Friday, May 31, 2013

Telling a good story

My patients are amazed when I answer their emails or (even more surprisingly) answer the phone. "Hello, this is Dr. Lamberts," I say. This usually results in a long pause, followed by a confused and timid voice saying something like, "Well ... uh ... I was expecting to get Jamie." Yet I am often able to deal with their problems quickly and efficiently, forgoing the usual message from Jamie to get to the root of their problem. It's amazingly efficient to answer the phone.

Financially, the new practice has been in the black since the first month, and continues to grow, albeit slowly. The reason for the slow growth is not, as many would predict, the lack of a market for a practice like mine. It's also not that I am so busy at 250 patients that growth is difficult. In truth, when we aren't rapidly adding new patients, the work load is nowhere near overwhelming for just me and my nurse. In that sense I've proved concept: That it's not unreasonable to think I can handle 500, and even 1,000 patients with the proper support staff and system in place.

Which brings us to the area of conflict, the crisis point of this story: the system I have in place. The hard part for me has been that I have not been able to find tools to help me organize my business so it can run efficiently. I have well documented my realization that the electronic medical record (EMR) systems I've tried have not met my approval. [Author's Note: To those who are students of writing, I just used a literary device called irony, specifically the irony of a ridiculous understatement. I was able to use the term EMR without descriptions like "sucks at high decibel levels" or "crappier than a Carnival Cruise ship." Other example of this type of understatement include calling the Korean war a "Police Action," and referring to Congress as "a bunch of mindless fools."]

I've tried multiple solutions to this problem, only to have found little to improve my efficiency. Sure, I can handle the current load of patients with the (non) system I have, but what happens when I grow? I'm trying to build something that can grow, and something that others can emulate. It's obvious that I need a better system than I've found up to now.

So what do I need? Surely the freedom from both E/M coding and the utterly ironic "meaningful use" criteria have made documentation of care much simpler, which they actually have. The thing that most EMR systems devote 90% of their energy, documentation of office visits, is one of the smaller problems I face. This has caused some readers (not on my blog, thank goodness) to conclude that I don't need computers at all! I can go real "old school" and return to the days of paper and illegible handwriting. These folks are morons (and they get me very irritated) because they aren't willing to think about what health care could look like if it weren't corrupted by our pitiful system. But, I ask, would they ask their bank to stop using computers and keep their financial records on paper? Would they go to a travel agent instead of booking their flight online? My suggestion that they write their comments to my posts on paper and mail them to me has not been met with any understanding or aplomb. Sad.

Perhaps the problem is that I still use the term "medical record," or (worse) "EMR," to describe what I am looking for. While computers have been an important part in the corruption of the system, they have not been the cause of the screwing up, they have simply made the screwing happen at a much faster rate.

So what am I looking for? The same thing I look for in a good story. The best stories excel in three areas:
--Back Story. What happens before the crisis? How did the person get to the crisis? What are the motivations? What are the inner conflicts? What is at stake?
--Narrative. How well does the story-teller communicate what's happening during the crisis? How well do they describe the setting, the action, the dialog? Do you feel what they feel? Do you believe what they say?
--Resolution. How does the crisis get resolved? Does it make sense? Does it satisfy the listener?

These are also important parts of good medical care for any given patient at any given time:
--Back story. What has happened to the patient in the past? Do they have diabetes? Do they smoke? Did their father have a heart attack at age 45?
--Narrative. What is going on now? What are the symptoms?
--Resolution. What is the plan to get their problem resolved? Does it make sense? Does it satisfy the patient?

So what system am I looking for to help this?
--Back story. Organization of data is key here. The information needs to be complete, but it also needs to be well-organized. It needs to prioritize important things (like the father with a heart attack at 45), and allow me to get a quick, accurate idea of who I am dealing with. Real world examples: Evernote, Wikipedia, Google.
--Narrative. Communication tools are key here. While a typical EMR product stands in the way of communication, focusing instead on obfuscation by documentation, a good system would improve communication. This has been the easiest to attain, using online communication tools and simply being free to answer the phone. Real life examples: email, Twitter, Facebook, iPhones.
--Resolution. This is perhaps the hardest part (as it is in story-telling), and the worst done in our current system. I am looking for a robust task-management system that can organize what needs to be done to get to where I need to go. Examples: Wunderlist, online calendars.

