of probiotic supplements, or the more dramatic and perhaps regrettably if aptly named "fecal transplant," may be quite helpful under such circumstances.

And there is growing awareness as well that our resident microbes influence almost every aspect of our physiology, from hormonal balance to metabolic rate to immune system function and inflammation.

I believe these bugs tell us more about ourselves than how inescapably germy we are.

In his characteristically articulate, compelling, and well-researched book, Outliers, Malcolm Gladwell builds a new podium for John Donne's time-honored admonition: "No man is an island." Gladwell demonstrates that the very examples of "self-made" people our society most reveres are in fact products of both aptitude and opportunity, circumstance and communal support. Neither triumph nor disaster is ever wholly owned by just one individual.

As with all of my ostensible sojourns into the tangents of philosophy, this one leads reliably back to my day job. The salient public health threats of our time are a wide array of social and environmental factors that in the aggregate contrive to make obesity, diabetes, and other chronic disease epidemic. Lifestyle factors that each of us potentially controls every day constitute the master levers of medical destiny, exerting greater influence on years in life and life in years than anything else. But these lifestyle factors are in turn much influenced by the modern environment in which we live, and which, collectively, we devised.

Against this backdrop, we have gravitated to the poles of ideology. Some invoke personal responsibility, as if lifting oneself up by the bootstraps is fully independent of all other influences, including, presumably, the existence of a boot-maker. Others argue for environmental reform as if we are entirely helpless while waiting on the world to change.

A middle path would concede that we like to be autonomous, and sometimes have the stuff to do so, but often don't, and are never entirely apart from the influence of others. An approach informed by biology would see an opportunity for common ground somewhere between "get there alone or die trying," and running a hammer and sickle up the flagpole.

In the case of nutrition, it is nonsense to pretend that parental or personal responsibility should suffice to overcome the clever and well-compensated efforts of people trained in marketing and advertising. But it is equally important to acknowledge that there are ways to confront the challenge of eating well in the modern world collaboratively, ways that don't require higher authorities telling us what to have for breakfast.

The human body is, quite simply, unviable without the biological body politic. With that as precedent and precautionary tale, perhaps society can acknowledge the same exigency, and accept that some challenges are best, or even only, addressed communally.

We would be in proud company to so concede. John Donne has told us so. Margaret Mead has told us so. Malcolm Gladwell has told us so. Hillary Clinton has told us so. Whoever said "in unity there is strength" told us so. And perhaps most irrefutably, Dr. Seuss has told us so.

I tell you so, as well, and these are the words I prefer: The best defense of the human body resides often with the body politic.

I am quite prepared to defend my autonomy. When I decide to ride my horse, or see The Avengers, or read Plato, I am deciding. I disavow any need to hold a referendum on the matter for my resident bacteria.

But maybe our inner reality can help us cool off the overcooked rhetoric on which our society seems so inclined to feed. Like it or not, we are all social, give or take the "ist," biologically. We are co-dependent on a whole population of other organisms. We cannot survive on our own, even within our own skins. I concede that without my resident microbes, I would die. Indeed, I concede that without them, I could never have lived.

Autonomy matters. Personal responsibility matters. We often can, and as often should, take matters of moment into our own hands. We often can, and as often should, be masters of our fate, and captains of our souls.

But we should nonetheless acknowledge that the best defenses of the human body reside largely, and often inextricably, with the body politic. Public health is for the public, and is best advanced by the collective efforts of the public.

In society, as in our own skin, from Gladwell's outliers of sociology to the gastrointestinal microbes of biology, we are never, ever alone.

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--Colon, rectal tumors genomically the same

Colon and rectal cancers share the same pattern of genomic alterations and can be grouped as one, according to The Cancer Genome Atlas (TCGA) project's large-scale study of colon and rectal cancer tissue specimens.

The study also found several of the recurrent genetic errors that contribute to colorectal cancer. The study, funded by the National Cancer Institute (NCI) and the National Human Genome Research Institute (NHGRI), was published in Nature.

