Friday, August 31, 2012

QD: News Every Day--Americans die more often for treatable conditions

Americans die more often for treatable health care conditions than their European counterparts, a study found.

Amenable mortality--deaths that should not occur when there's timely and effective health care--among men from 1999 to 2007 fell by only 18.5% in the United States compared to 36.9% in the United Kingdom. Among women, the rates fell by 17.5% and 31.9%, respectively, researchers reported in Health Affairs.

The United States not only had the highest rates of amenable mortality in 1999, but it also had smaller improvements in rates between 1999 and 2007 than the other three countries.

While U.S. adults had the lowest cancer mortality rates, they had more cardiovascular deaths, especially from cerebrovascular disease and hypertension.

All this comes despite the fact that American spent $7,960 per capita in 2009, or twice the average in Western European countries.
Thursday, August 30, 2012

I want to ration your health care

I want to ration your health care. Well, I don't want to do it personally, and not to you specifically. And that's the problem. Policies on the individual and societal levels feel very different. We are not culturally prepared for "rational" rationing. We're happy to do it irrationally; if you don't have insurance, you're probably not going to get proton beam therapy for your prostate cancer. Someone might be willing to chemically or surgically castrate you, though.

Even if you do have insurance, should you be able to get, for example, proton beam therapy? Therapies new and old are often available and used independent of how good they actually work and how cost-effective they actually are. What if (and I'm making up the numbers here) proton beam therapy, which costs gazillions of dollars, decreases cancer recurrence by a few percentage points, and decreases impotence by a few more? Is it worth it? For you? For us?

I'm not beating up on proton beams; never pick a fight with ionizing radiation unless you're sure you will win. The wider point stands though. In the U.S. we practice medicine with complete irrationality. There are thousands of lives that can be saved by simple practices that so many of us ignore. There are thousands more that can be saved by the proper use of medications.

And yet we continue to pour money into a fantasy. We believe that a 95 year old with cancer just might be the one to survive the ICU, with just one more day on the ventilator, just one more round of dialysis. We believe that our own patient with pancreatic cancer might be the one who feels better on Gemzar. We believe we can cure our obesity-related disorders without exercise, without medicine, and without society-level interventions (it worked with smoking).

The American medical system is an irrational fantasy, one in which we swoop down and cure one person's problem at a time, forgetting that the system as a whole is making us all sick and broke.

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--Palliative care increasing in larger hospitals, in the Northeast

The number of hospitals with more than 50 beds that has a palliative care team increased from 658 (24.5%) to 1,635 (65.7%), a 148.5% increase from 2000-2010, part of a steady increase for 11 straight years, according to an analysis by the Center to Advance Palliative Care.

Other key findings include:
--87.9% of hospitals with 300 or more beds have a team compared to 56.5% of hospitals with 50-299 beds.
--The Northeast has the greatest growth and the highest prevalence. (75.8% of hospitals in 2012 compared to 73% in 2011.)
--The South shows some growth, but still has the lowest prevalence. (52.7% of hospitals in 2012 compared to 51% in 2011.)

"Palliative care teams are transforming the care of serious illness in this country because they address a fragmented health care system and put control and choice back in the hands of the patient and family," said Diane E. Meier, MD, FACP, director of the non-profit Center, said in a press release. "Hospitals today recognize that palliative care is the key to delivering better quality and better coordinated care to our sickest and most vulnerable patients."
Wednesday, August 29, 2012

Medical skepticism goes to summer camp

GlassHospital has trekked up to the White Mountains in the 'Live Free or Die' state of New Hampshire, where the air is pure and the Wi-Fi is spotty. We're working as camp doctors, tending to the sprains and bruises of an energetic group of youngsters and staff who amaze us with their talents and good will.

No better setting than to explore a recent perfect storm of media coverage over sports drinks.


Are they controversial?

Mom always told me after a long summer day of playing outside to replenish my electrolytes with Gatorade, or some such concoction. Didn't yours? [Actually, it wasn't my Mom. I think it was those TV commercials featuring Michael Jordan. I want to be like Mike, at least on the b-ball court ...]

And therein lies the problem.

As with all products that have medical claims, it pays to examine the evidence above the advertising claims. If we are brand loyal, we want to believe Mike. We want to believe that stuff is good for us. We want to be like Mike, after all.

Must be because of the upcoming London Olympics, but one scientific article (thank you, British Medical Journal) led to lots of UK media coverage, followed by a piece in the Atlantic and a post on NPR's "The Salt" blog. I'll list & link them here:
--BMJ article "The Truth about Sports Drinks" article "The Controversial Science of Sports Drinks"
--NPR blog post "Some Athletes Reject High-Tech Sports Fuel in Favor of Real Food"

If you're really wonky about this stuff, here's a link to a video (spoiler alert: super boring 9 minutes of white people sitting around a table talking in low voices) in which the BMJ editors discuss their hassles amassing enough evidence about this issue to crank out a meaningful paper. Turns out a lot of the info on these drinks is "proprietary," held in confidence by the manufacturers of the drinks.

Remind anyone of, say, tobacco?

Read the links, form your own opinion, and comment below.

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.

QD: News Every Day--Fitness in mid-life means fewer diseases in old age

Fitness in midlife appears to be associated with a lower risk of common chronic health conditions later in life in men and women older than 65 years and enrolled in Medicare, a study found.

Researchers linked Medicare claims with participant data from the Cooper Center Longitudinal Study, which looked at 14,726 healthy men and 3,944 healthy women from 1970 to 2009 for eight chronic conditions: congestive heart failure, ischemic heart disease, stroke, diabetes, chronic obstructive pulmonary disease, chronic kidney disease, Alzheimer's, and colon or lung cancer.

Results appeared online at Archives of Internal Medicine.

With a median follow-up of 26 years, the highest level of midlife fitness (quintile 5) was associated with a lower incidence of chronic conditions compared with the lowest midlife fitness (quintile 1) in men 15.6 vs. 28.2 per 100 person-years and in women 11.4 vs. 20.1 per 100 person years, according to the study results. Age- and sex-specific quintiles of fitness were based on treadmill times.

Researchers suggest a moderate increase in fitness may mean a reduction in chronic conditions as people age. For example, a 1- to 2 metabolic equivalent improvement in fitness resulting in promotion from the first to the second fitness quintile at age 50 years was associated with a 20 percent reduction in the incidence of chronic diseases at ages 65 and older.

Among those participants who died, researchers note that higher midlife fitness appeared to be more strongly associated with a delay in the development of chronic conditions than with survival.

"Compared with participants with lower midlife fitness, those with higher midlife fitness appeared to spend a greater proportion of their final five years of life with a lower burden," of chronic diseases, the authors concluded.
Tuesday, August 28, 2012

Contaminated truths: Wellbutrin, depression, GSK and evidence

Like any perpetually anxious physician, I had one thought when I read the jaw-droppingly obscene details about GlaxoSmithKline's briberies and deceit. Well, maybe two thoughts. The first thought was that I don't play nearly as much golf as these other doctors do.

The second thought was, "Oh my God, I hope I didn't prescribe any of these medications unnecessarily!"

