Monday, September 30, 2013

Adventures in medicine: part 4

In the last post we saw how complicated the visit is from Dr. Ron’s perspective, and how many things were working to pull him away from our hero, Chuck. So what about Chuck? What about his perspective? I ended the previous post with the statement: “All Chuck knows is that his back hurts and that perhaps buying the Roomba wasn’t such a good idea. He just wants to make sure there’s nothing serious going on, and he wants to feel better.”

In other words, Chuck is interested in two main things: quality of life and quantity of life.

What he wants to avoid is: death, disability, disfigurement and pain. Please note that I could have used “dysesthesia” to keep with the “D’s,” but chose to speak English (a talent which many doctors lack).

Now, when Dr. Ron listens to the story of a patient like Chuck, there are three main tasks he focuses on: 1) Ruling out serious problems (or assessing risk), treating symptoms and making a diagnosis.

He does this by listening to Chuck’s story (his symptoms), looking for objective findings (via physical exam, labs, or other tests), and looking over Chuck’s back-story (his past problems, symptoms, and risk factors).

From Chuck’s vantage point, as long as Ron has ruled out bad stuff and makes his back feel better, he doesn’t benefit from making a firm diagnosis. That’s what Chuck thinks he’s paying for (both from his wallet and from the precious moments of his life wasted in the waiting room). But here’s where things start to get complicated: Ron doesn’t actually get paid for the two things that Chuck wants the most (ruling out bad stuff and treating symptoms), instead he’s paid for:

1) Coming up with “diagnosis” (problem) codes to describe Chuck’s situation.

2) Coming up with “procedure” codes to describe what he did in the office.

3) Doing his medical record in a way that “justifies” his codes to insurers (in case he’s audited).

4) Paying a bunch of staff to make sure this information is submitted exactly right, as any mistakes could result in denial of payment.

Ron’s new fancy-schmancy computer record program is built to make sure all of the information needed to justify the charge is put in properly, and that the diagnosis codes and procedure codes are also properly entered so they can be electronically submitted to the insurance company. Ron likes the fact that it makes this easier, but it bothers him that so much of the note is just “packaging material” that obscures the most important part of the note to both doctor and patient: the plan.

To make matters worse, Ron has to find a code from the ICD-9 code list, which are specific codes that the insurers accept for treatment. This is sometimes hard, as the codes for common things (like weakness of the arms) are mysteriously missing, while codes for strange things (like being injured by a space ship) are on the list.

To “improve” this situation, the government is soon to introduce ICD-10, which will increase the number of codes by 500%, now including the important code for “burns incurred from flaming water skis” (it’s about time).

Ron’s EMR gets to these codes (relatively) easily because they are essential to be paid.

Additionally (and worrisome to Ron), the insurers are taking these diagnosis codes and problems on the list to measure the “quality” of Ron’s care. Ron worries about this because payment is increasingly being linked to quality measures, and the folks doing the measuring are the ones doing the paying, which means they would benefit from measuring low. Another negative of having problems accumulating on lists is the all-inclusive nature of the lists, which include:
• Chronic disease (like diabetes, hypertension)
• Past events (heart attacks, cancer)
• Symptoms (back pain, fatigue)
• Risk factors (family history of heart disease, cancer)
• Abnormal test results (high cholesterol, low sodium, abnormal chest x-ray)
• Exam findings (heart murmurs, skin lesions)
• Minor problems (allergies, baldness)
• Acute problems (Viral infections, sinus infections)

This makes these lists grow quite large, which is often made worse if the acute problems are don’t drop off of the list, which is often the case. Taking the time to clean up and organize records is something most doctor’s offices don’t have time to do.

What does this have to do with Chuck’s Roomba-assisted back injury? Nothing good. Unfortunately, it makes Ron focus on the least important thing: the diagnosis (remember, Chuck really just wants to rule out bad things and feel better). It rewards doctors for finding problems and doing procedures to fix those problems. It also rewards Ron for putting things into the chart that makes it jumbled and confusing. Since Ron’s pay is dependent on his documentation, he spends much of his time and energy putting information into the record, as Chuck sits and watches him type.

So, for the 10 minutes in the exam room together, the majority of time is spent inputting information and finding diagnosis codes. Ron feels bad about this, a feeling that tempts him to do what many doctors do: order X-rays, MRI scans, and prescribe medications for a simple back strain. But Ron knows that these do nothing useful for Chuck and just raise the cost. Ironically, Ron’s decision to do the right thing makes Chuck wonder about how good of a doctor Ron is, as he leaves with nothing to show for his time and inconvenience other than a sympathetic look, instruction to take ibuprofen, and a back exercise sheet. It seems like a waste of time and money.

Ron agrees with this assessment, wishing that he was rewarded for doing the right thing, not penalized. Both Ron and Chuck leave the visit frustrated. Chuck goes home to plot against his cat, while Ron moves on to the next patient, hoping for something a little more satisfying.

To be continued …

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.

New hepatitis C screening recommended for baby boomers

If baby boomers weren’t special enough, now the U.S. Preventive Services Task Force has singled them out as a special group to be screened for hepatitis C virus (HCV). Individuals born between 1945 and 1965 are recommended to undergo this one-time blood test screening because they are at high risk for the virus.

What is it about this age group that gets special notice? According to the Centers for Disease Control, baby boomers account for three out of four people with HCV. Many of them contracted hepatitis C from blood transfusions or needle procedures before we had a screening test for the virus. Others may have caught it from high risk behaviors like injecting drugs, HIV or piercing or tattoos in unclean environments. It is less common to contract it through sexual relations, but it can happen.

We have had a test that could screen for hepatitis C antigen for many years but only recently are we able to treat chronic hepatitis C with anti-viral medications. There is an increased incidence of hepatocellular carcinoma (liver cancer) in people who acquired HCV two to four decades earlier and many people have no idea that they are carrying the virus. It is hoped that by screening patients in this age group, patients can be identified at earlier stages of disease and receive treatment before developing complications from liver damage.

HCV infection is the leading cause of complications from chronic liver disease. More than 30% of U.S. adults that receive liver transplants have HCV.

Baby boomers just need to undergo screening once.

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.

Stinting on stents

Former President George W. Bush underwent an angioplasty, and the details sparked a public debate about the controversies of heart disease treatments.

His spokesman stated that he underwent a routine physical exam and had no symptoms of heart disease. A stress test showed EKG changes and a CT angiogram found a blocked artery. He was transferred to another hospital and underwent an angioplasty, a procedure in which a stent (a wire mesh tube) is inserted into the blocked artery and pushed against the artery walls to prop it open.

Before delving into the details of the ensuing controversy, let me make clear that we don’t have enough details about Bush’s care to make any judgments about it, and the rest of the post will be about angioplasties in general, and not about Bush’s case specifically.

Whenever a public figure undergoes a medical procedure there is a concern that the public will misunderstand the details and assume that the procedure is also right for them. (A recent example is Angelina Jolie’s revelation of her double mastectomy.)

The controversy regarding Bush’s care centers on the fact that while angioplasties are known to be lifesaving during or immediately after a heart attack, in patients with stable heart disease they have no advantage over medications other than for relief of chest pain. We are told that Bush was not experiencing chest pain, and he is known to be an active athlete, having hosted and participated in several lengthy bicycle rides since leaving office. So the justification for the angioplasty is unclear.

Our best evidence comparing angioplasty to medications in patients with narrowed coronary arteries comes from the COURAGE trial which published its findings in 2007. The trial showed that rates of heart attack and death were the same whether patients with blocked arteries underwent angioplasty or were put on optimal medications.

This is where the media sometimes distorts the story. The press coverage of Bush’s angioplasty had frequent questions about the necessity of the angioplasty and the cost of such a procedure. That is precisely not the point, and gives the public the incorrect idea that angioplasties are expensive and beneficial luxuries. BMWs, after all, are unnecessary and expensive, but very nice. And if a VIP gets something unnecessary and expensive, shouldn’t I want one too? The point of the evidence about angioplasties is that in most patients they have no benefit. Focusing on “necessity” misses that point.