There is a known negative association between aggressiveness of colorectal tumors and the phenomenon of hypermutation, in which the rate of genetic mutation is abnormally high because normal DNA repair mechanisms are disrupted, the National Institutes of Health stated in a press release.

In this study, 16 percent of the specimens were found to be hypermutated. Three-fourths of these cases exhibited microsatellite instability (MSI), which often is an indicator for better prognosis. Microsatellites are repetitive sections of DNA in the genome. If mutations occur in the genes responsible for maintaining those regions of the genome, the microsatellites may become longer or shorter; this is called MSI.

The researchers observed that in the 224 colorectal cancer specimens examined, 24 genes were mutated in a significant numbers of cases. In addition to genes found through prior research efforts (e.g., APC, ARID1A, FAM123B/WTX, TP53, SMAD4, PIK3CA and KRAS), the scientists identified other genes (ARID1A, SOX9 and FAM123B/WTX) as potential drivers of this cancer when mutated.

Editor's Note: QD will resume on Monday, July 30.
Thursday, July 19, 2012

Asking questions to better understand

Recently we made a diagnosis that really mattered for a patient. He came to us for an entirely different problem. Here is the rough sequence of events:

Man in his 50s, no recent hospitalizations, admitted for new atrial fibrillation with rapid ventricular response. His symptoms followed several days for nausea, vomiting and decreased oral intake. His abdomen was minimally tender. All routine labs were interpreted as unremarkable including liver tests and lipase. A CT suggested pancreatitis, but he had BS present and no other symptoms.

His atrial fibrillation responded to IV diltiazem drip and converted to sinus rhythm. He had two more episodes of atrial fibrillation, but eventually maintained sinus rhythm.

I first saw him on day 3 of his hospitalization. On day 4 his Hgb dropped from 13 to 10.5 and he reported a large melanic stool.

Review of his original labs provided a clue that we had missed. His initial BUN was 42 with a creatinine of 1.4. But in the housestaff's defense, they had checked his stool for blood at that time and it was negative.

I have left out things that I did not know until I got to the bedside on day 4. Some questioning led us to a totally different diagnosis.

I asked for questions. As a sign of the problem, 2 commenters suggested tests. One commenter was spot on.

The melanic stool required explanation. Therefore asking questions that might give information towards a diagnosis is the proper course. I picked the right first question: What medications were you taking? He was taking 3 medications including Voltaren (diclofenac), a strong non-steroidal.

"How long have you been taking Voltaren?" I asked.

"10 years."

"Why were you taking it?"

"For my arthritis."

"What kind of arthritis do you have?"

"I don't know, just arthritis."

A careful examination revealed PIP and MCP joint abnormalities, spongy, squishy and tender, while the DIP joints had some mild deformities but no squishiness or sponginess.

Now I knew the sequence of events and the underlying problem. Do you?

The tender spongy PIP and MCP joints raised the likelihood of rheumatoid arthritis. We considered hemochromatosis, but the patient did not have diabetes or cirrhosis and he had a low ferritin.

The rheumatoid factor was positive and both the CRP and ESR were significantly elevated. The hand X-rays confirmed symmetrical inflammatory arthritis.

He responded dramatically in less than 24 hours to low dose steroids.

We postulated that he had had undiagnosed rheumatoid arthritis for 10 years, treated with NSAIDs. The NSAIDs cause GI bleeding and dyspepsia. He became volume contracted, which stimulated his atrial fibrillation.

By discharge he remained in sinus rhythm, and was discharged on low dose steroids for his rheumatoid arthritis.

To me the point of this story was that we ignored or failed to appreciate his arthritis. Evaluating his GI bleed made us focus on the arthritis because we focused on why he was taking diclofenac.

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 as parts one, two and three at his blog, db's Medical Rants.

QD: News Every Day--55% of office doctors now use EHRs

More than half of office-based physicians use electronic health records, and 2012 could see an increase of half as much again, CDC researchers reported.

