Wednesday, October 31, 2012

Last day

Last day of work.

Lots of important questions run through my mind: what do I wear? Do I shave? Do I wear sandals? Should I have gotten a haircut?

In the office, I see consults on my desktop, consults that really mean very little to me now, as the majority of these patients won't go with me. I click on them anyway to see what the consultant thinks. Someone else will have to do the same, but I can't stop doing the job.

There are lab results that I respond to. Repeat the test in 2 weeks. Someone else's problem then, but mine now. All of the follow-up visits are with others, and my patients all want to talk about me. It's not about me, however, as they are going to the doctor. As much as it is momentous, I am a caretaker, so I can't stop doing that job.

In some ways, today has little meaning. It is the period at the end of the sentence. No, it is less than that, as punctuation can change the whole sentence. It is the last sentence in the novel, the words that suggest the nature of the sequel. The book has been written already over the past 18 years, and today is but a quiet ending. The seeming gravity of the day comes from the mass of my time already spent. What I do today won't be of much consequence.

So I just push through it like it's a normal day. I listen to people, make plans for them, try not to be distracted by the obvious and miss the subtle. I think on the long-term despite the reality of the short-term. I'm still a doctor. I am still their doctor, even if it's just for today.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.
Tuesday, October 30, 2012

Social history of medicine, self-reliance and health care today

Over my vacation I read a bit on the history of health care in the United States. The Social Transformation of American Medicine, by Paul Starr, was first published in 1982. The author, a professor of sociology and public affairs at Princeton, gives a fascinating, relevant account in two chunks. In the first section, he details the rise of professional authority among physicians in the U.S. In the second part, he focuses on the relationship of doctors to corporations and government.

I couldn't put this book down. Seriously, it's a page-turner, at least in the first half, for anyone who cares about medical education, doctors' work, and how people find and receive health care. In an early chapter, on medicine in colonial and early 19th Century America, Starr recounts the proliferation of medical schools and doctors, or so-called doctors, in the years after 1812.

One problem of that era, besides a general lack of scientific knowledge about disease, was that it didn't take much to get a medical degree. State licensing laws didn't exist for the most part, and where they did come in place, such as in New York City, they were later rescinded. Then as now, many practicing folks didn't want regulations.

Doctors were scarce and not always trustworthy. People, especially in rural areas, chose or had to be self-reliant. Many referred to lay sources for information. Starr writes of the "domestic" tradition of medical care:

"... Women were expected to deal with illness in the home and to keep a stock of remedies on hand; in the fall, they put away medicinal herbs as they stored preserves. Care of the sick was part of the domestic economy for which the wife assumed responsibility. She would call on networks of kin and community for advice and illness when illness struck ..."

As he describes it, one book, William Buchan's Domestic Medicine, was reprinted at least 30 times. It included a section on causes of disease and preventive measures, and a section on symptoms and treatments. By the mid-19th Century a book by John C. Gunn, also called Domestic Medicine, or Poor Man's Friend ... offered health advice in plain language.

Starr considers these and other references in the context of Protestantism, democracy and early American culture:

"... while the domestic medical guides were challenging professional authority and asserting that families could care for themselves, they were also helping to lay the cultural foundations of modern medical practice--a predominantly secular view of sickness ... the authority of medicine now reached the far larger number who could consult a physician's book."

Reading this now, I can't help but think of the Internet and other popular and accessible resources that challenge or compete with doctors' authority. Other elements of Starr's history pertain to current debates on medical education, credentialing and distribution of providers.

Just days ago, for example, the New York Times ran an editorial on a trend of getting Health Care Where You Work. The paper reported on Bellin Health, an allegedly non-profit entity, that designs on-site clinics for medium-sized companies. "It has managed to rein in costs while improving the availability and quality of care--in large part by making it easier for patients to see nurses and primary care doctors," according to the Times opinion. The clinics are "staffed part-time by nurses, nurse practitioners or physician assistants, who handle minor injuries and illnesses, promote healthy living and conduct preventive screenings."

The editorial touts Dartmouth Atlas data and other high marks for the care Bellin provides at low costs to possibly happy workers and their satisfied employers. Still, it's not clear to me that an on-site clinic would be a great or even a good place to seek care if you had a subtle blood disorder or something like the newly-reported Heartland virus.

On reading the editorial on delivering health care to the workplace, I was reminded of Starr's tale of the development of clinics at railroad and mining companies in the first half of the 20th Century. This happened mainly is rural areas where few doctors lived, at industry sites where injuries were frequent. The workers, by Starr's account, were generally suspicious of the hired physicians and considered them inferior to private doctors whom they might choose if they became ill. They resented paying mandatory fees to support those on-site doctors' salaries. Doctors' groups, like the AMA, generally opposed and even ostracized those "company doctors" for selling out, or themselves, at a lower price.

The second half of the Social Transformation, on failed attempts at reform before 1982, is somewhat but not entirely outdated in light of Obamacare and 40 years intervening. But many of the issues, such as consideration of the "market" for doctors and the number of physicians we need, relate to the papers of this week including an Economix column by another Princeton professor, Uwe Reinhardt, who puts forth a view that, well, I don't share. As I understand his position, Reinhardt suggests that there may be no real shortage of doctors, because physicians can always scrunch their workloads to fit the time allotted. But that's a separate matter ...

In sum, on the Social Transformation, today: Worthwhile! Curious! Pertinent! Starr's book is chock full of history "lessons" that might inform medical practice in 2012. And I haven't even mentioned my favorite segments on prohibiting doctors' advertisements (think websites, now), the average workload of physicians before 1900 (think 5 or so patients per day), and the impact of urbanization on medical care and doctors' lives and specialization.

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

Med Men and medical advice

It's never really discussed.

We don't learn it in med school. There are opaque references to it in residency.

Once we're out, it slowly becomes an unpleasant realization. We give it other names, and ascribe the motivation (or lack thereof) to others–our patients.

It's selling.

Patients look to us for medical advice. It's a vulnerable state to be in. A generation ago, we simply told you what to do. And you did it.

Now we practice "shared decision making," and make recommendations to you that you are free to accept or reject.

The conversations are seldom on the level. Most of you don't want to outright defy us. You risk our ... wrath? Our disfavor? Our disappointment (always my parents' strongest weapon).

When you don't follow our recommendations, we call you non-compliant.

The newer, more politically correct term, is non-adherent. Sometimes we just say you're a "bad patient."

But doctors are really (M)ad Men (and of course, increasingly, women). We have to sell you our ideas, even when you've become increasingly knowledgeable and justifiably more critical.

The truth is, selling is easy most of the time: We believe in what we're offering--intellectually and emotionally--and some of our ideas are so commonplace (colon cancer screening, treatment of high blood pressure, etc.) that you are receptive to the ideas. It's a win-win.

It gets a lot harder when we don't necessarily believe in what we have to offer, or are outright skeptical of something that you ask for.

Communication is one of the 'competencies' on which we evaluate trainees. It's vitally important. But we don't teach it or evaluate it well.

Here's a powerful example, appealing to both our minds and hearts, and making the complicated simple and appreciable even by a child.

I wish for better, more straightforward communication amongst all of us.

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.
Monday, October 29, 2012

Like my doctoring? Thank my wife

Sunrise yesterday was beautiful. Maybe it was my mood, or the tail end of Hurricane Isaac. Either way, coffee and a sunrise is a nice way to start a day.

Medicine was particularly good to me and my patients this week. I was able to give lots of good news, and bad news was tempered by my ability to briefly bend the broken health care system to my will.

My ability to devote my full attention to patients derives in no small part from my wife. We are in the midst of moving, PalKid is starting school, and MrsPal is the default home manager. By taking on that role, she is helping my patients as much as I am. When you see a married male doctor, please remember that because of the way our society views gender roles, he is often able to care for you because of his wife.

I have cut back a bit on my hours, which gives me more time with the family. Last night while my wife worked on planning the move, I got PalKid showered, removed her nail polish (gold on the hands, pink on the feet), blew her hair dry. I loved every second of it, but once again, is was fundamentally a choice. If I hadn't done it, or I had been at work, the duties would have fallen to my wife by default.