It is entirely possible that Bush’s care was flawless. One possibility was that his stress test was extremely abnormal. Such very abnormal tests were excluded from the COURAGE trial, and we have no definitive evidence whether medications or stenting is best in those cases.

The important thing for the public to understand is that VIPs sometimes get terrible care. I’ve personally seen that myself. Physicians often over-test and over-treat celebrities, wrongly thinking that this will protect them from blame for any adverse outcome later. It’s much easier to tell a prominent patient that we will fix your problem with a high-tech and very expensive solution, rather than taking the time to educate the patient that we should start a few very old and very inexpensive medicines which have been proven to save lives. Paradoxically, we’re frequently much more comfortable doing the right thing for patients who will not draw public attention.

I wish the former president continued good health. I wish the rest of us a careful review of the evidence before we burst into our doctors’ office demanding a stress test.

Learn more:
Did George W. Bush Really Need A Stent? (Forbes)
Former president’s stent surgery revives debate on heart care (Chicago Tribune)
President George W. Bush has stent procedure (Salon)
George W. Bush Gets Angioplasty and Stent – Was It Necessary? (The Voice in the Ear, a blog about stents)
My previous posts about angioplasty:
For Most Heart Patients Medicines are as Good as Angioplasty
Is There a Patient Educator in the House? (About a study which showed angioplasty patients did not understand the benefits of the procedure)

Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.

QD: News Every Day--Vaccination rates rising among health care professionals

72% of health care personnel reported getting the flu vaccine for the 2012–13 season, an increase from 66.9% coverage during the previous season.

To estimate influenza vaccination coverage among health care personnel during the 2012–13 season, CDC conducted an opt-in Internet panel survey of 1,944 self-selected health care personnel in April 2013. The CDC reported its findings Sept. 27 in Morbidity and Mortality Weekly Report.

By occupation type, coverage was 92.3% among physicians, 89.1% among pharmacists, 88.5% among nurse practitioners/physician assistants, and 84.8% among nurses, the CDC reported. Vaccination was highest among hospital-based people (83.1%) and was lowest among those at long-term care facilities (58.9%). Vaccination coverage was higher for people offered free, on-site vaccination for one (75.7%) or multiple (86.2%) days compared with people not offered free, on-site vaccination (55.3%).

Among health care personnel reporting that their employer required them to receive influenza vaccination, overall vaccination coverage was 96.5%, with coverage above 95% in all occupational settings, including long-term care facilities (95.8%). Vaccination rates were 76.9% among health care personnel who worked in facilities where employers promoted but did not require vaccination (range: 67% [long-term care facilities] to 85.7% [other clinical settings]) and 50.4% among health care personnel who worked in facilities where employers neither had a vaccination requirement nor promoted vaccination (range: 45% [long-term care facilities] to 67.7% [hospitals]).
Friday, September 27, 2013

AAFP: Even docs aren't exercising.

I just went to a great session on exercise prescriptions, which you can expect to read more about in an upcoming issue of ACP Internist, but one interesting aspect was the focus of speaker Christopher Bunt, MD, on getting his audience to exercise more.

He provided some data on the failure of physicians to live up to the healthy living standards they prescribe. For example, a survey of the 20,000 attendees at the American Heart Association's Scientific Assembly in 2010 found only TEN people who lived up to the organization's "Simple 7" rules for reducing cardiac risk. More anecdotally, he pointed out how few physicians at this conference take the stairs to their sessions, and how many take shuttle buses from hotels just a few blocks away (which I already noticed, and I have to put a little plug for ACP in here--we don't shuttle our internists the half-mile from the Hyatt to the San Diego Convention Center!).

Dr. Bunt took a few minutes during his session to have the audience develop their own exercise plans. Since I've already swam, speed-walked and climbed the stairs of the convention center multiple times during my visit, I used the time to check my email and feel superior. And then we got to the recommendation about how everyone is supposed to eat 4-5 servings of fruit and vegetables a day. Oops. Unless strawberry margaritas count, I think may need to write myself a vegetable prescription.

Of Lyme disease and lemonade

One of the more salient and concerning items of medical news reported recently is an analysis by the Centers for Disease Control and Prevention indicating that there is 10 times as much Lyme disease in the U.S. as formal reporting channels suggest. Rather than the 30,000 official cases each year, which would already make Lyme the most common tick-borne illness in the country, there are roughly 300,000 cases. An increase in Lyme prevalence by an order of magnitude is a disconcerting proposition.

The report, which was issued at medical conference in Boston, combines findings from three separate, ongoing studies overseen by the CDC. One is looking at medical claims, another at lab reports and the third is a survey of the population. The new estimate is the result of triangulating the findings of these diverse approaches, thus lending hybrid vigor to the enterprise.

But before we make this news sourer than it already is, we need to note that this does not mean that Lyme disease rates have gone up tenfold. The data in question are comparing actual rates to reported rates, not comparing trends over time. The new report does not indicate anything about a sharp rise in Lyme disease, just a prevailing tendency to underreport. It still matters that there may be 10 times as much the disease among us as we officially recognize, but it’s not nearly as worrisome as a sudden explosion in the number of cases.

Then again, Lyme disease is cause for concern at almost any level, let alone at the impressive prevalence the new data suggest. The condition is caused by the bacterium,Borrelia burgdorferi, transmitted (as I suspect everyone knows) by tick bite, and specifically in most cases, the blacklegged tick. The bacterium is classified as a spirochete, the particulars of which need not concern us here, except to note that the germ responsible for syphilis, Treponema pallidum, is in in this same category.

Syphilis, a scourge since long before effective treatment was available, is notorious for progressing through complex stages and involving multiple organ systems over a span of decades if left untreated. The Lyme organism can do much the same. Just like Treponema pallidum, Borrelia burgdorferi can, given the opportunity, invade and damage the central nervous system. The late stages of both syphilis and Lyme can impair the functioning of multiple organ systems, the nervous system prominent among them.

So, there is no question about the existence of chronic Lyme. What is controversial is the validity of chronic Lyme in the aftermath of a full course of antimicrobial therapy.

In some cases, a “full” course may not be enough. Like any germs, the Lyme organisms can develop partial or even complete resistance to specific antibiotics. In some cases, the course of treatment may not be long enough to fully eradicate the disease, or the drug chosen might not be optimal. Treatment can fail. But usually, it succeeds. Given that a full course of appropriate antibiotic is administered to susceptible organisms, the evidence is strong that this reliably does the job most of the time. When treatment is prompt and the disease in its early stage, it is almost invariably cured.

And yet, many people report “chronic Lyme” in the aftermath of what should be decisive therapy. Some go on to get very extended courses of antibiotics, which in some cases still fail to resolve the clinical syndrome, or do so only temporarily.

Some such patients, including some in my own practice, undergo very extensive testing to determine if viable organisms have somehow dodged all those bullets directed at them. That testing can include a lumbar puncture with culture of cerebrospinal fluid, one of the places the organisms can hide. When even that is negative, it does indicate with a high degree of reliability that the organisms are indeed dead and gone.

Consequently, many Lyme experts, including my colleagues at Yale, go to some length to refute the validity of “chronic Lyme.” In the absence of the infecting organism, a chronic infection simply isn’t possible.

This is certainly true, but it says nothing about symptoms. The persistence of chronic symptoms after an infection, and the pushback by experts that this is not “chronic Lyme” have led to what some now call “the Lyme wars.”

The wars are an unfortunate distraction. Is the persistence of symptoms from an infection possible long after the infecting organism is gone? Of course. Just talk to anyone using braces after a polio infection decades ago.

The adamancy of some experts that chronic Lyme following effective treatment doesn’t occur, and the insistence by patients that it does may miss the essential point: something is still wrong with these patients. Maybe only the experts are qualified to say if it is Lyme infection, but only the patients can say how they feel.

