Tuesday, April 30, 2013

Obamacare fee will cost you

Americans are learning of a new fee attached to Obamacare. This fee is expected to rake in $25 billion over three years, and many corporations aren't happy. Millions of dollars could flow from major companies into government coffers if the fee is implemented as planned. The cost? Sixty-three dollars per person per year.

Given that most employers would pass the fee onto employees, that would add $63 (probably pre-tax) to a yearly insurance bill. That works out to about $2.50 per pay period for me.

And what does this exorbitant fee get us?

The fee is meant to offset the cost of insuring people with medical problems. Since Obamacare demands that insurance companies take everyone, not just the healthy, the cost of providing insurance will go up. Let's step back and examine the premises here.

Obamacare is not health care reform as such. It's insurance reform. Rather than changing the basic structure of health care in the U.S., it aims to create better access to insurance, especially for people who traditionally have been hard to cover.

Health insurance takes a pool of money from premiums and uses it to pay medical bills. For-profit insurance companies get to keep the leftovers, so it's in their best interest to minimize how much they pay out. One way to do this is to insure the healthiest people possible. This is why they would like to exclude pre-existing conditions.

If we ask insurance companies to insure everyone at affordable rates, we have to make it worth their while. The new fee would help offset the cost of caring for people with expensive, pre-existing conditions.

Arguments against the fee come in a few flavors. Employers, who provide most working people with insurance complain that they are paying someone else's bill, and they are. The cost to individual workers is negligible, so why whine?

This money will essentially flow right into insurers pockets through a government run fund. We could argue that paying insurance companies to administer these plans is a gift, a government subsidy. I would agree with that, but insurance reform rather than health care reform is what we as a nation have chosen.

One way or another we have to pay for health care. Right now the uninsured are paid for by all of us as they rack up unpaid charges at emergency departments and clinics. This fee appears to make it more explicit, and to spread the pain fairly evenly. In the system we've chosen, this doesn't seem like such a bad deal.

But if I read about insurance executives holding meetings in Bora Bora, I'm going to be rather annoyed.

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog at Forbes. His blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.

'They came and took my deathbed away'

Evelyn (not her real name) is 72. Three years ago she was diagnosed with multiple myeloma (MM).

MM is a rare type of blood cancer. Some famous folks who've died from multiple myeloma include Sam Walton, Geraldine Ferraro, Roy Scheider (the first Brody, Homeland fans ...), Roger Neilson, a former hockey coach (New York Rangers, among others) also died from MM. It occurs when there is a proliferation of a specific kind of white blood cell known as the plasma cell. Plasma cells have a special role in immunity. They make antibodies, which are specialized proteins that help fight infections.

When plasma cells turn cancerous, they start cranking out antibodies in huge quantities. Those large amounts of protein thicken the blood. They also clog up the kidneys, impairing their function (which is often how MM gets diagnosed). MM also causes lytic lesions of bones, clusters of plasma cells in the bone marrow set up shop, which weakens bones and leads to fractures. It's an interesting disease in that it has effects on so many parts of the body and gives many different signals enabling its discovery.

Those many signals also serve as targets for interrupting progress of the disease. We've made strides in treating MM over the years, so much so, that it's not surprising to see people with advanced MM live more than five years from the time of diagnosis.

Evelyn took a downward turn when she was diagnosed. She weakened from the disease itself, and then treatment wore her down even further. She lost weight. She was hospitalized. First with pneumonia. A second time for dehydration.

Her oncologist stopped treatment for anything beyond symptom control. The numbers measuring her "disease burden" had improved, but in the big picture, she was close to dying.

She was offered the opportunity to enter hospice. She declined, but still a hospital bed was ordered for her to use at home with the rationale that if she were eventually confined to bed, it ought to be adjustable so that she could attain maximal comfort.

Here's the thing: After her last hospitalization, she started feeling better. Might have been the antibiotics for her pneumonia. Could have been that the fluids "perked her up."

Whatever it was, her appetite improved. Her weight picked up. She was more mobile, and started attending church regularly again.

After about six months of this, the company that had provided her hospital bed came and collected it. Mind you, Evelyn still has a terminal diagnosis, even though she's doing remarkably better.

When I asked her how this came about, she merely stated, "They came and took my deathbed away. Said someone else needed it."

Made my week.

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--Internal medicine sees increased mean earnings over last year

Internal medicine specialists earned a mean of $185,000 last year, a 9% increase created by the shortage of primary care practitioners and the results of health care reform boosting payments for Medicare patients, a report said.

Medscape's Physician Compensation Report: 2013, represents data from nearly 22,000 physicians collected in February 2013.

Physician income is rising overall, with one-third of specialties surveyed earning more than $300,000 annually. This year's three top-earning specialties were orthopedics ($405,000), cardiology ($357,000) and radiology ($349,000).

Overall, men earn 30% more than women; in primary care that gap is 17%. The gap varies by specialty but narrows when physicians work set hours in large health systems.

This year 24% of respondents were either in an ACO or plan to join one, compared to 8% last year.

Physicians working in hospitals earned a mean of $260,000, compared with $225,000 in last year's report, and the income of solo practitioners ($216,000) has declined and is lower than that of employed physicians, who experienced an increase in income ($220,000).

Still, satisfied with compensation is rising for primary care physicians, 51% this year compared to 46% last year and 49% in 2011.

The percentage of physicians in a concierge or cash-only practice increased from 4% to 6%, and 20% of internists offer ancillary services to create cash flow in their practices.

Also among the findings:
--18% of all doctors (22% of internists) spent more than 50 hours a week seeing patients.
--9% of all respondents (and 11% of internists) plan to stop taking new Medicare patients but will continue caring for their current ones, while 2% will no longer treat even their current Medicare patients.
--23% of all physicians will drop insurers who don't reimburse well, while 18% said that dropping poor-paying insurers is not appropriate behavior, and 20% said that they need all payers.
--More primary care physicians would not choose their specialty again compared to some subspecialists. Among internists 19% would not do so, compared to 25% who said last year that they would not.

A second survey, the MGMA Physician Placement Starting Salary Survey: 2013 Report Based on 2012 Data, reported that primary care physicians reported $180,000 in median first-year guaranteed compensation, up from $175,000 in 2011. Practices are increasingly offering signing bonuses, relocation expenses, even additional vacation time, likely to attract new physicians during a shortage of primary care providers.
Monday, April 29, 2013

What do Americans want from health care?

I know what I want, in health care, that is. I want it to be efficient, effective, thoughtful and inexpensive. I want it to create healthy people who don't need very much health care. I want it to involve elegant solutions to problems that take less time, money and effort. I want it to be so much easier and less expensive that taking care of all of our people uses even less resources than taking care of only some of them, as we do now.

But the health care industry in America is bigger than me, and bigger than all of the doctors who work in it, even if we could all agree on what we want. So what does it want?

Is it even reasonable to think about health care as an entity? I propose that it is, that this way of looking at it makes the direction it has taken much more understandable.

We observe that bureaucracies grow, even though we complain about how they should shrink and become more efficient. Agencies beget more agencies, and attempts to reduce bureaucracies often don't work. I've seen what happens at our local university when educational budget cuts happen. They cut positions, but the people who remain are expected to pick up the functions of the ones who lost their jobs, which leaves the scope of the bureaucracy the same size as before, but temporarily overworks the people who remain (until they hire new people to unload them).

The health care delivery system in the U.S. has progressively grown, primarily driven by the growth of insurance, both government and privately funded. This has brought financial professionals heavily into the delivery of care, and has also increased the amount of money available for services. The availability of financial resources makes it more possible to continue to treat patients who become sicker and more dependent upon it. It is also more feasible to develop very expensive technological approaches to illness, which expands the system to include scientists, device manufacturers and the companies with their own workers and advertising professionals. This just gets bigger geometrically.

Even if individuals within this vastly complex system want care to be cheaper and less complex and patients to be less dependent, the system itself does not want this, and continues to grow. It's hard not to invoke the metaphor of a large, stupid and perpetually hungry giant. Even without the metaphor, mathematics explains why complex, inefficient technological medicine that creates dependency wins out over elegant, efficient and cost effective medicine. The complex and inefficient version is bigger. By its nature it is bigger, which, in the absence of an external force deterring it in some way, or some catastrophic imploding event, means it will continue to be the bulk of what health care is.