I have no idea how to change this in my household or in our society, but I do keep trying to remind myself that it would help if both parents stopped thinking of one or the other as the "real" parent. I often fail at this, but hope to keep improving.

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.

Forgive me

"My heart is blighted like grass, and withered, for I forget to eat my bread."
--A patient's prayer, Psalm 102

[None of the anecdotes in this post are descriptions of any specific patient. They are amalgams of many patients. Specific details have been distorted or invented to preserve anonymity.]

I diagnose and treat medical problems. I love doing it. Sometimes I make a big difference in someone's life. More often, I just reassure them that they're going to be OK. Or I give them advice about what they need to do to live healthier. But what I do has limits, and people frequently bring me problems that are well beyond my ken.

A business man comes to me for chest pain. He feels guilty because he has been misleading his business partner in a negotiation.

A wife has vague urinary symptoms after her affair of several years ends.

A middle aged man comes to me for insomnia. His endless work responsibilities have caused him to miss important events with his kids.

Of course, they each believe they may have a medical problem, so I examine them and order the appropriate tests. I rule out coronary disease, and infections, and hormonal problems. I call them with the good news. The tests are all normal. But they are not relieved. Their symptoms persist or even worsen.

I think I must be missing something. I send the business man to a cardiologist, the wife to a urologist, the father to a sleep specialist. More diagnostic tests are ordered. They are all normal. Good news, right? No. They are not reassured. Their symptoms continue and with every unrevealing test result they seem to give their symptoms more attention.

All primary care doctors see lots of these cases. These patients are seeking care in the wrong marketplace. They don't have a medical problem. Their conscience is bothering them. They're not sick; they're guilty. They do not require medicine. They seek absolution.

But I have no prescription for that, no advice for attaining forgiveness, for undoing wrong deeds. Perhaps I should send them to a psychologist. I ask some questions looking for symptoms of depression or anxiety disorder. I come up empty. They're mentally healthy, yet they are miserable.

What's the medical specialty that helps people who've done wrong? What's the service industry that undoes guilt? I'm no expert, but as far as I can tell, the only methodical approaches to this are in organized religions. My colleagues and friends who are psychologists and psychiatrists may object. But it seems to me that mental health professionals can only clarify the patient's goals and feelings, clarify if the ethical damage can be undone, and work through the feelings. That's a lot, but it doesn't strike me as what these patients are craving. They want to atone. Organized religions have a formula for that.

I'm not here to tell you to go to church. And I'm certainly not going to delve into theology or suggest that any religion's recipe for forgiveness is true in a fundamental or exclusive sense. I'm just suggesting that if you know you've done something wrong, and you feel terribly about it, maybe you don't need a doctor. Maybe you need a minister, a priest, or a rabbi.

Like I said, I love what I do. I can fix some medical problems, and I can help prevent others. I can help you live more days and make those days healthier. But there is more to life than that. Sometimes there is also wrongdoing, and guilt, and redemption. For that, I have no training. Forgive me.

Learn more:
Forgiveness (Wikipedia)

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--Physical activity doesn't offset sedentary lifestyle

A meta-analysis added some deeper levels of insight into studies that claimed an association between sedentary behavior and chronic diseases, particularly diabetes.

European researchers identified in the literature two cross-sectional and 16 prospective studies (15 of 18 moderate to high-quality) that tallied nearly 800,000 participants.

Results appeared in the November issue of Diabetologia.

The greatest sedentary had a 112% increase in the relative risk (RR) of diabetes compared to the least amount of time (RR 2.12; 95% credible interval [CrI], 1.61 to 2.78). A Bayesian predictive effect and interval was significant only for diabetes.

Also, there was a 147% increase in the RR of cardiovascular events (RR 2.47; 95% CI, 1.44 to 4.24), a 90% increase in the risk of cardiovascular mortality (hazard ratio (HR) 1.90; 95% CrI, 1.36 to 2.66) and a 49% increase in the risk of all-cause mortality (HR 1.49; 95% CrI, 1.14 to 2.03).

"[T]he reported associations were largely independent of physical activity, adding further weight to the concept of sedentary behaviour being a distinct behaviour in its own right," the researchers wrote. "This is an important conclusion because it suggests that the deleterious effects of higher levels of sedentary behaviour are not mediated through lower amounts of MVPA (moderate-to-vigorous intensity physical activity)."
Friday, October 26, 2012

The acid-base problem solved part 3--Hickam’s dictum for the patient

So my two renal consultants have done a wonderful job, but have forgotten a key point. This point does not relate to the acid-base problem, but still should be mentioned.

We have a patient with hyponatremia (modest), hypotension, and chronic steroids. The primary hospital service diagnoses iatrogenic adrenal suppression late. When I discussed this patient at morning report, before hearing about the cortisol level and the ACTH stimulation results, I stressed that this patient should have received stress dose steroids on presentation. We should have a high index of suspicion for glucocorticoid deficiency. Giving stress dose steroids will not hurt the patient, and could save many complications.

Once I assumed glucocorticoid deficiency, I had to consider the possibility of total adrenal failure. However, I could not develop a good hypothesis.

My former intern guessed the urine lytes: Na 90 K 20 Cl 88.

This gives us indirect evidence of hypoaldosteronism and the type IV RTA that was postulated. I had to guess the tacrolimus could cause a type IV RTA. Apparently this is rather common as Eric pointed out so well. The team actually measure renin and aldo and proved that they were both low.

So this patient had "ticks and fleas." He had two significant adrenal problems for different reasons.

I suggested that this patient might do well with 9 alpha fludrocortisone as he had no contraindication.

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--4 factors account for most PAD in men

Smoking, hypertension, hypercholesterolemia and type 2 diabetes accounted for the majority of risk associated with men developing peripheral arterial disease (PAD), a study found.

Researchers conducted a prospective study of nearly 45,000 men without a history of cardiovascular disease in 1986 from the Health Professionals Follow-up Study and followed them until January 2011 to unravel how these factors and combinations of factors influenced who developed PAD.

Results appeared in the Oct. 24/31 issue of the Journal of the American Medical Association.

During a median follow-up of nearly 25 years, there were 537 cases of PAD. Age-adjusted incidence rates were:
--No risk factors: 9 (95% confidence interval [CI], 6 to 14) cases/100,000 person-years (n=19),
--One risk factor: 23 (95% CI, 18 to 28) cases/100,000 person-years (n=99),
--Two risk factors: 47 (95% CI, 39 to 56) cases/100,000 person-years (n=176),
--Three risk factors: 92 (95% CI, 76 to 111) cases/100,000 person-years (n=180), and
--Four risk factors: 186 (95% CI, 141 to 246) cases/100,000 person-years (n=63).

Men without any risk factors had a hazard ratio of PAD of 0.23 (95% CI, 0.14 to 0.36) compared with all other men in the cohort. The multivariable-adjusted hazard ratio for each additional risk factor was 2.06 (95% CI, 1.88 to 2.26).

At least one of the four risk factors was present in 96% of PAD cases at diagnosis (95% CI, 94% to 98%). The absolute incidence of PAD among men with all four risk factors was 3.5/1,000 person-years.

"We found a somewhat lower increase in risk of PAD associated with hypercholesterolemia compared with the other 3 risk factors," the researchers wrote. "This may reflect the importance of effective treatment for hypercholesterolemia. While treatment for hypertension does not appear to fully reduce its associated risk for CHD, statin therapy treats hypercholesterolemia extremely effectively, essentially eliminating its associated risk."
Thursday, October 25, 2012

Medical device approval process under fire

All parents have heard their kids complain that but for 1 or 2 percentage points, they would have achieved a higher grade.

"This is so unfair! My average is 89.9999 and he is still giving me a B+!"

Every kid should receive an A, of course, since psychologists are now professing that every kid is a prodigy in some new measure of intelligence. Academic intelligence, the conventional and obsolescent notion, has been sidelined to make room for other types of smarts, such as musical intelligence, existential intelligence, interpersonal intelligence, spatial intelligence and many others.