This is a simplification of what really goes on, but it gives some idea of where I am heading. My goal is not software, it is good medical care. I am financially motivated to keep patients well, to efficiently answer their questions, and to handle their problems early, as it means I have more time and can handle more patients. Keeping patients well and at home was bad business for me in my former life (good riddance to that), but it is what patients want. The more efficient I can be at meeting that desire of my patient, the better off both me and my patients will be.

They still will call, though. I think they get a kick out of me answering the phone.

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.

A little public health victory

Like hand hygiene, getting workers to stay home when sick is an example of a horizontal infection prevention strategy. Horizontal strategies are multipotent (not aimed at a single pathogen), generally simple methods. While most humans inherently know that it's not a good idea to come to work with fever or diarrhea, many either can't or won't stay home and risk infecting co-workers, customers, or patients.

One major reason for presenteeism is lack of sick time, a particular problem for food service workers and other low wage earners. But the healthcare industry has its problems too, as many hospitals provide workers with paid time off (PTO) as opposed to sick leave. PTO is time that can be used for vacation, personal days or sick time. While this has some advantages, it also presents problems. For example, time off for illness reduces vacation time, so a sick worker may have to choose between working with the flu or going to Disney World. A worker that has used all of his PTO, may also feel compelled to work while ill.

New York City took a step in the right direction when it mandated five days of sick leave with pay for employees who work in companies with 20 or more workers. Smaller businesses will be forced to allow workers to have sick leave without pay with no threat of job loss.

From a public health perspective, the first step to reducing presenteeism is ensuring that workers have sick leave. However, for doctors and nurses, we'll need other solutions to keep them home. Perhaps denormalization of presenteeism would be a start. Maybe someday coming to the hospital while sick will be viewed like smoking on rounds. While I bet that sounds implausible to many, I remember attending physicians smoking during morning report when I was a medical student in the mid-1980s.

So kudos to New York, the only city in the world with a mayor who has a school of public health named after him!

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--Restrict high-dose, long-term NSAIDs to those who understand the risks

The vascular risks of high-dose diclofenac, and possibly ibuprofen, are comparable to coxibs, whereas high-dose naproxen is associated with less vascular risk than other NSAIDs, a study concluded.

Compared with placebo, of 1,000 patients allocated to a coxib or diclofenac for a year, three more had major vascular events, one of which was fatal, researchers reported in a meta-analysis of 280 randomized trials of NSAIDs versus placebo that looked at nearly 125,000 people and 474 trials of one NSAID versus another that looked at more than 229,000 people. Results appeared online May 30 at The Lancet.

Major vascular events increased by about a third in patients taking a coxib (rate ratio [RR] 1.37; 95% confidence interval [CI], 1.14 to 1.66; P=0.0009) or diclofenac (RR, 1.41; 95% CI, 1.12 to 1.78; P=0.0036), chiefly due to an increase in major coronary events (coxibs: RR, 1.76; 95% CI, 1.31 to 2.37; P=0.0001; diclofenac: RR, 1.70; 95% CI, 1.19 to 2.41; P=0.0032). Ibuprofen also significantly increased major coronary events (RR, 2.22; 95% CI, 1.10 to 4.48; P=0.0253), but not major vascular events (RR, 1.44; 95% CI, 0.89 to 2.33). Naproxen did not significantly increase major vascular events (RR, 0.93; 95% CI, 0.69 to 1.27).

Vascular death was increased significantly by coxibs (RR, 1.58; 99% CI, 1.00 to 2.49; P=0.0103) and diclofenac (RR, 1.65; 95% CI, 0.95 to 2.85; P=0.0187), nonsignificantly by ibuprofen (RR, 1.90; 95% CI, 0.56 to 6.41; P=0.17), but not by naproxen (RR, 1.08; 95% CI, 0.48 to 2.47; P=0.80).