So why even try to find the elegant solutions? There is abundant talk of implosion and the Affordable Care Act has made some attempts to externally deter the growth of the health care industry. I don't see the former as happening anytime soon and the latter seems unlikely to have a major impact, but if we keep looking for ways to make health care be less expensive and more of what we, as patients, really want, those solutions will be available when we really need them.

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.

A call for physician payment reform

Readers know that I dislike the current fee-for-service model, because it encourages volume throughput. A new commission agrees: To contain health care costs, pay doctors differently.

We cannot control runaway medical spending without changing how physicians in this country are paid, which is currently the single most significant driver of health care costs. We pay physicians according to the number of services they provide. The skewed financial incentives inherent in a fee-for-service model promote fragmented care and encourage doctors to provide more--and more costly--care, regardless as to whether those services improve the health of patients.

The best way to improve health care is to change payment models to promote primary care and better care co-ordination. Some will not like this approach because with any payment change there are winners and losers. We should focus on the most important winners: patient care and spending.

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--Elderly women inappropriately given antibiotics for suspected UTIs

Nearly half of older women diagnosed with a urinary tract infection (UTI) in an emergency department setting did not have confirmatory findings on urine culture and were given antibiotics inappropriately, a study found.

To determine how often older women presenting to an emergency department are diagnosed with a UTI without a positive urine culture and to whether the way urine is collected improves the accuracy of the urinalysis, researchers conducted a retrospective chart review of 153 women ages 70 and older in an academic-affiliated emergency department in Providence, R.I. from December 2008 to March 2010.

A confirmed UTI was defined as a positive urine culture, with microbial growth of 10,000 colony-forming units (CFU)/ mL or more for clean-catch specimens and 100 CFU/mL or more for newly inserted catheter specimens. Diagnosis of UTI was defined as the designation by an emergency department physician.

Results appeared in the Journal of the American Geriatrics Society.

Of 153 individuals with an emergency-department-diagnosed UTI, only 87 (57%) had confirmed cases according to culture. Of the remaining 66 with negative cultures, 63 (95%) were administered or prescribed antibiotics in the emergency department. Researchers noted that catheterization improved the accuracy of urinalysis when assessing older women for possible UTI (P=.02), with catheterization yielding a lower proportion of false-positive urinalysis (31%) than clean catch (48%).

Diagnosis of a UTI in the emergency department was not generally based upon having urinary symptoms. Only 18% of the older women diagnosed with UTI came to the emergency department with it as a chief complaint. Other common complaints included change in mental status and falls. Researchers noted that older women commonly have asymptomatic bacteriuria, which the Infectious Diseases Society of America and the American Medical Directors Association recommend should not be treated.

Researchers wrote that emergency department physicians "cannot rely exclusively on a positive UA or the presentation of urinary symptoms as a predictor of a positive culture result."
Friday, April 26, 2013

Metatstatic medical regulations and health care reform are job security for bureaucrats

This week I promised you specific examples of dumb rules that we doctors must comply with. Here are just a few. There are enough ridiculous regulations to fill multiple blogs devoted only to this issue posting hourly around the clock. Yeah, I sound a mite cranky now. The truth is that I still enjoy the work of doctoring. I love my time with my patients. There is, however, an increasing burden of stuff thrust upon us that takes time, energy and money away from our healing mission. Perhaps, these regulations are solving someone's problem somewhere. I suppose that this should comfort me knowing that somewhere in a government cubicle, a bureaucrat is smiling.

We are required to ask patients their ethnicity. Of course, many of them including myself are uncertain how to respond to this accurately. I'm sure that our staff conveys an impression of knowledge and professionalism when they shrug their shoulders in cluelessness after patients ask the purpose of this inquiry.

A few times per week, I am given a several pages of forms to sign off on. This lists all the patients whom I have joyously performed procedures on recently and the sedation that I administered. Of course, I cannot recall any of these interactions days later. I have been told that signing this complies with some requirement issued from a windowless government office located somewhere within the Milky Way. I can assure readers with total certitude that this act helps no living or deceased human being, or provides any beneficial function for the medical profession or any other occupation. It is possible that this provides employment for a government sinecure, so perhaps my signature helps to contain unemployment. Call me a patriot.

We have to report to Medicare on every single patient we perform a procedure on if he suffered a burn or fell down. Let me come clean with readers and disclose our stats on these two misadventures. After successfully probing tens of thousands of patients, none has taken a tumble or been singed by lightning. We are also required to report if pre-operative antibiotics were administered on time. Sounds good, except years pass before we ever give a patient antibiotics before a colonoscopy. The government, hungry for data, makes us send in a code on every patient that didn't receive antibiotics, which is 99.97% of them. So, why the reporting mandates? Because our endoscopy center is lumped into the same category with facilities that perform actual surgeries. Ever hear the phrase "One size fits all"? Where do these right wing ideologues get the idea that there's any waste in Medicare?

We cannot discuss off label use of medications with pharmaceutical representatives, a silly rule that I discussed in a prior post. Like many regulations, there's a rational basis for it, but it morphed into OperationOVERKILL. This reminds me of the anecdote of a young boy who was punished when he kissed a girl in school. An innocent romantic gesture? Hardly. This was a brazen violation of an ironclad sexual harassment policy. Luckily, the third greater only planted a buss on the cheek. If there had been unwelcome lip contact, then the youngster may have been whisked out of the country to endure extraordinary rendition and enhanced interrogation techniques.

If a principal of a school is fed up with kids running in the halls, should all kids be required to have their ankles shackled so that compliance with school policy cannot be violated? If you don't regard this hypothetical as silly, then please stop reading this blog. You were probably one of those kindergarten miscreants who played pat-a-cake with a kid of the opposite gender. Touching another kid's skin is verboten and is a clear stepping stone to playing tag, flag football and other delinquent activities. I think that all children under the age of 10 should be required to wear mittens while on school property. Boys who cannot control their lips should be fitted with muzzles. Let's do this for our kids.

If anyone out there has their own rules and regulations tales, pray tell.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

QD: News Every Day--Medical interns spend 12% of their time on direct patient care

Medical interns spent 12% of their time examining and talking with patients, more than 40% of their time behind a computer and 7% of their time walking the wards, according to a new Johns Hopkins study that closely followed first-year residents at two large academic medical centers in Baltimore.

Observers followed 29 internal medicine interns at The Johns Hopkins Hospital and the University of Maryland Medical Center for three weeks in January 2012, for a total of 873 hours, using an iPod Touch to mark down what the interns were doing minute-by-minute.

The conclusions appeared online in the Journal of General Internal Medicine.

Interns spent 12% of their time talking with and examining patients; 64% on indirect patient care, such as placing orders, researching patient history and filling out electronic paperwork; 15% on educational activities, such as medical rounds; and 9% on miscellaneous activities.

"Most of us went into medicine because we love spending time with the patients. Our systems have squeezed this out of medical training," said Leonard S. Feldman, MD, FACP, the study's senior author and a hospitalist at The Johns Hopkins Hospital, in a press release.

The 12% figure "seems shockingly low at face value," Dr. Feldman said. "Interns spend almost four more times as long reviewing charts than directly engaging patients."

Studies in 1989 and 1993 found that interns spent between 18% and 22% of their time at the bedside. In those studies, however, researchers found that a large chunk of time was spent sleeping at the hospital.

Dr. Feldman questioned whether the time spent with patients is enough to give interns the experience they need. Better electronic medical records may help reduce time spent combing through patient histories on the computer. And, an intern's patients could be grouped together on the same hospital unit so the intern doesn't have to move from floor to floor to see patients.

"It's not an easy problem to solve," Dr. Feldman said. "All of us think that interns spend too much time behind the computer. Maybe that's time well spent because of all of the important information found there, but I think we can do better."
Thursday, April 25, 2013

Trickle-up economics and a new health care model

It's been a month since I started my new practice. We are up to nearly 150 patients now, and aside from the cost to renovate my building, our revenue has already surpassed our spending. The reason this is possible is that a cash-pay practice in which 100% of income is paid up front has an incredibly low overhead. My admitted ineptitude at financial complexity has forced me to simplify our finances as much as possible. This means that the accounting is "so simple even a doctor can do it," which means I don't need any front-office support staff. I don't send out bills because nobody owes me anything. It's just me and my nurse, focusing our energy on jury-rigging a computerized record so we can give good care.