I agree that there's a lot more to being smart than conquering number theory and linear algebra, but I wonder whether this effort to broaden the definition of intelligence is simply so more parents can have smart kids. Personally, I think that the conventional definition of intelligence is too rigid and we should be open to where rigorous research leads.

Fortunately for me, I did not discover that there is a category of navigational intelligence, which would have cost me at least 40 revised IQ points.

In my day, a grade of 94% was a solid A, and we strived to reach this threshold. Were our teachers too lenient? Should a grade of A required that at least 99% of our answers were correct? Where do we draw the lines to separate excellence from acceptable? Who makes the decision?

Last year, a public fight erupted over an Institute of Medicine (IOM) report that had not even been issued that argued for tougher rules for medical device companies. The report had been commissioned by the FDA and was in response to several recalls of medical devices that had malfunctioned and harmed patients. Advocates of medical device companies cried foul, claiming that the 12-member panel was biased. Look for a lot more of this strategy when comparative effectiveness research (CER) goes forward. If a CER panel's conclusion is against your interest, then attack the panel. Lawyers have mastered this technique generations ago. If the facts are on your side, attack the law. If the law is on your side ...

Is the IOM on target or is the aggressive push-back from the industry legitimate? I do know that is an easy task to make medical device companies and pharmaceutical companies appear callous, avaricious and indifferent to human suffering, when this may be entirely false. Can you say demonization?

Of course, we want medical devices and pharmaceuticals to be safe and effective. We expect that artificial hips, pacemakers, defibrillators and stents will perform superbly. Safety and testing policies should be made by experts independent from industry, but I believe that industry is an important voice at the table. Indeed, several constituencies should be represented, including the public. If we strive to eliminate every real and potential conflict of interest, then we will lose many voices of medical experience from the real world.

I'm not suggesting that reform in the device approval process is unnecessary. But, there are truths that must be acknowledged.
--No medical device or drug is 100% safe or effective.
--A percentage of medical devices will fail which may result in injury, reoperation or death.
--A failed medical device is not tantamount to corporate misconduct

What percentage of medical devices should perform as intended? 90%? 95% 98%?

How much testing and clinical trials should medical devices be required to undergo before they can enter the market? If the device is similar to an existing device, or is an existing device that is applying for a new use, should the testing process be the same as for a new product?

A grade of 98% sounds like an A+ to most of us, but this may not be sufficient in the medical device universe. Would we be content on an airplane knowing that we have a 98% chance of landing safely?

If we all agree that the medical device industry needs tougher standards so that their safety and effectiveness levels approach 100%, then we will need to accept higher medical costs and a reduction in innovation. Will this trade off serve the greater good?

I'm sure if the federal highway speed limit were lowered to 50 miles per hour that lives would be saved. No one is hollering for this reform. What should the medical device speed limit be?

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.

Human survival and the battle of the SExS

If all of us were simply to make better use of our feet, our forks, and our fingers; if we were to be physically active every day, eat a nearly optimal diet, and avoid tobacco; fully 80% of the chronic disease burden that plagues modern society could be eliminated. Really.

Better use of feet, forks, and fingers, and just that, could reduce our personal lifetime risk for heart disease, cancer, stroke, serious respiratory disease, or diabetes by roughly 80%. The same behaviors could slash both the human and financial costs of chronic disease, which are putting our children's futures and the fate of our nation in jeopardy. Feet, forks, and fingers don't just represent behaviors we have the means to control; they represent control we have the means to exert over the behavior of our genes themselves.

Feet, forks, and fingers could reshape our personal medical destinies, and modern public health, dramatically, for the better. We have known this for decades. So why doesn't it happen?

Because a lot stands in the way. For starters, there's 6 million years of evolutionary biology. Throughout all of human history and before, calories were relatively scarce and hard to get, and physical activity in the form of survival was unavoidable. Only in the modern era have we devised a world in which physical activity is scarce and hard to get and calories are unavoidable. We are adapted to the former, and have no native defenses against the latter.

Then, there's roughly 12,000 years of human civilization. Since the dawn of agriculture, we have been applying our large Homo sapien brains and ingenuity to the challenges of making our food supply ever more bountiful, stable, and palatable; and the demands on our muscles ever less. With the advent of modern agricultural methods and labor-saving technologies of every conception, we have succeeded beyond our wildest imaginings.

So now, we are victims of our own success. Obesity and related chronic diseases might well be called "SExS,," the "syndrome of excessive successes."

The problem with this beyond its obvious consequences is its profound cultural inertia. Having worked for 12,000 years to reduce physical exertion and increase available calories, it's rather a challenge to suddenly reduce available calories and increase exertion. Everything in modern society is inclined the other way.

And, of course, the so-called "military industrial establishment" stands in the way as well. Many of our modern institutions, from big food, to big pharma, profit from the obesogenic status quo. Although, of note, the military per se certainly does not, quite the contrary. Ever more concern is being expressed about the potential for rampant obesity to interfere with our military preparedness. So it's just the "industrial establishment" in this case.

But those institutions that do profit have deep pockets, and use them to oppose sudden change. Over time, food companies can reformulate and sell better products that preserve profit margins, but they are not inclined just to sell less of what they make right away. Over time, drug companies can become health promotion specialists; but they are not going to sit back and watch their stock values plummet.

What all this means, quite simply, is that progress toward the public health prizes that beckon will tend to be incremental, at times slow, and almost never perfect. Perfect tends to be the enemy of good in the real world.

That point was apparently lost on a certain David Lazarus, who wrote an opinion piece in the Los Angeles Times that was highly critical of Anthem Blue Cross for operating a program that provides clients with discount coupons for better, but often quite imperfect, foods.

The program is provided by a company called LinkWell, which links food companies to insurance companies in just this way. The insurance companies provide access to their clients, and the food companies pay to discount their better-for-you offerings. The idea is that people can be "nudged" this way toward better choices; the food companies can sell their products; and the insurance companies can potentially reduce their costs. In principle, everyone can win.

I find that principle quite sound, and for that very reason, and the fact that I have long been an avowed public health pragmatist, I serve on Linkwell Health's Board of Advisors.

Mr. Lazarus ridiculed the fact that Anthem provided coupons for deodorant. This, of course, has nothing to do with health but everything to do with building bridges. By sending out coupons for some products unrelated to health, Linkwell, Anthem, and the other insurance companies using the program gain traction to address the choices that do influence health.

Mr. Lazarus also beat up on those, noting that better-for-you ice cream is still ice cream. He suggested that the coupons be limited to vegetables and fruits, or maybe meats and fish.

Leaving aside an apparent willingness to attribute the same health effects to meats and vegetables, Mr. Lazarus' suggestion has intrinsic merit. The best foods generally do come direct from nature, and switching from one ice cream to another may not do much for health, personal or public.

But there is one important problem with Mr. Lazarus' suggestion. It doesn't work.

We have been encouraging Americans to eat more fruits and vegetables for literal decades, and yet only 1.5% of us (yes, 1.5%!) get the recommended daily intake of both. We have goaded and harangued, given produce out for free, and financially incentivized it. These things do make a difference, but a very small difference. That is in part because there are important barriers to more produce intake other than price, and in part because people are simply accustomed to choosing many foods that come in bags, boxes, bottles, jars, and cans.

This is not likely to change overnight, and arguments to the contrary make perfect the enemy of good.

I have been subject to such arguments myself. I led the development of a nutritional guidance system intended to guide people to more nutritious choices within any given food category. Yes, in fact, if you are inclined to eat ice cream, there truly are more and less nutritious choices. Yes, if you are inclined to eat chips, there are better chips. And frankly, it just isn't relevant, when you are inclined to eat chips, that broccoli is better for you.

The purists among my colleagues criticize such guidance because it does not advocate for consumption of pure foods only, although those, of course, do score highest of all. But I am not aware of any scientific evidence that encouraging people to eat pure foods
In contrast, I am aware of real-world evidence that guidance for trading up every food choice to a slightly better one can make an enormous difference. And that it actually has done so, repeatedly. And that simply by making slightly better choices often, the net nutritional benefit can add up to
lower rates of both chronic disease and premature death.

