Thursday, January 31, 2013

Questions and answers

Things have been crazy. It's much, much more difficult to build a new practice than I expected. I opened up sign-up for my patients, getting less of a response than expected. This, along with some questions from prospective patients has made it clear that there is still confusion on the part of potential patients. So here is a Q and A I sent as a newsletter (and will use when marketing the practice).

About My New Practice
Q: When will it open?
A. My office will open in January, 2013, but the exact date is still not set. I had initially hoped to be already seeing patients, but things always are harder than they seem.

Q: How much will it cost?
A. I will charge only a monthly payment which depends on the age of the patient:
$40/month for children under 3
$30/month for people ages 3 to 29
$40/month for people ages 30-49
$50/month for people ages 50-64
$60/month for people 65 and up.
There is a $50 charge for the first month for people under 40, $100 for those 40 and up.
There is a $150/month family maximum ($200 maximum for 1st month).

Q: Are there other charges?
A. As of now, there are none. All office visits and any procedures done in the office are covered by the monthly fee.

Q: How can I afford to do this?
A. I have greatly decreased my overhead by not accepting insurance and keeping my charges simple. My goal is to have 1,000 patients paying the monthly fee, which will limit the number of staff I need to hire.

Q: What will patients get for the monthly fee?
A. In addition to office visits, patients will get:
--direct access to me via phone,
--access to me through secure messaging,
--a personal health record, a health summary customized for each patient giving detailed information to help with care outside of my office,
--a personal care plan summarizing scheduled care done, due now, and due in the future,
--regular review of the personal health record and care plan to assure it is up to date,
--enhanced coordination of care with specialists, hospital physicians, and
--a health library of information for patients to answer questions when they come up.

Q: Why did I do this?
A. I get to be a doctor again (perhaps for the first time). I got tired of giving patients care that wasn't as good as it could be. I got tired of working for a system that pays more for bad care than for good. I got tired of forcing patients to come in for care I could've given over the phone. I got tired of giving time that should be for my patients to following arduous regulations. I got tired of medical records not meant for actual patient care, but instead for compliance with ridiculous government rules. Making this change gives me the one thing our system doesn't want to pay for: time devoted for the good of my patients.

Q: What makes this better for patients?
A. The main advantage is that I am finally able to give them the care they deserve: care that is not hurried, not distracted by the ridiculous complexity of the health care system, and not driven by the need to see people in person to give care. This means:
--I don't ever have to "force" people to come to the office to answer questions. This means that I will let people stay at home (or work) for most of the care for which I would have required an office visit in the past.
--I will be able to give time people deserve to really handle their problems.
--I won't have to stay busy to pay the bills, so I can take care of problems when they happen (or when they are still small), rather than having to make people wait to get answers.
--Patients won't get the run-around. They will get answers.
--I won't wait for patients to contact me to give them care. I will regularly review their records to make sure care is up to date.
--I will help my patients get good care from the rest of the system. Avoiding hospitalizations, emergency room visits, unnecessary tests, and unnecessary drugs takes time; I will have the time to do this for my patients. This should more than make up for my monthly fee.

Q: What's the advantage of patients having their records?
A. Health care is disjointed, with little communication occurring between different locations of care. Care is often done blindly, not knowing the overall picture of the patient's care done elsewhere. This means patients repeatedly answer questions about their care, care they often don't understand or remember.

My patients will have an accurate summary of their care which they can print out or bring up on their computer, phone, or tablet when information is needed. I will work with them to keep this summary up to date and as useful as possible. While others may be afraid of the consequence of patients seeing their records, I am far more afraid of the uninformed care they get when those records are not available.

Q: Will this mean patients will need to come in more often to "get their money's worth?"
A. There certainly is a risk of this happening, but my intent is to empower my patients, not coddle them. The ideal for every patient is that they spend as little time dealing with doctors and hospitals as possible. My goal will be to use my time to give my patients tools to make good decisions and stay healthy.

My old business (and the rest of the health care system) depended on people being sick or uninformed to pay the bills, but my new system has no such motivation. I can finally have the same goal as my patients: their health. I think this will ultimately save them a lot of money, and (most importantly) keep them healthy, informed, and away from doctors.

Q: What are my future plans?
A. If the business is successful, my hope is to add staff to offer more services. I hope to hire a dietician to educate my patients about their diets. I hope to hire a social worker to deal with the non-medical burden many of my patients carry. I hope to hire nurses to visit complicated patients to make sure they are taking medications properly, or to deal with small problems before they become big ones. I hope to hire a counselor to improve the emotional welfare of my patients. This will enable me to grow the size of the practice without becoming overly busy.

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.

Why doctors should write

I am a physician who writes and I think that more of my colleagues should do so. Not because we are such skilled wordsmiths or understand plot and characterization. We don't. But, we confront the human condition every day. We see pain and struggle and fear and rebirth. We have much to share.

Beyond my own profession, I think everyone should write, because everyone has something important to say and to share.

To paraphrase an old Pete Seeger song, where has all the writing gone? Long time past seen. I long for longhand. I plead for paper. I pine for a pen.

Sadly, there has been steady erosion in the craft of writing, which I attribute to the new and improved forms of communication that have supplanted the written word. In addition, folks don't simply regard writing as a worthy pursuit. Writing today means tweeting, e-mailing, texting and various other keyboard or voice activated techniques.

This progress, like many other technological advances, has exacted a cost that may be difficult to measure, but is real and it matters. Today's communications are either robotic directives, such as "board meeting cancelled," or "you're fired," or are coded messages that require cryptographers to decipher, such as TTYL and C U L8R!

Writing is intimate. It's real and it's raw. It angers and soothes.

I am so struck when I read letters written by ordinary folks in the 18th and 19th centuries, many without any formal education, who write with such grace and poignancy. Yes, they were somewhat flowery, but they conveyed warmth and feelings that can never be transmitted on Twitter. That they were written in longhand only adds to their authenticity and intimacy.

Today, on those rare occasions when I receive a signed note in longhand, it is a singular experience. I picture the writer at his desk, pen in hand, composing a personal message just for me. The writer might be delighting in the scene that will follow, when I am holding the envelope and imagining its contents. After I open the letter, I hold it in my hands and absorb its words. Afterwards, I can stash it in a drawer to join with other companions that I have received in the past. Unlike the ethereal iCloud, the desk drawer is a real, live treasure chest that I can see and touch.

Master writers from the past created their opuses in long hand and in ink. How did they do it and get it right? Today, this would be an unfathomable task. Today, students and the rest of us write and research in a very different way, cutting and pasting our way to the final draft. I recall as a high school student learning that Hemingway would tell his wife that when he was staring out the window, he was working.

I love words and respect those who use them well. When I am writing, I often wrestle to find the precise word. Is the right word stubborn or tenacious? Bossy or assertive? Timid or reserved?

While we physicians confront an enormous dose of life experiences every day, every one of us has something worth writing about. I'm sure that on any given day, we could send someone a note of love, a letter of apology, a prayer for healing or a description of an experience that moved us.

Why don't we do this? IMHO, I think I know why.

 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--Yoga may diminish afib symptoms, improve quality of life

Yoga improves symptoms and quality of life issues in patients with paroxysmal atrial fibrillation, a single-center, pre-post study found.

To put some hard numbers to the concept that exercise might provide a cardiological benefit, researchers enrolled patients with symptomatic paroxysmal atrial fibrillation into a 3-month observation period followed by twice-weekly 60-minute yoga training for next three months.

Results appeared online Jan. 30 at the Journal of the American College of Cardiology.

Among 49 patients who completed the study, yoga reduced symptomatic atrial fibrillation episodes (3.8 +/- 3 vs. 2.1 +/- 2.6, P less than 0.001), symptomatic non-atrial fibrillation episodes (2.9 +/- 3.4 vs. 1.4 +/- 2.0; P +/- 0.001), asymptomatic atrial fibrillation episodes (0.12 +/- 0.44 vs. 0.04 +/- 0.20; P less than or equal to 0.001), and depression and anxiety (P less than 0.001)

There was significant decrease in heart rate, and systolic and diastolic blood pressure before and after yoga (P less than 0.001).