My own clinical experience indicates that there is a syndrome of chronic symptoms post-Lyme infection. It may be because of injury to the immune system, the nervous system, or due to these and/or other effects. But just as the poliovirus can infect, be dispatched, and leave permanent effects behind, we don’t necessarily need to find viable Borrelia burgdorferi to have lingering consequences of their temporary stay.

In my clinic, and many others, we work hard to treat the aftermath of Lyme accordingly, with varying degrees of success. The infection should be treated decisively, certainly. Once it has been, any lingering symptoms should be given the full measure of respect they deserve and treated diligently as well, whether or not they have anything to do with ongoing infection. Patients should perhaps be less adamant about why they don’t feel well, since it can be hard to know. But clinicians are well advised to remember that only a patient can say how she or he feels, and ultimately, that’s really what matters most.

The one aspect of the debate with clear practical implications is that if chronic Lyme symptoms are due to chronic Lyme, more antibiotic treatment is warranted. If such symptoms are due to the lingering effects of a vanquished infection, antibiotics may be ineffective and more likely to do harm than good. A shared understanding of this between patient and clinician, and a willingness to listen to one another, should allow for the right kind of personalized care.

Fortunately, though, this challenging area is just a small part of the Lyme disease landscape. The large number of cases to which the new report refers mostly represents early-stage Lyme. When identified and treated in its early stages, most Lyme gets better.

This is what the literature tells us, but being a Connecticut resident, I have seen it up close and personally as well. I have treated Lyme in patients, friends and relatives alike. I’ve treated myself for it twice over the years. My horse has been treated several times and some years ago, I had to take one of our dogs to a veterinary hospital at 3 a.m. for what turned out to be Lyme disease, that responded promptly to antibiotics.

A report highlighting the prevalence of Lyme should raise awareness and suspicion, increase early detection and extend early and effective treatment to more of those involved. That’s the good news in a seemingly bad report. This analysis may also stimulate new efforts directed at Lyme prevention by various means, from tick control to immunization.

While waiting, we all have means to defend ourselves. These begin with prevention, most of which is common sense. Clothing can be used as a reliable defense against both excessive sun and ticks. Pets can be treated appropriately so they are less likely to share viable ticks with us. Showering promptly after outdoor activities that represent opportunities for ticks is likely to send them into the plumbing before they can dig into our skin. Ticks need to be embedded for 24 hours or more to transmit Lyme, so just having a tick crawl around a bit and try to get settled is not a danger.

I suspect we are all familiar with the adage about doing the best we can with a bad situation: when life gives us lemons, we are supposed to make lemonade. If 10 times more Lyme among us is the lemons in this case, I’m not sure there’s lemonade to be made. Perhaps that’s just as well, since lemonade tends to be loaded with sugar, and that carries its own liabilities.

Lyme is common, but no more so now than before this report. This is simply recognition of what has been, not a portent of some new threat to come. More awareness means more reliable prevention, detection and treatment. We may not have a recipe for lemonade here, but we have no reason for panic either.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

C. diff infection? Think of the effect of proton pump inhibitors

Following up on last year’s MMWR that reported that “nearly 75% of all Clostridium difficile infections (CDI) related to U.S. health care have their onset outside of hospitals,” CDC researchers have released a new study in JAMA Internal Medicine looking specifically at the epidemiology of community-associated CDI. The study used data from the Emerging Infections Program, which began to actively collect CDI data in 10 states starting in 2009. This report uses data from 984 patients collected over 29 months with true community-onset CDI, as they excluded community-onset, healthcare facility associated infections.

Somewhat surprisingly, 36% of patients had not received antibiotics and 18% had no outpatient health care exposure. Not surprisingly, 31% of those who had not been exposed to antibiotics had been exposed to PPIs. I highlighted the risk of CDI from PPIs in my ICPIC talk when I discussed this meta-analysis by Kwok and colleagues. In this CDC study, those patients lacking significant outpatient healthcare exposure were also more likely to be exposed to infants and household members with active outpatient health care exposure suggesting a potential route of transmission. I agree with the authors' primary conclusion that a reduction of outpatient PPI use may be necessary to reduce the risk of CDI. As Mike Edmonds, MD, FACP, pointed out four years ago, PPIs are also associated with HAP, VAP, and SBP, so there are many reasons to be concerned about PPIs.

There is an excellent accompanying editorial by some guy named Kent Sepkowitz, who discusses the “PPI-zation” of the U.S. and the difficulties facing any public health initiative targeting PPIs. For one, PPIs are the third most utilized drug in the U.S. and they are addictive since discontinuation is associated with withdrawal symptoms. For another, unlike antibiotics, PPIs are widely available over the counter and supported by huge advertising campaigns. Looks like PPIs are here to stay.

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). This post originally appeared at the blog Controversies in Hospital Infection Prevention.

QD: News Every Day--Infectious disease specialists state case for seeing one sooner

Hospitalized patients with severe infections such as meningitis and Clostridium difficile (C. diff.) are significantly less likely to die if they receive care from an infectious diseases specialist, a study reported.

The study, commission by the Infectious Diseases Society of America, appeared online Sept. 25 and will appear in the Dec. 15 issue of Clinical Infectious Diseases.

In the study, researchers looked at Medicare fee-for-service patients who were hospitalized between Jan. 1, 2008 and Dec. 31, 2009 and had at least one of 11 infections: bacteremia, Clostridium difficile, central line associated bloodstream infections, bacterial endocarditis, HIV/opportunistic infections, meningitis, osteomyelitis, prosthetic joint infections, septic arthritis, septic shock and vascular device infections.

Researchers matched patients and evaluated the outcomes for 61,680 cases in which a hospitalized patient saw an infectious disease specialist to 65,192 cases that did not involve an infectious disease specialist.

Patients who saw an infectious disease specialist had significantly lower mortality (odds ratio [OR], 0.87; 95% CI, 0.83 to 0.91) and fewer readmissions (OR, 0.96; 95% CI, 0.93 to 0.99) compared to those who didn’t. Those who saw an infectious disease specialist had a longer length of stay (1.3% by days; 95% CI, 0.5% to 2.1%), but spent less time in the ICU (3.7% in days; -5.5% to -1.9%).

“Infectious diseases are the second leading cause of death worldwide. In an age where health care-acquired infections are linked to payment penalties and bundled payments leave little room for error, the impact of infectious disease physicians is more critical than ever in providing high quality care,” said lead author Steven K. Schmitt, MD, FACP, chair of the Infectious Disease Society of America’s Clinical Affairs Committee. “As the ‘detectives’ of the medical world, infectious disease specialists have additional years of training and possess the expertise to quickly identify and treat potentially life-threatening infections.”

Also, researchers noted, patients seen by an infectious disease physician within 2 days of being admitted to the hospital are 6% less likely to be readmitted to the hospital within 30 days of discharge compared to patients seen by one after the first 2 days.

“These findings are in line with healthcare reform efforts being implemented through the Affordable Care Act, which shows that including infectious disease specialists in up-front care of patients provides better outcomes at lower costs,” said Daniel F. McQuillen, MD, FACP, a co-author. “Further, the association of infectious disease specialist involvement with reduced readmission rates suggests an important role for the infectious disease physician in transitions of care from the hospital to the community.”
Thursday, September 26, 2013

AAFP: And now for something completely different.

I've been hearing all day about the need to reduce health care spending and the dire shortage of primary care physicians. And then I went to a session about aesthetic procedures.

I know, I know--as the speaker explained, someone has to provide these services that people are increasingly willing to pay for (even during our current recession, apparently, the market was growing "to 13 million procedures last year"). And primary care physicians have the skills to provide this care "with a very high profit margin," as the speaker noted. Although he also recommended that you get the cash upfront.

But after learning all day about the gaps in care for the homeless or chronically ill elderly patients living on their own, I can't bring myself to tell you all about how to go into this business. You'll just have to ask somebody else.