If only perfect would do, then calorie counts, nutrition fact panels, and ingredient lists would be moot. We could simply tell everyone to eat more spinach, and leave it at that. If only perfect would do, then modest doses of daily physical activity would be pointless. Either make the Olympic Team, or enjoy your couch.

But just recently came evidence that a mere 20 minutes of daily physical activity can be the difference between a child succumbing to type 2 diabetes or not. That matters. As do the actual choices made among foods in packages. So the public health can, in fact, be advanced with programming to empower modest amounts of daily physical activity in adults and children alike, and by programming in , supermarkets, or that is sent in the mail to help people trade up their food choices.

I quite agree that Linkwell's program is not perfect, and I am confident the company executives would say the same. No doubt Anthem would agree as well. But the reason the program isn't perfect is, quite simply, because those involved in it are committed to doing some good in the real world, where perfect tends not to be a viable option.

In the real world, often the best you can do is insert the thin edge of the wedge, and then keep pushing. You can be candid about ideals and objectives, but often must be compromising about opportunities so something gets done while waiting on the world to change.

For better health, people really should eat more wholesome foods direct from nature, mostly plants. But between here and there, choosing better cereals, breads, chips, crackers, sauces, spreads, dressings, and, yes, even ice cream can add up to dramatic improvements in overall diet quality. And that, in turn, could result in meaningful improvements in health. And it's actually feasible.

That's what Anthem, and Linkwell, are working on: progress, imperfect though it may be. In my view, that's good.

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--Substance abuse treatment rates rise in ambulatory care settings

There was a 70% increase in ambulatory care visits for substance abuse from 2001 to 2009, with opioid-related visits increasing six-fold in this time, a study found.

Researchers analyzed a sample of nearly 9,000 visits, representing an estimated 42.2 million adult visits, from two ambulatory care surveys administered by the National Center for Health Statistics from 2001 to 2009. Results appeared in a research letter Oct. 22 at Archives of Internal Medicine.

The absolute number of visits for substance abuse increased from 10.6 million in 2001 through 2003 to 18 million in 2007 through 2009 (P=0.006). The absolute number of opioid-related visits increased from 772,000 in 2001 through 2003 to 4.4 million in 2007 through 2009. This is a relative increase of 7% of all substance use disorder visits in 2001 through 2003 to 25% of visits in 2007 through 2009 (P=0.004), researchers wrote.

Physicians prescribed pharmacotherapy in 6.3 million visits, representing 15% of all substance use disorder visits. These visits increased more than 6-fold, from an estimated 643,000 visits in 2001 through 2003 to 3.9 million visits in 2007 through 2009 (P less than 0.001). Physicians prescribed buprenorphine or methadone in 4.8 million visits and acamprosate, disulfiram or naltrexone in 1.5 million visits.

Psychosocial therapy rate did not change significantly over time, representing 59% of all visits across all time spans (P=.87).

This may be good news, researcher wrote. "Increasing recognition of previously undiagnosed disorders, improving familiarity with and use of available medications, and more frequent ambulatory care by individuals with substance use disorders all likely contribute to the trend of increasing visits over time."
Wednesday, October 24, 2012

My last week at the practice I built

This is it.

Eighteen years of practice is now condensed to my final four days seeing patients in the practice I built. While I am not bitter about what has happened (in fact, a large part of me is delighted), there is a sense of finality in this as one of my life's major passings.

This has been the stage on which I've been asked to perform, standing beside the stories of people's lives and living out my own drama as theirs unfolded. This is where my life most intersected others, where I saw pain and joy, birth and death, suffering and triumph. I helped these people and learned from them in the process. I was teacher and student, helper and helped, healer and healed.

Whether I've profited most or gave myself dry (I've felt both often), it has been what I've done. Now I walk off of that stage onto another one, still dimly lit with little substance. I walk from the known to the unknown, the familiar to the hypothetical. I have great ideas, but now those ideas must become reality, and that reality must work well enough to justify leaving what I have left. Enthusiasm and innovation don't pay the bills or heal the sick; it takes work.

A friend called me "courageous" in taking this step, which may be true. But courage doesn't exist without fear, and fear is a lot of what I feel at this point. Yes, I do think I am doing the right thing, but that is no guarantee of success. Many good ideas have been dashed against the rocks of life for many different reasons. Courage is overrated, as is faith. Both courage and faith call to step out in fear and ignorance, trusting in something that isn't visible at the moment. It's not fun.

So I take a deep breath as I enter into this last week of my old life. I pray for the serenity to accept what is, not fear what I can't do anything about, and live in the moment I've been given.

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--Diversity drives medical school enrollment

Overall enrollment and diversity of applicants drove a 3.1% increase in medical school enrollment, according to figures released by the Association for American Medical Colleges.

More than 45,000 students applied to medical schools this year, and first-time applicants, considered to be a barometer of interest in medicine, set another record, increasing by 3.4%. First-time enrollment at medical schools grew 1.5% to more than 19,500 students.

All major racial and ethnic groups saw increases in applicants and enrollees this year, AAMC said in a press release. A record number of black and Hispanic students applied. After decreases in both applicants and enrollees in 2011, the number of American Indian and Alaska Native applicants and enrollees increased. Asian applicants and enrollees also increased.

ACP's executive vice president and CEO, Steven Weinberger, MD, FACP, said, "Hopefully there would be more of an interest in primary care but we don’t know whether that's the case. In any case, being able to increase the diversity of the workforce would be great and any movement along those lines is in the best interests of health care and of our patients."

Medical schools are on track to increase total enrollment 30% by 2016. But AAMC's president and CEO said medical school enrollment will not translate into more doctors unless Congress lifts the 1997 limits on residency training positions.

Dr. Weinberger described the cap on residency slots as a bottleneck that will result in international medical graduates, who currently comprise about one in four residents, not being able to secure residencies.

ACP has advocated for private insurers to join in paying for residencies, a position called all-payer funding of graduate medical education.
Tuesday, October 23, 2012

Challenges for building capacity of the clinical informatics subspecialty

The new clinical informatics subspecialty promises to provide professional recognition to the increasing number of physicians who work in the specialty of combining information with their medical expertise to improve quality and safety while lowering the cost of health care. The American Board of Preventive Medicine (ABPM), the administrative home for the subspecialty, is currently defining the criteria for those who will be eligible to take the certification exam without formal training (i.e., "grandfathering" by virtue of previous work in the field, whether by the "practice pathway" or prior training, which will be allowed for the first five years of the subspecialty's existence), developing the first board certification exam, and defining criteria for future fellowship training.

The new subspecialty will provide a great opportunity for professional recognition of physicians who work in clinical informatics. One concern, however, is how our field will build capacity to train the critical mass of those who wish to become trained and certified in the subspecialty. There are a number of unique aspects of this discipline that will make this task challenging. In this posting, I will speak to these from my position as a program director of one of the largest clinical informatics educational programs in the United States.

There will be challenges both during the grandfathering era as well as when formal fellowship training is required. For the former, there will likely be exclusion of some who have the knowledge or the experience, but not both, to be deemed clinical informatics subspecialists. For the latter, if this field follows a "traditional" path of requiring all entrants to the field to obtain training only in 1-2 year, on-site fellowships, then we may be unlikely to match the need for these specialists or the aspirations of those who often enter the field in middle of their careers.

Data and Perspectives

Our informatics educational program at Oregon Health & Science University (OHSU) has been an extremely popular approach for all, including physicians, to receive training in clinical informatics. The program is available both on-campus and via distance learning, with the asynchronous nature of courses in the on-line program allowing students to train without having to move or leave their current jobs. A total of 1,359 individuals have enrolled in the OHSU informatics program since its inception in 1996. During that time, 441 people have received a total of 12 PhD degrees, 184 master's degrees, and 278 graduate certificates. (The graduate certificate is a subset of the master's degree program covering the core content of the field. While it has been in existence for over a decade, its numbers increased significantly from funding by the Office of the National Coordinator for Health IT [ONC] University-Based Training [UBT] Program for "short-term training," especially in the workforce role of "clinician leader.")