In 2011, 55% of physicians in office-based practices had adopted EHRs, and about one half of those who didn't have a system in place reported either already having purchased a system or planning to adopt one within the year.

Researchers reported their findings in a data brief at the Centers for Disease Control and Prevention website.

Among the key findings:
--About three-quarters of physicians who have adopted an EHR system reported that their system meets federal meaningful use criteria;
--85% of physicians who have adopted an EHR system reported being somewhat (47%) or very (38%) satisfied with their system.
--About three-quarters of adopters reported that using their EHR system enhanced patient care.

Solo practitioner adoption was 29%, dual-practitioner adoption was 60%, three-to-10 practitioner practices was 62%, and 11 or more practitioners was 86%.

Only half of physician-owned practices were adopters, whereas virtually all physicians in health maintenance organizations, three-quarters of physicians in community health centers and seven out of 10 physicians in academic health centers had adopted EHR systems

In case you missed it ...
NPR reports on the last people to rely on pagers for communication, namely, hospital doctors.

90% of hospitals still use the low-tech devices. While hospitals are experimenting with streamlining pages into smartphones, the merger may not happen for a decade or longer, according to the news broadcast.

Pagers are simple. There's no data security issues, batteries are simple to replace, and they are cheap. Yes, there's an app for that, but there's security risks to the data on the smartphone, their battery life and recharging cycle risks missing important pages, and one hospital in the report spent tens of thousands of dollars to test an app on 16 smartphones.
Wednesday, July 18, 2012

Are antipsychotic drugs becoming less effective?

According to a report published today at Reuters, antipsychotic drugs appear to be losing their efficacy. This is supposedly because there is a rise in the affect of the placebo effect.

The Reuters story is well-written (go and read please), but is missing a "Part II." If the data are correct and there is a narrowing gap between drug effect and placebo effect, what are the most likely explanations? Is it true that placebo responses are rising? Or that drugs are becoming less effective?

Let's step back and examine the question being asked, and the possible answers.

When clinical drug trials are done, the drug in question (the test drug) is usually compared to a placebo, an inert substance designed to look, taste and feel the same as the test drug. This is one way of separating the true effect of the drug from other effects, such as simply being involved in a study. Example time (skip if you already know this stuff).

Hypothesis: Oral Wonderflonium increases scrotal volume in human adult males. This is based on a mouse model that showed some promising results. Aspiring Academic Medical Center (AAMC) decides to test the hypothesis. They recruit 400 human adult males and measure their scrotal volumes on entry into the study (up to you to imagine how it's done). They treat the males with Wonderflonium for six months and then re-measure the scrotal volumes. Lo and behold, the average scrotal volume of the group increases by 20%. The folks at AAMC submit the paper to Second Tier Medical Journal.

Two of the reviewers at STMJ love it. Increased scrotal volume! Wonderflonium! Twenty percent! The final reviewer is less enthusiastic. "How do we know it was the Wonderflonium? After all, we're not comparing these people to anyone else. Maybe the drive two and from the center increased their scrotums. Maybe there's something at the coffee cart. Go back and re-work this."

The AAMC folks want to re-do the study, but ran out of money, as Wonderflonium is very hard to come by. But over at Major Academic Medical Center (MAMC), there's a guy with a big grant who grabs the whole idea by the, um, reins and sets up a new study. This time another 400 men are recruited, but half receive Wonderflonium and half receive a placebo that is outwardly identical to Wonderflonium.

This time, the results are published: Wonderflonium increased scrotal volume by 18% over placebo. Woo. Hoo.

The potential market is huge, especially among a certain set of inadequate-feeling, 'roid-raging gym rats. Several more studies are designed by academics and by drug companies (sometimes indistinguishably). Wonderflonium is flying off the shelves as the studies continue to give positive results.