And I didn't. Not really. Let me explain: one of the medications mentioned in the indictment is Wellbutrin (generic bupropion), a medication that is useful by itself for depression and smoking cessation. The evidence for these is untainted by Big Pharma, though it's susceptible to the same problems and controversies afflicting all pharmacological treatment for depression.

But another claim, which I have heard for the past few years, is that Wellbutrin is useful to "augment" pharmacological treatment for depression with SSRIs. To be honest, the claim was one of many that I have heard from colleagues that I did not verify with a good look at the evidence. (How much that we have heard from colleagues, superiors, and teachers are things we haven't verified ourselves? That's why we should be open about our biases and ignorance, and ask patients for equal measure of skepticism and trust.)

When I read the GSK doings, I decided to check and see if what I had thought true about Wellbutrin as an "augmentive" therapy actually was true. And I found out – it is, kinda. There was a randomized controlled trial in the New England Journal of Medicine of patients who had "failed" (that is, not achieved remission of their depression) with SSRIs. They compared bupropion as augmentation (that is, together with an SSRI) to buspirone as augmentation. The results were promising. As the researchers say with commendable restraint, "Augmentation of citalopram with either sustained-release bupropion or buspirone appears to be useful in actual clinical settings."

Taking a closer look, though, leads to some misgivings. There was no placebo group (i.e., patients given SSRI and a sham drug), and no group with the SSRI alone. Further, while the endpoints were specified in advance, and GSK had no active role, per the paper, in study design, authorship, or funding, the disclosure section of the article reads like an encyclopedia of pharmaceutical companies. All the authors were getting money from them all.

Do I think Wellbutrin is a useful augmentive therapy for depression? I'm not as sure as I was, after actually reading the paper. But the uncomplicated truth of its usefulness has filtered down to us, and spread throughout doctors everywhere, partially due to GSK's perfidy. Without their overpushing Wellbutrin, I might have more confidence in the possibility of genuine clinical usefulness.

How many clinical truths are contaminated by pharm money?

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--Heavier women do worse with breast cancer recurrence, survival

Heavier women treated for breast cancer have higher rates of recurrence and mortality, a study found.

Obesity was associated with inferior outcomes in patients with hormone receptor-positive operable breast cancer treated with standard chemohormonal therapy, reported researchers who looked at the relationship between body-mass index (BMI) and outcomes in three adjuvant trials that included chemotherapy regimens with doxorubicin and cyclophosphamide.

Results appeared online at Cancer.

When evaluated as a continuous variable, increasing BMI in obese women (greater than 30 kg/m2) and overweight women (BMI between 25 and 29.9 kg/m2) was associated with inferior outcomes in hormone receptor-positive, human epidermal growth receptor 2 (HER-2)/neu-negative disease for disease-free survival (P=.0006) and overall survival (P=.0007), but not in HER-2/neu-overexpressing or triple-negative disease.

When evaluated as a categorical variable, obesity was associated with inferior disease-free survival (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.06-1.46; P=.0008) and overall survival (HR, 1.37; 95% CI, 1.13-1.67; P=.002) in hormone receptor-positive disease, but not other subtypes. In a model including obesity, disease subtype, and their interaction, the interaction term was significant for overall survival (P=.02) and showed a strong trend for disease-free survival (P=.07). Similar results were found in two other trials.

The study's lead author told Reuters that heavier women may produce more estrogen, and that higher insulin levels can stimulate breast cancer cells.

"The highest priority is just getting through the chemotherapy if chemotherapy is necessary and taking their endocrine therapy," Dr. Sparano said. "But for those who are obese or overweight, there may be additional benefits that one can achieve through diet and through weight reduction that may produce a reduction in the risk of recurrence that's just as significant as the reduction that they get from the standard therapies."
Monday, August 27, 2012

Score one for internal medicine

We recently returned from a meaningful/purposeful vacation in Peru. I am an Internist and my wife is an ophthalmologist and we were precepting students on a medical mission in the Sacred Valley in the Andes. Our middle school daughter was our medical Spanish translator. She would split her time helping in both areas, ophthalmology and internal medicine. She got a kick out of helping patients get prescription glasses and the thrill of helping some kids see clearly for the first time. After a couple of days, she got very comfortable with this and was able to independently get 20 patients a day to 20/20. When helping in the internal medicine area, she learned the importance of history taking and the conversation in diagnosis and patient care. She got a good exposure to this as she was the one translating the questions to the patient and translating the answers back to me. After a couple days she told me, "This is so cool! It's like solving a mystery by talking to people. I love it! You guys are low tech, but high talk!" There is hope for internal medicine yet! Neil Mehta MBBS, MS, FACP, practices internal medicine at a large tertiary care hospital in Ohio. He is also the Director of Education Technology (Academic Computing) for his medical school and in charge of his hospital system's home grown Learning and Content Management System. He is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management. This post originally appeared at Technology in (Medical) Education.

Better bedside manners heal doctor-patient relationships

Would you rather your physician be an astute diagnostician or a compassionate and empathic practitioner? Of course, we want our physicians to be blends of these qualities. We want it all. We want them to be chimeras of Drs. House and Welby. But, is this possible?

I can't say. I suspect that it is easier to cultivate soft bedside manners than it is to teach medical acumen, although the latter was the overriding priority when I was in medical training. No points were awarded in our morning reports with the chief of medicine for holding a patient's hand during the night. Big win, however, if the intern could recite 14 causes of hypercalcemia. The message was that "hard medicine" is what really matters.

The importance of bedside manners depends upon the specific medical circumstance at hand. Good bedside manners may mean less if you are going to see a physician once for a procedure than it would if the doctor-patient relationship were to be ongoing.

There has been more emphasis on medical humanity in medical training in recent years, although the trajectory has not been a straight and steady incline. Resistance to reducing excessive and oppressive work schedules of interns and residents is still viable, but progress has been made. I'm not suggesting that medical interns work a 40 hour work week, but I do reject that exhausted and somnambulating house staff are a necessary feature of medical training and education. And, if medical reform keeps progressing, how much dedication can we expect from house staff who will later join the ranks of employed physicians who are on a time clock?

Perhaps, shift work doctors will have meaningful doctor-patient relationships. Since these physicians will have more of a life, perhaps they will relate better to their patients as human beings. I'm not certain of this, but I offer it as a possibility.

I have come to appreciate how important are the soft sides of medical practice. Of course, medical knowledge is critical, but medical judgment is paramount. We've all seen medical geniuses who wielded a clumsy clinical axe. Conversely, we've admired great healers who were not scholars. If I'm sick, I'll pass on the medical prodigy in favor of an excellent listener and judicious practitioner. Remember patients, no doctor has it all.

Here are a few clinical scenarios I've encountered recently that require a non-scholarly remedy:
--A physician is interviewing a man with hepatitis C. His wife is at the bedside. Do you ask then about a history of intravenous drug use, which is an essential question in this circumstance?
--A nurse gives a patient more sedation than the physician ordered. Should this be reported to her supervisor if no adverse consequence occurred?
--A colleague requests that you do a procedure on an elderly patient that can be medically justified, but isn't truly necessary. What should the proceduralist's next move be?
--A patient is convinced that his complaints have a medical explanation, although the physician strongly suspects they are psychologically based. What's the doctor's game plan here? One false step and the doctor-patient relationship may be ruptured. Physicians wrestle with these kinds of issues every day. Sometimes, we get them right and sometimes we misfire. We're not perfect, even though we often feel that this is the expectation.