There are currently 291 students actively enrolled in the OHSU informatics program, 95 (32%) of whom are physicians. A similar proportion of our graduates are physicians, many of whom have gone on to leadership roles in clinical informatics, such as that of Chief Medical Informatics Officer (CMIO). A not-insignificant number of them were already CMIOs or other leaders upon entering the program, and some of those negotiated enrollment in the program or at least some courses within it as a condition of employment. Our data and experience clearly show that informatics via distance learning is a credible pathway for physicians and others to become clinical informatics professionals.

Our experience has also shown that essentially all types of informatics experiential learning can take place in a distance learning program. One concern we have always had in our program is the ability to gain experience through a practicum or internship. We have been able to institute such programs that allow students to carry out a mentored experience in "real-world" settings of health care organizations, companies, government agencies, and others. Our process tracks deliverables of the documentation of experiences and includes faculty monitoring of progress. It has even sometimes led to employment in those settings.

Some additional data from our program is relevant to the following discussion of challenges for building clinical informatics capacity of physicians. One is the median age of our students, which is about 41.5 years at matriculation into the program. The following chart shows the average age of physicians currently enrolled in the program. These data clearly show that most physicians in our program pursue informatics training and positions in the middle of their careers, i.e., do not follow the traditional contiguous progression from medical school to residency to subspecialty training and employment.

Another data point concerns the mapping of our curriculum to the core content of the new subspecialty, as laid out by Garnder et al. (2009) and included in the proposal for the subspecialty approved by the American Board of Medical Specialties (ABMS). We recently mapped the core content to our existing curriculum and found the material spread over 23 academic-quarter courses. Clearly the core content of clinical informatics will need to be consolidated into many fewer courses, but it is unlikely that any course of study will require the equivalent of a master's degree or at least a graduate certificate.

But clear unlike most other medical subspecialties, the knowledge base of clinical informatics is not a refinement of what the physician learned in medical school and built upon in residency. Consider, for example, a trainee in the area of critical care medicine. A future intensivist physician will have learned the basics of the diseases, treatments, tests, etc. starting in medical school. In medical school, the student will have started in basic science courses with the fundamentals of the cardiovascular system, the pulmonary system, and other applicable biomedical areas. As a clinical student, he or she will see their first cases of conditions such as sepsis, heart failure, and severe pulmonary disease in critical care units and other areas of the hospital. If interested in a career in critical care medicine, that medical student may then pursue a residency in internal medicine, surgery, anesthesiology, or other areas, but will continue to build upon the foundation of diseases and treatments learned in medical school. He or she will complete their training in a clinical fellowship, where more detailed knowledge emanating from the basics started in medical school will be mastered. Those who aspire to train in clinical informatics, however, will enter a new world of knowledge. While clinical expertise certainly will provide a partial foundation to the knowledge he or she must master, entire new areas of study will be brought into the equation. These include topics such as clinical decision support, organizational behavior and management, health information exchange, and standards and interoperability.

Challenges in the Grandfathering Era

The ABPM will soon be announcing what will qualify as "already working in the field," which will determine who will be eligible to sit for the certification exam in the first five years of the subspecialty. The proposal submitted to the American Board of Medical Specialties (ABMS) suggested that working in the field be defined as either having worked in the field at 25% or more effort for at least three years or by having completed a "non-accredited fellowship" of at least 24 months duration. What exactly is meant by the latter is unclear, especially since many who have entered the field have done so through graduate-level educational programs, such as the OHSU program described above, that meet or exceed the depth of a fellowship program, even if they are not pursued in a full-time manner.

I have concerns that there will be disappointment with the criteria, both from those who are not eligible and could likely pass the exam as well as those who will be eligible but find the knowledge content of the exam overwhelming despite their substantial experience working in the field. I know this is true of all new medical specialties that become formalized, and that it takes some time for a field to synchronize its training and its practice knowledge base. But as noted above, clinical informatics has some unique differences, especially with regards to a knowledge base that is not just a refinement of what is learned starting in medical school.

There will likely be many in the category of physicians who are deemed not to meet the grandfathering requirements for experience yet could likely pass the test. This may include those who have completed educational programs such as a master's degree or graduate certificate, either in informatics or a related discipline. Depending on how many of these programs qualify as a "non-accredited fellowship," there could be many physicians who pursued formal training in the field only to not be eligible under the initial certification process.

By the same token, there will also likely be many physicians who have been working in CMIO or other clinical informatics positions, thus meeting the practice requirements, but whom have little or no formal training in the field and lack mastery of the knowledge base to be able to pass the certification exam. Clearly there must be some bar set for knowledge in the field, but many experienced clinical informaticians will require substantial education to achieve the level of knowledge required to pass the exam. Some challenges will include where to set the bar and how to help those who fall below it achieve the knowledge to move above it.

Challenges in the Clinical Fellowship Era

There will be additional challenges for building capacity after the grandfathering era has ended and formal fellowship training is required. These challenges will likely be more daunting, especially if we want to broadly expand the capacity of the field to meet perceived needs for individuals trained and certificated in clinical informatics. Depending on how stringent the requirements are for full-time, in-residence fellowship training, it could be quite difficult to build the needed capacity.

The first challenge for clinical informatics training will be how new trainees learn the core content. Clearly a subspecialty fellowship in clinical informatics will require a more formal educational program than the usual half-day per week of lectures by local subject experts in a typical clinical fellowship. This point is driven home by an analysis of the core content mapped to courses in the OHSU biomedical informatics graduate program described above, where we found the material to be mapped over 23 academic-quarter courses. Certainly a course of study will need to be consolidated into many fewer courses, but the mastery of this knowledge will not be provided the usual half-day per week of lectures provided in a conventional clinical fellowship. Organizations that offer clinical informatics fellowships will need to provide this educational activity, or at least partner with others who can do so.

A second challenge for building the capacity is that many physicians (and others) enter the field of informatics in the middle of their careers. This is not a negative for the field, as many clinicians come to realization that some of the biggest challenges in health care involve managing and making best use of data and information. As such, they decide to pursue careers in informatics that will allow them to do that. This pursuit of informatics in mid-career is one of the major reasons for the popularity of distance learning programs. We have found that despite the large numbers of students in our program, one of our biggest challenges is filling classrooms on our campus. Even "local" students in the Portland area want to take "distance" classes due to convenience and/or daytime working constraints.

A third challenge for developing capacity concerns the ability of organizations to stand up on-site training programs to handle building overall capacity. In order to maintain a clinical informatics fellowship program, according to the training requirements laid out by Safran et al. (2009), organizations will need to provide not only practical, hands-on training under supervised certified clinical informatics subspecialists, but also a robust educational experience. A scan of existing informatics training programs shows that some have strong hands-on components and others have well-developed educational programs but few have both. While the quantity of clinical informatics subspecialists needed is not precisely known, it is clear that only a small number of programs would be able to stand up programs that could meet the requirements spelled out by Safran et al. in contrast to the potentially hundreds if not thousands of hospitals and other clinical settings that could benefit from these specialists. This necessitates a more efficient approach to training, a contribution of which distance learning approaches could provide.

A fourth challenge is who will bear the cost of fellowship training. While most educational programs are funded by tuition, clinical fellowships are usually paid positions where the cost is covered by a combination of graduate medical education subsidy through Medicare as well as patient care services provided by the trainee. While both of these traditional sources of fellowship funding might work in some settings, it is not clear in this era of reduced federal funding for medical training and squeezed hospital budgets that paid fellowships will be viable in many places.

A final challenge could be the accreditation of fellowship sites by the Accreditation Council for Graduate Medical Education (ACGME). This challenge is not limited to the clinical informatics subspecialty. While the ACGME has accredited some programs that allow elements of remote learning, e.g., (Emmett and Green-McKenzie, 2001), its view, like most of medicine, is that subspecialty training is mostly an activity that takes place in a full-time fellowship at one or more physical sites.