Our attention to care has not gone unnoticed. Yesterday I got a call from a local TV news reporter who wanted to do a story on what I am doing. Apparently she heard rumor "from someone who was in the hospital." I was the talk of the newsroom, yet I've hardly done any marketing; in fact, I am trying to limit the rate of our growth so I can focus on building a system that won't collapse under a higher patient volume. I explained this to the disappointed reporter why I was not interested in the interview by telling her that I left my old practice because I needed to get off of the hamster wheel of health care; the last thing I want to do now is to build my own hamster wheel.

I've also gotten interest from a place I didn't expect: local specialists. I always thought what I am doing applies only to primary care, as it is hard to do a monthly fee for the procedure-oriented specialties. But as the enthusiasm for my new type of practice grows in the community, it may spur a boom in cash-paying patients.

Why? One of the provisions in the Accountable Care Act (ACA) is that small businesses (with over 50 employees) who want to avoid the penalty for not having insurance can opt to contract with a direct-care physician like myself in conjunction with a high-deductible health care plan. Even though I have made no effort to attract such interest, I've already been approached by two businesses of 100 employees to make such an arrangement. Again, I turned the offer down for now, saying I am quite interested, but would only do so when my practice was ready. But the fact that this happened while I am doing my best to avoid attracting such attention suggests to me that the desire for this is very intense in the small business community. This makes sense, as they don't want to pay the fines, but also don't want to pay the exorbitant cost of standard insurance, and so would jump at any other option.

The end result is a potentially large influx of patients who are basically self-pay. The specialists, who see me lowering my overhead significantly by taking cash payment up-front, see the same opportunity for their practices. The hitch for them is that they are not allowed to give discounts to self-pay patients that they are not also giving to Medicare patients.

Yes, it is illegal for a Medicare provider to give a discount to non-Medicare patients who cannot afford the cost. There are ways around this rule, and I hope to work out something for my specialist colleagues so they can give significant discounts in exchange for cash up front (which is, by the way, the same logic that the labs use to give the enormous discounts I am offering to my patients on lab services). I have had multiple specialists show very high interest in such an arrangement. I'll fill you in as this develops.

This seems quite ironic to me, a sort of "trickle-up economics," where I am spreading the benefit of offering discounted care in exchange for cash to the higher-paid specialists. It is a win-win-win arrangement, though, as the specialists benefit from reducing their overhead while getting guaranteed payment, I benefit by increasing the value of my type of practice even more to my patients, and the patient benefits by getting cheaper care. This, of course, raises the likelihood that more businesses will opt for this payment model, and the movement gains momentum.

Who loses? The "increased overhead" comes in the form of the front-office staff doing billing, coding, and collections. This is the staff my simple-minded approach to finances has heretofore avoided, and hopes to continue avoiding.

I may be completely wrong in this, as it may not consider other factors (which wouldn't surprise me), but I am not wrong about the intense interest I see in what I am doing. It is palpable. When I spoke at HIMSS over the weekend (ironically as keynote for a pre-conference targeted at large health systems building ACOs), the reception was remarkably positive. My message of simplicity is falling, apparently, on very fertile soil. Did they realize the implication of "cost savings" is the need for less employees and the result to downsize their business? I took great pains to emphasize the point, yet the reception was vigorously positive.

I suppose little should surprise me, in a world where the have-lesses could have their abundance trickle up to the have-mores. Who knows, maybe people will even pay attention to the economic wisdom of a doctor with an accounting impediment.

Nah. That's ridiculous.

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

QD: News Every Day--Knowledge gaps, short patient visits cited as reasons for fouled diagnoses

Knowledge gaps and short patient visits were cited by physicians as to major contributors to diagnostic errors, a study reported.

Diagnostic errors were the most common, costly and dangerous of medical mistakes among malpractice claims, as was reported yesterday.

In a separate study, researchers surveyed primary care physicians in an integrated health system across 10 geographically dispersed states in 2005 about barriers to timely diagnosis in the outpatient setting and assessed their perceptions of diagnostic difficulty. The survey also included two open-ended questions, the first about a specific incident of delayed diagnosis and a second that asked for suggestions to reduce delays in diagnosis.

Authors examined the extent and predictors of diagnostic difficulty, defined as reporting more than 5% patients difficult to diagnose. Results appeared in BMJ Quality & Safety.

Of more than 1,000 respondents, inadequate knowledge (19.9%) was the most commonly reported cognitive factor. Half reported more than 5% of their patients were difficult to diagnose; more experienced physicians reported less diagnostic difficulty.

The most common cognitive issue reported was inadequate knowledge base (19.9%), followed by inadequate detection or perception of a clinical problem (12.7%). Also reported were misidentification of a symptom or sign (6.8%) or overestimation of the reliability or saliency of a finding (9.2%).

Open-ended suggestions to reduce diagnostic delays included lengthening patient visits, reducing panel sizes and assigning nonclinical work to non-physicians (21%). Also, respondents cited wait times for diagnostic tests and for results to be conveyed to physicians and patients (13%) as areas of improvement, and that improved access to specialists would reduce diagnostic delays (10%).

Researchers noted that knowledge gaps appear to be a prominent concern among primary care physicians.

They wrote, "Misdiagnosis relates to several system and cognitive factors but knowledge gaps might be more often responsible than previously estimated. Interventions that address practice level issues such as time to process diagnostic information and better subspecialty input might potentially reduce diagnostic safety concerns in primary care."
Wednesday, April 24, 2013

Personal genomics--maybe an excellent idea?

My son, who is 19, wanted a nice jacket and his genome for Christmas this year. He had found out that a company called 23andMe would tell him about his genetic susceptibility for diseases and his ancestry for only $99. 23andMe is a private company that started doing direct to consumer genetic testing in 2007 and has progressively lowered their prices and increased the amount and sophistication of information they give clients since then.

My sister bought my son the genetic kit and the padded envelope was under the tree for him on December 25th. He opened up the little plastic tube inside, spit in it and sent it back. In a couple of months he had all sorts of interesting information. He was most interested to see what parts of the world his ancestors sprang from, but also got information about scads of other things including his sensitivity to caffeine, ability to recognize bitter tastes, whether his muscles were predominantly "fast twitch" suggesting he would be a good sprinter, whether he would be sensitive to certain medications for which we have that genetic test, and whether he carried genes for some common conditions such as cystic fibrosis or hemochromatosis. With each piece of information there was a link to information about how good the science was that backed up the association, what the disease was and how common it was in the population.

23andMe got its name from the fact that there are 23 pairs of chromosomes in the human genome. Evaluating genes from a spit sample in this way was named invention of the year in 2008. It uses microarray analysis to look at single nucleotide polymorphisms (SNPs) via the company Illumina. (Illumina also provides its own service of full genome sequencing which is far more expensive than the $99 test that 23andMe performs.) After submitting the sample, the client can fill out tons of surveys and questionnaires which the company can use to make even more predictions about characteristics based on SNPs.

It is possible to detect increased or decreased risk of certain diseases such as Alzheimer's disease, melanoma and breast cancer. There are certain SNPs that are associated with an increased risk of heart attacks when one drinks coffee. There are SNPs associated with higher risk of an adverse reaction to warfarin, statins or certain drugs for HIV or hepatitis C.

When I, as a primary care physician or hospital physician, see a patient, it would be incredibly useful to know what the person's individual propensities are. Is this the patient who should be watched closely after being started on a certain drug, or perhaps not started on it at all? Should further testing be done for cystic fibrosis, or is this very unlikely? Is this one of those people I should tell to drink coffee, because it is good for them, or are their needs different? I spend many hundreds of dollars of the patient's and their insurance company's money finding answers to these questions.

Hemochromatosis is a genetic disease in which iron builds up in the tissues, causing arthritis, fatigue, diabetes, heart failure, skin changes, liver cirrhosis and cancer. It is pretty common, about 1/200 Caucasians have it, and it usually doesn't present until the fourth decade, often with some life threatening disease. By reducing iron intake and therapeutic removal of blood, iron stores can be kept at safe levels, completely preventing actual disease, but none of the most standard blood tests detect it when it is still early. A 23andMe test detects the most common genetic abnormalities that cause it. Using the tests that I order to detect it would cost over $600, the last time I looked into it.