All NSAID regimens increased upper gastrointestinal complications (coxibs: RR, 1.81; 95% CI, 1.17 to 2.81; P=0.0070; diclofenac: RR, 1.89; 95% CI, 1.16 to 3.09; P=0.0106; ibuprofen: RR, 3.97, 95% CI, 2.22 to 7.10; P less than 0.0001; naproxen: RR, 4.22; 95% CI, 2.71 to 6.56; P less than 0.0001).

Authors wrote that the study "showed clearly that the vascular risks of diclofenac, and possibly ibuprofen, are similar to coxibs, but that naproxen is not associated with an increased risk of major vascular events. However, it also showed that the excess risk of both vascular and gastrointestinal events can be predicted once the baseline risks of such hazards are known, which could help clinical decision-making."

An editorial noted that someone prone to vascular or gastrointestinal outcomes wiuld occur a 4% to 19% risk of requiring treatment over 10 years of taking NSAIDs.

The editorial stated, "These risks translate to a high drug-related burden of morbidity and mortality in populations where NSAID use is common. Individuals taking NSAIDs, especially at high doses, incur substantial risk when drug use persists for extended periods," and "long-term use of high dose NSAIDs should be reserved for those who receive considerable symptomatic benefit from the treatment and understand the risks."
Thursday, May 30, 2013

Medical school graduation and 'The Calling'

It was a privilege being a part of graduation for the Indiana University School of Medicine (IUSM) and this special day for the graduates; I was honored to be a recipient of a Trustee Teaching Award, and so I was able to sit on the stage for the ceremony and watch all of the graduates receive the hood, as well as congratulations from the Deans. What an awesome spectacle! Over 300 IUSM medical students became physicians, and their names now all end with "MD". Very cool!

I wonder what others think about graduation ceremonies. It is a long day for all; the room is packed with people (there were over 3000 at the Sagamore Ballroom at the Convention Center in downtown Indianapolis). Parents, grandparents, spouses, significant others, friends, children and others were able to witness this special day for the graduates. I saw the pride in so many faces. Eight of them will be joining me as part of the IUSM med-peds Residency Program (sorry, my pics didn't turn out so great; you all walk too fast!).

One student who would have graduated today passed away earlier this year. His wife spoke to those in attendance after an honorary posthumous degree was granted. There was not a dry eye in the room, including my own.

This year our amazing Dean, Dr. D. Craig Brater, is retiring after over 25 years of service to the IUSM. He will certainly be missed, and has been the face of IUSM, leading us with honesty, integrity, and humility for 13 years.

In addition, graduation today included a keynote speaker, Dr. Tom Nasca, the CEO of the Accreditation Council for Graduate Medical Education, which is responsible for graduate medical education in the United States. It was an honor to meet him before the ceremony. Dr. Nasca is probably one of the busiest physicians in the United States now, overseeing the accreditation of all of the training programs of residents and fellows. He is an internationally known medical educator. We were blessed to have him be part of the ceremony.

In his address today, he showed no slides about duty hours. He did not mention Milestones or competencies. Rather, he focused on the "why" of going into medicine, as a "calling." He told a story about a dialysis patient who had an incredible impact on him when he was in nephrology training. He reiterated why many of us choose medicine as a profession: to care for others, and delved into the impact that a patient can have that teaches us as physicians or physicians-in-training. This was inspiring, and helped me to reflect and understand why I do what I do: to help patients, to train the doctors of the future, and to help educate students, residents and faculty in some small way.

To all the medical students graduating and becoming physicians over the next few weeks: kudos to you for all of your hard work. The journey is not yet over, and the learning is really just beginning! Be proud of your amazing accomplishments, but more importantly, embrace what lies ahead. The opportunities to do good in the world, and care for others, are now coming to fruition. Congratulations to the class of 2013!

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.