Road Ahead

The need for clinical informatics subspecialists is clear, and the aggregate capacity to train adequate numbers is probably available. However, the traditional fellowship where experiential and didactic learning takes place in a single organization is likely impractical, certainly for the numbers that most estimate are needed for the subspecialty. Based on our experience in training physicians and others for careers in informatics, we believe the approach that is most effective and scalable will be to combine the online curricular delivery with practical experience on the ground augmented with additional interactions among trainees, including in-person or virtual approaches.

There are likely creative ways to build the capacity of clinical informatics training programs. One would be to allow institutions that could offer up robust experiential training to partner with those can provide the education, with the latter in a remote manner. Our program is already in discussion with two organizations that are considering melding our educational programs with their on-site training. Not only will we provide "out-sourcing" of coursework to these institutions, but we will also engage with their faculty in faculty development. We also plan to make use of telecommunications modalities to allow interaction among their trainees, our faculty, and even our local trainees.

There are other reasons why clinical informatics fellowship training should be more distributed. The world of clinical informatics is very different in high-resource academic centers compared to community hospitals and other clinical settings. The latter types of organizations are less likely to achieve "meaningful use" of information technology (Desroches, Worzala et al., 2012). A robust training experience should include these types of settings as well. Distributed training experiences will also allow for more interaction among trainees. As a single health care organization is likely to only be able to accommodate a few trainees, an integrated multisite program will allow more trainees to interact and share knowledge and experiences.

Clinical subspecialty training has historically been provided at one or a small number of sites, with educational activities also provided at those locations. However, with the growing proliferation of specializations that physicians can undertake today (Cassel and Reuben, 2011), many of which did not exist during their initial training, clinical informatics will not only benefit from novel approaches but could also provide an opportunity for medicine to reconsider how physicians train in many other specialties. Regulatory bodies will need to recognize these problems and authorize training programs that achieve their educational goals, even if in non-traditional ways. Just as the rest of education has adapted to and embraced the use of technology, medicine must do likewise.


Cassel, C. and Reuben, D. (2011). Specialization, subspecialization, and subsubspecialization in internal medicine. New England Journal of Medicine, 364: 1169-1173.
Desroches, C., Worzala, C., et al. (2012). Small, nonteaching, and rural hospitals continue to be slow in adopting electronic health record systems. Health Affairs, 31: 1092-1099.
Emmett, E. and Green-McKenzie, J. (2001). External practicum-year residency training in occupational and environmental medicine: the University of Pennsylvania Medical Center Program. Journal of Occupational and Environmental Medicine, 43: 501-511.
Gardner, R., Overhage, J., et al. (2009). Core content for the subspecialty of clinical informatics. Journal of the American Medical Informatics Association, 16: 153-157.
Safran, C., Shabot, M., et al. (2009). ACGME program requirements for fellowship education in the subspecialty of clinical informatics. Journal of the American Medical Informatics Association, 16: 158-166.

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.

Have electronic health records led to fraudulent upcoding by physicians?

Over the past several decades medical costs in the United States have escalated rapidly, exceeding the pace of inflation and threatening bankrupt to Medicare. As we heard in a recent presidential debate, different solutions have been proposed on how to slow Medicare's growth and reduce cost. President Obama highlighted his administration's success in tackling fraud and waste within the system. This strategy appears to be supported across party lines.

On face value it seems like a good idea, but what is not entirely clear to those of us within the medical community is how waste and fraud will be defined. I have discussed this in a previous blog: "When is Unneeded Care Criminal?"

As reported by the New York Times, recently attention has been focused on going after doctors and hospitals who some believe may be "upcoding" the complexity of their patient encounters to CMS and other insurers for the purpose of receiving better reimbursement. Apparently since the advent of electronic health records there has been a trend toward physicians' reporting higher complexity office visits.

The AMA (American Medical Association) Wire reports:
"The Centers for Medicare & Medicaid Services (CMS) notified the AMA that Connolly, a recovery auditor for what is commonly known as the Medicare RAC program, will begin auditing how physicians report CPT® code 99215, used to report evaluation and management (E/M) services. CMS appears to have also granted Connolly authority to extrapolate its review of sample claims to potentially recoup funds on 99215 claims it did not evaluate individually."

The AMA strongly objects to these audits and has written a letter to CMS pointing out that:

"Audits of such complex services would result in erroneous payment recoupment and undue expense for physicians and CMS. According to the agency's own report to Congress, 46 percent of appealed Medicare RAC determinations are decided in favor of the physician or other health care professional."

What does upcoding mean? Medicare and other payers require that doctors use a convoluted coding system for billing medical visits based on their documented complexity. The system is so complex that for years it has outsmarted doctors who have been tasked with remembering the numerous elements required to justify the level of the visit (1 through 5), and then document the details required to support the billing level.

The selection of an appropriate billing code, as outlined in an 89-page guide prepared by CMS, if done correctly would without a doubt take the same amount of time (or perhaps more) as seeing the patient. The end result: most physicians, with limited time and partial recall of the complicated rules, pick the code that they feel best encompasses the visit level based on perceived complexity.

In the past when doctors dictated or hand wrote patient notes it was more difficult to include all of the historical factors required to support a higher level billing code. The use of electronic health records, however, has made the process easier by automating the incorporation of past medical history, medications, allergies, social history and family history into clinic notes, thereby allowing physicians to justify a higher level code. Until recently, based on personal experience, the tendency may have been to "under-code" complex visits, with fear that documentation would be inadequate to justify a more complicated billing code. In reality, it is very time consuming to fully document the complex information that is exchanged in the context of a 15-30 minute office visit.

he purpose of medical documentation is to convey information. Ideally doctors would be able to document the salient portions of each patient encounter that would help other providers care for the patient in the future. In many ways electronic health records have helped facilitate medical documentation. However, at the same time they have also led to the inclusions of extraneous information (for the purpose of supporting billing codes) that one is required to sift through while getting to the meat of the visit.

What is particularly enraging about these allegations of "upcoding" and fraud is that finally physicians have a tool to help ease the burden of Medicare's inane billing code system--electronic health records; but now, after going through all the work and tremendous expense of transforming our practices and adopting these systems, we are threatened by the specter of accusations of fraud for "upcoding" the same visits that we've been "down-coding" for years. If politicians would like to eliminate waste from Medicare why not simplify its billing system so that medical practices would not have to employ full time coding experts to ensure that their practices remain fiscally solvent? Of course, this would also eliminate a bunch of jobs.

Juliet K. Mavromatis, MD, FACP, is a primary care physician in Atlanta, Ga. Previous to her primary care practice, she served on the general internal medicine faculty of Emory University, where she practiced clinical medicine and taught internal medicine residents for 12 years, and led initiatives to improve the quality of care for patients with diabetes. This work fostered an interest in innovative models of primary care delivery. Her blog, DrDialogue, acts as a conversation about health topics for patients and health professionals. This post originally appeared there.

11 years later, insurance may cover the bill

The way doctors bill and get paid is a byzantine process and it is no wonder the "private practice" doctor is an endangered species. It takes a keen sense of business, a love of medicine-not money, and a sense of humor to survive. Here is my latest story. You can't make this stuff up.

I saw a patient in September 2001 (note the date ... 11 years ago). I billed her insurance company, Employers Mutual, LLC for $185. I never got paid.

Now fast forward to September 2012. I received a document from an attorney who informs me that he is a receiver in a class action suit and $48 million in unpaid claims is being claimed. It appears I am a Category B creditor and will receive a pro-rata share. He recovered $16,559,576.88 and took $4,831,214.40 in attorney fees.

It looks like in the future (?) I may receive a check for $37. No promises are given.

I remember my practice back in 2001. I worked about 80 hours a week and never even had enough money to fund a retirement plan for myself. Getting paid a fraction of my charges was common and getting stiffed by insurers completely was also par for the day.

I am happy for the windfall of $37 for the work I did 11 years ago. I still see patients in a private practice but my main income now comes from my employed administrative position. Waiting 11 years for a fraction of payment is not a sustainable business model.