Not surprisingly, different physicians have their own individual approaches to medical and ethical issues. Every physician is unique by virtue of different training, personality style and experience. I wonder how the pay-for-performance panacea will measure all of this.

Doctoring is tricky business, and we don't know the specific ingredients and proportions that constitute a great physician. There is no recipe. It's an amorphous mixture of humanity, humility, medical knowledge, clinical experience, excellent communication skills, compassion and personal warmth. And, of course, we're supposed to run on time.

As patients, which qualities in your physicians do you value most?

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--tattoo ink poses dangers, CDC says

Tainted tattoo ink may lead to infection, the CDC announced last week.

Twenty-two cases of nontuberculous mycobacterial infection due to tattoo ink have been reported in New York State, Washington State, Iowa and Colorado in 2011-2012, said a report in last week's MMWR. All cases were found to be related to ink contamination, which can occur during manufacturing or if the ink is diluted with nonsterile water before it's used, the report said. 

An accompanying editorial note stated that the FDA considers tattoo inks cosmetics and they are not specifically required to be sterile. "However, intradermal introduction of nonsterile substances, such as tattoo ink, can pose a health risk and is a public health concern," the editors wrote.

The CDC recommended that ink manufacturers be held to higher product safety standards, including production of sterile inks. It also said tattoo artists should:
  • avoid using products not intended for tattooing; 
  • avoid diluting ink before tattooing, and use only sterile water if dilution is necessary;
  • avoid using nonsterile water to rinse equipment during tattoo placement; and 
  • follow aseptic techniques during tattooing, such as using proper hand hygiene and disposable gloves.
To reduce their risk for infection, the agency said, consumers should:
  • use registered tattoo parlors; 
  • request inks manufactured specifically for tattoos; 
  • ensure tattoo artists use appropriate hygiene; 
  • be aware of that infection could follow tattooing, and seek medical advice for persistent skin problems; and 
  • notify the tattoo artist and FDA's MedWatch program if an adverse event occurs.
The full MMWR report is online.
Friday, August 24, 2012

More thoughts on high value, cost conscious care

Apparently my post hit an important nerve. First my point about subspecialists should not be generalized to all subspecialists or the idea of subspecialists. As opposed to the 1970s when I trained, too often I see subspecialists now only considering their organ when evaluating a patient. Too often I see both generalist physicians and subspecialists failing to fall back on the basic principles of a careful history and physical and then understand what specific tests to order.

One can blame academe somewhat. Too many subspecialty consults in academic centers end with a laundry list of tests, excluding almost anything that could ever be part of the differential diagnosis.

One can blame the payment system. The generalist physician, rather than spending adequate time with the patient, orders a consult to save time.

One can blame the patients. Tara Parker-Pope initiated these expenses even though she should have known better.

That's where my daughter's ankle comes in. At the time, the injury seemed unremarkable. Her pediatrician suggested waiting it out, but after a month with no improvement, I sought a second opinion from a sports medicine specialist, who ordered an MRI, but ended up referring her to a pediatric orthopedic surgeon.

Patients (and physicians) too often forget that time is our friend. We become impatient when the physician cannot explain the symptom(s) immediately, so we abandon our generalist and figure that the subspecialist is a better choice.

We in academe must teach our students about the thought process in medicine. We in academe must role model history taking at the bedside, and then have discussions about that. We must demonstrated physical exam clues and explain how we use them in our decision making.

We must take the time to do things right. We have a responsibility to all the patients our learners will see in their careers.

We must remember that tests do not replace a careful history, they supplement that history. We must teach parsimony, a rare consideration during training.

And we must tell all those who will listen that good medical care takes time. We must stop talking about productivity. We are not making widgets; we are caring for important people--our patients. Each patient deserves our full attention and adequate time.

Only then can we produce high value cost conscious care, for it starts at the bedside, not at the computer order screen.

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.

QD: News Every Day--education, reminders may improve skin cancer self-assessment

Computer-assisted education along with reminders and other instruction may help improve patients' performance of skin self-exams, a new study reports.

Researchers randomly assigned 132 adults from dermatology clinics to intervention and control groups. Patients in the intervention group took a computer-assisted tutorial on melanoma and skin self-exams, received a hands-on skin self-exam tutorial, got telecommunication reminders to perform skin self-exams every month, and were given a brochure about detection of melanoma. Patients in the control group received the brochure only.

The study lasted three months, and the main outcome measure was patients' self-reported frequency of skin self-exams. The results were published online this week by Archives of Dermatology.

At the three-month follow-up survey, intervention-group patients were more likely to have performed skin self-exams compared with control-group patients. They were also more likely to report feeling confident about identifying melanoma during a skin self-exam. Both differences were statistically significant.

The authors acknowledged that their study was not blinded and that selection bias may have been present, among other limitations. However, they concluded that interventions of the type they tested can make skin self-exams more common and can increase patients' confidence in identifying suspicious lesions. They called for future research to determine whether other, similar types of interventions could also help change patients' behavior.

Thursday, August 23, 2012

Poor science writing leads to bunk nutritional advice

Journalist Virginia Hughes pointed me (and all her twitter followers) toward an interesting piece in the New York Times. In it, "opinionator" Mark Bittman makes some rather provocative statement about cow's milk.

According to Bittman, we drink too much of it. In the U.S., where obesity is becoming the norm, there's some truth to this. Milk is rich in calories and should be consumed by adults in moderation. In kids it is an important staple. What are his arguments against milk, and where do they come from? Are they convincing?

First he tries to shock us with large numbers, and by converting volume into weight:

"Until not long ago, Americans were encouraged not only by the lobbying group called the American Dairy Association but by parents, doctors and teachers to drink four 8-ounce glasses of milk, "nature's perfect food," every day. That's two pounds! We don't consume two pounds a day of anything else; even our per capita soda consumption is "only" a pound a day."

First of all, "until recently" renders the rest of the sentence moot. "Until recently" barbers performed surgery. "Until recently" beta blockers weren't recommended in heart failure. And the fact that it was recommended by a milk producers lobbying group shouldn't surprise us. I don't know of any of my colleagues who recommends that our adult patients drink 32 oz. of milk daily.

In fact the real recommendations are more subtle. The U.S. Department of Health and Human Services recommends three cups per day of low fat or fat free milk products which can include milk, yogurt, cheese, or soy milk.

So far, his arguments against milk are simply "it seems like a lot". Perhaps he's saving his better arguments.

Or not. His next argument is that many Americans are lactose-intolerant. So what? If you are lactose intolerant and want to drink milk, you can by lactose-free milk. You can eat yogurt. If you still don't want milk, no one is making you. Most people, after linking their abdominal distress to milk, will use their brains and substitute something like soy milk for cow's milk. This does not invalidate dairy recommendations.

He then goes on to state that water is "nature's perfect beverage." By what measure? If we are speaking simply of hydration, then milk and water are about equivalent. If we are talking about other nutrients such as vitamins and minerals, water is empty. Of course, it's also empty of sugar, which may be a good thing. Right?

"But, says Neal Barnard, president of the Physicians Committee for Responsible Medicine, "Sugar--in the form of lactose--contributes about 55 percent of skim milk's calories, giving it ounce for ounce the same calorie load as soda.'"

