American College of Physicians: Internal Medicine — Doctors for Adults ®

Wednesday, January 16, 2013

Evidence based medicine--but which evidence?

In the last year I've become more and more comfortable using online resources to determine the best treatments for the diseases I see. My favorite site is UpToDate, which has experts write articles that review the literature and share their experience to produce very readable background information and succinct recommendations. UpToDate is expensive, but most hospitals that have computer systems also have subscriptions to it, so it's easy to access when I am reviewing labs, tests or other data.

I've also been impressed with the American College of Physicians PIER (Physician's Information and Education Resource) which is available to me as a member of the ACP and has links to new articles and practical recommendations. It is less exhaustive than UpToDate. For instance there is no specific article dealing with Brucellosis (a cattle related infectious disease), but very easy to use and right up to the minute. For absolutely free I can use Medscape, as can anyone reading this, and articles there are also well written and frequently updated.

Mostly there is pretty good agreement among the different sources, but occasionally not, and often UpToDate does not include up-to-date information and fails to address controversy. Even when it does, it is sometimes dismissive, saying that a certain therapy "cannot be recommended." That sure carries more weight than "The authors have a bias against this because we haven't done it much" or "This is very promising and other physicians use it with good results but we don't."

Even though there are oceans of studies on any given subject, sometimes the studies are poorly done or don't address the most important questions. Sometimes apparently well-done studies turn out to be wrong when they are replicated. Sometimes new data is just too counter-intuitive to be adopted right away. Nevertheless, on several subjects I have been disappointed by both PIER and UpToDate.

Acute pancreatitis is a very painful inflammation of the pancreas, a digestive organ filled with really nasty juices which leak out and cause damage to surrounding tissues. The most common cause of this is heavy alcohol use, followed by gallstones, medications and bad luck. Some cases of pancreatitis are so severe that the patient dies due to complications of whole body inflammation or destruction of internal organs. Most cases are much milder and many patients may weather pancreatitis at home, unaware that they ever had it. Fully 35% of patients who come to emergency departments with pancreatitis are sent home and most of them do well.

The standard treatment for pancreatitis, though, per UpToDate and PIER, is to admit the patient to the hospital, have them take nothing by mouth and receive IV hydration and pain medications until the belly is no longer tender. Recently, I believe, UpToDate changed this to say until the pain starts to go down, which is definitely different. Nothing is said about discharging patients to home, other than to mention that some patients with recurrent pancreatitis will manage their attacks by taking only clear liquids and will not come to the hospital. And there are studies that show that patients who have mild pancreatitis can do better if they are allowed oral nutrition, which I've noticed sometimes makes a patient much more comfortable as well.

The original argument had been that food made the pancreas squeeze out its juices and that the pancreas should be rested. It turns out, though, that the inflamed pancreas doesn't really do anything with or without food. I would like my sources to mention this, and give some guidelines for the outpatient management of pancreatitis, since many patients with this condition are not admitted to the hospital.

Pulmonary emboli are blood clots produced, usually in the legs, that go to the lungs, potentially causing deficiency of oxygen and sometimes catastrophic effects on the heart and blood pressure. Some of these, though, are quite small and cause hardly anything, except maybe some mild chest pain. Because we have really sensitive CT scanners to look for pulmonary emboli, very small ones are more effectively diagnosed.

The standard treatment for pulmonary emboli, and the one recommended by UpToDate is to start an injectable anticoagulant, along with an oral one, warfarin, that doesn't kick in for a few days, continue the injectable one for 5 days and then the oral one for anywhere from 3 months to lifetime. This last spring, the New England Journal of Medicine published an article looking at the effectiveness of a new oral anticoagulant rivaroxaban in the treatment of pulmonary emboli. It works right away and is less expensive than the combination of the oral and injectable option and requires no monitoring. The two treatments were equivalent, with less bleeding in the rivaroxaban treatment arm. The FDA approved rivaroxaban for this. Using rivaroxaban rather than injectable anticoagulants makes it much easier to allow a patient to go home rather than stay in the hospital, which has turned out, in many cases to be as safe as hospital admission. Why is it not mentioned in my go-to sources?

Bleeding from ulcers in the stomach or duodenum can be devastating. They are often caused by use of anti-inflammatory drugs, also by infection with the H. pylori bacterium and are more common in drinkers and smokers. Reducing acid produced in the stomach is very effective in helping these heal and so when someone is admitted to the hospital with a bleeding ulcer, they are started on a proton pump inhibitor medication right away.

Originally the medications were only available as capsules, then the intravenous version became available and now it is recommended that we give these medications by intravenous constant infusion for 72 hours when the bleeding is significant. This is based on the observation that the half-life of these medications is rather short so constant infusion is likely to be more effective in keeping the acid levels persistently low. A recent article, however, found that twice daily bolus dosing of these medications was no less effective in preventing re-bleeding than the infusion. Infusions are fine, but require constant monitoring and a devoted IV line. Intermittent dosing can share an IV with other medications or blood products. When there is an infusion, frequently a central IV line must be started in order to have an adequate number of access points, and central lines have all sorts of potential complications, from collapsed lungs to blood stream infections. It would be nice if UpToDate would mention that intermittent intravenous dosing was a reasonable option for delivering these drugs.

And flu shots. A recent Cochran review questions the utility of routine flu shots for patients not at increased risk, yet UpToDate doesn't mention this at all. Phooey.

When physicians are judged by their peers or in law courts, our performance is compared to the standard of care for the communities in which we work. Standard of care is often strongly influenced by easily available references. As we move toward practicing medicine based on evidence of effectiveness, it would be nice to see the references we use recognize dissenting opinion and contradictory results.

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.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
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.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, 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.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is 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.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

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

David Katz, MD
David L. Katz, MD, MPH, FACP, 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.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, 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.

Medical Lessons
Elaine Schattner, MD, FACP, 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.

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

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
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.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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