Lately there have been many articles looking at the health benefits of drinking coffee and eating dark chocolate. We have a large database of nurses who drank astounding amounts of coffee and also participated in a longitudinal study of health outcomes. We don't know anything about these peoples' genetics, but we do know that, in general, the moderate to heavy coffee drinkers did better on many measures. Dark chocolate appears to have positive effects on blood pressure and other cardiovascular outcomes. One of the tests in the 23andMe profile is fast vs. slow caffeine metabolism. It turns out that fast caffeine metabolizers may have reduced risk of heart attack when they drink coffee and slow ones have an increased risk. There are many reasons why a person might drink coffee or eat dark chocolate other than improving their health, but knowing about my caffeine metabolism would definitely have some effect on my consumption.

For a patient, there are so many terrible diseases out there vying for one's attention. Which should we focus on? The site has some very good generic advise for patients on what they might do to reduce risk for disease, since only a portion of that risk is genetic.

There have been many articles discussing the pros and cons of personal genomics. It is possible that detecting an increased risk of an expensive disease could affect insurance costs or willingness of a company to hire a person. Insurance discrimination based on this information is definitely illegal, and 23andMe information is kept secure, but anything anywhere on the internet is potentially common knowledge. Some people have been concerned that since the information is given directly to the consumer rather than involving a physician to interpret the results, misunderstandings could occur with unknown consequences. Genomic information is used as part of medical evaluations, including full genome sequencing for rare and mysterious diseases and characterization of specific mutations in malignant tumors to find out which of the many very expensive cancer drugs will work for them. This information definitely requires a doctor to order and interpret it correctly.

The information a person gets from the 23andMe site is useful at some level for an educated consumer, but would be even more useful if shared with a physician. That process would take time and it might be challenging to get a primary care doctor to engage in it. If physicians became familiar with the format, it would be possible to review the information at a designated appointment for that purpose, as doctor and patient looked at the results together on a computer. Because genetic data is difficult to interpret and explain, physicians often refer patients to genetic counselors, but these visits are usually expensive and time consuming and reserved for people with definite medical risks or recognized diseases.

Why, one might wonder, does it cost only $99 to get all of this awesomely useful information? Ordering any little part of this information, without the website support or genealogy stuff, costs far more than if I, as a physician, order it for my patients. The low cost is at least partly because this venture bypassed the usual regulatory steps and isn't paid for by medical insurance. It is also not yet profitable, and was initially bankrolled by Google cofounder Sergey Brin, Genentech and some other investors. Because it gets more powerful information and becomes more efficient as it gets more customers, it is becoming progressively more profitable at the same time it becomes more affordable. There are other companies that do personal genomics, but I have been unable to find any that use this model and have anywhere near the level of success that this one does, so I don't think competition is doing much to bring costs down.

Today I got online and pressed the "buy now" button for a 23andMe kit. Soon my padded envelope will arrive and I will spit in a tube and wait for my results. Ninety nine dollars is a very small price to pay for a chance to know what my particular medical issues might be. So much of the evidence in evidence based medicine is based on the idea that the responses of a single person will be the same as those of an unselected population. Population based research leads us to believe that exercise, olive oil, coffee, dark chocolate, red wine, statins and fish are good for everyone, but are they, in fact, good for me? 23andme can't answer most of those questions yet, but if enough people are analyzed there eventually will be a better understanding of individual patient's needs.

As I re-read this post, after getting the initial comment (see below), I realize that it reads like an advertisement for this particular company. I do not intend that, but I really can't find other services that are comparable. There are lots of companies that are rolling out genetic evaluation products and I expect that in a few years there will be many viable competitors. Using genetic testing to individualize treatment is all over the doctor news this week. Eric Topol, a cardiologist and geneticist, spoke about it here. The practice of using genomics is moving very fast and it is impossible to know what impact it will have. It has the potential to increase health costs astronomically, or improve and streamline care. I am excited to see what a direct-to-consumer model can do, unconstrained by many of the perverse incentives that make medical progress slow and expensive.

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.

Good riddance to TB testing

We suspended our tuberculin skin test program for health care workers due to the nationwide shortage of tuberculin. I say, Glory Hallelujah! I can't think of a more poorly performing test. Really, it's junk. And we've reached a point at our hospital that no health care worker will take isoniazid after a positive skin test until an interferon-gamma release assay has been done and is positive. However, there doesn't appear to be a good correlation between the skin test and the IGRA, so when the two tests are discordant, it's a coin toss as to which is the true result. To complicate matters even more, there's also a nationwide shortage of isoniazid. And don't even get me started on the use of isoniazid to treat latent TB (see here).

Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., 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. This post originally appeared at the blog Controversies in Hospital Infection Prevention.

QD: News Every Day--Diagnostic errors the most common, costly of malpractice claims

Diagnostic errors were the most common, costly and dangerous of medical mistakes among malpractice claims, and not surgical and OB/GYN claims, a study found.

Researchers analyzed more than 350,000 paid, closed malpractice claims from the National Practitioner Data Bank from 1986 to 2010. Results appeared online at BMJ Quality & Safety.

Diagnostic errors were the most common type (28.6%) and accounted for the highest proportion of total payments (35.2%). The most frequent types were failure to diagnose (54.2%), delay in diagnosis (19.9%), and wrong diagnosis (9.9%).

Following diagnostic errors, malpractice claims were related to treatment (27.2%), surgery (24.2%), obstetrics (6.5%), medication (5.3%), aesthesia (3%), monitoring (2%) and other miscellaneous (2%).

The most frequent outcomes were death, significant permanent injury, major permanent injury and minor permanent injury. Diagnostic errors more often resulted in death than other allegation groups (40.9% vs 23.9%, P less than 0.001) and were the leading cause of claims-associated death and disability. There were more outpatients claims than inpatient ones (68.8% vs 31.2%, P less than 0.001), but inpatient diagnostic errors were more likely to be fatal (48.4% vs 36.9%, P less than 0.001).

The inflation-adjusted, 25-year sum of diagnosis-related payments was $38.8 billion (mean per-claim payout $386,849; median $213,250; IQR $74,545 to $484,500). Per-claim payments were higher for permanent, serious morbidity that resulted in a need for quadriplegic, brain damage, lifelong care (4.5%; mean $808,591; median $564,300),for major morbidity (13.3%; mean $568,599; median $355,350), or for significant morbidity (16.9%; mean $419,711; median $269,255) than for those where the outcome was death (40.9%; mean $390,186; median $251,745).

Researchers noted that diagnostic errors directly increase health care costs through the adverse outcomes, inappropriate tests and treatments, and malpractice claims. Health care costs are indirectly increased through rising medical liability premiums, defensive medicine and the loss of physicians who no longer practice because of insurance premiums.

"Theoretical arguments to the contrary, notwithstanding, empirically, the malpractice system in the USA appears to increase costs while decreasing quality and safety, and threatening access," they wrote.
Tuesday, April 23, 2013

Doctor shortage isn't going away

Making doctors brings to mind the aphorism about making sausage: We may like the result but the process is not for the faint-of-heart. Maybe this is one of the reasons the public knows so little about medical training.

Policy makers often know just as little as the rest of the lay public. A few years ago a prominent senator suggested increasing the number of internal medicine residency spots to mitigate the shortage of primary care physicians (PCPs) in the US.

This same error was widely reported in the media after Match Day this year. On Match Day, medical students learn where they will continue their training. This year, the number choosing primary care specialties such as internal medicine, pediatrics, and family medicine rose.

About 4% of American medical graduates are choosing careers in primary care. As the number of primary care residents grow, this number will probably increase a bit, but I wouldn't count on it. About eighty percent of the time, primary care residents choose to move on to a subspecialty. The reasons are complex, but not unknowable. PCPs tend to work longer hours and get paid less than their specialist colleagues, but their debt burden isn't any less. With average medical school debt approaching $200,000 it's no wonder doctors reach for higher-paying positions.

As health care reform rolls along, some of this pay differential will shrink, but I doubt it will be enough to convince people to go into primary care. The only way to make PCPs is to make it economically advantageous. This will require subsidies for medical education, perhaps in exchange for service. While I like the idea of service, it probably isn't viable in the U.S. Doctors wishing to avoid further disruptions to their lives will continue to choose high-paying specialties.