That's a deceptive statistic from an unreliable source. First of all, the Physicians Committee for Responsible Medicine is an animal rights front that advocates vegetarian and vegan diets for just about everyone. Their interest is not in nutrition, but in how our eating habits affect animals.

The statement is also very deceptive. An 8 oz. glass of milk has about 122 calories. An 8 oz. coke has about 100. So Coke is better, right? Well, no. about 100 % of Coke's calories comes from sugar (26 g per serving). The same glass of milk contains only 12 g of sugar. About one third of milk's calories comes from sugars, the other two thirds of fats and proteins. Coke and milk are comparable only in calories, perhaps the most misleading of facts.

Next argument, some people have bad milk allergies. OK, true. And some people are allergic to walnuts. If you're allergic to it, it's pretty clear that no one would recommend 32 oz. per day of milk. Foolish argument.

He goes on to give an anecdote from his past on how dairy seemed to give him heartburn, but he made changes suggested by a doctor who wrote a book on "detoxification." This same doctor writes about the supposed auto-immune basis to all disease, and appears to be into some deeply flawed autism work.

So far, Bittman has quoted a deceptive animal rights front and a doctor who has no special knowledge of dairy and nutrition but does have some questionable associations.

Bittman's ideas about milk are largely wrong, are based on opinions not of experts but of non-experts with an ax to grind, and are on their face based more on ideology and anecdotes than science. As a science writer, he has some explaining to do.

Before you pull some sort of "Milk Shill Gambit", I don't work for anyone who would benefit from milk sales. I don't personally drink milk since I'm lactose intolerant. I do love yogurt though.

Apparently he's not a "science writer". I would call the piece an attempt at science writing based on its content. As either food, nutrition or science writing, it fails.

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.

Massive online medical education coming to medical informatics

A few months ago, I wrote a post about the new development of massive open online courses (MOOCs) and what disruptive innovation they might have on higher education. While noting that academic biomedical and health informatics sat at the intersection of the two industries having the least amount of disruptive innovation, health care and higher education, I did note that MOOCs could have an impact, if they ever came to our field.

Well now they have, and it turns out that one of my projects is playing a major role in their development. The Health Informatics Forum, an international blogging and social network site for informatics, has started to turn the entire ONC Health IT Curriculum into a MOOC. They recently posted Unit 1 of Component 1 on their site, with announcement of plans to add a new component every four weeks.

How successful will this effort be? There will certainly be value in providing learning materials to the entire world. But there are some caveats. First, as those of us in the ONC Health IT Curriculum project have noted, the materials are designed more for educators than learners. While they provide a rich amount of learning substrate, like all good education they require more, including a teacher, a structured learning process, and ideally fellow learners. In addition, any professional educational experience also requires a connection to the real world through practical opportunities, such as internships.

Furthermore, in any rapidly changing field, such as health IT and informatics, the curricular materials must be regularly updated and otherwise improved. It will be interesting to see how sites like The Health Informatics Forum address this latter challenge, particularly as the field evolves. (For example, the Stage 2 meaningful use rules as well as new HIPAA regulations are due out in the next few weeks. As of now, neither of these are covered in the ONC curriculum.)

One final caveat is that the total quantity of these materials represent about 20 college-level courses. This means that any one person will require a great deal of time and effort to work through all of them. By the same token, there are a number of advanced informatics topics that are not covered by the ONC curriculum, such as secondary use of data, natural language processing, and analytics, to name a few. Still, I will be eager to see how this all works out, and hope to lend my expertise to increase its likelihood of success.

It turns out that The Health Informatics Forum is not the only organization that has utilized the totality of the ONC materials as a large learning experience. Two other organizations have done this as well, one of which charges a fee, which is allowable under the Creative Commons license under which the materials have been released:

The discussion around MOOCs also continues to flourish in the press. The New York Times has run a series of articles, mostly focused on the two efforts led by Stanford (Coursera) and Harvard/MIT (edX) but now expanding to include other universities in their partnerships. This has included articles about the expansion of Coursera as well as the early experiences of Coursera and edX and one call for caution:
--Expansion of Coursera
--Early experience of Coursera
--Early experience of edX
--One professor's concern about the impersonal aspects of online learning I actually disagree that online courses need to be impersonal, but I do agree there is no better form of education that the close interaction between the teacher and learner.

It is still too early to tell how these efforts will fare, and what their impact will be on higher education. As one who has been teaching online for 13 years, I can say that learning is very possible, and often desirable, especially when the learner is separated from the learning experience by distance or time. We have many students in our distance learning program at Oregon Health & Science University (OHSU) who desire our education but live far from Oregon and/or work during the time that on-campus classes are offered. In fact, we have a number of "local distance" who live in the area but value the convenience of the online classes.

But our courses at OHSU are anything but MOOCs. They feature direct interaction from our faculty. Furthermore, students can participate in and get credit from structured practicum and internship experiences. This leads one to wonder whether MOOCs might become a means to deliver higher education rather than complete experience in and of themselves. Nonetheless, it will be interesting to see the outcome of this natural experiment in education.

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.

QD: News Every Day--burnout risk appears worse for doctors on the 'front lines'

Doctors on the "front lines" of medical care, including general internists, are at higher risk for burnout than doctors in other specialties, and physicians overall are at higher risk than the general population, according to a new study.

Researchers used data from the American Medical Association Physician Masterfile and surveyed a sample of the U.S. population to compare burnout risk by physician specialty and between physicians and the general population. Among 7,288 included physicians, 45.8% reported at least one burnout symptom on the Maslach Burnout Inventory. The highest burnout rates were reported among physicians working in emergency medicine, general internal medicine, neurology and family medicine.

Satisfaction with work-life balance was highest among physicians working in dermatology, general pediatrics and preventive medicine and lowest among those working in general surgery, general surgery subspecialties and obstetrics/gynecology. In a comparison with the general population, more physicians reported burnout symptoms and dissatisfaction with work-life balance (37.9% and 40.2%) than did a probability-based sample of 3,442 employed adults (27.8% and 23.2%); the difference for both variables was statistically significant.

On the basis of their results, the study authors concluded that the prevalence of burnout among U.S. physicians "is at an alarming level." They noted, however, that available evidence on how best to alleviate physician burnout is limited and called for additional research on the topic "to identify personal, organizational and societal interventions."

The full text of the study, which was published by Archives of Internal Medicine, is available free of charge online.
Wednesday, August 22, 2012

The surgical intensive care unit [SICU]

I open the heavy, wooden door to the unit. On my left are the patient rooms, equipped with minimal privacy; to my right are members of the healthcare team shuffling around. I continue toward my destination, a small room containing a couple desks and computers dedicated to mid-level providers, but cannot help but notice how eerie the unit is. Although there are at least fifty individuals within this space, it is relatively quiet, aside from the occasional blips emitting from the numerous machines all the patients seem to be hooked up to.

As I peer into a patient's room, I notice infusion pumps, a ventilator and an endless expanse of tubing coming from all directions. A monitor displays various waveforms floats at the head of the bed. The bedding has a wallpaper-quality pattern on it that feels oddly comforting, despite the patient's weak body sprawled upon it.