A few years later, someone goes back and looks at the data. The most recent studies are showing that scrotums among gym rats aren't actually getting much bigger, something expected given the wide use of the drug. He goes back and finds recent studies have shown that scrotal size is only up by about 3-4% vs. placebo. WTF?

The researcher notes that scrotums in the placebo groups in the latest study are up more than in the original, and that this increase in placebo response is responsible for what seems like a decrease in the drug's efficacy.

His colleague has a different idea, one examined in detail by Dr. David Gorski at Science-Based Medicine. His colleague looks at the trend, and she sees something familiar: new drugs seem to work better right after their discovery.

She proposes the Scrotum Problem is due to the "decline effect," a mixture of factors that better explains the trend. The early studies of the new drug may have captured a less random moment in time. As more and more people are treated, there is a "regression toward the mean," with more studies giving us more accurate (and less impressive) numbers. There may also have been some publication bias, in which studies with interesting positive results were more likely to be submitted and published.

What is less likely is that something about placebos has changed. While placebo scrotum volumes increased, there may be many explanations for this. Study design can affect placebo response considerably, as can measurement biases. But since placebos don't change, they're not to blame.

So before we all get too excited about the increasing placebo effect killing off new drug development we need to ask smarter questions: Are we looking at the right end points and doing it correctly? Are we allowing expectations to trump good study design? Are we jumping the gun on new drugs by relying on initial small studies? Are we moving the goal posts in our original studies by hunting for statistically significant effects that we didn't lay out in our hypothesis?

All could be true. But a sugar pill is still a sugar pill.

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.

What doctors are supposed to write

I had a patient (details changed to de-identify) some time ago who, when I asked him how he was feeling, responded, "Pretty fucking awful."

He saw a copy of the note and was upset, not because he was ashamed of his language, but because he was taken aback that a doctor would use such language in a note.

I explained to him that I always try to record what a patient says to me, since that conveys useful information. He was mollified.

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.

QD: News Every Day--Safety-net hospitals could face pay hurdles under health care reform

Health care reforms may prevent safety-net hospitals from fully recouping Medicare dollars, a study cautioned.

Provisions of the Affordable Care Act tie from 1% to 3% of hospital payments to quality measures, one of which is patient-reported experience from the Hospital Consumer Assessment of Healthcare Providers and Systems survey.

This is a safety-net hospital's Achilles' heel, the authors report, since these facilities had lower performance than non-safety-net hospitals on all patient experience measures except quietness of hospital environment.

Results appeared online at Archives of Internal Medicine.

Researchers looked at nearly 3,100 hospitals that scored in the highest quartile of the Disproportionate Share Hospital index and how they fared in the Hospital Consumer Assessment of Healthcare Providers and Systems survey in 2007 and 2010.

Safety-net hospitals were more likely to be:
--large hospitals that were for profit or publicly owned,
--major teaching hospitals,
--in the South and West,
--staffed with fewer nurses,
--serving fewer Medicare patients and more Medicaid and black patients.

The greatest differences were in overall hospital rating, where patients in safety-net hospitals were less likely to rate the hospital a 9 or 10 on a 10-point scale compared with patients in non-safety-net hospitals (63.9% vs. 69.5%; P less than .001).

Other differences were reported for the proportion of patients receiving discharge instructions (2.6 percentage point difference; P less than .001) and who thought they always communicated well with physicians (2.2 percentage point difference; P less than .001).

Although both groups of hospitals improved from 2007 through 2010, the gap in overall rating between safety-net hospitals and non-safety-net hospitals increased (3.8% in 2007 vs. 5.6% in 2010; P=.08).

Researched reported that safety-net hospitals had a 60% lower odds of meeting performance benchmarks for hospital payments (odds ratio, 0.4; 95% confidence interval, 0.3 to 0.5; P less than .001) compared with non-safety-net hospitals.