Quality of life parameters as measured by the SF-36 improved, including physical functioning (P=0.017), general health (P less than 0.001), vitality (P less than 0.001), social functioning (P=0.019), and mental health domains (P less than 0.001). Researchers wrote, "This is likely the benefit from the emotionally supportive atmosphere at yoga training centers, and the positive impact by the caring relationships, change in diet and life style modification associated with yoga practice on physiological parameters cannot be underestimated."

Researchers concluded, "These findings underscore the therapeutic value of a low-cost noninvasive therapy such as yoga to effectively complement the conventional treatment strategies in improving atrial fibrillation patient care. Given the high prevalence of atrial fibrillation and costs of conventional therapy, the public health relevance of these findings is very pertinent."
Wednesday, January 30, 2013

Transitioning from fee-for-service medicine to what really works

I just read in a recent issue of "Aequanimitas," the newsletter of Johns Hopkins Osler medical service, a brief interview with J. Mario Molina, the CEO of Molina Healthcare, an organization which coordinates managed care for recipients of Medicare and Medicaid for several states. It looks like he must have been one of my senior residents when I was an intern. It sounds like he practiced for a few years before taking on the leadership of his family business.

He expressed his firm belief that medical care would soon be moving away from paying physicians for the individual services they perform and, instead, paying them for keeping patients healthy. Since it will be organizations, not doctors, who are paid for care, it will quickly become clear that paying for anything that prevents dire illness with its astronomical associated costs will benefit the whole. Medical institutions may find themselves in the business of making their communities healthy. This is not foreign to large medical organizations, but being paid well to allow patients to become sick and then taking extravagantly good care of them does encourage organizations to focus more on the acute care aspect of what they do.

Physicians perform studies about whether a given medical intervention actually works, and whether, for what it costs, it is better than the intervention it seeks to replace. We have looked at the placement of stents in coronary arteries to treat or prevent heart attacks and have gained lots of information about which kind of stents are good for which kinds of coronary disease, comparing this technology to simply dilating arteries and looking at coating the stents with drugs that encourage blood vessels to stay open. This has at least given us information upon which to base what should be cost effective care.

But what about social programs? Giving a person financial aid, to eat, obtain housing, feed children, get medical care, is presumably for the purpose of improving health and happiness. But have we actually checked? Which social programs deliver the best result for the money? Could one public swimming pool prevent delinquency and save money on jail and public assistance? Could regular access to massage therapy save money of physical therapy or prevent orthopedic procedures? Could better training to prepare a person for work reduce devastating work related injury and associated medical costs?

It will be interesting to see how we make decisions about spending "health care" dollars as the dividing line between prevention and treatment of illness becomes blurred. If a community was given all of the health care dollars presently spent on caring for its members along with knowledge of which programs or services or projects made people healthier and so less in need of expensive medical interventions, effective prevention would be funded.

It may be a bit of a trick to get data on what works. Perhaps it's time to start looking at this sort of thing more scientifically. I'm thinking about an article on the front page of the New England Journal of Medicine in some happy future time entitled, "Effect of ballroom dance classes and weekly social dancing on emergency room visits and admissions in elderly adults." Or perhaps, "Health outcome effects of regular home visits by a mobile primary care physician team." Or "Reduction in total joint surgeries in a community with publicly funded massage therapy and Tai Chi Chuan classes." The possibilities make me smile.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

Maintenance of Certification and quality: There are two sides

I had written a previous post on this subject earlier, but with two articles out this week in premier journals (the New England Journal of Medicine and JAMA), I am seeing some interesting chatter on Twitter from well-respected physicians describing the downsides of Maintenance of Certification, or MOC.

Here are two previously written blogs (#1 and #2) outlining these "downsides." It is clear to me how these physicians feel about the MOC process.

There could be many ways to discuss the issue of MOC in this blog. I will try to focus on simplicity: "for" and "against," along with literature that highlights each of these arguments.

Arguments challenging the current process of MOC
1. It takes physician's time away from direct patient care.
2. It is a "scam," due to the fact that it is very costly, with the beneficiaries of monies being the leadership of the Boards comprising the ABMS (American Board of Medical Specialties). [Interesting that this article is not referenced in PubMed, but can be found through standard non-medical search engines.]
3. It is out of touch with the current practice of medicine.
4. It has not been shown to benefit patients or patient care.

Arguments in favor of the MOC process
1. If not the current ABMS MOC process, then there exists the possibility that other regulatory agencies (such as OSHA) could dictate how physicians should practice (see quote in article by Dr. Robert Wachter).
2. There exists a correlation between higher scores on MOC examinations and quality of care. (Article 1 and Article 2).
3. Physicians who spend the majority of their time in practice, not just "academic types," validate the content of MOC examinations.
4. The farther out a physician is from training, the lower is the quality of care provided. While this seems to be a pretty harsh statement against the "there is no substitute for experience"-argument, the current literature does support this position.

I am sure that there are many other arguments for and against MOC. This blog is not intended to be a mathematical "weight comparison" of articles on the topic. My own opinion on this is simple: physicians need to engage in lifelong learning (Article #1 here and Article #2 here), under the "Practice-Based Learning and Improvement" competency.

Whatever the ideal process should be for this, I cannot say with certainty, but I would much rather have those within my own specialty, who also understand educational methodologies, regulate ongoing physician certification, rather than others that are removed from the day-to-day challenges of the current practice of medicine. The current leaders in my specialties, who dictate the regulations as they currently stand, are the ABIM and the ABP. This was summarized in my Annals of Internal Medicine letter to the editor earlier in 2012.

So what do you think about the process of MOC as a way for the ABMS to hold physicians to a standard acceptable to the public? Is it working well? If not, what could be improved?

In full disclosure, I am not employed by the ABIM or any of the ABMS boards. I personally know one member of the ABIM, from his days as a former program director. I have not written examination questions for the ABIM or the ABP. I get no royalties from the ABIM, the ABP or the ABMS, and have no stock in these companies or any of their subsidiaries.

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.

QD: News Every Day--Hour-long training session improved how doctors explained new prescriptions

Five basic elements can improve how physicians can talk to patients about new prescriptions, a study found.

An hour-long educational session for doctors improved patient ratings of how doctors explained new prescriptions, according to the controlled trial.

Doctors were audio recorded after the training session to assess how they communicated five basic elements regarding a new prescription to patients, who also received a patient information handout.

Results appeared in the Annals of Family Medicine.

In the study, 7 general internists, 6 family physicians and 14 internal medicine residents from academic internal medicine and family medicine offices at the University of California, Los Angeles prescribed 113 new medications to 82 of 256 patients from February 2009 to 2010.

Physicians were taught about five basic elements of a new prescription, medication name, purpose, directions for use, duration of use, and side effects. The session, which included role-playing, also addressed typical reasons for not doing this, such as fear of scaring patients with side effects.

The mean communication index for medications prescribed by physicians in the intervention group was 3.95 (SD=1.02) compared to control group physicians (2.86, SD=1.23, P less than 0.001), regardless of whether chronic vs. nonchronic medications were prescribed.

Counseling about three of the five communication index components was significantly higher for medications prescribed by physicians in the intervention group, as were patients' ratings of the experience (P=0.02). Higher communication index scores were associated with better patient ratings about information about new prescriptions (P=0.003).

Researchers wrote, "Interestingly, higher MCI scores also were associated with more reports of communication about topics not directly included in the intervention. For example, the intervention encouraged physicians to discuss potential medication side effects with patients, but patients also reported better communication about the risk of experiencing side effects and what to do if side effects occurred."

While not included in the study, researchers added, "This finding, however, suggests that new medication discussions which include more basic elements of medication communication are also more complete in other ways."
Tuesday, January 29, 2013

Where is the health care crisis?