If we want primary care doctors, we need to pay them enough to live and repay their debt (remember that they enter the workforce far later than their non-physician friends). We have to also reduce the costs of medical school.

The person who figures out how to implement this in a cost-effective way may not yet have been born, but I remain cautiously hopeful.

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog at Forbes. His blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.

QD: News Every Day--Statins may lessen stroke severity, study says

Pretreatment with statins was associated with lower stroke severity, at high doses as well as at low to moderate ones, a study found.

To examine the effects of pretreatment with statins at high doses (defined as 40 mg of rosuvastatin or 80 mg of any other statin) and low to moderate doses (less than 40 mg of rosuvastatin or less than 80 mg of any other statin) on ischemic stroke severity, researchers conducted an observational study of consecutive admissions to the stroke unit of an academic hospital, the only stroke center for a population of about 750,000 people in Madrid, Spain from 2008 to 2010. Mild stroke severity was defined as National Institutes of Health Stroke Scale (NIHSS) score 5 or less on admission.

Results were published online April 17 in Neurology.

Of 969 ischemic stroke patients, 23% were taking low to moderate doses and 4.1% were taking high doses of statins before their strokes. Statins were associated with lower NIHSS scores on admission. Nonstatin patients had a median score of 4 (interquartile range [IQR], 9) compared to patients taking low to moderate doses (median, 4; IQR, 9) and patients on high doses (median, 2; IQR, 4) (P=0.010).

After adjusting for variables, statins were associated with a higher probability of mild stroke severity in the unmatched analysis (low to moderate doses odds ratio [OR], 1.637; 95% confidence interval [CI], 1.156 to 2.319) (high doses OR, 3.297; 95% CI 1.480 to 7.345) The propensity score matched analysis results showed that statins were associated with a higher probability of mild stroke severity (low to moderate doses OR, 2.023; 95% CI 1.248 to 3.281) (high doses OR, 3.502; 95% CI, 1.477 to 8.300).

A dose effect was not apparent because the confidence intervals overlapped, the authors noted.

They wrote, "This study shows that pretreatment with statins is associated with lower stroke severity and this association is independent of both total cholesterol and low-density lipoprotein cholesterol levels, also suggesting that statins may have a cytoprotective effect that is independent of their lipid-lowering effect."
Monday, April 22, 2013

Does the medical profession need to lighten up?

Recently the Israeli Army (Israel Defense Forces to be precise) reacted to its soldiers doing the Harlem Shake and posting the video on Social Media. Some of those responsible were put in jail!

Stop right there. What are your thoughts at this point? Most likely if you do not have a close connection with that part of the world, you are thinking, "What's the big deal? They are just young adults, let them have some fun, keep their sense of humor!"


OK hold that thought.

Now take a story closer to "home". If you are related to the health care profession or close to someone who is, you know that we take our professional image very seriously.

We hear stories of how students were forced to take down a video of them dancing with skeletons. Most would side with the school authorities due to the disrespect to the dead and those who made the ultimate sacrifice by donating their bodies for education and research.

But remember, the skeletons are plastic models and not human bones. Clearly there is a fine line between entertainment and disrespect to our patients or the dead.

Many medical schools have theater programs where students present parodies of the medical profession and these are supported by the school administration with the proceeds from the ticket sales going to worthy charities.

Are we fooling ourselves? Does the general public feel the same way about our reaction to the medical student videos as we feel about the Israel Defense Forces reaction to the soldiers' video?

Are we too close to this? What do non-medical people think? If we think that we should not risk disrespect to the dead or a threat to our professional identity for just entertainment value, what if videos were used for patient education?

What if a video full of sexual innuendo increased the number of patients getting flu shots?

What do you think? Does the medical profession need to lighten up?

Neil Mehta MBBS, MS, FACP, practices internal medicine at a large tertiary care hospital in Ohio. He is also the Director of Education Technology (Academic Computing) for his medical school and in charge of his hospital system's home grown Learning and Content Management System. He is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management. This post originally appeared at Technology in (Medical) Education.

What do 21st Century health care professional students need to learn about informatics?

I am increasingly involved in efforts to determine the content and competencies in informatics for 21st Century clinicians. Not only medical students at Oregon Health & Science University (OHSU) but also other healthcare professionals, such as nurses, physical/occupational therapists, nutritionists, and others at OHSU and some other health science universities.

This effort is congruent with the growing push for interprofessional education. The rationale behind inter professional education is that if the health care system is to embrace the vision of team-based coordinated care, then clinicians of the future must have at least some of their education together. The 21st Century clinician needs to understand that the care they provide will be monitored for quality, safety and cost. This will hopefully be done in a constructive and self-improving way, but also making sure that mistakes and waste are not swept under the proverbial rug of the paper chart (or not documented at all).

Informatics can be viewed as the ultimate interprofessional activity. There is really very little about informatics that is specific to any health care professional. Yes, physicians, nurses, and others need to learn the informatics applications specific to their work. But the underlying concepts of informatics, i.e., the use of information to improve health and health care, really apply to any health care professional (not to mention the patient, the researcher, and others!)

So what does the 21st Century clinician need to know about informatics? Rather than provide a list, I will explain my thoughts in narrative form, showing the key informatics concepts that might comprise a list bolded so that they may form a list later.

A first critical concept is that informatics is not the same as computer literacy. Computer literacy is one of many requirements to use informatics successfully, but knowing how to use a computing device (PC, tablet, or smartphone) is not the same as having skills in informatics, i.e., using that device to improve health, health care, public health, or research.

Certainly one fundamental skill for 21st Century clinicians is something we began teaching in the late 20th Century, which is how to find information to apply to patient care. This is not just knowing what terms to enter into a search engine, but the whole process of asking answerable questions, finding information to answer them, critically appraising that information, and applying it to patients (or populations). The skills of the 21st Century clinician start, and not stop, with the knowledge of how to enter simple queries into Google or Pubmed. The 21st Century clinician should a power searcher, a skill we often associate with librarians or informaticians. Not that there is no roles for librarians and informaticians, but they should be more teachers and consultants when it comes to finding information.

Starting from the beginning, the 21st Century clinician must be skilled information retrieval, what some might term search or others might term knowledge management. Whatever we call it, the 21st Century clinician must know how to formulate a clinical question as an answerable one, and then be able to select the appropriate resource and make optimal use of it.

This use needs to include knowing what content is in different search systems. This clinician must know that Google has almost all pages on the "visible" Web but not the part that is hidden from its indexing crawlers, while Pubmed is a bibliographic database that indexes biomedical and clinical journal literature. The 21st Century clinician must know about specialized resources such as the AHRQ Guidelines Clearinghouse and the CDC Travel site. He or she should also have an understanding of the major commercial publishers as well as what their professional societies offers.
,br />Once they know how to use a search site, they must be able to phrase an appropriate query. Even sites like Google, with its ultra-simple interface, has additional features that can greatly enhance its retrieval capabilities. Pubmed has a myriad of features of great value to clinicians, probably the most important being the Clinical Queries interface that help focus the content of the search on more evidence-based articles. But it also offers much more.

Finally, once information is retrieved, the 21st Century clinician must know how to critically appraise information retrieved and apply it to the patient (or population). As with searching, the type of appraisal varies with the search engine used. With output from general search engines like Google, the clinician must be able to assess the trustworthiness of the information. Google's algorithm of ranking pages by number of others that link to it actually does a pretty good job of promoting reputable sites to the top of the output. But it is not perfect, and the user must be discriminating. (Back in the 1990s, we used to teach clinicians to avoid using general search engines, since they did not discriminate well among good vs. poor sites, but that is less of an issue, not only because search engines are better but also because people are more savvy about the Web.)

Of course, clinician competency in informatics in the 21st Century goes well beyond searching. The modern clinician must also know how to make optimal use of patient data and information. He or she must know how to use informatics to strive for Berwick's triple aim of better health, better care, and lower cost. In my mind, the best vision for this approach comes from the recent Institute of Medicine (IOM) report, Best Care, Lower Cost. This report creates a framework from which essentially all informatics competencies can be contextualized. It presents a compelling vision for a healthcare system that is patient-centered, learning, and population-based, concepts to be explained more fully below.