I watch the patient's chest rise and fall in a rhythmic, forceful manner. There is a line straight down the center where the surgeon gained access to the heart. A wave of awe washes over me as I think back to the open-heart surgery I witnessed earlier that morning, it never ceases to amaze me how we can stop the heart completely and miraculously bring it back to full function.

Turning my attention to the bustling healthcare team, I see a group of nurses, physician assistants and physicians discussing patient care. ... should this drip be stopped? ... my patient is in a-fib, what's our next course of action? ... I think this patient is ready to be transferred up to the floor. Every workstation monitor is filled with the EMR [electronic medical record] software, with its plethora of tabs, buttons and drop down menus.

I walk into my target room and start to read up on the patients we will be rounding on. CABGs [coronary artery bypass grafts], AVRs [aortic valve replacements], MVRs [mitral valve replacements] ... these open-heart surgeries have become a part of my knowledge. Although there are non-cardiac patients within the unit, they are outnumbered.

Rounds begin when the cardiac surgeon appears; most of the time it's at 9 a.m., but it can vary. He reminds me of the "stereotypical-surgical-type", confident and assertive. But over the course of my time in the SICU, I grow to appreciate his personality. Most importantly, the teaching is top-notch.

We assemble our team outside of the first patient's room. One of the physician assistants presents the case and paints a numerical picture of the patient's status [vitals, ABG, electrolytes]. The surgeon probes for more information, ... why was this patient extubated? ...what can we do about these pulmonary pressures?, until he is satisfied. Then, the group walks in.

"How are you feeling today?"

"Much better. When am I leaving this place? I want to take a shower!" We chuckle and assure the patient that a shower lies within the immediate future.

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.

Plain English about ounces, pounds, dollars and sense

One of the arguments for bariatric surgery in principle is that by addressing the problem of often severe obesity effectively, the procedure should alter the entire trajectory of health in a way that saves money. Obesity and its complications are costly; fixing the one and forestalling the others should attenuate those costs.

But such pecuniary hopes attached to weight loss surgery were themselves somewhat attenuated this week with the publication of a new study in the Archives of Surgery. The study, limited to older, male patients in the Veterans Affairs hospital system, showed that costs rise acutely with the surgery itself, as one would expect, but then fail to fall for the three years following. Reasons at this point remain a matter of speculation and debate.

Before following where this leads, I hasten to add that saving money is not the primary reason for bariatric surgery, any more than for coronary bypass. In general, intervening to address severe threats to health carries a cost, often a high cost, and one our society has proven repeatedly it is willing to pay. Bariatric surgery can reverse disease, avert death, and extend life. That it is often the best thing going for the treatment of severe obesity, is well-established by the available evidence currently in hand. I believe strongly it should be available to all who need it.

Our societal problem is letting too many need it in the first place.

As for costs, they don't make or break the case for bariatric surgery once it is needed, any more than they make or break the case for organ transplants, dialysis, burn unit care, or coronary bypass. In general, saving and improving lives in peril costs money. We can let people die for free, that doesn't make it a good idea. In this, as in all things, we tend to get what we pay for.

But it would be one helluva' good idea to prevent so many people from needing medical procedures our society ultimately cannot afford, in the first place. That certainly includes bariatric surgery, which could go away all but entirely, if we did all that it takes to make healthful eating and physical activity every day our prevailing cultural norm, but also extends to coronary care, dialysis, amputations, and more, since so much chronic disease is propagated either directly by obesity, or by the same factors that propagate obesity. We have known for decades that bad use of feet, forks, and fingers represent the leading causes of premature death and virtually all of the major chronic diseases that bedevil our personal fortunes and national economy alike.

Dealing with advanced disease with surgery, or for that matter drugs, like the weight-loss drug Qnexa, just approved by the FDA, carries costs our society cannot bear, even when such interventions work well, which is only sometimes. What would work better for health and vitality, and costs alike, is prevention. Lifestyle as medicine.

While we keep spending vast fortunes on a status quo that, if we are quite blunt about it, covers the expenses of the highly imperfect efforts of all the king's horses and all the king's men, we could spend vastly smaller sums to blaze new trails entirely.

Consider a study in which a group of ordinary people who are lean and healthy in the midst of an obesigenic environment are enrolled. The group should be diverse, younger and older, male and female, richer and poorer, employed and unemployed, in school and graduated, all variations of skin pigment, and so on. They should at first be overfed and underexercised a bit to prove they are as human as the rest of us, and gain weight when that happens. People who are genetically impervious to weight gain would be ineligible. We want people who can gain weight, but don't. For what it's worth, I'd be a perfect study subject so far.

Once we have such a group assembled, we should use readily available research methods to make a systematic audit of their skill sets, and the resources/tools they use as a matter of routine to stay healthy and lean. Using semi-structured survey methods and focus group techniques, this process would be iterative, meaning information is fed back to the group to prime the flow of more information, which would continue until nothing new is disclosed. The audit is done when you know all there is to know.

Then, the inventory of skills and tools could be assembled, and matched against the daily challenges they are used to overcome. And just on the chance you are having doubts that such methods are plausible, we have put them to good use already, although not quite as expansively as I am proposing here.

Once the inventory of skills and tools is identified, the next step would be to figure out how best to get them to everyone. Some tools might be most readily put into people's hands in school, others at work, others at church, others in the supermarket, others still online, and so on. We could create a map linking each resource, tool, or skill to the best means of getting it into everyone's hands.

Maybe this is sounding tough, but consider that just about every baby born in the United States learns to speak English. That's a pretty tall order, really, just ask any adult from elsewhere who doesn't speak it and is trying to learn. Growing up in a culture that surrounds you with exposure to English makes it natural to learn English, something very hard to do later on.

This is directly analogous to prevention, which requires you "grow up in it," but is easy and painless, as compared to dealing later on with what you didn't learn early. That's costly, hard, and painful.

In fact, the way we respond to obesity and related chronic disease in the U.S. is like waiting to send every adult to night school to learn English, painfully, poorly, expensively, and late, rather than having them grow up speaking fluently all along. We should certainly continue offering English-as-a-second-language classes to those who need them, just as we should continue paying for bariatric surgery and coronary bypass operations for those who need them. But not at the expense of routine fluency in either case.

English can be spoken fluently; so, too, can health. The research steps required to learn what the minority who now speak fluent health know, and how everyone else can learn it, are not trivial, but they are not rocket science, either. They are not free, but they are vanishingly less expensive than the status quo, in both dollars, and human costs. Having some experience with this kind of research, a back-of-the-envelope calculation suggests the whole thing could be done for less than the cost of 100 bariatric operations. And we are doing roughly 10 times that many in the U.S. every day!

There is English literacy; and there is health literacy. We could create a culture in which everyone simply acquires health literacy the way they acquire language. It is, if anything, probably a bit less hard!

Applying sense to get at the missing links of science as I've described them may sound as if it entails some heavy lifting. Perhaps. But compared to the crushing weight and unsustainable costs of the status quo, it is as ounces to pounds, as cents to every dollar.

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--get the lead out

Lead levels previously considered acceptably safe may be linked to increased risk for adverse events, according to new research.