Benefits of a mandatory gloving policy

We spend a lot of time discussing the importance of clean hands in preventing hospital-acquired infections (HAIs). Most of the time we equate clean hands with hand-hygiene compliance and complicated and fleeting surveillance and educational programs. It would be one thing if these efforts led to compliance levels above 90%, but even the Joint Commission could barely get compliance above 80% after massive efforts.

This leads me to one question: Are we asking the wrong question?

Instead of focusing solely on driving hand hygiene compliance above 90%, perhaps we should focus on clean hands. If we ask a new question: "What do we need to do at our hospital to get health care worker hands to be 90% clean?" we get very different answers than if we focus solely on increasing hand rub use. For example, we could begin studying long-acting hand disinfection products that work all day or environmental cleaning products that keep hands clean in the first place. And another thing we could consider looking at is the benefits of the humble examination glove. We just published a study in Pediatrics, led by Jun Yin, a PhD student, in statistics, that aimed to do just that.

At the University of Iowa, we have a policy that mandates that health care workers wear gloves for all patient contacts during RSV season. We wanted to see if we could take advantage of this natural experiment to see what happened to HAI infection rates during the mandatory gloving periods compared to non-gloving periods. To do that we completed a quasi-experimental study using time series analysis (Poisson regression models) on data from 2002-2010. We studied the effect in five units including a 20-bed PICU, a 62-bed NICU, a five-bed Pediatric Bone Marrow Transplant Unit, a 26-bed Pediatric Hematology-Oncology Special Care Unit, and a 35-bed Pediatric Medical/Surgical Mixed Acuity Unit.

What did we find? Universal gloving periods were associated with a 25% reduction in HAI rates after adjusting for long term trends and seasonal effects. There was a 37% reduction in bloodstream infections (BSIs), a 39% reductions in central line-association BSIs and an 80% reduction in hospital-acquired pneumonias. The reductions were statistically significant in the PICU, NICU and Bone-Marrow Transplant Unit.

Yes, this unfunded study has limitations. It's a non-randomized, single center study. There could have been other factors that started just when RSV season started every year along with the gloving policy (although we couldn't think of any). Since this intervention was turned on and off every year for nine years (with an exemption in 2009 for the novel H1N1 pandemic), it's unlikely there were other interventions that biased these results every year at the exact same time.

Perhaps we need further study and cluster-randomized trails. We won't have to wait long. There is an important AHRQ-funded study that Anthony Harris's group is just completing at the University of Maryland that looks at the benefits of mandatory glove+gown policies in ICUs. However, this study won't tell us if it's the gowns or gloves or if they work in Pediatrics. So what do we do in the interim while waiting for future trials and magical interventions that get hand hygiene compliance above 90%? All we are saying is "Give Gloves a Chance."

Reference: Yin J et al. Pediatrics April 22, 2013

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.

The third year of medical school--jaded yet humane

Recent research suggests that medical students lose empathy during the third (the main clinical year) of school.

Talking with end of the year third year students might make you think differently. Understanding the psychological changes that likely occur during the third year should make you think differently.

Medicine seems easy during the pre-clinical years. You get smokers to stop and prevent COPD and coronary artery disease. Patients just need to listen to our advice and their clinical outcomes will improve. The answers are clear (and either a, b, c, d or e) during the preclinical years.

But the third year exposes our students to the realities of human beings and our society. No longer are patients homogeneous in their willingness and ability to change. No longer do all our stories have happy endings.

Our first exposure to clinical medicine creates angst, shock and disbelief. We often see the brutality of disease, and recognize that many patients with severe disease could have prevented their affliction through life style changes. We see patients come in with drug overdoses, the same patients who demand that we give them more opiates for the pain. We see the ravages of alcohol, smoking, obesity and illegal drugs.

This exposure leads to many students and residents becoming jaded. At first we focus on the apparent futility of making diagnoses and giving recommendations. We focus on our society not having provisions for the unfortunate to receive necessary outpatient care and medications.

But as you talk with third year students you hear their struggles with the jadedness. You hear them trying to emulate physicians who have passed through the jaded stage and who have regained their empathy.