So here's my beef. At the recent Forbes Healthcare Summit there was a lot of focus on speakers and vendors offering very cool new tech, from future "Tricorders" that can diagnose multiple diseases, is non-invasive, and hand-held; personal genomics, where data from your own genome is cheap and easy to get and can be integrated with clinical knowledge to produce better care; targeted therapies for various diseases, using the specific biology of a patient and her disease to design a treatment.

All of these are awesome, but really have little impact on our most pressing health care problems.

In the U.S., we manage to deliver a triple-whammy: health care that is less effective than in other nations, is only available to limited numbers of people and costs a ton. There are a number of factors that go into this, most of which are historico-cultural.

Since the end of World War II, we have insured people largely through employers, setting up a system where those who can least afford it to find insurance on the open market. Obamacare, which is largely insurance reform rather than health care reform, takes some steps toward patching this problem, but not solving it. Health care exchanges will probably make privately-purchased insurance more affordable, but when you're not making money, the price difference isn't significant.

We have social safety nets developed during the Depression and the late 60s and early 70s. These are supposed to protect our most vulnerable, and do to a degree. Medicare--government insurance for the elderly--has been wildly successful. It's relatively easy to work with, but from a doctor's and patient's perspective. But it does cost a ton, of which more later. Medicaid--public insurance for the poor--has had some hits and misses. It has managed to largely protect mothers and children, but generally leaves out any other poor people. It's also poorly-funded, something that Obamacare will try to rectify, but there will be barriers, more of which later.

We talk up prevention but we largely don't mean it. Many insurance companies and employers are starting to discover the cost-savings of prevention programs, but prevention is still less favored than treatment, and in the long run, treatment is more expensive, both in dollars and lives.

The key to many of these problems is to improve access and delivery of primary care, and to set up at least minimal care guidelines (that is, rationing). Like much of American industry, health care has been driven by capital and innovation, and has produced what earlier generations would call miracles. But these successes are outweighed by the failure to focus on the social aspects of health care, especially public health and cost.

When capital for innovation comes largely from health care costs paid for by employees and insurers, the cart has driven the horse. Innovative care gets paid for after-the-fact, without significant evaluation as to cost-effectiveness and efficacy. A new heart procedure, for example, may be found help individual patients for a brief time, but if studied long-term, may be found to be too expensive and lead to flat or poor outcomes. But we learn that after it has been implemented. The immediate results seem great, the bills get paid, and no one's the wiser. Except that we can't afford it, and patients suffer for it.

This same trend drives the urgency of doctors to specialize. Specialists get to use the new toys, the ones that make the money. There is no systematic way in the U.S. to evaluate treatments for their medical and social utility, their cost-effectiveness. The ability has existed for decades, the will has not.

Many Americans tend to be fiercely independent and suspicious of government intervention in their lives. But the only way to have real health care reform is cooperation, and probably some top-down structure.

It's true that individual insurance companies have economic incentive to cut costs. On the ground this gets very messy. Each insurance company behaves differently. If I want to get a test for a patient, the hoops I need for approval require completely different processes for each company. In the office, this leads to untenable waste, undoable work. It creates a dis-incentive for doctors to order tests, although I don't know how that plays out in real life. Limitations on care should be on the basis of evidence, not inconvenience.

Electronic health records, seen as a critical step in improving communication, prevention, and cost of care don't even communicate with each other. Rather than make data sharing easier, EHRs often create enormous, wasteful, useless records designed so that every entry meets the requirements of every insurer. Hospital discharge reports and letters from specialists have become useless and unreadable.

We have what is probably the most technology-intensive health care system in the world, and it has produced overall lousy results. Our focus should turn toward providing better, evidence-based and cost-effective care to more people. I really want a Tricorder, but I'm willing to hold off for a few decades to get our house in order first.

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.

An epidemic of gun violence

Last week I wrote about the 1st Amendment. This week I'm going to talk about the 2nd. There is an epidemic of gun violence. This is a serious health problem. Watching your diet, exercising, and taking pills is all for naught if a bullet kills you.

In Newtown, Conn., one of the worst mass shooting occurred last week when a gunman shot his mother at home, apparently with her own gun, then walked into an elementary school and shot six other adults and 20 children, before shooting himself. Gun rights are hotly debated and highly politicized, but gun violence is a serious health issue. The National Rifle Association (NRA) and others have been strong proponents of gun rights, and have fought hard to fight off attempts for even the slightest form of control, including restrictions on semi-automatic and assault weapons.

One of their arguments is that citizens can protect themselves with guns, and that concealed guns are a particularly effective deterrent because potential assailants won't know who may be armed. But in 61 cases in the U.S. in the past 30 years, maybe only one was stopped by a gun other than their own, or by the police. Even if people want guns to protect themselves, they shouldn't need to cover the contingency of an invading army, so I see no need for high capacity bullet magazines.

Many mass shooters have mental illness and we need to do a better job providing access to mental health treatments. Some illnesses, such as schizophrenia, often don't really manifest until people are in their teens or early 20s, allowing them to purchase guns when their sick enough to do real damage, but not so severe that they would have more trouble planning an attack or convincing someone to sell them a gun.

Even if not mentally ill, young men tend to act less rashly as they get older, and are more likely to consider the consequences of their actions. From a list of 22 of the deadliest mass shootings around the world, 65% of them were under 30. We already have a law that says that people can't buy alcohol until they are 21-years-old, even though they can vote and serve in the military at 18years old. Perhaps the right to own a gun should only be allowed for those who are at least 30 years old.

We need to close legal loopholes, such as sales between private buyers, that allow people to avoid background checks before purchasing guns. I need to fill out more paperwork to prescribe shoes for a diabetic than to buy an assault weapon. We need people to speak up and let our politicians know that gun violence caused by guns is not acceptable. We'll never prevent all such tragedies, but we should try to minimize the possibility as best we can.

Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington. This post originally appeared on his blog, World's Best Site.

QD: News Every Day--People informally track their health, symptoms

Nearly seven in ten (69%) U.S. adults track a health indicator like diet and exercise or a symptom such as blood pressure for themselves or a loved one, but they're doing it mostly mentally, a survey found.

Pew Research Center’s Internet & American Life Project found that:
--60% track their weight, diet or exercise routine;
--33% track health indicators or symptoms, like blood pressure, A1c, headaches or sleep patterns; and
--12% track health indicators or symptoms for a loved one.

Half of respondents track of progress in their heads. One-third track it on paper. One-fifth use a spreadsheet, website, app or device.

Overall, tracking works, the respondents said. Nearly two-thirds said tracking has led them to change their approach to staying healthy, ask a doctor new questions or to get a second opinion, or affected a decision about their illness.

The survey was done by phone among more than 3,000 U.S. adults from Aug. 7 to Sept. 6, 2012.
Monday, January 28, 2013

One-click solutions for Web 2.0 and social media for cardiologists

I was preparing for my presentation at a major medical conference in India. The presentation is on use of Social Media for Physicians. The conference is focused on mostly cardiology topics for general internists. The organizers asked me to make sure the talk was practical and could leave the attendees with some easy to follow take home points.

As always, the challenge with a presentation is knowing your audience. I did not have a good feel for this, not having attended this conference before. I struggled to select the appropriate content for the presentation. I needed to show them what was possible, and then what they could do to get started.

I decided to give them some highlights on using Google Reader to stay current with medical (cardiology) literature and use of Twitter to network with cardiologists and to get updates and insights. To make it easy for them to get started I created an OPML bundle of cardiology journal feeds and a Twitter list of cardiologists to follow. This post by Larry Husten was very helpful to get started.
Having gone through that effort, it is probably worthwhile to share these for others to use and share.

Getting your cardiology journals delivered to your doorstep:
--Get started with Google Reader.
--Then subscribe to 11 top cardiology journals with one click. (Click on subscribe).
--Go to Google Reader and all 11 journal feeds should be available at one place. These can be tagged and shared on Twitter, Facebook or Google+, Tumblr, etc., and also be searched!