AAFP: Conflicting ideas

My second AAFP session of the morning was about patient engagement, and how communications technology and a better understanding of patients' perspectives could combine to eliminate all the problems of medicine, especially that pesky nonadherence to your advice. I'm not exaggerating. Literally, the speaker told us that "The family physician's office of the future will have no one in the waiting room, because everyone's healthy." Or those few who haven't been prodded into health will be identified for pre-emptive action by "red lights" in the electronic health record.

And then the next session was about genetics, and how in the future, gene testing will be widespread and the ability to know what diseases patients are at risk for will change the course of medicine. We'll have prenatal testing, perinatal testing (how all this knowledge will be acted on, we didn't get into) and pharmacogenetics to tell us which drugs to take.

Seems like a bit of a contradiction there, no? It might be convenient if our health were entirely determined by our behavior or our genes, but the reality seems a lot more complicated. Sometimes we get sick for some reason that has nothing to do with either, as was pointed out by a questioner in the gene session who has Parkinson's, but had helpfully learned from 23andme that he's at low risk for the disease. I'm sure both of these expert speakers actually know that health is more complex, but it's useful to remind ourselves of this when we're tempted to trumpet a cure for the challenges of health care.

AAFP: Everything can kill you.

A guy who waterproofs boats for a living suddenly comes down with flu-like symptoms.
A retired man who likes to strip furniture in his basement has multiple myocardial infarctions, the last fatal.
An Alzheimer's patient has toxic levels of heavy metals in her blood after pottery class at a day program.

Finding toxic causes for illness can require a physician to use his detective skills, Peter Ziemkowski, MD, an associate professor of family medicine at Western Michigan University, explained this morning. (I'm at the American Academy of Family Physicians annual meeting in San Diego today and tomorrow.)

He offered those three anecdotes (and others, including a hiker who got too close for his health to a beaver dam and the infamous Colorado popcorn-sniffer) to emphasize the importance of getting a thorough history from patients who may be presenting with a toxic exposure.

In the first case, the patient had smoked a cigarette, which heated up the waterproofing material on his hands and released dangerous fumes. In the second case, the patient could potentially have saved by his physicians' recognition that paint thinner in a confined environment can cause ischemia. And the third patient had drunk down a Dixie cup of ceramic glaze, which wouldn't be harmful at the time of manufacture, but changes chemical structure when it's left on the shelf.

So pay attention, and don't be afraid to look up potential exposures you don't know about, Dr. Ziemkowski advised.

He also provided some reassurance about a couple exposures you and your patients might have been fearing. First, don't worry about that popcorn chemical (diacetyl)—most of the microwave popcorn companies have taken it out of their recipes. Second, there is a scary black mold (stachybotrys) that can cause serious respiratory problems, but there are lots of other common molds (which won't hurt immunocompetent people) that are also black. Inconveniently, the only way to distinguish them is to have a lab run a culture.

Don't call me a health care provider - I'm a doctor

One thing doctors like to do is to use fancy language. Patients, however, want physicians to use simple terms. Perhaps, using highfalutin language makes physicians feel more scholarly and important. Of course, this bombast only confuses patients who may be too timid to respond that they don’t have a clue what we’re saying. If your doctor is speaking in tongues, then ask for a translator. He’ll get the message.

Many professions have their own technical languages that are necessary for internal communications or scholarly work. Beyond this, there is also a pomposity that drives this lexical elitism.

In the medical profession, medical terms seem to offer no advantage over colloquial alternatives. Yet, physicians want to “speak like doctors,” whatever that means.

Cool medical term: Lame alternative
Thrombus: Clot
Stenosis: Narrowing
Cephalalgia: Headache
Transient Ischemic Attack: Mini-stroke
Nevus: Mole
Exanthem: Rash
Cholelithiasis: Gallstones
Pyrosis: Heartburn
Epistaxis: Nosebleed

Folks following health care reform need their own glossary to explain the new lexicon. I can’t keep this stuff straight and I’m in the business. One must be familiar with pay-for-performance, comparative effectiveness research, accountable care organizations, insurance exchanges, medical homes, pharmacy benefit managers and value-based pricing. See how warm and fuzzy the medical profession has become?

Here are a few antiquated terms that are rarely included in the medical policy and health care reform articles I peruse:
• compassion
• healing
• empathy
• caring

The new medical rhetoric is so sanitized, or should I say antiseptic, that it threatens to anesthetize the profession. Want proof? Look at how medical apparatchiks describe me. I’m no longer a doctor or a physician. I’m now a health care provider.

I’m not hung up on the doctor title. I never introduce myself as ‘Dr.’, even to my patients. But, to regard me as a health care provider attempts to redefine who I am and what I try to do. It aims to circumvent the core of what doctoring should be, which is humanity. While health care reformers can redact the term humanity, they can’t extract true humanity that must be the essence of the profession. If we accept that we are health care providers, then we’re not doctors anymore. When the government health care reformers and its minions are speaking in tongues, let’s demand a translator.

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.

Strict work hours are not the right solution

Lisa Rosenbaum has described the problem well: Why Doesn’t Medical Care Get Better When Doctors Rest More?

We have a classic conundrum in medical training. We want our trained doctors to care deeply for their patients and to have superb bedside manner, to have excellent diagnostic skills, and generally to put patient care as the highest priority.

But we hamper education and tell our trainees that we must put their sleep as a higher priority than patient care.

We do need to have reasonable work hours, but we have become a bit too draconian in the prescription of work hours. Most residents that I know want to provide the best care for their patients. They often “cheat” on the work hours to achieve that.

Some residency programs demand that residents leave at an appointed time. What does that teach about professionalism?

Some residency programs have creatively designed their new work hours to limit hand-offs and still meet the “requirements.”

Residents do not seem to sleep more when given the work hours adjustments. They seem to learn less about the natural history of disease.

I am in favor of work hour restrictions, but would prefer that residents have more flexibility. I would prefer that we put patient care first over strict resident work hours.

Whenever you create strict rules you have inevitable unintended consequences. The rush to make rules without studying the implication of those rules flies in the face of our evidence based profession.

Residents need sleep and they need to become excellent physicians. We need a bit more flexibility to achieve both goals. We can do it, but not if rules are rigid.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.

QD: News Every Day--10% weight loss combined with exercise helped knee pain

A 10% weight loss and exercise led to less knee pain and better function after 18 months than diet or exercise alone, according to a study.

The randomized trial included 454 overweight and obese community-dwelling adults ages 55 years or older with a body mass index of 27 to 41 with pain and radiographic knee osteoarthritis from July 2006 to April 2011.

The interventions consisted of intensive diet-induced weight loss plus exercise, intensive diet-induced weight loss, or exercise. The diet and exercise interventions were center-based with options for the exercise groups to transition to a home-based program.

Results appeared in the September 25 issue of the Journal of the American Medical Association.

Mean weight loss for diet and exercise participants was 10.6 kg (11.4%); for the diet group, 8.9 kg (9.5%); and for the exercise group, 1.8 kg (2.0%), the authors wrote. After 18 months, knee compressive forces were lower in diet participants (mean, 2,487 N; 95% CI, 2,393 to 2,581) compared with exercise participants (2,687 N; 95% CI, 2,590 to 2,784, pairwise difference [Δ]exercise vs diet=200 N; 95% CI, 55 to 345; P=0.007).

Concentrations of interleukin 6 were lower in the diet and exercise patients (2.7 pg/mL; 95% CI, 2.5 to 3.0) and diet participants (2.7 pg/mL; 95% CI, 2.4 to 3.0) compared with exercise participants (3.1 pg/mL; 95% CI, 2.9 to 3.4; Δ exercise vs diet and exercise=0.39 pg/mL; 95% CI, −0.03 to 0.81; P=0.007; Δ exercise vs diet=0.43 pg/mL; 95% CI, 0.01 to 0.85, P=0.006).