We should not despair about the physicians of the future. We should continue to help them cross through this jarring yet necessary first exposure to the world of disease and the world of health.

For what we do remains noble. Most patients want to improve their lives and adhere to our appropriate recommendations. We often do make a major difference.

Today I gave a patient a rather tough love speech about the root of his problem. We opined that he may not respond "appropriately." The residents were particularly jaded, because they see the patients who do not listen and change. But we all forget that we often do not see the successes, unless they occur in our clinic population.

We must remain optimistic and accept a batting average that is reasonable. Each patient deserves our humanity. Some patients make it difficult, and I will admit that sometimes we fail. Some patients push our buttons and turn on the jaded switch.

But I believe that our students will continue to work through the challenges of becoming a truly empathetic physician. And we should not bemoan the psychological changes of the clinical experience but continue to help our students and residents to grow and succeed.

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--Lifestyle goals tough to reach for many Americans

Measures of lifestyle federal goals set for Americans have proven elusive, a snapshot survey found.

The Centers for Disease Control and Prevention updated their measures of key health behaviors for alcohol use, cigarette smoking, leisure-time physical activity, body mass index, and sleep using data from the 2008-2010 National Health Interview Survey using data from nearly 77,000 responses. Recent federal initiatives for smoking, physical activities and diet were also assessed through this report, the latest that the government has been compiling.

The report states, "The strength of this approach is that it provides a 'snapshot' of the important subgroups of the U.S. population in terms of general health behavioral characteristics. For example ... it is possible to identify which groups are most likely to drink heavily, smoke cigarettes, fail to meet federal guidelines for physical activity, be overweight or obese, and get less than the recommended number of hours of sleep. Together, these estimates help pinpoint the groups who might benefit most from health education or other interventions."

The CDC reported that:
--About 6 in 10 (64.9%) U.S. adults were current drinkers in 2008-2010; about 1 in 5 adults (20.9%) were lifetime abstainers.
--About one in five adults (20.2%) were current smokers and over one-half of adults (58.6%) had never smoked cigarettes. Less than one-half of current smokers (45.8%) attempted to quit smoking in the past year.
--Nearly one-half (46.1%) of adults met the federal guidelines for aerobic physical activity, about one-quarter (23.0%) of adults met the federal guidelines for muscle-strengthening physical activity, and about one in five adults (19.4%) met both guidelines.
--About 6 in 10 adults (62.1%) were overweight or obese (BMI ≥ 25), with about 4 in 10 (36.1%) adults being of healthy weight (18.5 ≤ BMI < 25).
--About 7 in 10 adults (69.7%) met the Healthy People 2020 objective for sufficient sleep.
Wednesday, May 29, 2013

What does expensive care look like?

I have been working almost exclusively in hospitals for the last 17 months and I often get a chance to rub shoulders with the 1%, that is to say the people whose poor health puts them in the position to spend more health care dollars than the other 99% of the U.S. population.

At the opening speech of the American College of Physicians annual meeting a few weeks ago Ezekial Emmanuel, an adviser to the U.S. Office of Management and Budget and head of the department of Medical Ethics and Health Policy at the University of Pennsylvania gave some interesting statistics. In the United States, 1% of patients at the highest level of medical spending are responsible for 22% of healthcare costs and the bottom 50% of health care utilizers use a little over 3%. I looked at the article, from the Agency for Healthcare Research and Quality, and found that this percentage is relatively stable over many years, and, in fact, the costs are slightly less concentrated in the upper 1% than they were in 1996. Also, and maybe more dramatically, the top 5% of patients consume about half of healthcare costs.

So, after hearing these figures, I paid really good attention to the patients I saw in the hospital, trying to see who was most likely in that top 1%. Patients in the hospital are probably going to be the people who consume the greatest amount of resources, since hospital costs are by far the largest share of U.S. medical expenditures. In 2011, hospital costs were over $850 billion, topping doctor and clinical services at $541 billion and prescription costs at $263 billion. The breakdown of total healthcare costs is pretty interesting and can be found here, at the Center for Medicare Services (CMS.)