"Although the new VBP [value-based purchasing] rules pay for improvements as well as achievement, our findings suggest that SNHs [safety-net hospitals] face challenges on both fronts," the authors concluded. "If SNHs are unable to substantially improve patients' experiences over the next several years, hospital-based incentive programs are likely to disproportionately penalize these institutions."
Tuesday, July 17, 2012

The Medical Skeptic

I've become a big fan of the "Medical Skeptic" genre.

The idea is that while modern medicine provides many marvels, sometimes we do too much, and that can be counterproductive.

Case in point: Screening for (and sometimes even treating) prostate cancer.

In a nutshell, though it seems counterintuitive, it's a bad idea to invasively look for or treat a cancer that won't cause suffering or death. The side effects (erectile dysfunction, urinary incontinence) are far worse than living with the condition. (The difficulty is that of course there are exceptions to this. Some people do die from prostate cancer. It's just that the science of knowing whom hasn't developed to where we'd like.)

Excellent books in this genre that I'd recommend include Overdiagnosed, by Gilbert Welch, et al., and How We Do Harm, by Otis Brawley & Paul Goldberg.

Due to my interest, I search the web for this kind of information. As I've also become more active on Twitter, I've started locating tips on good reading material there.

In particular, I've started following the tweets of a particular tweeter (Twitter-er?) who calls himself "Medical Skeptic" (@Medskep).

I've noticed that he's prolific-he tweets dozens of times a day. It's impossible to keep up with the flurry of information. But to me, his tweets are almost always educational. His method is to look at a problem of medical over-use, and search for high-powered evidence of its harm (though he will tout benefits when they are there. Gotta call 'em as he sees 'em).

If there's a common theme, it's this: Eating the right food, exercising, and getting enough sleep are the three most important behaviors for maintaining health. Regardless of whether you're healthy to begin with or suffer from a chronic condition, the same advice applies. All the other medical interventions we provide would be relatively unnecessary if we could abide by these three principles.

In a given week, @Medskep might tackle the physiologic underpinnings of coronary disease–and he'll link to writings that show that if we lived by healthier standards, we'd almost entirely obviate the need for stents or bypass surgeries. Another day he'll explore the validity of using SSRIs (Prozac, Paxil, Zoloft, etc.) for depression, and demonstrate that their overuse is a triumph of marketing and politics over sound science.

Heavy stuff.

I went to his blog and didn't find anything about him (it hadn't been updated in years, like a fallow field). So I direct-messaged him on Twitter, and we struck up a phone conversation.

I asked him if he'd heard of the blog "Science Based Medicine," whose writers are doctors and scientists with an agenda of debunking spurious claims about alternative medicine. It seemed to me that he was engaged in a similar pursuit.

He'd heard of them, but for many reasons (chief among them that he considers himself an informed lay-person rather than a scientist or practitioner), he's chosen not to go that route.

Of course, the biggest difference is that @Medskep turns his spotlights on "conventional" medicine, something the folks at SBM do less regularly.

@Medskep is a man of protean interests. He's held many jobs in different fields, and demonstrated that you're never too old (in contrast to last week's post) to gain deep new knowledge. In sum, I'd say he's a man driven to find truth, for the love of pure knowledge and no financial gain.

If you're interested in learning more, I'd encourage you to sign up for Twitter (it's free) and follow @Medskep and @GlassHospital.

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.

'If your doctor doesn't listen, you need a different doctor'

A couple of generations ago medical culture was aloof and authoritarian. Doctors did not give advice to patients, they gave orders. Patients were expected to follow those orders. Questions might have been tolerated, but patient requests for explanations or suggestions for a different approach were considered very unusual.

I thought this paternalistic model of doctoring ended long before I was trained. I was trained to think of the patient's autonomy as the core of the patient-doctor relationship. I was taught that I should explain various alternatives, answer questions, and allow the patient to make the final decision directing her care. Doctors were expected to make recommendations, but also to encourage questions, second opinions and exploration of alternatives.