A study in this week's Annals of Internal Medicine used data from the National Health and Nutrition Examination Survey to evaluate whether lead levels in the "acceptable" range, that is lower than 1.21 micromoles per liter (less than 25 micrograms per deciliter), are associated with gout. Data from 2005-2008 on 6,153 patients 40 years of age and older who had no known kidney disease were examined. The main outcome measures were self-reported diagnosis of gout by a physician and serum urate levels, and the principal exposure variable was blood lead levels.

A gout prevalence of 6.05% was found among patients in the highest quartile of blood lead levels (mean, 0.19 micromoles per liter or 3.95 micrograms per deciliter), compared with 1.76% in patients in the lowest quartile (mean, 0.04 micromoles per liter or 0.89 micrograms per deciliter). In addition, each doubling of blood lead levels was associated with unadjusted odds ratios of 1.74 for gout and 1.25 for hyperuricemia.

After adjustment for renal function, diabetes, diuretics, hypertension, race, BMI, income and education level, the highest quartile of blood lead levels was associated with a 3.6-fold higher gout risk and a 1.9-fold higher hyperuricemia risk than the lowest quartile.

The authors noted that their results may have been affected by measurement error and that they didn't use measurements of lead levels over time, among other limitations. However, they concluded that even low levels of lead exposure may cause harm and that national goals for prevention, detection and removal of lead should be refined.

"These data suggest that there is no such thing as a 'safe' level of exposure to lead," they wrote.
Tuesday, August 21, 2012

Accountable care organizations and physicians: Are we partners or prey?

During my college years, we loved the album Bat Out of Hell by Meat Loaf. We would wail along with Meat Loaf as he screamed out his passionate interpretation of Paradise by the Dashboard Lights. Another memorable song on that album was Two Out of Three Ain't Bad, which offers an important lesson to those of us interested in health care reform.

No, Meat Loaf was not a medical policy wonk who offered health care solutions via allegory in his ballads. It's the song title that caught me as I read yet another article on accountable care organizations (ACOs). Take a look at this banal three word description: Accountable Care Organization.

These new organizations have much more to do with accountability and organization than they do with care. In other words, Two Out of Three Ain't Bad.
ACOs are another coercive mechanism to track and compare physicians using quality metrics that are far removed from true medical quality measurements.

As practicing physicians understand, and government reformers don't, defining and measuring medical quality isn't counting beans in a bottle. They claim they can count what can't be easily counted. Conversely, just because something can be easily counted, doesn't mean it really counts.

Of course, the ACO concept is attractive: more accountability, lower costs and higher medical quality. This three-legged stool can stand only if all three of these legs are sturdy. I'm skeptical.

These partnerships between hospitals/insurers and physician groups provide lump sum payments to doctors to care for a population of patients. If physicians spend less money on care than this sum, then they can retain the savings. This sounds quite reminiscent of the Health Maintenance Organization (HMO) era, where there was a conflict of interest that restricted patients' medical care in order to save money. We recall how popular this model was for physicians and for our patients.

HMOs were soundly rejected. Are ACOs merely repackaged HMOs in new bottles?

Beware of any ACO that contains the word partnership, unless you consider a 95-5 split to be a partnership. A mouse captured in the talons of a raptor doesn't feel that he and the bald eagle are partners.

For those who simply must know ACO details, I encourage you to peruse the 429 page proposal issued by the Center for Medicare & Medicaid Services (CMS) in March 2011. If any reader does so, kindly leave a comment below so we can arrange for an expeditious psychiatric referral for you.

Of course, ACOs are not really about quality, any more than pay-for-performance initiatives are. They are about cost control and reimbursement redistribution. Physicians sign up, not because we are smitten by ACOs promises, but because we don't want to be excluded from the panels.

Will ACOs, in their ultimate form, be good for patients? This is unknown and unknowable at present. ACOs are swirling in the wind, and various constituencies are swatting at it. We don't know what its final form will be or where it will land.

So, what's the ACO score so far?
1) ACOs will employ thousands of bean-counting bureaucrats, which will reduce unemployment.
2) ACOs will help to control medical costs.
3) ACOs will be championed by physicians throughout the country.

Which of the above statements are true? Meditate on the words of Meat Loaf, a prophet in his generation. Two Out of Three Ain't Bad.

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.

On and off the label for everyday practice of medicine

The Vegas-cavorting executives of GSK recently made news for their off-label shenanigans, promoting medications for uses which had not been approved yet by the Food and Drug Administration. Bad enough.

Is it worse or better, though, to realize that the everyday practice of medicine involves an order of magnitude more questions, and more specific questions, than can possibly be addressed by the FDA?

I want to discuss with a patient the treatment of her reflux. Sure there are a bunch of approved medications available. We are taught in medical school that the proton pump inhibitors are more effective than the H2 (histamine receptor) blockers. But which of the PPIs are more effective? Which strike the best balance between cost, side effects, and symptom relief? And how do any of them compare to non-pharmacologic treatments?

There are precious few studies to answer any of these questions. Sure, let's blame Big Pharma. They have blood on their money. But is it any wonder that doctors are susceptible to such inappropriate influence, when the appropriate variety is so hard to come by, not due to any venality, but due to the imperfections of our research system? Studies of one drug against placebo are valued; comparative effectiveness studies that pit drugs against each other are vanishingly rare. And forget about considering cost!

So sure, let's blame greedy pharmaceutical companies for what they've done, but let's acknowledge the difficult spots patients and doctors are in when they try to find the best evidence to answer clinical questions. If we figure it all out, we can celebrate in Vegas.

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--rapid tests not always accurate for swine-origin influenza

Rapid diagnostic tests are not always accurate for swine-origin influenza, the Centers for Disease Control and Prevention reported last week.

The CDC recently tested seven commercially available rapid influenza diagnostic tests (RIDTs) to evaluate their accuracy in detecting influenza A (H3N2) variant virus. Only four of the seven tests were able to detect all seven influenza A (H3N2) variant strains. One test detected five of seven, one test detected three of seven, and one test detected only one of seven. The results were published online by MMWR.

An accompanying editorial note emphasized that a negative RIDT result should not be considered conclusive when testing for influenza A (H3N2) variant virus. "Results from RIDTs, both positive and negative, always should be interpreted in the broader context of the circulating influenza strains present in the area, level of clinical suspicion, severity of illness, and risk for complications in a patient with suspected infection," the note said. "Clinicians should minimize the occurrence of false RIDT results by strictly following the manufacturer's instructions, collecting specimens soon after onset of influenza-like illness (ideally within the first 72 hours), and confirming RIDT results by sending a specimen to a public health laboratory."

Further guidance from the CDC on this topic is available online.
Monday, August 20, 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.

5 examples how teaching costs of care is like opening Pandora's Box

Last week, I tried something new with our residents. We tried to talk about why physicians overuse tests.

This is the topic of the moment, as the American College of Physicians just dropped their long-awaited new High Value Cost Conscious Curriculum for what has now been dubbed the "7th competency" for physicians-in-training.

In addition to the ACP curriculum, which I served as one of the reviewers for, I also am involved with another project led by Costs of Care to use video vignettes to illustrate teaching points to physicians-in-training called the Teaching Value Project.

With funding by the ABIM Foundation , we have been able to develop and pilot a video vignette that that depicts the main reasons why physicians overuse tests. The discussion was great and the residents certainly picked up on the cues in the video such as duplicative ordering, and that the cost of tests are nebulous to begin with.