Getting your cardiology fix on Twitter
--Create a Twitter account (optional for read-only mode).
--Go to the Twitter cardiology list
--View Tweets and follow the conversations and links
--Join Twitter to participate

So there you are, two quick one-click solutions to introduce cardiologists into Web 2.0/Social Media.

A conversation with @Allan Palmer on Google+ made me realize that this might have come across as a final solution for the attendees. I need to stress that this is just the first step. There are several frameworks for understanding why some people are late to adopt IT innovations. The Technology Adoption Model is based on perceived usefulness and perceived ease of use.

The Diffusion on Innovation theory by Rogers adds that an innovation must be easy to try, and its use should be visible to others (peers).

Based on these frameworks, one would seek to provide late adopters an easy to use approach to try these tools, and allow them to see other colleagues using it. Ideally one would add some hypothetical cases to illustrate the utility.

Thus for this conference, I could create an example of a patient on a statin who has questions about adding niacin to the regimen or a patient with history of coronary artery disease who is on a beta blocker and getting severe fatigue from it. These would lead to recent articles on these topics and conversations on Twitter and blog posts about these studies.

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.

Palliative care, the right to die, and ensuring that patients' wishes are followed

She was 94 years old with advanced Alzheimer's. She thought it was 1954 and asked if I wanted tea. Not a bad memory for someone in a hospital bed with a broken left hip.

She'd fallen at her assisted living facility. It was the second time in as many months. She'd broken her collarbone on the previous occasion.

Over the past year, she'd lost 30 pounds. This is natural in the progression of Alzheimer's. But it's upsetting to families all the same.

My patient was lucky. She'd lived to 94, and had supportive children who were involved in her care. Her son had long ago been designated as power-of-attorney for her health care. This meant officially that his decisions regarding her care were binding. She was not capable of making sound decisions, medical or otherwise.

The patient had been under the care of a geriatrician. His office chart told me that the option of hospice and palliative care had been discussed with the family. They were interested in learning more; the son had agreed that "Do Not Resuscitate" status was appropriate for his mother. Doing chest compressions on a frail 94 year-old is something none of us want to do.

The morning after her hospital admission for the broken hip, the medical intern called me with an ethical dilemma: "She's DNR," the intern explained. "She's having intermittent VTach on the monitor, and I fear she won't be stable enough to have the hip repaired. The family is open to the idea of hospice, but I don't know whether to treat the arrhythmia or not."

Elaine (not her real name) is one of our brightest interns. She's thinking about going into geriatrics. Situations like this are in many ways the most meaningful for doctors. Too often we stress about minutiae at the expense of the big picture; helping guide a family and patient through a period of critical illness is of true service.

"Bearing witness is our most important role," a mentor once taught me.

I came in to round with Elaine. We went immediately to the patient's room. The son and one of his sisters were there supporting their mother.

In the bed I saw a pale, thin, older woman who appeared to be lying comfortably. I asked her if she was in pain. "Would you like some tea?" she asked.

I told her she didn't look 94. She smiled. I told her she had a beautiful smile, and she smiled again.

We proceeded to discuss the medical issues with the patient's son and daughter:
--advanced dementia
--weight loss
--multiple falls
--hip fracture
--irregular, potentially unstable heart rhythm

"What would your mother want?" I asked them. "If she could decide for herself, what would her goals be?" Given her frailty, even with repairing the hip she'd never walk again.

Understandably, the concerns were about her suffering and feeling pain. At the moment, we were all in agreement that she looked comfortable. I broached the subject of not doing anything to treat the arrhythmia or the broken hip--of not putting the patient through surgery.

The son was clear. "She wouldn't want surgery," he told us. His sister agreed. Consensus! We would refer her to hospice. She'd live out her days in comfort, forgoing the indignities of further medicalization.

At that moment, the orthopedic nurse practitioner walked into the room, carrying a consent form. She approached the opposite side of the bed. Before she could launch into her speech, I cut her off. "The family has decided on hospice," I informed her. I asked to speak with her outside.

"We've only not operated on two occasions that I can remember," the nurse practitioner told me. Her comment unnerved me. Clearly we were deviating from standard operating procedure here. "If a hip's broken, we fix it," is what she was telling me.

She documented our conversation and the fact that the family had declined surgery in the chart.

I went back in the room. I asked the family if they had any more questions. Satisfied that we'd answered everything to the best of our abilities, I excused myself and Elaine. We thanked the son and daughter for their courage, and affirmed that I thought they were making the right decision to forgo surgery.

Outside the room, we debriefed about the encounter. I was very proud of Elaine's poise in a difficult patient/family situation, and how well she reasoned through the multiple options. I told her that I admired her instinct to mitigate harm to the patient by not over-medicalizing the situation, as many would have done since it's almost always the path of least resistance in the hospital.

Alas, we congratulated ourselves too soon.

The next morning I came in to round. The patient's name was still on our list.

We went to her room. She wasn't there. But the bed was missing, too.

After the fact.

"Did the patient in 1214 get transferred to hospice?" I asked to no one in particular outside her room.

"She's in the OR," said the ward clerk.

What the fuck?

I was furious. A patient whose dying wish was to be made comfortable, at 94 with dementia, severe weight loss, who'd never walk again, had been "taken" to the operating room, possibly against her family's wish to have her broken hip "pinned?"

How had this decision been made? Who'd made it? And why the fuck had nobody talked to me about it? As the attending physician, I was legally and ethically responsible for the care of the patient.

I called the OR. I got the surgeon on the phone. "This patient had an advance directive. Her son, who's her power of attorney, wanted her to go to hospice. What's she doing in the OR?"

"I'm just covering my colleague," came the reply. "He consented her. I'm just going to "pin" her hip, not repair or replace it. Please clarify this with the family and let me know what they want to do--as soon as you can--she's already on the table and the spinal's been administered."

Great. The train had not only left the station, it was already hurtling down the tracks. I did not appreciate the "covering" surgeon's passivity. He was just doing what he'd been told. Hey, fella-how about taking some responsibility to clarify and verify things before cutting on anyone? Did it strike you as weird to take an emaciated, demented 94 year-old to the operating room?

Apparently not. Not at all. I remembered the nurse practitioner's bizarre comment from the day before: "We've only not operated on a broken hip twice." Is that because those patients were already dead?

I found the family in the surgical waiting area. Oddly, it was the patient's other two daughters, not the power-of-attorney son and nurse daughter with whom I'd spoken the day before.

"Did you and your siblings consent to this procedure?" I asked them. "Yesterday your brother and sister told me that they wanted no further intervention; they wanted your mother to go to hospice to live out her remaining days in comfort."

"Well, yes," one of the daughters told me. "They told us it's a minor operation and will just "stabilize" things before she goes to hospice. They warned us that she'd be in pain any time she moved, and we didn't want that. Isn't this the right thing to do?"

With all my soul I wanted to scream at her, "Let your poor mother die! Why on earth would you subject her to this ridiculous "operation" and spinal anesthesia? And what the fuck kind of surgeon comes by after the decision has been made and brainwashes a poor family into an unnecessary operation and doesn't have the courtesy to discuss the "plan" with the attending physician?"

But I didn't say that.

She needed my support. "Well, this is among the most difficult situation anyone ever faces," I said. "There's no right answer. For some people, NOT doing surgery would be the right decision. For others, a sense of fixing what's broken will seem like the right course of action."

I asked the two sisters if their brother and other sister had agreed with this. I was surprised that they weren't there at the scene. Perhaps the power-of-attorney brother who'd made a resolute decision a day earlier based on what his mother would have wanted had changed his mind. Perhaps he'd felt guilty disagreeing with his sisters, and wanted consensus above all else. Perhaps it really was a "minor" procedure and the right course of action to mitigate the mother's suffering.

But I'd seen her in her bed. She'd smiled at me. She'd discussed having tea. She wasn't writhing uncomfortably or looking in distress.