The diet and exercise group had less pain (3.6; 95% CI, 3.2 to 4.1) and better function (14.1; 95% CI, 12.6 to 15.6) than the diet group (4.8; 95% CI, 4.3 to 5.2) and exercise group (4.7; 95% CI, 4.2 to 5.1, Δ exercise vs diet and exercise=1.02; 95% CI, 0.33 to 1.71; Ppain=.004; 18.4; 95% CI, 16.9 to 19.9; Δ exercise vs diet and exercise, 4.29; 95% CI, 2.07 to 6.50; Pfunction<0.001).

The authors wrote, “… intensive weight loss may have both anti-inflammatory and biomechanical benefits; when combining weight loss with exercise, patients can safely achieve a mean long-term weight loss of more than 10%, with an associated improvement in symptoms greater than with either intervention alone.”

A 2005 study published in Arthritis & Rheumatism assessed the joint load for 142 overweight and obese older adults and found that each pound lost translated to a fourfold lighter load on the adults’ knee joints, ACP Internist reported in its May 2013 issue.

The article stated that all too frequently, doctors overlook the painful joint disease at a stage when preventive measures such as exercise and weight loss could be most beneficial. It also examines the impact of updated guidelines from the American College of Rheumatology that highlight the value of trying exercise and weight loss first, whenever feasible.
Wednesday, September 25, 2013

How subsidizing doctors' salaries can be financially sound

I have been doing locum tenens work as a hospitalist for nearly two years. One of my reasons for doing this is that the practice of medicine in the U.S. is very interesting, and by working in very different places I get to see how things work and don’t work, and make up cool theories. I have time to read and listen to people and have become curious about several true things which don’t seem to fit together.

1) Hospitals are paid an absurd amount of money to take care of patients.

2) Small hospitals can barely survive financially.

3) Small hospitals, rural ones with 25 beds or fewer (critical access hospitals) are paid more generously by Medicare than large hospitals.

4) Hospitals that employ physicians subsidize them above the money they bring in as professional fees, to the tune of about $100,000 per year per physician.

5) Hospitalists and hospitalist programs are expensive, in the range of 1-2 million dollars per year for a 25 bed hospital.

6) Hospitals are willing, even happy, to start hospitalist programs.

7) Hospitals have a slim enough margin (net income divided by total revenues) that changes in payment schemes has resulted (in times past) in the financial collapse of many of them, especially those that serve vulnerable populations.

So how can hospitals be so financially tenuous despite the fact that they are the largest cost center of the huge health care sector of our economy? Are they just whining?

I have been eager to get my hands on a hospital budget or two to try to piece together how hospitals spend their money, to see if there is some obvious extravagance. I have asked to be allowed to see the budget of the hospital that I know best, and somehow e-mails were lost or it wasn’t very high on anyone’s to-do list or it was a deep dark secret or something. Finally I Googled the right collection of words and found a link on the Washington Department of Health website where I could see quite a number of budgets for Washington State hospitals, even ones I knew something about.

I learned various things, which should be taken with grains of salt, because these budgets were not very detailed and may have misrepresented the truth in some important way. Still. It is the best I can do, and is somewhat instructive. I looked at one 300 bed hospital and one 25 bed critical access hospital and this is what I learned.

1. Hospitals have a profit margin of about 3-4%, which is a fact I have also read this elsewhere. This is considered very small, and makes them vulnerable to small changes in payments.

2. Hospitals bring in about $4,000-$5,000 per patient per day spent in the hospital. They also make a pretty big portion of their revenues by serving outpatients (doing things like blood tests and imaging and outpatient procedures.) Since most hospitals are paid according to diagnosis rather than length of stay, at least for a large proportion of patients, they make more money with fewer resources if the patients are discharged sooner rather than later. Small hospitals make more per patient per day than large ones.

3. The majority of a hospital’s expenses are the salaries of the many people who work there, nurses, technicians, administrators, employed physicians, janitors, cooks etc. These costs generally go back into the communities they serve since people usually spend their money for food and rent and stuff they buy.

What I glean from this is that significant cutbacks in hospital expenses will probably involve cutting local jobs. That may not be a bad thing, in the big picture, especially if the workers are perpetuating an inefficient system, but hospitals are often the economic heart of their communities, so cutting jobs is not ideal. There may be some extravagance in some salaries and there may be waste elsewhere, but finding it will probably be laborious.

I also figured out how it might serve a hospital to have an expensive hospitalist program. If a hospital spends $1 million dollars to have a hospitalist program, with an average length of stay of about 4 days and a daily revenue per patient of about $5,000, and if a that hospitalist program resulted in only 50-60 more patients being admitted to the hospital in a year, the program would pay for itself. The same goes for other subsidized physicians. If a hospital has to pay each of 3 surgeons an extra $100,000 per year above their actual professional fees to work at that hospital, those surgeons would only have to bring in a total of 20 more patients to pay for their subsidy. Not having a viable surgery department in the hospital, on the other hand, would result in a tremendous loss of patient volume, which would be financially devastating.

Because the budget information is so vague, I can’t tell how much of a hospitals’ costs are fixed and how much are based on volume of patients, which could significantly alter my calculations. Still, with very, very round numbers, it does appear that attracting more patients, especially those whose insurance pays well, would easily make it worthwhile for a hospital to employ physicians in various capacities.

So how does this information fit in with my ongoing thesis that health care is too expensive because we do stupid things? Much of the volume of actual work done in a hospital is aimed at servicing the wasteful procedures and tests which we do because that is how we do things. If we truly want to reduce health care costs, we need to be thrifty in a way that saves hospitals as much money as is necessary to offset any reduction in payments. This is definitely possible, but we do need to be sensitive to details of cost efficiency and realize that spending less on health care, at least at the level of hospital services, will impact the folks who are employed by the hospital and the communities where they live.

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.

President 43's stent: paragon or patsy?

In case you missed it, former President George W. Bush had a stent placed in one of the arteries that feeds his heart.

The 67 year-old came through the procedure with flying colors, we are told. Stents are tiny metal mesh tubes that get inserted into clogged arteries, essentially to prop them open.

Mr. Bush, heretofore thought to be in excellent shape, seems an unlikely candidate for the procedure. We hear tale of him riding his bike, running, controlling his weight, avoiding tobacco and alcohol, and having low cholesterol. His stress level is remarkably lower than just a few years ago. In terms of heredity, his longevity seems assured: His parents are both alive and near 90.

If he were my patient, I would not have ordered a “stress test.” The “pre-test probability” of finding coronary disease was extremely low. It’s not just because I’m a minimalist. I would be following the best available scientific evidence on the issue.

Of course, in the real world we don’t all follow the wisdom of the sages. He is a former President, after all. If I were his doctor, I’d work toward immortality for him, too.

Here’s the thing: Stents don’t help us live longer. They are merely a form of symptom control for angina, that weird word that means chest pain caused by narrowing of the coronary arteries. And Mr. Bush had no symptoms! One non-indicated test (the stress test) begat another (a CT scan of his heart arteries) and so on through to a risky and costly procedure of dubious value in his case.

Stents cost more than the alternative. They’re no better in terms of outcome than medical management, our term for using effective pills that provide the same amount of disease-specific longevity. Most importantly, having a stent placed involves real risk: (low, very fast voice) bleeding, kidney failure, infection, abnormal heart rhythm, tearing the blood vessel.

Daily pills, you say? Yuck. But having a stent placed also requires at least one additional daily pill. So no real trade off there.

Luckily for Mr. Bush, we live in a place where free enterprise is a core value. Yes, even in health care. Especially in health care, where there’s inherent information asymmetry between buyers and sellers. We doctors are free to peddle our wares; is it surprising that paying customers sometimes get a touch more than they need? “Just to be on the safe side,” we rationalize. Yet in medicine, doing more than necessary is the opposite of safe.

It’s human nature to want to do more. Fighting human nature is an uphill battle.

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--AAFP adds PSA tests, pelvic exams for The Pill to its Choosing Wisely list

The American Academy of Family Physicians released its third list of duplicative or unnecessary tests and procedures, which now includes routine prostate-specific antigen tests and pelvic exams for oral contraceptives, as part of the ABIM Foundation’s Choosing Wisely campaign.