I guess old habits die hard. A recent study in Health Affairs interviewed 48 patients in the San Francisco area about their interactions with their doctors. Most of the patients were over 50 years old, lived in affluent neighborhoods, and were highly educated. Nevertheless, the patients revealed several obstacles to having discussions with their doctors about their treatment plan.

Patients reported that their doctors can be authoritarian, that the patients feared being labeled "difficult", and that they felt pressure to defer to the physician.

What's going on here? It would be interesting to have the researchers actually watch the actual doctor visit to identify any of the doctors' behaviors that are making patients feel reticent to speak up. Are doctors so rushed that they brusquely close the conversation? Are older patients simply deferring to the doctor because that's how they were raised, even though younger doctors encourage dialogue?

Thinking about this made me terribly self-conscious. Am I scaring my patients from asking questions? My patients ask lots of questions. Are they afraid to suggest treatment alternatives? They e-mail me all the time me about treatment alternatives that they discovered on the Internet or from their extremely well-meaning and knowledgeable neighbor. I always take their questions seriously.

Am I authoritarian? I am opinionated, but I hope I always leave the final decision about treatment to the patient, and I hope even when arguing against a proposed treatment plan I do so respectfully.

Of course, I realize that humans are self-delusional creatures, so perhaps I'm just fooling myself. Perhaps I'm only thinking of the few assertive patients who dare dialogue with me while the rest cower beneath my raging authoritarianism.

So I suppose the best I can do is use this post as an open letter to any frightened patients who yearn to have a conversation with their doctor, but dare not. Speak up! If your doctor doesn't listen, you need a different doctor.

Learn more:
Afraid to Speak Up at the Doctor's Office (The Well, the New York Times health blog)
Are you afraid to talk to your doctor? (CNN Health)
Authoritarian Physicians And Patients' Fear Of Being Labeled 'Difficult' Among Key Obstacles To Shared Decision Making (Health Affairs, abstract available without subscription)

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--Drug shortages lead to reuse of one-dose vials, staph outbreaks

Two outbreaks of Staphylococcus aureus in Delaware and Arizona occurred when drug shortages led medical staff to re-use single-dose vials for more than one patient, the CDC reported.

The Centers for Disease Control and Prevention discussed the outbreaks in MMWR.

The Arizona Department of Health Services found an outbreak of methicillin-resistant S. aureus (MRSA) stemming from contrast injections for radiologic imaging to guide medication needle placement.

Each morning, clinic staff members diluted the contrast medium and transferred it to vials to use in the morning and the afternoon.

Three patients with resulting MRSA infections were treated for severe infections, including acute mediastinitis, bacterial meningitis, epidural abscess and sepsis. Hospitalizations ranged from 9 to 41 days, with one patient requiring additional long-term acute care. A fourth patient was found dead at home six days after treatment at the clinic. The cause of death was reported as multiple-drug overdose, but the CDC report noted that a MRSA infection could not be ruled out.

Although the contrast medium is manufactured in lower concentrations, the Arizona clinic reported difficulty getting a reliable supply.

In Delaware, the Division of Public Health investigated seven patients hospitalized for septic arthritis or bursitis after receiving bupivacaine from a single-dose vial at an orthopedic clinic. All patients required debridement of the infected sites and intravenous antimicrobial therapy, and were hospitalized from three to eight days.

Of the seven patients with S. aureus infections, five received their injections on the same day. Three more patients developed symptoms that suggested an infection but did not have cultures taken and were treated with oral antibiotics as outpatients.

The orthopedic practice had used 10 mL vials of bupivacaine for single-patient use, but a national drug shortage forced staff to switch to 30 mL vials. Two staffers who had been preparing injections were colonized with S. aureus, and one had a strain that was indistinguishable from the outbreak strain.

"Since 2007, the year that injection safety was included as part of Standard Precautions, 20 outbreaks associated with use of single-dose or single-use medications for more than one patient have been reported," CDC staffers wrote in their report. "These investigations help remind health-care providers of infection prevention practices that are critical for patient safety."
Monday, July 16, 2012

Meaningful use leads to meaningless records

This July will mark the 16th anniversary of the installation of our electronic medical record.