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.
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.

QD: News Every Day--Task Force continues stance against hormone replacement therapy

The United States Preventive Services Task Force held to its stance against the use of estrogen and progestin for the prevention of chronic medical conditions in postmenopausal women and the use of estrogen alone for the prevention of chronic conditions in postmenopausal women who have had a hysterectomy.

These are both Grade D recommendations (moderate or high certainty that the service has no net benefit or that harms outweigh the benefits), and have not changed since the Task Force's previous recommendations in 2005.

The recommendation appeared online Oct. 22 in Annals of Internal medicine.

Following a review of 51 articles published since 2002, the Task Force concluded that risks associated with these hormone replacement therapies (HRT) outweigh the chronic disease prevention benefits. Specifically:
--Estrogen alone and estrogen plus progestin reduce the risk for fractures, but increase risk for stroke, thromboembolic events, gallbladder disease and urinary incontinence.
--Estrogen alone decreased risk for breast cancer.
--Estrogen plus progestin increased risk for probable dementia and breast cancer.
--The risk for breast cancer increased for women with prior oral contraceptive use, prior menopausal estrogen plus progestin therapy, or current smoking.

The recommendations apply to average-risk women who have undergone menopause, and are not about the use of hormone therapy to treat symptoms of menopause, such as hot flashes or vaginal atrophy.

The USPSTF said in the report that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision making to the specific patient or situation.

Juliet K. Mavromatis, MD, FACP, is a primary care physician in Atlanta, Ga., addressed just how to do that in her blog.

The Task Force provided a patient guide to help doctors explain the issues to their patients.

And, ACP Internist detailed how physicians, researchers and women have been experimenting with alternative solutions to the problems of menopause, including non-oral hormone formulations, smaller doses and non-hormonal therapies. Even today, nearly one in 10 doctors prescribes hormone replacement therapy for patients, a survey found.
Monday, October 22, 2012

Computers in patient care

I'd like to start this blog with a comment that I am a strong proponent of using emerging technologies to help improve patient care. I believe in the power of mobile computers to help us with patient care. I believe that we should use technology to augment the care we provide, not replace it. However, I had an interesting hallway conversation with one of my fellow attendings earlier this week, which caused me to reflect on this topic, and ultimately write this.

Electronic medical records are touted to help improve efficiency, to be able to collect information to help us improve the care we provide, as well as other positives that are well-described. The government is even providing incentives to health care systems and physician practices for meaningful use. I have believed in the power of computerized physician order entry, or CPOE, for a while, having had it at one of our training hospitals when I was training in 1994 to 1998.

However, the discussion I had the other day made me really think. Trainees (and attendings, as well; we are not any different) spend so much of their day on the computer, and this appears to be coming at the expense of face-to-face time with the patients. This article suggests that direct time with patients is not ideal for residents on call, and that much of the time on call is spent in front of a computer. 12% of the time was spent in direct patient care. 12%! I am concerned about this, and I bet patients would also have similar concerns.

This article, with a drawing by a child highlighting what they see with regards to doctors and computers, pretty much sums it up: even children are noticing that doctors are tethered to the computer. This has to change!

I do believe that we can fix this. It starts with acknowledging this elephant in the room (or, more aptly, the "computer in the room"). I am currently spending a few weeks on the inpatient service at our county hospital, and had the chance to discuss this with our medical students. We made sure that rounds on patients including going to see the patients and interact at the bedside, not just exclusively sitting around a table discussing the patients. We discussed motivational interviewing (and demonstrated it) and getting to know patients as people. We reflected on why all of the students went into medicine, and none said "to type information into a computer." "Stop and smell the roses" was the take-home message of the day, the roses being, among other things, time with patients.

Please, please make sure that staring into a screen doesn't replace sitting at a patient's bedside. Please make sure to talk to your patients, to look them in the eye, to ask them what they think, and to answer their questions. It will help the patients, and it will promote the humanism that is at the heart of the patient-physician relationship. Yes, computers and mobile tablets can help us care for patients, but in my opinion, there is a bond between a patient and a physician which should never be replaced by a computer. Let's not break that bond!

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

The internist as a puzzle solver: my (a)vocation

I've been getting GAMES magazine for years. Decades, actually, on and off. I remember doing logic games way back in elementary school, and I still do them first in my GAMES magazines. When I was a kid, my grandmother and I would do jigsaw puzzles together, and I now find myself doing them with my own children.

During a lunchtime panel of the Internal Medicine (IM) Interest Group at UNC today, I was drawn to something that one of my colleagues on the panel said. He noted that if you separate the "medical" specialists (internists, pediatricians, etc.) from the "surgical" specialists (orthopedic surgery, urology, etc.), there is often a difference in the type of intellectual arguments the two groups have. Paraphrasing, he said: "Medical specialists argue more about what diagnosis the patient has over what the treatment of the diagnosis is. Surgical specialists argue more about what the treatment should be, often whether or not to operate, over what the diagnosis is."

Of course, this is an overly broad generalization. He did not mean to say that internists don't argue over treatment plans or that surgeons don't argue over diagnosis. Clearly both do. He pointed out that some medical specialists, like oncologists, tend to keep their discussions more focused on the latter type (e.g. "Should this patient with breast cancer receive chemotherapy?"), and surgeons similarly have to make sure the diagnosis is correct before they operate.

Nonetheless at general internal medicine "morning report", residents often focus on creating a broad differential diagnosis and then figuring out what data they'd need to get the right answer. In other words, using their logic to solve the puzzle the patient is presenting to them.

Thinking back now, I find it interesting that I made a conscious decision in the latter half of medical school to change my career path from surgery to medicine. Puzzle solving has occupied a good portion of my recreational time since childhood. Maybe my choice during medical school to go into IM was my subconscious way of making sure I would enjoy my career. I'm certainly glad I made that choice!

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

QD: News Every Day--Chances are patients don't blame their doctors for high health care costs

Patients seem to be clear on what's driving the cost of health care.

When given a list of factors that contribute to health care costs, 75% of survey respondents who had a primary care provider said that insurance companies were "very" or "completely responsible," 74% said that pharmaceutical/drug companies were "very" or "completely responsible," 62% said that the cost of malpractice insurance was responsible, and 59% said the government was responsible.

Only 30% felt that physicians were responsible (with one percent saying "completely responsible," plus 29% saying "very responsible").

Results were published online by the study's sponsor, The Physicians Foundation.

Among the findings:
--79% said that they were "very satisfied" or "extremely satisfied" with the visit(s). Only one percent said that they were "not at all satisfied."
--Twice as many respondents said that insurance companies were a negative influence on the quality of patient care, 55% vs. 27% who said that insurers were a positive influence.
--Respondents felt the Affordable Care Act would have a negative impact on health care. While 35% had no opinion regarding the impact of the new law, among the 65% who did, 60% feel the impact of the law will be negative, vs. 40% who believe the impact will be positive.

Results were based on responses of 2,236 adults that completed a survey in July 2012, selected from among people who have agreed to participate in Harris Interactive surveys. In this group, 78% had a family physician or primary care doctor. Of these, 95% had health insurance, with half having employer-offered coverage, 23% having Medicare (46% of those 55 years of age and over), nine percent having a self-paid/individual plan and five percent having Medicaid.

Ninety-four percent of patients with a primary care doctor had seen that provider at least once in the past year, and the average number of visits was 3.5.
Friday, October 19, 2012

Physician rankings could be perverse

Yesterday's New York Times had a wonderful op-ed, "Want to Ruin Teaching? Give Ratings>"

"This type of system shows a profound lack of understanding of leadership. Principals need to create a culture of trust, teamwork and candid feedback that is essential to running an excellent school. Leadership is about hiring great people and empowering them, and requires a delicate balance of evaluation and encouragement. At Harlem Village Academies we give teachers an enormous amount of freedom and respect. As one of our seventh-grade reading teachers told me: "It's exhilarating to be trusted. It makes me feel like I can be the kind of teacher I had always dreamed about becoming: funny, interesting, effective and energetic."