This third list accompanies two previous ones, the organization said in a press release.

1) Do not prescribe antibiotics for otitis media in children aged 2-12 years with non-severe symptoms where the observation option is reasonable.

The “observation option” refers to deferring antibacterial treatment of selected children for 48 to 72 hours and limiting management to symptomatic relief. The decision to observe or treat is based on the child’s age, diagnostic certainty, and illness severity. To observe a child without initial antibacterial therapy, it is important that the parent or caregiver has a ready means of communicating with the clinician. There also must be a system in place that permits reevaluation of the child.

2) Do not perform voiding cystourethrogram (VCUG) routinely in first febrile urinary tract infection (UTI) in children aged 2-24 months.

The risks associated with radiation (plus the discomfort and expense of the procedure) outweigh the risk of delaying the detection of the few children with correctable genitourinary abnormalities until their second UTI.

3) Do not routinely screen for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam.

There is convincing evidence that PSA-based screening leads to substantial overdiagnosis of prostate tumors. Many tumors will not harm patients, while the risks of treatment are significant. Physicians should not offer or order PSA screening unless they are prepared to engage in shared decision making that enables an informed choice by patients.

4) Do not screen adolescents for scoliosis.

There is no good evidence that screening asymptomatic adolescents detects idiopathic scoliosis at an earlier stage than detection without screening. The potential harms of screening and treating adolescents include unnecessary follow up visits and evaluations due to false positive test results and psychological adverse effects.

5) Do not require a pelvic exam or other physical exam to prescribe oral contraceptives.

Hormonal contraceptives are safe, effective, and well tolerated for most women. Data do not support the necessity of performing a pelvic or breast examination to prescribe oral contraceptive medications. Hormonal contraception can be safely provided on the basis of medical history and blood pressure measurement.

“The AAFP has shown tremendous leadership by releasing its list of test and procedures,” said Richard J. Baron, MD, FACP, president and CEO of the ABIM Foundation. “The content of this list and all of the others developed through this effort are helping physicians and patients across the country engage in conversations about what care they need, and what we can do to reduce waste and overuse in our health care system.”

Launched in April 2012, Choosing Wisely is a national effort that has brought together more than 50 medical specialty societies, including ACP, to identify common tests, procedures and medications that may not be necessary or beneficial to patients.
Tuesday, September 24, 2013

5 pearls for better mentoring

Our institution, the Indiana University School of Medicine, Department of Pediatrics, hosts an annual Pediatric Chief Resident Conference. I was privileged to be a part of this, giving a discussion on quality improvement. The chief residents were engaging, had fascinating ideas, and demonstrated wonderful participation, in addition to harboring motivation to make change.

We were proud to host Dr. Nancy Spector, known in the education world for her impressive work on mentoring within medical education. She gave a phenomenal Grand Rounds presentation on the topic of “Mentee-Centered Mentoring”, and provided some wonderful pearls on the topic that participants could immediately take back to their home institutions. She discussed different models for mentoring, including a riveting discussion of “Speed Mentoring” (akin to “speed dating”). She provided us with five steps to successful facilitated mentoring, which I will summarize here:
Step 1: Determine an important project.
Step 2: Find the right leader to facilitate.
Step 3: Communicate effectively (planning regular communication), which may include getting work done during meetings.
Step 4: Manage projects skillfully.
Step 5: Assure benefits to participants.

Some of her final pearls for successful mentoring programs included the importance of cultivating mentoring relationships, consider having a portfolio of mentors, and also that mentees should drive the process. Her talk provided the audience with a framework for how to create a successful mentoring program. It provided us with outstanding reflection on how we can improve ourselves and each other! I highly encourage you to follow our tweets from the Grand Rounds presentation, which can be found at #IUPedsGrRounds.

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--Pain diagnoses double in past decade, as does opioid prescribing

Patients’ complaints of pain have not changed in the past 10 years, while providers’ diagnoses of pain as a primary complaint nearly doubled, a study found. And while opioid prescribing nearly doubled, nonopioid alternative prescriptions have not.

Researchers applied outpatient data from the 2000–2010 National Ambulatory Medical Care Survey to examine the diagnosis and management of nonmalignant pain in office-based settings. Results appeared in the October issue of Medical Care.

Primary symptoms or diagnoses of pain varied little from 2000 to 2010, remaining about one-fifth (20.7%) of visits. While patient-reported pain as the primary symptom was consistent, provider-reported pain increased nearly 50% from 2000 (5.7% of visits with pain as a primary diagnosis; 95% CI, 4.96% to 6.49%) to 2010 (8.5%; 95% CI, 7.53% to 9.42%). Musculoskeletal pain was about half of all nonmalignant pain visits from 2000 to 2010.

From 2000 to 2010, although rates of opioid use increased 73% from 11.3% of visits (2000) to 19.6% of visits (2010), prescribing rates of nonopioid pharmacotherapies remained relatively constant (26% to 29%). By 2010, of 164 million pain visits, about one-half (47%; 95% CI, 43.24% to 50.06%) were treated with a pain medicine, one-fifth with an opioid (20%; 95% CI, 17.17% to 22.06%), and one quarter (27%; 24.59% to 29.49%) with a nonopioid drug such as NSAIDs, acetaminophen or adjuvant therapy.

Using opioids with nonopioids increased as well. Taking opioids with NSAIDs increased 39%, from 3.7% of visits in 2000 to 5.2% of visits by 2010. Taking opioids with acetaminophen increased from 0.5% to 0.6% of visits and opioids with adjunctive therapies increased from 2.9% to 7.1% of visits.

Opioid prescribing increased 62% from the year 2000 (15.1% of visits; 95% CI, 11.77% to 18.39%) to the year 2010 (24.4%; 95% CI, 20.80% to 28.04%). Nonopioid prescribing for musculoskeletal pain decreased from 38% (95% CI, 34.09% to 41.06%) of visits in 2000 to 29% (95% CI, 25.55% to 32.48%) of visits in 2010. These declines were primarily driven by reductions in NSAIDs.

G. Caleb Alexander, MD, FACP, corresponding author, and co-authors wrote that the increased provider diagnoses of pain may reflect awareness campaigns such as the “Pain as the fifth vital sign” initiative and the World Health Organization pain ladder, or increased pharmaceutical marketing of new drug therapies. “Nevertheless, there is still considerable discordance between patient and provider reports of pain, which may be due to a variety of factors, such as clinicians’ tendency to diagnose underlying causes of pain rather than pain itself, and is worthy of further investigation.”

What not to call patients

There are many words that doctors have used for patients that we shouldn’t use anymore. Realizing the inappropriateness of such terminology does not require much heavy lifting, and, yet, we are still using these epithets time and time again. I thought I’d give some examples, if only to get them off my chest.

1. Non-compliant: As if the patient is supposed to be a good, obedient servant, following the doctor’s orders, turning neither to the right nor the left.

2. Denying: [“The patient denies chest pain, shortness of breath ...”]: As if these are accusations, and the patient is protesting their innocence.

3. Difficult: Like a problem or a disease, the difficult patient is meant to be solved, not helped.

4. Suffering from “pseudoseizures”: If a patient has a non-epileptic, or psychogenic, seizure, there is little that’s “pseudo” about it.

5. Uncontrolled diabetic: Again, the one-dimensional assessment. There is diabetes, a disease, to be controlled, but then, by metonymy, the patient becomes their disease.

What words can’t you stand when they are used to describe you, or your patients?

Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.
Monday, September 23, 2013

Adventures in medicine, part 3

So, to pick up from previous posts, Dr. Ron wants to play for Simon Powell on “Doctor Idol,” and Chuck (“Chuck,” I mean) wants to play for the Mud hens. What’s wrong with that? Nothing, actually, aside from their total lack of athletic and musical talent. What’s wrong is the part of the stories preceding these winsome wishes of our dear compadres.

1. The Interaction

Both doctor and patient imagined a simple interaction between doctor and patient, as they are the only two humans physically in the exam room. Unfortunately, there are many others in the doctor’s office and exam room in a non-physical, but very real, sort of way.