This also means an understanding that the patient record is more than "charting," and that its value goes beyond being able to read it. Certainly the 21st Century clinician must be facile with all aspects of the electronic health record (EHR), being able to easily move from one system to another, and to understand why it is critical for health information exchange (HIE) to make any one record as complete as possible. But the EHR is more than looking up information about a patient. It becomes critically important as healthcare moves from a focus on quantity to one of value. The notion of value includes quality, patient safety, and attention to cost. This requires coordination of care, and not just providing medical procedures, nursing interventions, therapies, etc. in isolation. Coordination requires teamwork and communication.

In this context, the health record is no longer a passive collection of information used mainly to justify billing. Rather, it is a source of data, organized into coherent information, that allows the healthcare team to deliver the best, safest, and most cost-effective care. As such, the 21st Century clinician must have a basic understanding of informatics issues, such as capturing data that is correct and complete as well as consistent in its expression. He or she must be able to work in partnership with informatics professionals to achieve what we know is so critical in the application of informatics, such as adhering to standards, achieving system interoperability, appropriately and optimally implementing clinical decision support, and maintaining security to assure privacy and confidentiality.

This view also requires that the 21st Century clinician have some understanding of areas like quality measurement and improvement. If nothing else, he or she should understand quality measures because his or her work will increasingly be measured, used to assess quality and how to improve it, and maybe even influence their level of pay. But they should also understand the rationale for measuring quality, including how consistent quality of care is now, and how to work with clinical leaders to select, implement, and improve measures.

Another important area of safe, effective, and coordinated care is patient engagement. Not only is patient engagement the best thing to do from a healthcare standpoint, but 21st Century patients, especially aging and Internet-savvy baby boomers, will demand it. Patients will want healthcare that adapts the online features of other modern industries, such as being able to view their own data and interact with their clinicians and healthcare system (e.g., online scheduling of appointments, prescription refills, and even consultations that are appropriate for online). These will likely take the form of a personal health record, accessible from a patient portal that allows access to all information, not just that from the system of the provider organization.

The 21st Century clinician must also have some knowledge and understanding of the appropriate use of telemedicine and telehealth, done both to remote locations as well as more locally in patient's homes and other settings.

Complementary to the patient-centric view, the 21st Century clinician must also understand population-based care and the informatics underlying it. The clinician and their team will be caring for populations of patients. They must be able to view their care needs and results across their patient population. When a new test or treatment comes along that is determined to be highly effective, they must be able to quickly identify patients who are candidates for it. They must also be able to identify outliers in their populations who require intervention, such as those with excessively high blood pressure or blood sugar, missed appointments or screen tests, or those at risk for hospital (re-)admission.

I also believe there are other areas where 21st Century clinicians should have an understanding. One of these is bioinformatics, especially as it relates to personalized medicine. No, the modern clinician need not understand complicated gene sequencing algorithms, but he or she should have an understanding of how genomics and related areas are transforming our understanding of maintaining health, diagnosing disease, and treating it. If the vision of personalized medicine comes to pass, the 21st Century clinician will need the help of decision support and other tools for help in applying it to individual patients. He or she should at least have a basic understanding of genomewide association studies and their ramifications.

The 21st Century clinician must also understand the strengths and limitations of clinical research. He or she must understand the differences and value contributed by experimental and observational studies. Ideally, the student will have participated in research while in their training. But even if not, he or she should understand issues like data quality, study design, and the limitations that come from the sharp focus perspective of a clinical study. The 21st Century student should more generally be able to participate well in the learning health system laid out in the vision of groups like the IOM.

There is certainly a great deal of informatics for the 21st Century clinician to learn and be able to apply. From the pedagogical standpoint, there is also the issue of how to deliver it. One way not to deliver it is to have its own separate course, isolated from the rest of the curriculum. There will be a need for educators who are specialists in informatics to (collaboratively with clinical educators) design the learning and to deliver that which is appropriate for lecture, group discussions, and other didactic settings. But informatics is one of those topics that is best infused throughout the curriculum, especially in clinical settings where it is being used.

Curriculum change can be hard. Academia can be one of the most tradition-bound settings, resistant to change. But just as health care must change, so must the education of its clinicians. Informatics is one excellent means of fostering interprofessional learning and interaction.

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

QD: News Every Day--Western diet linked to less than ideal health in old age

A study put some specific numbers to the generally accepted concept that a lifelong healthy diet can influence health in old age, a study found.

Low adherence to the Alternative Healthy Eating Index (AHEI) was associated with an increased risk of cardiovascular and noncardiovascular death, and the Western diet of fried, sweetened and processed food, red meat, refined grains and high-fat dairy products were more likely to place people in the bottom third than the top (odds ratio, 0.58; 95% confidence interval [CI], 0.36 to 0.94), independent of other health behaviors.

Results appeared in the May issue of The American Journal of Medicine.

Data were drawn from the Whitehall II cohort study of 5,350 London-based office staff, aged 35-55 years, who worked in civil service departments that included 3,775 (70.6%) men and 1,575 (29.4%) women with baseline mean age 51.3 (SD 5.3) years of age.

Diet was assessed at baseline from 1991 to 1993. Mortality, chronic diseases and functioning were followed to derive 5 outcomes: ideal aging free of chronic conditions and with high performance in physical, mental, and cognitive functioning tests, nonfatal cardiovascular events, cardiovascular death, noncardiovascular death and normal aging for people who didn't fit into the four previous groups.

At follow-up, 4% met the ideal aging criteria, 12.7% developed a nonfatal cardiovascular disease, 2.8% died from cardiovascular disease, and 7.3% from noncardiovascular causes over the mean 16-year follow-up. The remaining 73.2% followed a natural aging course.

A diet of vegetables, fruits, and fish was inversely associated with noncardiovascular mortality after adjusting for sex, age, total energy intake (OR per 1-SD increment, 0.76; 95% CI, 0.68 to 0.84). However, this association was attenuated after further adjustment for health behaviors such as smoking status and physical activity (OR, 0.90; 95% CI, 0.79 to 1.01).

Participants in the top tertile of the Western diet had substantially lower odds for ideal aging compared with participants in the bottom tertile after adjustment for age, sex, and total energy intake (OR, 0.52; 95% CI, 0.33 to 0.82) and health behaviors (OR, 0.58; 95% CI, 0.36 to 0.93). The Western diet was associated with higher odds of both cardiovascular mortality (ORs per 1-SD increment, 1.53; 95% CI, 1.16 to 2.01) and noncardiovascular mortality (OR, 1.36; 95% CI, 1.14 to 1.61) in the age, sex, and total energy intake-adjusted model, but those associations were attenuated after further adjustments.

Also, those in the highest tertile of "Western-type" dietary pattern, compared with those in the bottom tertile, were more likely to have poorer musculoskeletal (OR for below-median walking speed , 1.45; 95% CI, 1.14-1.84) and cognitive functioning (OR for below-median test score, 1.58; 95% CI, 1.27 to 1.97).

That a Western diet in middle age may be a risk factor for less than ideal health in old age is a novel finding, the authors noted. "We showed that specific dietary recommendations such as the one provided by the AHEI may be useful in reducing the risk of unhealthy aging, while avoidance of the "Western-type foods" actually might improve the possibility of achieving older ages free of chronic disease and remaining highly functional."
Friday, April 19, 2013

ACP Potpourri

Greetings from San Francisco, where I attended the American College of Physicians 2013 Scientific Program, the annual conference covering the latest progress in internal medicine. Though the conference is obviously geared for physicians, I've compiled below a half dozen points from the various lectures that I think might be of interest to patients. Feel free to skim, and if you want to learn more about any point, follow the links.
Ezekiel Emanuel, MD, PhD, gave the keynote address. Those unfamiliar with his biography and his work on health care reform can learn more by following the link. His speech highlighted the many changes anticipated in health care in the next few years and was intended to reassure us that physicians will be leaders in the transformation of American medicine. The specifics he discussed, however, were largely centrally planned policy directives over which physicians will have little influence. This makes me suspect that physicians will be passengers, not drivers, in the coming revolution.

More than one lecture mentioned the very important study a year ago that demonstrated that patients with sinus infections treated with antibiotics don't improve any faster than on placebo. A very large fraction of all antibiotic prescriptions are for sinus infection, and as my regular readers know antibiotic use increases the risk of bacterial resistance and of Clostridium difficile infection.