I was angry. Had the consenting surgeon simply seen dollar signs? No broken hip goes unfixed? He's a hammer and the patient was a nail?

Let me take the high road: Maybe he genuinely believed that pinning the patient's hip would improve her quality of life in the days she had left. Maybe he had some evidence I'm unaware of that pinning hips in demented 94-year-old patients is the most efficacious plan of action. All bow down before the gods of evidence.

But he should have spoken with me. As a colleague. As a professional. As the one responsible for the patient's care. Maybe he could have persuaded me that this was the right thing to do. Maybe he'd have even turned the tables and shown me that I was the one being inhumane. After all, how "right" is it to send a feeble old woman to die with a broken hip?

It's too bad for all involved here that his thought process was not made transparent. He and I will clearly be having a conversation, likely with hospital administration in attendance, about what happened here. This is a conversation we should all be having.

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--New norovirus strain hits Americans in the gut

A norovirus strain from Australia has led to an outbreak in America, the CDC reported.

GII.4 Sydney has since caused acute gastroenteritis outbreaks globally. In the United States, this strain caused 141 (53%) of the 266 norovirus outbreaks reported from September to December 2012. The other outbreaks were caused by 10 different GI and GII genotypes, including GII.4 New Orleans, the previously dominant strain.

The Centers for Disease Control and Prevention reported on the new strain's progress in MMWR.

The CDC noted that the trend was statistically significant, with four (19%) of 21 outbreaks in September 2012; 22 (46%) of 48 in October 2012; 70 (58%) of 120 in November 2012; and 45 (58%) of 77 in December 2012 (chi-square test for trend, P less than 0.01).

Most (72 [51%]) of these GII.4 Sydney outbreaks resulted from direct person-to-person transmission; 29 (20%) were foodborne, one (1%) was waterborne, and the transmission mode was unknown in 39 (28%). Long-term-care facilities and restaurants were the most frequently reported settings, accounting for 91 (65%) and 18 (13%) of the outbreaks, respectively.

GII.4 noroviruses are the predominant cause of norovirus outbreaks, and the GII.4 Sydney strain appears to have replaced the previously predominant strain, GII.4 New Orleans. Compared with other norovirus genotypes, GII.4 noroviruses have been associated with increased rates of hospitalizations and deaths during outbreaks.

"Health-care providers and public health practitioners should remain vigilant to the potential for increased norovirus activity in the ongoing season related to the emergent GII.4 Sydney strain," the CDC noted.

Proper hand hygiene, environmental disinfection, and isolation of ill persons remain the mainstays of norovirus prevention and control.

The CDC report noted that new GII.4 strains emerge every 2 to 3 years, usually leading to an outbreak.
Friday, January 25, 2013

If online learning is the answer, then what is the question?

I have written about massive open online courses (MOOCs) before, once wondering whether disruptive innovation was finally coming to higher education and then further noting that a colleague was creating a MOOC from the materials of the ONC Health IT Curriculum. (I am pleased to report that the MOOC is making good progress.)

MOOCs also have attained quite a bit of discussion as part or all of the solution to the problem of runaway costs of higher education in the United States. The New York Times has called this year the Year of the MOOC, while others wonder if this is finally the time that Silicon Valley-style disruptive innovation will come to higher education.

I have skin in this game in a number of ways. One is that I direct a large graduate program in a public health science university that has minimal government financial support, i.e., the program is mostly dependent on tuition, training grants, and other sources of funding. This graduate program is in an academic department that I chair that is likewise being asked to achieve increasing fiscal self-sufficiency in all its activities.

I am also reaching the end of a well-funded project to develop a health information technology (HIT) curriculum for colleges and universities. In addition, I am the parent of two children, one of whom recently completed a bachelor's degree and the other who is still in undergraduate studies but planning further education beyond her bachelor's degree, both in public state universities. And of course, I am a U.S. citizen concerned about my country's long-term fiscal solvency while maintaining economic competitiveness through a highly educated populace.

To some, MOOCs are seen as a way to reduce the costs of higher education, which is under increasing scrutiny to demonstrate its value. Based on my own experience with distance learning, I am optimistic that online education can be efficient and scalable. Although I do not find myself in agreement with many of the political positions of Texas Gov. Rick Perry, I admit to having sympathy for his challenge to higher education to create a $10,000 bachelor's degree.

That said, I recognize that online courses alone do not an education make, especially a college education. College is also about maturation, participating in non-academic activities, and developing skills beyond just mastering of knowledge, such as leadership, mentorship, volunteerism, and more. I have no doubt that MOOCs can replace the kind of large lecture classes I took as an undergraduate at the University of Illinois, i.e., the "101" classes. But I am less convinced they can replace the smaller courses, the hands-on experiences, the volunteer activities, and so forth.

As enthusiastic as I am about the use of educational technology, I do not see online courses alone comprising the entire educational experience. Even in our online graduate program, we encourage networking and participation in professional organizations among our students. We have created a practicum and internship program that allows even our remote students to get real-world experience. A "distance education" in our program is not just a succession of online courses. Our students are engaged in a virtual community with us.

At the same time, I also worry that low-cost college education may create a two-class system, one of children of parents with the means to afford a four-year in-residence college education and all of its benefits, and the other of students whose college experience is mostly impersonal. I believe we need a balance.

Another interesting aspect about MOOCs and other online repositories of educational materials is the notion of "openness." I was prodded into thinking about this by some from the Office of the National Coordinator for Health IT (ONC) who want to see the curriculum be maintained in some open, perhaps crowdsourcing, project. This made me realize that MOOCs and similar initiatives are open in the sense that they are accessible to many people. But the openness is only one-way, i.e., the rest of the world cannot alter the "open" materials.

That is not necessarily a bad thing. Phenomena like Wikipedia not withstanding, I believe there is a role for materials that have authorship and authority. The Web facilitates their annotation, but not their underlying alteration. Even Wikipedia and the myriad of open-source software projects have found a need for governance. I relish the idea of everyone in the world annotating the ONC HIT curriculum, but I am less enthusiastic about everyone in the world updating the source materials.

Notwithstanding my concerns, I am excited to play a small role in the disruptive innovation of higher education through my own work. But I also know that MOOCs are not the complete solution. I envision a future where students are wedded to an educational institution, but have the flexibility of online learning and the ability to have some of their learning come from other teachers and institutions. Perhaps that is why initiatives like Semester Online, where 10 universities are sharing courses among each other, with appropriate transfers of academic credit and tuition money, will survive if MOOCs turn out to be a passing fad. We can probably learn from systems like the European Credit Transfer System (ETCS), which standardizes credits for higher education and allows their transfer across educational institutions.

I hope we can achieve a happy middle ground of making the best use of the dissemination and collaboration afforded by the Internet while still recognizing the value attachment to a real institution of higher learning. I also believe the cost of higher education can be reduced, but as former Harvard President Derek Bok used to say, If you think education is expensive, try ignorance.
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--10 recommendations for 10 years to cut $2 trillion from health care costs

Strengthening primary care and adjusting reimbursement to cover high-value care of complex patients could cut $2 trillion from health care costs in the next 10 years, according to policy analysts.

The Commonwealth Fund published its findings in a white paper.

The savings would total $1 trillion for the federal government, $537 billion for households, $242 billion for state and local government and $189 billion for employers.

For the federal government, net savings would easily offset the 10-year costs of the sustainable growth rate (SGR) formula, the white paper stated. The "major winners" would be households, which would have lower insurance premiums and out-of-pocket costs, the report said.