The outer circle is comprised of the entities or tasks that are taking Dr. Ron’s mind out of the exam room. These include:

• Insurance companies, with their complex rules (more to follow on this) of payment and ever shrinking payments.• The government, with its growing involvement in the office in areas of measurement, regulations, and (above all else) bureaucracy. Ron feels their ever-growing presence in the office each day.
• The huge amount of paperwork generated by both of these entities (and others).
• The media, with its hype machine built to sell advertising, not truth.
• Denials of claims (and decreasing reimbursement), which lead to …
• The need for higher patient volume, putting Ron further behind and giving Chuck more time to enjoy his waiting room adventures.
• The Internet with its double-edged sword of information/misinformation, leading to patient confusion and decreased patient trust.
• Specialists, who Ron uses to help him manage problems on his patients, but who often don’t send him any information about those visits, do procedures that Ron doesn’t always agree with, and are paid 3 to 4 times more than him (mostly through contracts negotiated by physician groups led by specialists).
• Hospitals, who alternately treat Ron as royalty (to get his referrals and ancillary orders) or dog poo (because he doesn’t generate direct revenue for them like the specialists do).

Sitting in the exam room between Chuck and Dr. Ron are things which are immediately on Ron’s mind, distracting his attention away from Chuck and his back.

While the threat of malpractice is not high for Ron, as a primary care provider, he knows he’s always one exam room away from potential catastrophe. The presence of these distractions make it harder to give the focus needed to avoid missing something important.

Financial pressures, either running the business itself (like Ron does) or cowing to the demands of the hospital overlords (as many other docs do), put finances at the center of the universe in the exam room. Are all the possible charges being entered on each patient? Is he spending too much time with them and therefore decreasing his overall volume?

CPT/ICD codes, whch Ron sees as a trap, with its incredible complicatedness, always seeming to give payers an “out clause.” Patients try to convince him to leave off a diagnosis, while billers want him to include the second digit after the decimal on every one. Ron wonders how digits after decimals became such an important thing in his life.

E/M coding compliance – Like most doctors, Ron realizes two things. That he is paid for documentation, not care. Having a specific number of bullet points in the history, review of systems, exams, and documenting certain thought processes are the things auditors look for when evaluating the records. Ron is forced to either put in a huge amount of information to justify the visit, or to “down code,” charging less for the visit than he deserves to avoid documenting diarrhea. No matter how hard he tries, he is never 100% compliant with documentation requirements. This is the ticking time bomb PCP’s face, as they realize that non-compliance with the impossibly complex documentation rules, in the eyes of hungry auditors has another name: fraud. Ron prays that no auditor with an agenda looks at his charts, as he knows that any doctor could be used as a public whipping-boy.

HIPAA – While Ron likes the fact that HIPAA keeps prying relatives out of the chart, he worries that he will mistakenly talk to someone who is not authorized and get into trouble. More worrisome is the fear of electronic communication or patient records getting out of the office, giving authorities another chance to take him down in public for something he has little control of, let alone understanding of.

Quality measures, while seemingly a positive thing, to reward good doctors, Ron always feels that the real agenda is to go after the “bad” doctors. He’s worried that because he doesn’t get rid of complicated or non-compliant patients, he will be labeled as an “underperforming” doctor, and get on someone’s “doctors to avoid” list. He also thinks it will be used as a reason to lower his payment.

Meaningful Use seems like a classic “bait and switch,” where doctors are lured into using computers with money, only to use the information gathered on him with those computers to increase his chance of being labeled as an “underperforming” doctor, or making the job easier for auditors to hit him with the charge of “fraud.”

All of this surrounds Dr. Ron with a series of barriers that Chuck must unknowingly cross to do the seemingly simple task of telling the doctor what’s wrong. All Chuck knows is that his back hurts and that perhaps buying the Roomba wasn’t such a good idea. He just wants to make sure there’s nothing serious going on, and he wants to feel better.

We’ll address those issues in our next post …

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.

Cyclosporiasis outbreak sickens hundreds

Cyclosporiasis is the name of the intestinal illness caused by the single-celled microscopic parasite Cyclospora cayetanensis. It is spread through ingestion of food or water contaminated by stool. (Oh, sorry. I hope you’re not reading this over lunch.) In the U.S., outbreaks of cyclosporiasis have usually been linked to contaminated imported fresh produce. It is not spread directly through contact from person to person.

The onset of the illness occurs about seven days after ingestion of contaminated food or water. Typical symptoms include prolonged watery diarrhea, abdominal cramping and nausea. Cyclosporiasis is treatable with antibiotics, although most people with healthy immune systems recover without treatment.

The Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) are investigating a recent outbreak of cyclosporiasis that has so far sickened 285 people in 11 states. (California is not among them.) Most of the illnesses started between mid-June through early July. 18 of the patients have been hospitalized. There have been no deaths.

The source of the outbreak has not yet been identified, though the investigation is ongoing.

Why am I bringing this to your attention? Just as an excuse to remind you to wash your hands and food preparation surfaces with hot soapy water before handling food, and to wash fresh produce thoroughly before eating it.

Learn more:
U.S. Health Officials Still Tracking Source of Stomach Bug Outbreak (US News)
Investigation of an Outbreak of Cyclosporiasis in the United States (CDC)
Parasites – Cyclosporiasis (CDC)
FDA Investigates Multistate Outbreak of Cyclosporiasis (FDA)

Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.

QD: News Every Day--Up to 440,000 deaths due to preventable adverse events

There could be 440,000 deaths annually due to preventable adverse events, and that’s a conservative estimate, a researcher concluded.

The study cited barriers to preventing adverse events, including increased volume of medical knowledge, lagging implementation of electronic medical records and America’s “patchwork” system of care. “It should be no surprise that (preventable adverse events) PAEs that harm patients are frighteningly common in this highly technical, rapidly changing, and poorly integrated industry. The picture is further complicated by a lack of transparency and limited accountability for errors that harm patients,” the author wrote.

An Institute of Medicine report from 1984 estimated 98,000 deaths annually from medical errors. To derive a more modern estimate, the researcher reviewed the literature and found 4 studies published from 2008 to 2011 that used the Global Trigger Tool to flag specific evidence in medical records, such as medication stop orders or abnormal laboratory results, which point to an adverse event that may have harmed a patient.

Four studies were found; each used similar methods to flag, confirm and classify adverse events by level of harm. All studies used a 2-tier approach that had nurses or pharmacists screen medical records to flag suspect events, and then had physicians determine if an adverse event had occurred and how serious it was.

Because the 4 study populations were so different, the researcher used a weighted average. In one study there were more than 4,500 records reviewed and 38 deaths associated with adverse events (0.89%). There were an estimated 34.4 million hospital discharges in 2007, and the average percentage of preventable adverse events among all adverse events in the three other studies was an average of 69%. The four studies combined tallied 34.4 million × 0.69 × 0.0089 = 210,000 preventable adverse events per year.

However, the researcher noted, the search capability of the Global Trigger Tool is limited, as is the incompleteness of medical records on which it depends. Some events may go unreported by physicians. The researchers applied a minimum estimate of a 2-fold increase to compensate, and then included an estimate of 40,000 undetected diagnostic errors (210,000 × 2) + 20,000 to calculate that there might be 440,000 premature deaths associated with preventable harm. And, serious harm seems to be 10- to 20-fold more common than lethal harm.

The researcher wrote, “In a sense, it does not matter whether the deaths of 100,000, 200,000 or 400,000 Americans each year are associated with PAEs in hospitals. Any of the estimates demands assertive action on the part of providers, legislators, and people who will one day become patients.”
Friday, September 20, 2013

Your medication can kill you

You probably already know that what you do know about your medicine could kill you. You may not know that what you don’t know could do so as well. Hold that somber thought; we’ll get back to it.