Some of the new government proposals for evaluating teachers, with their checklists, rankings and ratings, have been described as businesslike, but that is just not true. Successful companies do not publicly rate thousands of employees from a central office database; they don't use systems to take the place of human judgment. They trust their managers to nurture and build great teams, then hold the managers accountable for results."

While this piece is about teachers, it applies wonderfully to the idea of physician ratings.

"A government-run teacher evaluation bureaucracy will make it impossible to attract great teachers and will diminish the motivation of the ones we have. It will make teaching so scripted and controlled that we won't be able to attract smart, passionate people. Everyone says we should treat teachers as professionals, but then they promote top-down policies that are insulting to serious educators.

If we don't change course in the coming years, these bureaucratic systems that treat teachers like low-level workers will become self-fulfilling. As the great educational thinker Theodore R. Sizer put it, "Eventually, hierarchical bureaucracy will be totally self-validating: virtually all teachers will be semi-competent."

We live in a culture that loves attaching numbers to abstract concepts. We have laughable medical school rankings, business school rankings, etc. Now we are talking about physician report cards, implying that we can measure our complex profession with simple scales.

This concept is bankrupt. It ignores a fundamental understanding of physician quality. Our jobs are multidimensional. Some patients require diagnosis; some require disease management; some need pep talks; some need referrals. This list is incomplete. How can we measure all those attributes, and the many more that make us professionals.

Performance measurement can help me reflect on my own practice, but only if we measure things that I have control over and care about. We should not use performance measurement as a proxy for quality, as a method of adjusting pay, or as an excuse to provide inaccurate public reporting. We have an obligation to speak out against the madness.

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.

Guess the diagnosis of an acid-base problem-part 2

To recap, recently I heard about this patient: A man with a history of ulcerative colitis and PSC who had had both a colectomy with end ileostomy and liver transplant in the past. Now he presents with dyspnea and fatigue and increased stool output.

Your job is to let me know how to evaluate the patient further and define the acid-base problem.

VS P 90 R 20 BP 95/70 T afebrile, otherwise the exam is normal:
albumin 2.7


pCO2: 26

pO2: 105

calc HCO3: 12

Have fun! Part 3 will come out next Friday.

My thoughts at morning report are:
Pure metabolic acidosis with perfect compensation,
Anion gap = 15, but should be around 8 (rough rule of thumb alb * 3),0
Therefore delta gap is 7.

If we add back the delta gap to the observed bicarbonate, I concluded that the patient had a mild AG acidosis superimposed on a normal gap acidosis.

I could not decide between a renal acidosis (type IV with elevated K) or a diarrhea acidosis, therefore I asked for urine lytes.

I asked for the medications of prednisone 5mg daily, tacriiimus, a PPI and Immodium.

Your next job is to guess the urine lytes and tell me how this added information influences your thinking.

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--Multivitamins associated with less cancer incidence

Long-term daily multivitamin use resulted in a modest but statistically significant reduction in cancer after more than a decade of treatment and follow-up, a study found.

Randomized trials of higher-dose individual vitamins and minerals for cancer have never shown an association, but people take them anyway for that purpose. So researchers analyzed data from nearly 15,000 participants age 50 or older from the Physicians' Health Study (PSH II) starting in 1997 with treatment and follow-up through June 2011.

Participants received a daily multivitamin or equivalent placebo. Results appeared in the Oct. 17 issue of the Journal of the American Medical Association.

Participants were followed for an average of 11.2 years. Men taking a daily multivitamin had less incidence of total cancer (multivitamin and placebo groups, 17.0 and 18.3 events, respectively, per 1,000 person-years; hazard ratio [HR], 0.92; 95% confidence interval [CI], 0.86 to 0.998; P=.04) compared to placebo.

There was no significant effect of a daily multivitamin on prostate cancer (multivitamin and placebo groups, 9.1 and 9.2 events, respectively, per 1,000 person-years; HR, 0.98; 95% CI, 0.88 to 1.09; P=.76), colorectal cancer (multivitamin and placebo groups, 1.2 and 1.4 events, respectively, per 1,000 person-years; HR, 0.89; 95% CI, 0.68 to 1.17; P=.39), or other site-specific cancers.

There was no significant difference in the risk of cancer mortality (multivitamin and placebo groups, 4.9 and 5.6 events, respectively, per 1,000 person-years; HR, 0.88; 95% CI, 0.77 to 1.01; P=.07).

Daily multivitamin use was associated with a reduction in total cancer among 1,312 men with a baseline history of cancer (HR, 0.73; 95% CI, 0.56 to 0.96; P=.02), but this did not differ significantly from that among 13,329 men initially without cancer (HR, 0.94; 95% CI, 0.87 to 1.02; P=.15; P for interaction=.07).

Researchers noted that total cancer rates were likely influenced by the increased surveillance for prostate-specific antigen and subsequent diagnoses of prostate cancer.

"Approximately half of all confirmed cancers in PHS II were prostate cancer, of which the vast majority were earlier stage, lower grade prostate cancer with high survival rates," they wrote. "The significant reduction in total cancer minus prostate cancer suggests that daily multivitamin use may have a greater benefit on more clinically relevant cancer diagnoses."

One important caveat: Naoto T. Ueno, MD, FACP, in practice at the MD Anderson Cancer Center in Houston, points out that "[T]his was studied in healthy people (no smoking, not too fat)."
Thursday, October 18, 2012

A D-Day approach to the medical history

One of the joys of being a physician is learning the patients' histories. A joy, you say? Isn't taking the history simply part of the doctoring routine? You've all been there.

When did the pain start?
What made it worse?
Did it move around or stay in one place?

I agree that inquiries like these are not intrinsically joyful, but this is not my meaning here. I refer to history here in the conventional sense. I am interested in who the patients are as people, what they did and what they saw.

It is amazing how many seemingly ordinary folks have extraordinary tales and vignettes that they are quite willing to share, if they are asked. I have a sense that they are a reservoir of wisdom that we must actively draw from, as they may not volunteer their advice.

I recall a science teacher whose prior occupation was serving as a commander of a nuclear submarine. Even years later, his secrets remained tightly held, despite my gentle entreaties. He was, to borrow a phrase, a tomb of confidentiality. Perhaps, the sedation I would be administering prior to a future colonic violation might loosen his tongue. Oh, the secrets I've extracted in the endoscopy suite! Relax, patients. What's uttered in the endoscopy suite stays in the endoscopy suite, our own version of the Vegas Rules.

Another patient, now elderly participated in a historical event that changed the world. He took a leisurely boat ride across the English Channel on June 6, 1944 reaching the shores of Normandy. I've been to beaches many times in my life, but his experience was quite different. I was mesmerized as he recalled the fear that he and his men suffered as their craft approached the French shoreline. He told me of a chilling order that he never had to carry out. If any soldier refused to leave the craft, he was to shoot him. When I was an 18-year-old, I was a comfortable pre-med student. When he was the same age, he walked through the valley of the shadow of death and, unlike the psalmist, he did fear evil.

Another patient, now a nonagenarian, was a scrawny 17-year-old kid who awoke up one morning to hear bombs bursting in air. This quiet and modest man, several decades ago, was stationed in Pearl Harbor on the date that lived in infamy. I was tingling.

Just a few weeks back, an old man came to see me wearing one of the veteran baseball-style caps that many aging vets wear. For me, these caps are a reliable sign that there will be more to talk about than just heartburn and hemorrhoids. "Where were you stationed," I asked. "Iwo Jima," he answered. You know what's coming now, readers. This man witnessed the marines raising the flag on Mount Suribachi in, perhaps, the most iconic image ever captured in American military history.

Over the years, I have related these treasured vignettes to the kids, who rightly wondered if I actually performed any medical work in the office. For the years that we home schooled the two boys, my patients' experiences became part of their curriculum whenever possible. On more than one occasion, these gracious individuals met with us so that we could hear history directly from the folks who made it happen.

Seasoned physicians may not know the answers. But, they know what questions to ask. When your doctor is taking your history, is he asking the right questions? Am I?

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.