But, before I could rejoice about the teaching moments and reflection inspired by the video, I must admit that I felt like Pandora opening the dreaded Box. Many of the questions and points raised by the residents highlight the difficulty in assuming that teaching doctors about cost-conscious care will translate into lower costs and higher quality.

1) What about malpractice? One of our residents mentioned that really the problem is malpractice and that test overuse was often a problem due to the "CYA" attitude that physicians have to adopt to avoid malpractice. It is true that states with higher malpractice premiums spend more on care. However, this difference is small and does not fully explain rising health care costs. More interestingly, the fear of being sued is often more powerful than the actual risk of being sued. For example, doctors' reported worries about malpractice vary little across states, even though malpractice laws vary by state.

2) What about patients who demand testing? Another resident highlighted that even with training, it was often that patients did not feel like anything was done until a test was ordered. Watchful waiting is sometimes such an unsatisfying treatment plan. As a result, residents reported ordering tests so that patients would feel like they did something. In some cases, patients did not even believe that a clinical history and exam could lead to a diagnosis, as one resident reported a patient asked of them incredulously, "Well how do you know without doing the imaging test?"

3) What can we do when the attending wants us to order tests? All of the residents nodded their head in agreement that they have had to order a test that they did not think was indicated, because the attending wanted to be thorough and make sure there was nothing wrong. I find this interesting, since as an attending, you are often making decisions based on the information you are given from the resident. Could it be that more information or greater supervision would solve this problem,? Or is it that attendings are hard-wired to ask for everything since they never thought about cost?

4) Whose money is it anyway that we are saving? This is really the question that was on everyone's mind. Is it the patient's money? After all, if a patient is insured, it is easy to say that it's not saving their money because insurance will pay. Well, what about things that aren't even reimbursed? Doesn't the hospital pay then? Finally, a voice in the corner said it is society that pays. That is hard to get your head around initially, but it is true. Increased costs of care are eventually passed down to everyone. For example, patients will be charged higher premiums from their insurance companies who are paying out more. Hospitals will charge more money to those that can pay to recover any losses.

5) Will education really change anything? So, this is my question that I am actually asking myself at the end of this exercise. Education by itself is often considered a weak intervention, and it is often the support of the culture or the learning climate that the education is embedded in. The hidden curriculum is indeed powerful, and it would be a mistake to think that education will result in practice change if the system is designed to lead to overordering tests.

As quality improvement guru and Dartmouth professor Paul Batalden has said (or at least that's who this quote is often attributed to when it's not attributed to Don Berwick) "Every system is perfectly designed to achieve the results it gets." Therefore, understanding what characteristics of systems promote cost conscious care is a critical step.

However, before we dismiss education altogether from our toolbox, it is important to note that education is necessary to raise awareness for the need to change. And in the words of notable educational psychologist Robert Gagne, the first step in creating a learning moment is getting attention. And, by that measure, this exercise was successful. It certainly did get attention. Yet, it also did something else. It created the tension for change, a necessary prerequisite for improvement. It certainly cultivated a desire to learn more about how to achieve this change, which is what our team is currently working towards with the Teaching Value Project. So while learning why tests are overused is a first step, judging by Pandora's box, it is certainly not the last.

Special thanks to Andy Levy and Neel Shah for their hard work on this module.

Vineet Arora, MD, is a Fellow of the American College of Physicians. She is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist, supervising internal medicine residents and students caring for general medicine patients, and serves as a career advisor and mentor for several medical students and residents, and directs the NIH-sponsored Training Early Achievers for Careers in Health (TEACH) Research program, which prepares and inspires talented diverse Chicago high school students to enter medical research careers. This post originally appeared on her blog, FutureDocs.

QD: News Every Day--West Nile outbreak spurs Dallas to call for spraying, state of emergency

West Nile infections have led to 336 cases in Texas, including 14 deaths, which has prompted Dallas' mayor to call for aerial spraying and spurred calls for a state of emergency.

The Centers for Disease Control and Prevention maintains West Nile updates on its website and reported numbers for the entire country.

As of August, 693 cases of West Nile virus disease in people, including 26 deaths, have been reported, of which 406 (59%) were classified as neuroinvasive disease (such as meningitis or encephalitis) and 287 (41%) were classified as non-neuroinvasive disease.

The total is the most cases reported to CDC by this week of August since West Nile virus was first detected in the United States in 1999. Texas reported half of all West Nile infections across the country, and more than 80% of the cases have been reported from Texas, Mississippi, Louisiana, Oklahoma, South Dakota, and California.

But, as public health expert David Katz, MD, FACP, cautioned, "as climate changes, so will epidemiology."

For more on how climate change spurred West Nile's "success" in adapting to America, read science writer Carl Zimmer's article outlining its spread across the U.S.
Friday, August 17, 2012

Dispensing docs and disability evaluations

An article in the New York Times sheds a little light in a dark corner of medicine, the world of workers' compensation. In particular, it highlights a world of doctors that dispense drugs in their offices, which improves both patient satisfaction and profit$.

Though fraudulent insurance claims are always easy headline-grabbers (see here for an example), the real world of workers' comp is complex and not always so tailor-made for sound bites. [See here for a PBS counterargument stating that 98% of claims are legitimate.]

Add to this mix the medical industry's role.

Doctors in practice loathe disability evaluations. They are time-consuming and require several pages of documentation. After more than a decade in practice, I still fear the repercussions of these assessments.

I'm inclined to want to advocate on behalf of my patients, especially when I know them and trust their stories. But:
--What if the patient is malingering and I'm unable to ascertain that? That makes me feel as if I'm party to fraud.
--What if the patient is truly disabled and my assessment fails to further their claim? That makes me a failed advocate.

Primary care doctors typically have no specialized training in conducting disability evaluations, and even less understanding of the byzantine world of workers' compensation.

As a result, most insurance companies now make claimants get evaluated at specialized occupational medicine centers, where the practitioners know exactly what to test for and how to document it to the satisfaction of the insurance companies. Yet there are always unintended consequences to this.

One example, as pointed out in the Times article, is that private equity funds have invested in companies that package or distribute drugs to doctors' offices. It seems that practices specializing in the business of workers' comp are particularly suited to be recipients of this investment.

What could private equity be doing in this realm, you ask?

Let's just say they're not in it to carry on the traditions of Hippocrates; rather, they see a handsome profit opportunity.

Turns out that most states (43 of them) allow doctors to dispense drugs, and in addition set their own prices on the medication. A handsome mark-up opportunity is thus enabled!

Don't the patients see through this price-gouging, you ask?

Here's the rub: Most of the time, health insurance (particularly the company's workers' comp insurance) foots the bill. So the patients don't care! They're just happy to get medicine as soon as possible after having been evaluated. Besides, so what if the overcharging sticks it to the workplace in which the patient was injured?

Some states have recognized this naked profiteering for what it is. Amazingly, California and my home state of Oklahoma are two of the states that have passed laws forbidding the huge markups.

Let's face it: When the governments of these two vastly different states are both calling out corruption, you can bet there's something rotten in Denmark going on.

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.