Yup. I am that weird.

Over the first 10-14 years of my run as doctor uber-nerd, I believed that widespread adoption of EHR would be one of main things to drive efficiency in health care. I told anyone I could corner about our drive to improve the quality of our care, while keeping our cash-flow out of the red. I preached the fact that it is possible for a small, privately owned practice to successfully adopt EHR while increasing revenue. I heard people say it was only possible within a large hospital system, but saw many of those installations decrease office efficiency and quality of care. I heard people say primary care doctors couldn't afford EHR, while we had not only done well with our installation, but did so with one of the more expensive products at the time. To me, it was just a matter of time before everyone finally saw that I was right.

The passage of the EHR incentive program (aka "meaningful use" criteria) was a huge validation for me: EHR was so good that the government would pay doctors to adopt it. I figured that once docs finally could implement an EHR without threatening their financial solvency, they would all become believers like me.

But something funny happened on the way to meaningful use: I changed my mind. No, I didn't stop thinking that EHR was a very powerful tool that could transform care. I didn't pine for the days of paper charts (whatever they are). I certainly didn't mind it when I got the check from the government for doing something I had already done without any incentive. What changed was my belief that government incentives could make things better. They haven't. In fact, they've made things much worse.

We first installed EHR in 1996, after we were scared by an abnormal chest X-ray that was missed due to our paper charting system. We were afraid we were giving bad care for our patients, and saw computers as the solution.

Ironically, our success with our implementation hinged on our non-conformity with our EHR product's design. We didn't care if we used every part of the product, instead focusing on only using things in a way that improved the care without hurting our office workflow.

Early on, we used a hybrid of paper and computers to give us the information in the proper format. Then, once our vendor opened up the product to customization, I totally abandoned the hideous clinical content they had made, designing my own forms that maximized both quality and efficiency.

But last year, our first year in the "meaningful use" era, our focused changed in a very bad way. We started talking more about our EHR complying with criteria than maximizing quality and efficiency. Our vendor jumped on this bandwagon, ignoring the fact that they were stuck in a pre-internet, office-network design, and instead put all of their resources into letting their users meet "meaningful use." In the past, the computers were a tool we used to help our patients; with "meaningful use" they became a distraction, taking us away from a clinical focus and driving us toward proper data-gathering.

This is sadly ironic. We were once using our computers in a meaningful way for the benefit of our patients, but now we are being pressured to abandon the patients in order to qualify for "meaningful use."

This should come as no shock to anyone who has watched American health care over the past 20 years. We have beaten doctors over the head with "clinical pathways," and "evidence-based medicine," all with a good intent: to make sure doctors gave good care. The problem was, however, that these criteria become more important than the patients they were meant to serve. The same is true with our payment system: designed with the initial intent of enabling patients to have access to care, but becoming a behemoth in the exam room, standing between the doctor and the patient.

So what can be done? I don't really know. I still do believe that universal acceptance of EHR, coupled with patient data flowing efficiently between points of care, could improve quality and save a bus-load of money. But I am not so sure about where we are heading. I want to use computers for the benefit of my patients, not for the sake of compliance to the guideline de jour, or the next great government incentive program.

To paraphrase a famous political campaign motto: It's about the patient, stupid.

So I am working to somehow comply with government guidelines (and get my incentive check so I can have a better shot at paying for four kids going through college in the next 10 years) but doing so while somehow not losing focus on the patient. I have to say, it's a very hard thing to do.

My dream of universal acceptance of EHR has turned sour. I am beginning to hate the words "meaningful use." I am starting to fantasize about a life without it, and maybe even a life without anybody else's definition of what the care I give should look like.

I want to be a doctor. I want to take care of my patients. I want them to be the most important thing, not the other people enticing me with their big checks. Can I stay in our system while still giving care that is meaningful?

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.