The patients at the hospital who use the most resources are people with chronic diseases, the old and sometimes the very old, often poor people on public insurance, either Medicare or Medicaid, and occasionally the outlier who has been extremely unfortunate or spectacularly unwise. They are often obese and many smoke cigarettes, drink excessive alcohol or use damaging illicit drugs. Frequently they have chronic pain and are on regular doses of opiates and other sedating drugs. Many are depressed. These are patients who have been in the hospital for a very long time, usually in and out of the intensive care unit, often with multiple surgical procedures or specialist driven interventions. They have long lists of medications and are likely to have experienced some sort of medical complication due to the complexity of their care.

It is very hard to care for the 1%. They have had so many tests that it takes extremely keen data management skills to make sure that all of the incidental abnormalities are followed up and that procedures that have already been done are not repeated. Their medication lists are hard to follow, and rationale for care is difficult to tease out from medical records. They are often frustrated and jaded with caregivers because they have seen so many mistakes and heard so many contradictory explanations and plans from their many specialists and rotating hospitalists. Some of them will never be well, but nobody will take the time to explain this, and even if a doctor did take the time, the patient finds it difficult to trust that they know what's going on.

The 1% have had just about everything done to them. In some cases this means that they no longer want anything medical for the rest of their lives. More often, though, they have been through hell and it doesn't seem so bad, and so they would do it again. I see this pretty often with patients on renal dialysis. Out of a total Medicare budget of over $522.8 billion dollars in 2010, $32.9 billion was spent on patients with end stage renal disease (ESRD), who made up a little over 1% of the Medicare insured population. Patients with ESRD do not have enough kidney function to survive without regular dialysis, usually 3 times weekly. For most of these patients this means several hours at a dialysis center where their blood is circulated through a series of filters which act as an artificial kidney. Fluid is removed, electrolytes are adjusted and toxins are filtered out. Sometimes medications such as antibiotics or blood cell stimulants are administered. Patients on dialysis are dependent on machines for life support, though they can walk around between sessions and do regular person things. Usually, to be on dialysis, a person has been sick a long time, and the kidneys are not the only organs that have suffered, so most patients with ESRD are at least a little bit sick all the time. Most are disabled from work, and the majority are not able to pursue an active life.

Other patients in the 1% are the old and very old, people over the age of 80, often with multiple chronic medical problems, at least one of which decompensates and lands them in the hospital. As a hospitalist, I often have the opportunity to talk to these patients or their family members about goals of care. Sometimes I find that they want a reasonable attempt to cure the problem at hand with the expectation of being able to return to home or nursing home with about the same level of function as before they got sick, and that they understand that it is also possible that an illness that is so bad that it lands them in the hospital might also be fatal or lead to an unacceptable level of disability.

We then address the question of "code status," whether they would want to have chest compressions and be on a ventilator should vital functions cease, and I explain that, in a person such as they, none of this is likely to be effective in bringing them back to life. The actual percentage of success for CPR in this population is about 5%. The downside of CPR, I will explain, is that it means that they will not have a peaceful death, and often it will be painful and traumatic. It is hard to have this talk, because it makes the poor patient imagine their death, hardly the comfort I would prefer to be offering. Some patients have already thought it through, and even before the discussion is under way they tell me that they have had a good life and when their time comes they would like to be allowed to depart in peace.

Some will hear the whole discussion and say "I think I'd like you to just give it a try and if it doesn't work, don't have me live forever on machines like a vegetable." This is then translated into a very simple medical order, "full code," and the patient will then get just about every medical procedure available that might even remotely lengthen their life until such time that any observer would consider that they are just being kept alive on machines like a vegetable, at which time life support is gently discontinued. The process of getting to comfort care from cardiac resuscitation can be quick, but more often involves an agonizing period in which a loved one is festooned with tubes and wires, pale, miserable, helpless and confused. "Full code" for the patient with multiple medical problems is a terrible thing.