The 10 steps are:
--Revise Medicare physician fees and methods of updating payment to pay for value;
--Strengthen primary care and support care teams for high-cost, complex patients;
--Bundle hospital payments to focus on total costs and patient outcomes;
--Adopt payment reforms across public and private payers;
--Offer Medicare beneficiaries a new "Medicare Essential" plan that provides more comprehensive benefits and better protection against catastrophic costs and includes provider and enrollee incentives to achieve better care, better health, and lower costs;
--Provide incentives for Medicare and Medicaid beneficiaries to seek care from high-value, patient-centered medical homes and other systems;
--Enhance information on clinical outcomes of care and patient experiences to inform treatment decisions and choices of providers and care systems;
--Simplify and unify administrative policies and procedures across public and private health plans;
--Reform medical malpractice policy and link to payment in order to provide fair compensation for injury while promoting patient safety and adoption of best practices; and
--Establish spending targets.

"U.S. health spending has been growing far faster than wages and putting stress on families and businesses as well as federal and state budgets," said Commonwealth Fund president and Commission chair David Blumenthal, MD, MPP, FACP. "We know that by innovating and coordinating care, our health care system can provide better care at lower costs. The Commission report lays out a framework and set of strategies to accelerate innovation, with the potential to substantially lower federal costs while protecting Medicare and Medicaid beneficiaries."
Thursday, January 24, 2013

Should drug reps be mute on off-label drug use?

Am I an apologist for the pharmaceutical companies? I don't think so, but others may disagree based on some sympathetic Whistleblower posts that have appeared in this blog. It is without question that the drug companies have been demonized and portrayed as rapacious gangs of greed who seek profit over all. Haven't you come across the pejorative term, Big Pharma? (Linguistic note: The adjective 'big' means evil.) Consider:
Big Oil
Big Government
Big Tobacco

Get the point?

I'm not suggesting that the pharm guys and gals are all Eagle Scouts. These companies operate to make money, just like car companies, the cosmetic industry, the airlines, banks and financial institutions, hospitals, manufacturers, the hospitality industry and retailers throughout the land.

Here's a bold Whistleblower pronouncement: There is nothing evil about making money.

Of course, I want our drugs to be safe and effective. We need the Food and Drug Administration (FDA) to provide oversight to protect the public interest. I acknowledge that the industry needs external review and enforcement powers to keep the industry responsible and accountable. There's a reason that professional football games need referees. Somehow, I don't think that the honor system on the gridiron would be sufficient. Players cannot police themselves.

But some of the constraints that drug companies face constitute unnecessary harassment that does not protect the public interest. Pharmaceutical representatives, or drug reps, are prohibited from discussing off-label use of their drugs with physicians. ("Off-label" refers to a medicine being used for a purpose not officially approved by the FDA.) I've always felt that this edict was silly and stifled communication between physicians and reps. Yes, some drug reps have aggressively marketed their products for off-label use. GlaxoSmithKline and Johnson & Johnson paid handsomely for committing this offense.

But, there is a clear difference between misleading promotion and honest communication. If I question a drug rep about off label indications of a drug, a straightforward response harms no one. In fact, it may give me new knowledge that I could use to help a living and breathing patient.

Relax, patients. I am well aware that pharm reps are sales folks and are not my primary resource for pharmaceutical education. But good reps have deep knowledge of a very narrow medical issue--their products--and often know stuff that I don't. They may, for example, know of side effects of their medicines that are not widely known.

Keep in mind that most of the medicines that we physicians prescribe are off label, which is entirely proper and is acceptable to the FDA. At present, the only folks in the country who can't discuss off-label use of drugs with me are the reps.

Recently, a federal appeals court set aside the conviction of a drug rep concluding that his marketing a drug for off label use was permissible under the freedom of speech doctrine. This ruling only applies to the region under the jurisdiction of the Second Circuit, but this will not be the last legal word on this issue. More details appear in the New York Times piece that reported the decision.

Where should the line be set here? I'm not sure, but I think the current FDA boundary is overly restrictive. We need a dose of leniency and a tincture of common sense from Big FDA.

 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.

An empirical scientific viewpoint about gun control

For just a moment, let's take a scientific viewpoint about gun control here and try to leave emotions (and the Constitutional argument) out.

The best type of study to determine whether gun control and/or regulation would be a Randomized Trial: randomizing a state or country to regulation or not.

Since that's not going to happen, the next best type of evidence we have to go by is observational, either case-control or cohort studies. The exposure is: gun control regulation. This could be considered dichotomously (yes/no) or continuous (level of regulation from strict to lenient/none).

The outcome is: death by guns. This could be considered in numerous ways: absolute numbers of gun deaths annually; relative numbers of gun deaths adjusting for size of population; number of gun massacres, etc. We could even consider any violent deaths, if you want to be more general.

In a case-cohort study, we'd look at the outcome first (let's say, massacres) and look backward for the exposure, then calculate an odds ratio that the outcome was significantly associated with the exposure.

In a cohort study, we'd look at the exposure first, looking at level of gun control as a continuous variable. This could be done retrospectively or prospectively. As of now, we could only do this retrospectively. Then look for the outcomes (deaths, massacres, etc.), and determine a risk ratio that the outcome was associated with the exposure.

Either way, the data would indicate that countries with increased exposure (increasing regulation) is associated with a decreased odds/risk of the outcome (fewer deaths, massacres).

Please note that I did not say that increasing regulation caused fewer deaths, just that it was associated with fewer deaths.

Now, I do not have numerical data, so I am only going on what I understand to be true, the empirical data. If those who would not believe this to be true, the best way to deal with this is to show data that decreasing the exposure to gun regulation (i.e., increasing the populace's ability to acquire firearms legally) is associated with fewer gun deaths.

Therefore, my preference is the following: until evidence (not raw emotions, beliefs, or Constitutional Amendments) that decreased regulation (including eliminating gun zones) results in decreased odds/risk for the outcome (gun death) is found in other countries, then there is no reason to accept the notion that we need to stop advocating for strict gun control. For that matter, stricter gun control has evidential support (even if not emotional support among some) and should be advanced.

If you choose to comment on this in the opposite direction, please think before you do. The anecdotal evidence currently being provided by those who would oppose stricter regulations is purely speculative. I am open to hearing the data to refute the above contention, but it needs to be at least as strong methodologically. In other words, "case reports" (testimonials by individuals) or "case series" (testimonials by groups, including lobbyists) are weaker forms of evidence scientifically, and I will not consider them as valid as the comparative empirical data I have put forward as an argument.

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--Easing transitions from hospital may lower rehospitalizations

Quality initiative related to transitions of care were associated with lower rehospitalization rates, but not with reductions of rehospitalizations as a percentage of hospital discharges, which is the more frequently used measure, a study found.

Researchers examined results of 14 intervention communities and 50 comparison communities from before (2006-2008) and during (2009-2010) implementing the quality initiatives.

Results appeared online Jan. 22 at JAMA.

The researchers found that the 14 intervention communities had an average reduction of 5.70% in rehospitalizations per 1,000 and of 5.74% in hospitalizations per 1,000 for fee-for-service Medicare beneficiaries over the 2-year intervention period. During the same period, the 50 comparison communities had a 2.05% mean reduction in rehospitalizations and a 3.17% mean reduction in hospitalizations.

Researchers noted that rehospitalizations as a percentage of hospital discharges did not change during the study period, with a difference of 0.06% in the intervention communities and -0.16% in the comparison communities.

And editorial summarized this and two other related studies, and noted that hospitalists, emergency physicians and others have long seen patient care become spread among an increasing number of subspecialists.

"This has likely been driven, at least in part, by the marked expansion in the number of subspecialists, who now outnumber primary care physicians by about 2 to 1," they wrote. "Medicare beneficiaries and their families must navigate seeing a median [midpoint] of 2 primary care physicians and 5 specialists during a 2-year period, and about one-third change their assigned physician from one year to another. This fragmentation escalates as patients approach the end of their lives with numerous physicians involved in a patient's care."
Wednesday, January 23, 2013

In the wake of marijuana legalization, what exactly are the health risks?