The latest recommendations for acute sinusitis is to use only nasal decongestants and pain relievers for 10 days after symptom onset. The vast majority of patients improve with only symptomatic treatment, either because they had a viral infection (for which antibiotics are ineffective) or because the nasal decongestants allowed drainage of the sinuses, allowing the patients' immune system to kill the few remaining bacteria. Only patients who have not improved in 10 days should be prescribed antibiotics. This may be a difficult change both for patients and physicians. I know that despite my best efforts I am occasionally pressured by (well-meaning) patients to prescribe unnecessary antibiotics. I hope I can educate patients about this in a way that does not frustrate them.

The new medications for obesity were discussed by several speakers. Belviq (lorcaserin) and Qsymia (phentermine/topiramate) will be available by prescription soon for treatment of obesity. The difference in attitudes towards these medications of the different speakers was fascinating. The professor who was a general internist was hesitant to recommend them based on the absence of long-term safety data and the terrible safety track-records of prior obesity medications that were withdrawn from the market. The obesity specialist, on the other hand, seemed quite enthusiastic to prescribe these medications given how empty our armamentarium is for this serious problem. (I side with the general internist.)

An important study last year showed that in patients with blood clots in their legs who are treated with a blood thinner (warfarin, Coumadin) for 6 to 18 months should continue taking aspirin thereafter to prevent a recurrent clot.

Women with normal bone density or mild osteopenia can wait 10 to 15 years before next rechecking their bone density, with very little risk of missing their transition to osteoporosis. I really should be recommending bone density testing less frequently in these women.

More than one lecturer on various different topics mentioned Choosing Wisely, the partnership between the American Board of Internal Medicine and various physician specialty organizations dedicated to educating physicians and patients about tests and treatments that have no benefits. Speakers about topics from ranging from preoperative chest X-rays to CT scans for acute sinusitis showed us the studies proving that the tests are worthless and mentioned that Choosing Wisely is trying to get physicians to stop ordering such tests. I remain supportive of the program's goals but pessimistic about its effectiveness. This may be effective if enough patients become well-informed, but hoping that thousands of physicians will behave against their interests by ceasing to order high-price low-benefit services is unrealistic. This may be another reason for patients to choose physicians who have no incentive (or disincentive) to recommend any specific test or treatment.

Finally, I was pleasantly surprised to find that many of the studies that were highlighted by the professors were ones I wrote about over the year. Reviewing the literature has helped me understand the studies, and composing the posts in non-technical language has helped me remember the key points. There is no better way to learn than to teach. Thank you for reading.

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.

Is a high calcium diet and calcium supplementation bad for you?

An article from Sweden was recently published showing that in a very large group of women, over 60,000 of them, followed for 19 years as part of an also very interesting study of the effectiveness of mammograms, women who get more calcium, in their diet or as supplements, had a higher risk of dying of anything, but especially of heart attacks. It is unclear why this would be true, but there are various theories.

Further, the study showed that this risk was more pronounced if the calcium was taken as supplements, but still present in women who got their calcium from the food they ate. The highest level of risk was in women who got more than 1,400 mg of calcium a day, and an intake of 700-1,000 mg a day did not particularly increase risk. The women with the lowest average calcium intake were not at any increased risk of death, which was a surprise to the researchers. Information about calcium intake was taken from the subjects' reports of diet and supplement use, which was further validated by phone interviews of recent food intake. Since most women think that consuming calcium is healthy, I would guess that there was a tendency to overestimate calcium intake, suggesting that real risk may be present with lower calcium intakes than the study states.

This is big news. Or is it? No, it actually isn't. In 2010 the British Medical Journal published a meta-analysis of studies of calcium supplementation in healthy people and concluded that there was increased cardiovascular death in those given supplements. There had previously been studies showing that calcium supplements in dialysis patients accelerated calcium deposition in blood vessels and increased cardiovascular death.

It has been part of our general medical wisdom for my many years of practice to recommend calcium, as food or pills, to our women patients. I remember several years ago when we began to be aware of the real impact of osteoporotic hip and spinal fractures in our aging population that physicians were encouraged to recommend to our post-menopausal patients that they take 1,200-1,600 mg a day of calcium. That was very hard to do. A cup of milk contains about 300 mg of elemental calcium, yogurt slightly more, cheese not much at all. Calcium fortified orange juice was about as much as milk. Dark green leafy vegetables contain calcium, but not a whole lot. A cup of collard greens, cooked, contains about 350 mg, but people rarely eat that much cooked greens. I would work through how to get all that calcium in the diet and usually suggest my patient take a chewable calcium pill for every meal they didn't eat something that was high in calcium. Luckily for my patients, I doubt many of them really did this.

Calcium supplementation seemed the right thing to recommend after estrogen, which is well known to reduce fracture risk, was discredited by the Women's Health Initiative due to what appeared to be an excess of heart attacks and strokes in treated patients. There were other medications for osteoporosis, but they had side effects and were really only approved for established osteoporosis, which most patients don't want to wait to get.

But why did we ever recommend calcium supplements at all? Did we have any good evidence that they worked? Sort of, but in retrospect, not really.

It does make sense, when you think about it, that calcium would strengthen bones. Bones are, after all, made mostly of calcium. Over the last three decades at least we have studied the effects of calcium supplementation on both bone density and on risk of fracture. We care most about risk of fracture, because bone density is just a test, and is not necessarily indicative of whether a person will break a bone. The most important kinds of fractures as we age are those of the hips and vertebrae. These are the ones that cause disability and death and are associated with the thinning of bones that comes to many of us with age, that is to say osteoporosis. Although some studies early on appeared to show that taking calcium, with or without vitamin D, reduced these important fractures, later analysis of all of the well done studies showed no benefit. There was even a suggestion that higher calcium intake might have been associated with more hip fractures. Many of these studies were done in the most scrupulous way possible, using double blind prospective methodology or correcting for factors that might make patients with higher calcium intake be those who were at higher risk of fracture in the first place.

What about vitamin D? Does this make a difference? In the Swedish mammography cohort, vitamin D supplementation did not reduce the risk of heart attack or death that was associated with increased calcium intake. In a recent large study out of Finland from 2010, combining calcium and vitamin D had a slight but not statistically significant effect on fracture risk in a group of 65-71 year old women living in northern Finland. Vitamin D itself is the subject of lots of research and although it may be good to supplement it, especially in people with risks for low levels, it is not clear that it reduces the risk of fracture in the majority of post-menopausal women.

So what is the bottom line here? It does appear that taking calcium supplements and deliberately pushing high calcium foods increases risk for death and doesn't save a person from disabling fractures. Doctors have so many things that they need to advise people about in a preventive office visit, getting exercise, quitting smoking, controlling their blood pressure, getting vaccinated against dread diseases. Now we just don't have to also tell our patients to drink milk and take large and unpalatable calcium pills. We should probably tell them if they are already doing that, to stop the pills and concentrate more on a healthy balanced diet, with plenty of fruit and vegetables and fish and olive oil. We can rejoice in having one less thing to fuss about!

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.

How strong is our first line of CRE detection?

I feel like I should expand on this recent post about why relying upon prompt laboratory detection of Carbapenem-resistant Enterobacteriaceae (CRE) carriers is unlikely to help contain spread (aside from during local outbreak responses). Why shouldn't screening be a pillar of our prevention efforts, particularly given the inspiring stories of local and regional CRE control that utilized screening to detect carriers? Leaving aside the question of how important screening was among multiple simultaneous interventions, these two reports are from academic tertiary care centers with robust on-site laboratory support and external funding to provide financial support for state-of-the-art screening approaches (such as rapid PCR detection of KPC producers).

The sad fact is that this level of clinical microbiology laboratory support is far from the norm. The trend over the past two decades has been toward consolidation and outsourcing of laboratory services, and reducing local resources available for diagnostic microbiology labs. I spoke about this trend, and some of the consequences, at the 5th Decennial conference a few years ago (you can view the slide set here). In the decade that has passed since we noted frequent errors in testing and reporting of blood culture results in a sample of 14 hospital laboratories, I doubt that much has improved. Yes, there are CAP proficiency surveys, but for several reasons these are not good indicators of actual laboratory performance. And while outsourcing microbiology to a regional lab may make short-term financial and technical sense for some hospitals, it also removes lab support further from the front line of patient care and infection prevention, prolongs turnaround times, and comes with a host of pre- and post-analytic problems.