Another 1% patient is the drug abuser or alcoholic, usually also a smoker. Some of these patients have pretty amazing stories. They have lived on the edge of the world for so long that being in the hospital is not necessarily any more dramatic than the rest of their lives. They develop blood stream infections, skin and muscle abscesses, AIDS and its complications, hepatitis C and its complications, cirrhosis of the liver with massive bellies and stick-like arms and legs. They come in to the hospital on multiple occasions, so sick we think they must die, and then recover, only to go out and do it all again. They want everything done, have no money or insurance to pay for it, and often leave against medical advice before we are even done treating them. Wow.

A smaller proportion of super healthcare utilizers have cancer, despite the fact that they lived well and are still young. They have genetic diseases such as cystic fibrosis, have organ transplants or bone marrow transplants or are babies born too early. Or they were hit by a car and developed multi-organ failure. Or they were bitten by a rodent with the plague and developed shock and had their limbs amputated. Or something else horrible happened that we could all stay up nights worrying about.

So what does it all mean and what should we do about it? Clearly a health care dollar buys much more happiness in the bottom 50% of Americans who make up only 3% of all healthcare spending. For these folks, their pneumonia is cured by an oral antibiotic or their broken arm is set and splinted or their head laceration is sewn up or they receive effective contraception or other preventive services which keep them on their feet, happy and functional. For the very sickest, a health care dollar buys close to nothing, no joy, no productivity, maybe one saline flush after the dose of antibiotic goes in.

I truly don't know what to do about it. It is not right that folks who persist in self-abuse use resources over and over while the working poor can't even afford basic health care. But it is also not up to me to police the choices that people make about how to live their lives. It is not right that huge amounts of money are spent to minimally lengthen the lives of the very old. Most of the very old with whom I have had this conversation agree heartily on that point. It is not right that physicians continue to advise very expensive technological care for patients near the end of life, especially since research shows (at least with lung cancer) that a palliative care approach both lengthens life for those patients and improves its quality.

I think that "full code" should not be the default assumption in patients for whom the likelihood of it being effective is very low. I think that it is up to us, as physicians, to figure out some way to educate our patients about this. Perhaps we need an advertising campaign to "Live well, die in peace," complete with a very accurate depiction of resuscitation versus a comfort care approach at the end of life. We need to change our payment structures so that it doesn't benefit us, as doctors or hospitals, to make patients dependent upon us. We need to have an accurate idea of costs and feel comfortable bringing them into discussions with our patients.

Primary care doctors need to have the time and expertise to discuss resuscitation with patients (who know and trust them) as they age and develop chronic medical problems. We all need to take more time to think about the what these many tests and treatments we prescribe are really good for and be a little more focused about applying them. If we reduce the complexity of the care we provide, we will free up time and energy to actually sit and listen to our patients, a much neglected but often magically effective treatment strategy.

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.

Quantified selves

Are you a data junkie?

Do you feel compelled to record your vitals, throughout the day, during workouts, or while you sleep?

Have you ever tried a calorie counting app to see what you really eat in a day?

If you own a smart phone, you are now able to do all of these things as never before.

A growing movement known as Quantified Self is putting people more in charge of their data and their health. NPR ran a great story on QS (embedded below). Some of the more popular apps were featured and some devoted QS'ers were interviewed.

As a doctor, I welcome people's engagement with their health. Anything that gives people a sense of control over their lives (and their "well-being") can't be bad.

Yet I do want people to keep these tools in perspective. You may find, like I do, that some of the subjects of the story are a bit, er, obsessive. And if you look at the comments, you'll see there are many skeptics, who express doubts that these modern tools will help Americans change their unhealthy habits, arguing that those motivated enough to quantify themselves are likely to be healthy types in the first place.

Know any good tracking apps? Share them with us.

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.

QD: News Every Day--Dialysis patients more optimistic about outcomes than nephrologists

Dialysis patients are more optimistic about survival rates and receiving transplants than their doctors, who often don't offer a more realistic prognosis, a study found.