Colorado and Washington states have legalized the recreational use of marijuana. I thought this would take longer to legislate, especially with the recent backlash from the federal government about medical marijuana. Eighteen states (including California, Alaska, Vermont and Oregon) allow marijuana to be used for medical reasons, but have restrictions on which conditions can be treated, which don't necessarily correlate perfectly with the diseases for which it is effective. I have worked in a state that doesn't allow legal marijuana use for anything, but have seen patients from neighboring states who did use medical marijuana and have tried to stay abreast of the laws and issues surrounding use.

Marijuana is relatively nontoxic. Nobody has ever died of overdosing on marijuana, though it is theoretically possible. Combining marijuana with other drugs can lead to overdose death, and combining marijuana with driving or other activities which require fast reaction time has undoubtedly resulted in trauma related death. Still, the chemicals, including tetrahydrocannabinol, which cause marijuana's high and helpful effects, are mostly not terribly harmful.

Marijuana can be smoked, in which case its effects are noticed quickly and last for 2-3 hours, or taken orally, in which case effects can be delayed for hours and can persist for quite a long time as the drug is more gradually absorbed. Smoking is a particularly good delivery method from the standpoint of a pharmaceutical because of the quick onset which means that a person is more able to accurately judge the appropriate dose, titrating to the desired effect.

Mentally, marijuana can cause anxiety and even paranoia. Usually, though, it is more likely to be sedating than anything else. It can cause euphoria and perceptual distortions. It interferes with formation of memory, which makes it a bad choice for students. It is often good for treating anxiety and sleeplessness, is especially good for nausea and relieves various kinds of pain, including the pain of fibromyalgia (a brain related sensitization to bodily pain with associated symptoms of sleep disorder, irritable bowel, headaches and sometimes confusion) which is difficult to treat with other pain medications. It can significantly reduce the need for opiate pain medications in patients with chronic pain, and opiates really can kill people. It is also potentially inexpensive, or free if people grow it themselves.

Physically, though, marijuana is not without drawbacks. It definitely increases appetite, which can be good in the setting of chronic illness, but can also lead to obesity. It causes men to grow breast tissue if it is used regularly, though the mechanism of this is not clear. This is primarily observational, but will probably be studied more as marijuana use becomes more common and legal.

Marijuana, when smoked, does not appear to cause lung cancer or chronic obstructive lung disease, in fact it seems to be associated with increased lung capacity in regular users. There is an uncommon disease, usually of young men, called cyclic vomiting syndrome, in which patients suffer days of vomiting with intervening periods of normal gut function. This appears in many cases to be due to marijuana use, and is not limited to heavy or regular use.

Marijuana is one of the many drugs that can cause pancreatitis, an inflammation of the digestive and insulin producing organ that can be painful and can eventually become chronic. It appears to be a very rare cause, though, and most people who develop this get it from alcohol abuse. There are physical symptoms of cannabis use, including conjunctival redness and increased heart rate, and there are withdrawal syndromes in regular users, including yawning, excessive sleepiness and panic attacks.

All in all, from a medical standpoint, is probably a good thing that marijuana is legalized. Patient who are presently dependent on physicians for opiate prescriptions might be able to be transitioned to marijuana, which would at least not kill them. When it becomes more practical to study marijuana's medical effects, there will be more evidence of both what it is good for and when its use should be discouraged.

It is, of course, still a mind altering substance and people will need to learn how to use it responsibly. Significantly more people will probably use marijuana when they can do so without legal repercussions and physicians will probably see more issues with dependence and habitual use. This is probably an excellent time to begin to study the social and medical consequences of having a very popular and powerful chemical more generally available.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

Making the most of the iPad Mini on rounds

On my birthday several weeks ago, I was lucky to get an iPad Mini from my husband. I already have an iPad and have shared my experience. In fact, we gave all of our residents iPads (one of them contacted Steve Jobs and got a response), and documented an improvement in efficiency on the wards. So why the Mini? What is all the fuss? Well, after finishing two weeks on service, I can finally tell you why the Mini is the new must-have for doctors and future doctors.

1) It fits in your white coat! Yes, while there were entrepreneurs who started creating the iCoat, the truth is who wants to wear a coat with a huge pocket on the side? This means that you also don't need to wear the "strap" that we require our residents to wear for the iPad since we did not yet invest in the iCoat.

2) You can hold it in one hand! This for me is the best part and very underappreciated point in the blogs and reviews I have read. This means you can tough the screen with one hand while you are palming it with the other. I don't even have the largest hands so I would say it definitely was just at the reach of my palm grasp but I can imagine it would be perfect for my male colleagues.

3) It fits in your purse! While the female docs may find palming the iPad mini not as easy as the men, never fear ... since this one is for the ladies. Many female doctors are always on a quest to find the right handbag/workbag combination. Owning an iPad always meant buying boxy "folio" type purses or shoving it to barely fit in a handbag. The mini is the perfect size for a medium size handbag, either hobo or satchel styles. This means that you can go from day to night without carrying your "work bag" to the restaurant. And for the men out there, you can always get a "murse" this holiday season. I hear that they are making a big splash.

4) You'll carry it more. Number 1 through 3 really boil down to the fact that it is hard to carry the iPad. Because it is so easy to carry, you won't find yourself without access to the electronic health record or paging directory. You may be more apt to show patients their images or X-rays or look something up because it is not as hard to use.

5) You'll make friends. Basically the minute I brought out the Mini, everyone, nurses, social workers, residents, students, and yes patients, were interested in seeing it. "Mini envy" as my students called it. It's a conversation starter that can improve collegiality and teamwork. When I visited floors that I did not usually work on (overflow patients), I met a nurse who asked me about the Mini, and the next day, she came to our rescue when we were trying to decipher the timing of a patient's medication and a potential new allergy.

6) It is more discrete to use at a conference (once everyone stops staring). The Mini is smaller so a bit more stealth in terms of answering a text page or checking a lab while you are sitting in case conference, and you can easily stash it back in your purse as noted above.

Some things to think about. The Mini is not without its pitfalls, many of which are predictable due to its size and interface.

1) For the visually challenged, it can be hard to see. Sure, you can always "magnify" things with the correct gestures. But, if you are in your Citrix Client looking at your electronic health record, it may not be so easy to magnify and you may have to hold it up closer to your face which can be awkward. Maybe I just need to get my vision tested? Either way, it's something to be aware of.

2) Easy to lose. As part of the residency program project, the nice thing about the iPad with strap is you can see it on the resident and its harder to walk off with. The Mini could disappear in a snap. Could someone even "pick-pocket" a doctor coat? Very possible.

3) It is not a complete substitute for a workstation or pen and paper. This is not unique to the Mini. There is a reason that mobile tablet computing is not a complete substitute for a workstation, the lack of a keyboard. As a result, some our residents carry "paper notes" with their iPad. The paper notes are to take notes of the to-do list that is created on rounds. Nothing like checking all those boxes off as an intern. The iPad does not replace that so readily, and while there others thinking about this space, it's worth noting that the preference for pen and paper to organize one's thoughts is very strong. I have to admit, watching the catchy commercial for the Windows Surface, there is still something so appealing about an external keyboard.

So what is the verdict for the Mini? Well, as we say in medicine, the risks of the Mini are outweighed by its benefits making it the perfect prescription for all the physicians or physicians to be in your life.

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--Hearing loss associated with cognitive declines

Hearing loss is independently associated with faster cognitive decline and more incidence of cognitive impairment in older adults, a study found, and the rates of declines were associated with the severity of the loss.

Researchers conducted a prospective observational study among nearly 2,000 older adults (mean age, 77.4 years) without cognitive impairment (Modified Mini-Mental State Examination [3MS] score, 80 or more). Hearing was defined at baseline and cognitive testing by the 3MS and the Digit Symbol Substitution test were done over a period of 11 years. Cognitive impairment was defined as a 3MS score of less than 80 or a decline of more than 5 points.

Results appeared Jan. 21 at JAMA Internal Medicine.

The nearly 1,200 people who lost hearing had annual rates of decline in 3MS and Digit Symbol Substitution test scores that were 41% and 32% greater, respectively, than those among individuals with normal hearing.