If current fiscal and political trends continue, with additional cuts to public health infrastructure and CDC's budget, it is difficult to imagine that we can do much in the short term to shore up our surveillance capabilities to respond to the CRE threat.

Meanwhile, thank goodness we're spending almost $500 million to stockpile a ridiculous amount of a new drug to treat smallpox. I wonder how we might expand our national CRE surveillance and response if each of our state public health departments could focus $10 million on the effort. My head hurts.

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

QD: News Every Day--'Broad benefit' and side effects outlined for drugs that reduce breast cancer

Tamoxifen and raloxifene reduced the incidence of invasive breast cancer and fractures by 7 to 9 cases in 1,000 women over 5 years compared with placebo, but not without side effects, concluded a review by the U.S. Preventive Services Task Force.

There was an increased incidence of thromboembolic events, the review concluded. Also, tamoxifen was more effective than raloxifene, but also increased the incidence of endometrial cancer and cataracts.

Seven good- and fair-quality trials were reviewed, and results appeared in the April 16 edition of Annals of Internal Medicine.

New results from STAR (Study of Tamoxifen and Raloxifene) showed that tamoxifen reduced breast cancer incidence more than raloxifene by 5 cases in 1,000 women. Neither reduced breast cancer-specific or all-cause mortality. Both reduced the incidence of fractures, but tamoxifen increased the incidence of thromboembolic events more than raloxifene by 4 cases in 1,000 women.

Specifically, placebo-controlled trials showed a reduction of invasive breast cancer for tamoxifen (risk ratio [RR], 0.70; 95% confidence interval [CI], 0.59 to 0.82; 4 trials; 7 cases in 1,000 women over 5 years) and raloxifene (RR, 0.44; CI, 0.27 to 0.71; 2 trials; 9 cases in 1,000 women). STAR also showed that more women receiving raloxifene had breast cancer than those receiving tamoxifen (RR for raloxifene, 1.24; CI, 1.05 to 1.47; 5 cases in 1,000 women over 5 years).

Placebo-controlled trials also showed that raloxifene reduced incidence of vertebral fractures (RR, 0.61; CI, 0.54 to 0.69; 2 trials; 7 cases in 1,000 women) and tamoxifen reduced incidence of nonvertebral fractures (RR, 0.66; CI, 0.45 to 0.98; 1 trial; 3 cases in 1,000 women). STAR showed that tamoxifen and raloxifene had similar effects on incidence of vertebral fractures.

Thromboembolic event incidence was increased for tamoxifen (RR, 1.93; CI, 1.41 to 2.64; 4 trials; 4 cases in 1,000 women) and raloxifene (RR, 1.60; CI, 1.15 to 2.23; 2 trials; 7 cases in 1,000 women) compared with placebo. STAR showed that raloxifene caused fewer events than tamoxifen in STAR (RR, 0.75; CI, 0.60 to 0.93; 4 cases in 1,000 women). Coronary heart disease event or stroke incidence was not increased in placebo-controlled trials and did not differ in STAR.

Tamoxifen caused more cases of endometrial cancer (RR, 2.13; CI, 1.36 to 3.32; 3 trials; 4 cases in 1,000 women) and was related to more benign gynecologic conditions; surgical procedures, including hysterectomy; and uterine bleeding than placebo. Raloxifene did not increase risk for endometrial cancer or uterine bleeding. In STAR, raloxifene caused fewer cases of endometrial cancer (RR, 0.55; CI, 0.36 to 0.83; 5 cases in 1,000 women), hyperplasia, and procedures than tamoxifen.

Women receiving tamoxifen had more cataract surgeries than those receiving placebo in one trial. Raloxifene did not increase risk for cataracts or cataract surgery compared with placebo and caused fewer cataracts than tamoxifen in STAR (RR, 0.80; CI, 0.72 to 0.95; 15 cases in 1,000 women).

The most common side effects among studies were vasomotor symptoms and vaginal discharge, itching, or dryness for tamoxifen and vasomotor symptoms and leg cramps for raloxifene. In STAR, raloxifene users reported more musculoskeletal problems, dyspareunia and weight gain, whereas tamoxifen users had more gynecologic problems, vasomotor symptoms, leg cramps and bladder control symptoms.

"Despite previous recommendations to identify women at increased risk for breast cancer and offer risk-reducing medications, use is low in the United States," the authors wrote. "It is not clear how to identify candidates for therapy. Although the trials indicate broad benefit, subgroup analysis and decision models suggest that high-risk women, particularly those who had hysterectomies, may derive the most benefit with the least harms."
Thursday, April 18, 2013

Lifelong learning and teaching in medicine

"It gave a tremendous level of self-confidence, that through exploration and learning one could understand seemingly very complex things in one's environment."
--Steve Jobs

In medicine, we knowingly commit ourselves to lifelong learning. Very early in our medical education, most of us are told that some portion of what we are taught will be found to be incorrect (or at least will be updated), which requires each of to find ways to keep up with our respective fields. Despite the amount of learning that we do, many of us have little understanding of the actual learning process.

A commonly used phrase in medicine is "see one, do one, teach one," making reference to increasing levels of understanding of the subject matter.

A more formal model to classify levels of learning objectives is Bloom's Taxonomy, which is divided into three types of learning, or domains: cognitive (knowledge), affective (emotional), and psychomotor (physical skills). For the purposes of medical education and this post, our focus is on the cognitive domain.

The cognitive domain is further divided into six increasing levels of learning, which are recognized by goals and objectives that the learner is able to demonstrate at each level. These have been updated since the original publication (the Wikipedia article above shows the old version).

Below is my attempt to give a simple explanation of the current iteration of the cognitive domain of Bloom's modified taxonomy (listed from lowest to highest level of learning).

Knowledge: Lowest level actions such as memorizing, recall of information, and basic concepts. Example: Listing types of inflammatory arthritis.

Comprehension: Understanding of information and meanings as well as context. Example: Understanding that arthritis could be divided into non-inflammatory and inflammatory causes, and further subdividing inflammatory causes into categories such as monoarticular, oligoarticular and polyarticular.

Application: Problem solving and making use of the information. Example: Recognition of a patient with inflammatory polyarthritis and deciding to order RF and CCP as part of the workup.

Analysis: Organization of parts and recognition of patterns. Example: Recognition that a patient with inflammatory polyarthritis has additional features such as rash and nail pitting, suggesting psoriatic arthritis.

Synthesis: Being able to formulate, defend, and argue information. Example: Developing a treatment plan for a patient that has an unclear diagnosis because of overlapping features.

Creation: Being able to assemble, recommend, criticize, support, or discriminate information. Example: Selecting a treatment plan for a patient who has failed standard therapies or has comorbid conditions making treatment decisions difficult.

The differences between levels of learning can be subtle, but by looking at the action verbs used to describe each level from the references above, you should be able to roughly estimate your current level of understanding for a topic.

As an example, most adult rheumatologists should find themselves at the level of creation in terms of management of rheumatoid arthritis, but might only be at the level of knowledge or comprehension for a topic such as the autoinflammatory syndromes (e.g. Familial Mediterranean fever or TRAPS).

Recognizing your current level of understanding is helpful when you want to increase your level of understanding for a topic. For the autoinflammatory syndromes, one might recognize that they are only aware of the names of these syndromes (knowledge level), and increase their learning level by organizing features that differentiate these syndromes into a chart (comprehension level or higher).

As mentioned above with "see one, do one, teach one", an effective way to maximize the learning process is to teach. While some of us are actively teaching residents and fellows to keep us functioning at the higher levels of learning, many do not have this option.

My suggestion would be to set up a simple website or blog (which we discuss in episode 6 of the podcast) to share what you have learned with others. The mental processes involved in organizing information to be shared will further advance your understanding, which can be furthered by ongoing discussions on social media. In my case, being part of discussions on The Rheumatology Podcast and posting on the blog there have undoubtedly increased my learning level for a number of topics.

If you're not ready to make the jump to blogging quite yet, Twitter is an excellent option for sharing short bullet points (for an example of this done extremely well, check out @RheumPearls).

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. This post originally appeared at his blog.