High value, cost conscious care is the antithesis of too much care

Tara Parker-Pope has written a personal article about her daughter's meandering through the health care non-system, Too Much Care? that most medical tweeters have already referenced. This article has added poignancy because we all see this problem too often:

After years of reporting on health, I considered myself a well-informed patient, but it took my elementary-school daughter to state the obvious: She was the victim of too much medicine. Every new blood test, scan or X-ray raised new questions, which led to more lab work, scans and X-rays. I know the doctors had good intentions, but it's a truism of modern medicine that the more you test and scan and look for problems, the more likely you are to find something wrong. My daughter's case had spiraled out of control.

Once one goes to a sub-specialist for a problem, money becomes no object. Why? Because you have insurance! Insurance means you do not really care how much it costs. Sub-specialists test because that is how they are trained.

We in medicine no longer spend time doing the careful history and physical examination that will minimize these costs. Our insurance system, unfortunately following Medicare's lead, pays more for tests than for a careful examination. A careful history and physical takes time. But we in medicine are not "rewarded" for taking enough time with patients. Our administrators tell us that we have to see more patients per hour. They focus on the volume not the experience.

We give "lip service" to quality, but instead of valuing quality we have equated quality with inane performance measures. We have forgotten Donabedian's classic formulation of medical quality. We have forgotten that he defined quality as multidimensional. Six years ago, in this blog I provided a series of Donabedian quotes that too many people of forgotten:

Which of a multitude of possible dimensions and criteria are selected to define quality will, of course, have profound influence on the approaches and methods one employs in the assessment of medical care.

Many factors other than medical care may influence outcome, and precautions must be taken to hold all significant factors other than medical care constant if valid conclusions are to be drawn.

Judgments of quality are incomplete when only a few dimensions are used and decisions about each dimension are made on the basis of partial evidence.

A major problem, yet unsolved, in the construction of numerical scores, is the manner in which the different components are to be weighted in the process of arriving at the total.

In addition to defects in method, most studies of quality suffer from having adopted too narrow a definition of quality. In general, they concern themselves with the technical management of illness and continuity of care, or handling the patient-physician relationship. Presumably, the reason for this is that the technical requirements of management are more widely recognized and better standardized. Therefore, more complete conceptual and empirical exploration of the definition of quality is needed.

The payment system is broken, and drives us away from high value, cost conscious care. We can only "bend the cost curve" if we remember the root cause. We must remember that the most valuable test in medicine is a careful history and physical. We need generalists--call it primary care if you want--but we need physicians who take responsibility for each patient, both in the outpatient and the inpatient settings. We need to increase generalism and decrease our tendency to overuse subspecialists. We need our subspecialists to remember their generalist roots.

Thanks to Tara Parker-Pope for giving us another reason to consider this issue. We can do better, but only if we can get the "money people" (Medicare and private insurance) to pay the right people the right amount.

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.

QD: News Every Day--Retail clinics filling a gap for simple care

Retail clinic visits have doubled- year-to-year, but still make up a small share of overall outpatient care, a study in Health Affairs concluded.

Retail clinic visits increased fourfold from 2007 to 2009, from 1.48 million visits in 2007 to 3.52 million visits in 2008 to 5.97 million visits in 2009. This is still smaller than 117 million visits to emergency departments and 577 million visits to physician offices annually.

From the beginning of 2007 to the end of 2010, the number of retail clinics increased from approximately 300 to almost 1,200, and the clinics have partnered with larger entities such as the Cleveland Clinic.

The American Medical Association, the American Academy of Family Physicians, and the American Academy of Pediatrics have in the past all spoken out against the clinics. The American College of Emergency Physicians called for a well-defined scope of practice for them.

The American College of Physicians has six points for retail clinic arrangements, including ensuring continuity of coverage and communication between the clinic and a primary care provider.

To assess retail clinics' growth, researchers looked at electronic health records and billing records from the three largest operators of retail clinics, which make up 81% of clinics in the U.S.

Peaks visits occurred in October and November, as clients sought flu vaccines, and to a lesser extent, treatment upper respiratory infections. The most common reasons for visits included vaccines, upper respiratory infections, ear infections, urinary tract infections, and allergies. Only rarely was there acute care, and about 1% of visits were for chronic disease care.

"The rapid growth of retail clinics makes it clear that they are meeting a patient need," the authors wrote. "Convenience and after-hours accessibility are possible drivers of this growth."
Thursday, August 16, 2012

Sunday cancer thoughts

I recently spoke to a woman whose mom has breast cancer. She seemed worried, but not because of the cancer, but because her mom is looking into "alternative" cancer therapies. The standard treatment for her mom is surgery, chemotherapy, and then five years of tamoxifen (I can't recall whether she also gets radiation) and she is not thrilled about it.

The idea behind the treatment is this: surgery removes the bulk of the tumor. Deep in the tumor, the cancer cells are resting, and in the resting state aren't susceptible to chemotherapy. With small tumors, surgery can be curative, but some others require more extensive treatment. Sometimes surgery may leave behind a few tumor cells, or some may have already escaped the breast. Chemotherapy kills these remaining cells, many of which aren't resting but actively trying to make more tumors.

Like hypertension and diabetes, we have decades of data on what works and what doesn't in the treatment of breast cancer. We use this data to drive how we treat patients. Statistics give us guidance, but not a crystal ball. We may know that (and the numbers are made up here) of 100 patients with disease x, 50 had a recurrence without chemo, but only 12 recurred after chemotherapy. But this doesn't tell us whether you will be one of the 12; we just know that your chances are better with the chemo.

Some of the complaints I've heard from people who look into alternative therapies are that the therapies are too toxic, creating too much collateral damage of normal cells; that cancer care seems the same for everyone and doesn't account for the individual; that their regular doctor doesn't seem to care but simply dumps them into the chemo factory.

These are all legitimate concerns, but to get your best chances, you have to overcome your fears about them. We are quite aware that chemotherapy is toxic. Cancer cells are very similar to normal cells and chemotherapy drugs usually simply kill "cells". Cells that are dividing faster (i.e. not resting) are the ones that get killed. This includes most cancer cells, cells in the lining of the gut, hair follicles, and others. Since many more of our cells are resting, most escape unharmed. The lively cancer cells die in higher numbers. Some chemotherapy is more toxic than others, but we follow the data where it leads us and present patients with options.

Sometimes we have better options than others. Most cancers have multiple genetic problems making it difficult to find one critical to the life of the cancer cell but not to normal cells. One type of leukemia, CML, has a perfect target. One gene defect and the protein it produces is responsible for most of the problems that turn normal white cells into CML cells. About 15 years ago, someone discovered a molecule that affects this protein and leaves most others alone. This is one of the best examples of targeted chemotherapy.

Finding medicines that can kill abnormal cells and leave healthy ones intact isn't easy. Anyone who claims to be able to do it but doesn't have the data to back it up is probably selling you something.

I understand the desire of patients to feel like they are being treated uniquely; hopefully they are. But it's usually the patient who is unique, not their disease. The art of medicine comes in treating the patient like a human being while trying to kill the cancer based on how the cancer usually behaves. To tell someone you can treat their cancer with targeted therapies when none are known to exist is an immoral lie. To tell them that you will treat them with compassion and understanding, and treat their cancer with the best proven treatments is good medicine.

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.