Compared to those with normal hearing, individuals with hearing loss at baseline had a 24% (hazard ratio, 1.24; 95% CI, 1.05-1.48) increased risk for cognitive impairment. Rates of cognitive decline and the risk for incident cognitive impairment were linearly associated with the severity of an individual's baseline hearing loss.

Researchers noted that those who lost some hearing would require 7.7 years to decline by five points on the 3MS compared with 10.9 years in individuals with normal hearing.

"Our results demonstrate that hearing loss is independently associated with accelerated cognitive decline and incident cognitive impairment in community-dwelling older adults," the authors comment. "The magnitude of these associations is clinically significant, with individuals having hearing loss demonstrating a 30% to 40% accelerated rate of cognitive decline and a 24% increased risk for incident cognitive impairment during a six-year period compared with individuals having normal hearing."
Tuesday, January 22, 2013

The great and powerful

Well, I did it. It wasn't easy, but I did it. But that comes later.

Yesterday, Forbes sponsored a Health Care Summit. It was a fascinating day-long conference featuring some of the most innovative minds in health care, policy, and technology, especially in the private sector. And me.

The tech stuff was very, very cool, but probably doesn't actually address the immediate needs of the health care system--delivery of better, more cost-effective care to more people. But it was an interesting glimpse into the future.

I got to ask Gov. Rick Perry of Texas a question during Q&A. Steve Forbes interviewed him about a health care boom in his state. Gov. Perry is a pretty impressive guy. He's tall and thin and folded himself into his chair a bit like a mantis, all angles and articulations. And I could see why a presidential run might not have suited him. Aside from the fact that I disagree with nearly all his policy ideas, he sat very much like a person with chronic back pain, one hand bracing him on the arm of the chair. I'd imagine Jack Kennedy looked similar, a mixture of pain, intelligence and charm.

But Perry is no Jack Kennedy. He emphasized his state's ability to attract doctors and researchers through tax cuts, tort reform, and other classically Republican economic ideas (not that I'm gonna complain about tort reform).

So I asked him, "Governor, what percentage of all of these doctors coming to Texas are primary care docs? Because we have a shortage. Only 4% of American medical grads choose primary care, mostly for economic reasons. How will you get PCPs down there?"

He admitted he didn't know much about the numbers, but that he was considering incentives including paying for education in exchange for service. This has always been a good idea, but our system doesn't make it worthwhile. Almost any specialist can make enough in a short period of time to pay off their loans, so unless you are drawn to primary care strongly enough, the economics don't work out.

Still, the dude answered the question directly. Maybe his policies help the Texas economy, but they aren't going to scratch the real health care problems. Like most policy makers, he doesn't seem to understand where the real problems lie.

I had a great conversation, which I hope to continue, with the President of the Joint Commission, Mark Chassin. I learned a ton about the Commission I hadn't known. For the non-medical peeps, the Joint Commission is a private entity that accredits U.S. hospitals, assessing them for safety, quality, etc. A failure to pass a JACHO inspection is a very, very big deal, and when they're in the house, entire hospital staffs tend to lose their shit.

To those of us on the ground, many of the JCAHO policies seem insane (and many of them probably are). Hospitals will prepare docs by giving them copies of the institution's "mission statement" so it can be dutifully recited to inspectors.

What concerns me more than mission statements is quality. We had a little chat about initiatives that JACHO has offered hospitals to, for example, make transitions from hospitals to home or nursing homes safer. Right now, when a patient of mine leaves the hospital, they, and I, get a many-page discharge document that no normal person could ever understand (and I include myself in that category).

Much of the reason for this sort of thing is hospital efforts to meet JCAHO and Medicare standards, standards that are often confounded with each other, an effort that is usually ham-fisted and non-sensical. It's not supposed to be that way.

As I gather my thoughts, I hope to share with you more from the conference, but first …

The night before, Steve Forbes hosted a reception at his offices. The surprise of the evening was an appearance by Dr. Mehmet Oz, one of the most disruptive forces in medicine, and someone who in my opinion, confounds sideshow barker nonsense with real medical science. He gave what was supposed to be an inspirational talk, but really, he just rambled from topic to topic, often contradicting himself. And everyone was starstruck.

It seems famous people like other famous people for being famous. I cannot think of a thing Dr. Oz has to offer American health care, other than his retirement from public life. But they flocked to him in the low-ceilinged gallery, jostling each other in the close space as if fighting for a New York cab, the kind that's never around when you need it.

I blame David Kroll for egging me on. I nudged slowly through the crowd of admirers and introduced myself, as a "fan and a critic." I told him I was a fan of his ability to communicate, but that my patients don't bring to me the message he thinks he's delivering. They would rather find some raspberry ketone than exercise and eat better.

"I don't sell any products. People use my image. Blah blah."

I thanked him for his time and nudged my way back out of the crowd.

The telling moment for me was during his speech. He closed with a joke, about a patient who had made use of a ton of "complementary medicine" during her hospital stay. When confronted with the bill, she replied, "but it's complementary!

That's not funny. Health care is expensive, people struggle to pay their bills and are terrified for their lives. To joke about billing them for services that are worse than useless, like reiki and acupuncture, is cruel and shows a lack of compassion.

But I got my say. As my dad says, "I don't think he'll lose any sleep over it."

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.

Hillary Clinton and brain injuries

Secretary of State Hillary Clinton was hospitalized with an initial diagnosis of a subdural hematoma after fainting, hitting her head and suffering a concussion. Later reports show she may have had a venous blood clot in her brain, rather than a bleed under the skull known as a subdural hematoma. The treatment is quite different as venous thrombi (clots) are treated with blood thinners.

Here is a repeat of a blog I did a few years ago about "a bump on the head."

Even a minor blow to the head can lead to serious trouble. A close relative of mine is an active, sharp guy in his 80s. He was hospitalized a few weeks ago with an infection and like many older folks, he wasn't aware of how weak he was and he tried to get out of the hospital bed and go to the bathroom and "whoops," he slipped and fell. Hospitals all have procedures in place to prevent falls and they monitor the number of patient falls and try very hard to get to zero. But, try as they do, falls happen. OK, he got a bump on the forehead and a bruised shoulder but, fortunately no broken bones.

Fast forward 4 weeks. One weekend Allen was slurring his words and not walking well. You would think they would rush to the hospital to get things checked out, but they decided to wait and see if he was better the next day. This is a huge mistake. In a prior post I wrote about stroke and the need to seek immediate attention for any change in speech or one sided weakness. I am always surprised at how many patients do not seek medical help and instead wait to see if things will improve on their own. Ten out of ten times, symptoms like this do not improve.

Allen and his wife finally went to their doctor and he was immediately admitted to the hospital. A computed tomography (CT) scan revealed a large hematoma on his brain. The fall that occurred several weeks earlier had caused bleeding around the brain. Blood vessels can be damaged when the skull receives a blow, especially when the head hits a hard surface like the pavement. A hematoma is caused by a bleeding vessel and a subdural hematoma occurs when blood collects in the small space between the brain and the skull. The blood clot presses against the brain and the resulting pressure can severely damage the brain unless a neurosurgeon removes the blood. Fortunately, blood and blood clots are easy to detect with a CT scan.

After the subdural hematoma was diagnosed, Allen was rushed to surgery and the blood clot was removed. He has a large "s" shaped scar where the skull was removed (and replaced) and he is now home and doing great. His speech is back to normal and he continues to improve each day. Without surgery, Allen would not have made it. It is always nice when a story has a happy ending.

There are several take home messages here:
1. Any sudden change in speech or weakness or trouble walking needs immediate attention at the emergency department of the closest hospital.
2. Any fall that causes facial bruising or loss of consciousness needs evaluation.
3. Any time the head smacks against a hard surface, there is a chance of brain trauma because the brain can strike the inside of the skull.
4. Symptoms can show up weeks after trauma so don't ignore changes in personality or behavior, especially in older folks.

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.