You, and I, and everyone else has seen those direct-to-patient drug ads that Big Pharma runs on primetime television. Invariably, they feature a person skipping through butterflies and wildflowers, demonstrating the wonders of better living through pharmacotherapy, as an announcer calmly rattles off the ways the drug can destroy your health: It can make your liver explode, and your eyeballs catch fire, and your kidneys fall out, and so on. But you won’t mind; you are too busy skipping through meadows.

Except, of course, that people do mind! In fact, I can’t understand those ads at all, since the purpose of advertising is to talk people into things, not out of them. Overwhelmingly, my patients who have seen such drug ads are scared to death of those medicines, and very much disinclined to take them. I don’t recall the last time a patient said to me: “I want that medicine I saw on TV that can make my eyeballs catch fire ...” Generally, it’s quite the opposite; if I recommend that medication, they tell me I must be crazy. As advertising goes, this really is odd.

Before getting to my point, I have a few things to point out to forestall a rush to judgment about my motivations.

I don’t like taking medications myself, not even when I need them. Most of my patients seem to feel that way, and I respect it. I am not on Big Pharma’s payroll and have no stake in the use of any drug. What’s more, I have worked for nearly a decade and a half in integrative medicine, in a model of my own devising, side by side with naturopathic colleagues, with a focus on natural treatments whenever possible. Even those looking for nasty things to say about me would really be pushing it to call me a pill pusher. I’m the guy patients come to see when they want alternatives to their prescribed drugs. Seriously.

It is in that context I need to point out that it’s not only what you do know about your medications that can hurt you; it’s what you don’t know. What people tend not to know is the side effects of not taking medication when it’s truly warranted.

I am a 50-year-old guy with five kids and a desk job. I take no medications. My blood pressure is that of a very fit 20-year-old, and my cholesterol is under 150, with HDL higher than LDL. There are more good biometrics where those came from, but that will do. I am not boasting. None of this is evidence that I’m a swell guy, or special in any way. This is all merely the result of practicing what I preach, and using lifestyle as my medicine.

Everyone could do the same with the right skill set, and if more people did, the pharmaceutical business would be a whole lot smaller and less profitable. From my perspective, that’s a consummation devoutly to be wished, and I am doing all I can to help people get there from here. I devote my time and energy to developing lifestyle programs for adults and children alike; to developing training programs in lifestyle medicine for clinicians and patients alike; and to writing books on the topic for both health care professionals, and everyone else. I practice lifestyle medicine, I preach it, and I am passionate about its potential to improve the human condition.

But I am also pragmatic. I look around and see a world awash in chronic disease, stealing life from years and years from life. And while lifestyle is best to prevent all that misery, modern medicines are often best for treating it.

Despite all the valid concerns about environmental contaminants, cancer rates and deaths have declined, not risen, over recent decades, due largely to advances in medical technologies and drugs. Stroke rates and stroke death have declined dramatically, due to advances in risk factor identification, and in particular, better pharmacotherapy for high blood pressure. Heart attack occurrence, and mortality, have declined, due overwhelmingly to advances in both technology, and pharmacology- from clot-dissolving agents, to statins. These are facts of epidemiology, not principles of ideology.

Lifestyle could be our best medicine, and I both plan and pledge to keep doing all I can to help make it so. The very best medicine means less time in clinics, because it reverberates through our culture.

But in the interim, we do have widespread diabetes, and heart disease, and hypertension, and dyslipidemia, and insulin resistance, and cancer, and so on. All too many of us have conditions that warrant treatment, and for which, fortunately, we often do have effective pharmacotherapy.

Here, then, is the point. Big Pharma is obligated to rattle off the side effects of their drugs in those ads; there are no corresponding ads to rattle off the side effects of needed drugs that go untaken.

Yes, side effects of medications can kill. But so can the side effects of declining medications we really need. When prescribed judiciously by clinicians who know what they are doing to patients who know what they are getting, drugs are far more likely to help than harm.

So here’s to needing less medication; we could make that happen. But until we get there from here, I advise an open mind and lack of prejudice. Get good information from sources you trust, and then take the path of most likely benefit, least likely harm, knowing it may or may not involve a stop at the pharmacy.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

What foods are in the Mediterranean diet?

The Mediterranean diet is fresh on my mind, having recently returned from a trip to Turkey. During my trip I became a particular fan of Turkish vegetables: white beans with tomatoes and onions in olive oil, oven baked green beans or okra, eggplant stuffed with walnuts with a tomato ragout, to name a few. My husband commented that I must be a true fan of olives, as he surveyed my breakfast plate, which was chalk full of several varieties of olives, raw cucumbers, tomatoes, a few arugula leaves, fresh cheese and bread. During my travels I also enjoyed a variety of grilled fresh fish served with lemon, seaweed salad, pomegranate juice, freshly pressed at the side of road, and roasted chestnuts, also sold by street vendors.

I was elated to hear that a new study published in the New England Journal of Medicine in April of this year validated the health benefits of the Mediterranean diet. The study randomized 7,447 women and men with risk factors for cardiovascular disease to receive either a Mediterranean diet enriched with olive oil, a Mediterranean diet enriched with nuts, or a standard low fat diet for the control group. Participants assigned to the two Mediterranean diet arms were found to have a significantly reduced risk of adverse cardiovascular outcomes (heart attack, stroke, death from cardiovascular causes) compared with the control group. The study was terminated after a mean follow up time of 4.8 years.

Are you wondering how your diet matches up with the “Mediterranean Diet” as defined by the recent study? I was after I read these results.

Here are the criteria with answers qualifying for the Mediterranean Diet shown in bold.

1. Do you use olive oil as main culinary fat? Yes
2. How much olive oil do you consume in a given day (including oil used for frying, salads, out of house meals, etc.)? 4 or more tablespoons
3. How many vegetable servings do you consume per day? (1 serving = 200g - consider side dishes as 1/2 serving) 2 or more (at least 1 portion raw or as salad)
4. How many fruit units (including natural fruit juices) do you consume per day? 3 or more
5. How many servings of red meat, hamburger, or meat products (ham, sausage, etc.) do you consume per day? (1 serving = 100-150 g) Less than 1
6. How many servings of butter, margarine, or cream do you consume per day? (1 serving = 12 g) Less than 1
7. How many sweet/carbonated beverages do you drink per day? Less than 1
8. How much wine do you drink per week? 7 or more glasses
9. How many servings of legumes do you consume per week? (1 serving = 150 g) 3 or more
10. How many servings of fish or shellfish do you consume per week? (1 serving: 100-150 g fish, or 4-5 units or 200 g shellfish) 3 or more
11. How many times per week do you consume commercial sweets or pastries (not homemade), such as cakes, cookies, biscuits, or custard? Less than 3
12. How many servings of nuts (including peanuts) do you consume per week? (1 serving = 30 g) 3 or more
13. Do you preferentially consume chicken, turkey or rabbit meat instead of veal, pork, hamburger or sausage? Yes
14. How many times per week do you consume vegetables, pasta, rice, or other dishes seasoned with sofrito (sauce made with tomato and onion, leek, or garlic, simmered with olive oil)? 2 or more

*From Table in S1 in Supplement to: Estruch R, Ros E, Salas-Salvadó J, et al. Primary prevention of cardiovasculardisease with a Mediterranean diet. N Engl J Med 2013.

Taking a closer look at the details of the study as described in the NEJM supplement, it seems to me that the particular factors of those listed above that really differentiated the Mediterranean groups from the control group were: the quantity of olive oil ingested, the increase in nuts consumed, and, somewhat less significantly, the amount of seafood consumed, legumes consumed, and sofrito sauce consumed.

In this study the particular kinds of nuts prescribed were walnuts, hazelnuts and almonds. However, there may be health benefits with other nuts as well. Here is some useful nutritional information from University of Michigan Health System (my alma mater) about nuts.

Personally, this study has changed my health practices. While I was already doing well with some of its components, since reading the specifics of the Mediterranean diet prescribed and found to be associated with reduced cardiovascular risk I’ve made greater attempts to incorporate legumes, nuts, and fish into my diet.

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