The result is that patients who become seriously ill may opt for life-sustaining care when palliative care is an option, another author wrote.

Patients undergoing hemodialysis have an annual mortality rate exceeding 20%, comparable to some types of cancer, researchers began. To compare the perceptions of hemodialysis patients and their nephrologists, actual survival rates, and to how patients' expectations influence their goals of care, researchers at two dialysis units in Boston conducted a medical record abstraction of 207 patients who underwent dialysis at any time from November 2010 through September 2011.

Researchers then conducted in-person interviews with 62 eligible patients whose predicted 1-year mortality was at least 20%, and then compared patients' and physicians' expectations about 1- and 5-year survival and transplant candidacy.

Results appeared online first on May 27 at JAMA Internal Medicine.

Of the 207 hemodialysis patients, 72.5% (n=80) had a predicted 1-year mortality of at least 20%. Of the eligible interviewees, 62 participated (response rate, 78%). Patients were significantly more optimistic than their nephrologists about 1- and 5-year survival (P less than .001 for both) and were more likely to think they were transplant candidates (37 [66%] vs 22 [39%]; P=.008).

Of the 81% of patients reporting a 90% chance or greater of being alive at 1 year, 18 (44%) preferred life-extending treatment even if it meant more discomfort, compared with 1 (9%) among patients reporting a lower chance of survival (P=.045). Actual survival was 93% at 1 year but decreased to 79% by 17 months and 56% by 23 months.

The authors wrote that clinicians should always find out a patient's preferences before sharing prognostic estimates.

Researchers wrote, "Perhaps of greater concern is our finding that nephrologists reported that, for 60% of patients, they would not provide any estimate of prognosis even if their patient insisted. This percentage of nondisclosure is higher than the percentage documented in the cancer literature and suggests that nephrologists may be even more reluctant to discuss prognosis with their hemodialysis patients than physicians caring for patients with cancer."

In an editorial, Mack Lipkin, Jr., MD, FACP, wrote that prospective research is needed to establish a basis for shared decision making, "[P]atients had unrealistic, favorable expectations about their likelihood of 5-year survival. As a result, should they become seriously ill, a significant percentage would opt for life-extending care, whereas those with more realistic expectations would choose comfort care. Disturbingly, few of their nephrologists had given them a prognosis, and several said they would not do so even if asked."
Tuesday, May 28, 2013

Scientists should embrace criticism

Some argue that the practice of medicine is more art than science, an antiquated and false dichotomy. Even were it true, modern medicine rests on a foundation of serious science. Most advances in medicine come through scientific discovery and statistical analysis of data.

A lot goes into keeping this system running well and, aside from money, one of the most important factors in medical science is doubt. There's a lot that goes into any advancement in science, a lot of places where things can go wrong. And the way we analyze statistics, a certain number of results will be incorrect despite being statistically "true". Any new finding, large or small, requires testing and re-testing, until the preponderance of the evidence points in one direction.

There have always been threats to this system, a system that has helped wipe out infectious diseases, increase our longevity and quality of life. The one on my mind today is the abandonment of doubt.

We see this in the centuries-old phenomenon of quackery. Before medical science was understood, people tried all manner of cures, most relying on false understandings of biology. The removal of ill humours by bleeding or purging, or the exorcism of evil spirits, and many other practices relied on a superstitious understanding of health and disease and a failure to understand statistics.

Some early uses of statistics in medicine hinted at the revolution to come. In 18th century England, Charles Maitland tested smallpox inoculation on prisoners, then orphans, keeping track of successes and failures and deaths. In the 19th century, Ignaz Semmelweis used statistics to find that hand washing could reduce deaths from childbed fever.

Semmelweis suffered no lack of skepticism from the medical community (his insanity didn't help him much) but as microbiology advanced, the reasons for his success became understood and widely accepted.

Quacks have never favored statistics. Quacks operate by playing to the fears and desires of their marks. More important than numbers are anecdotes, testimonials of how their latest potions or pills made someone better. I like to think of quacks as residing outside the scientific process, a peripheral annoyance, but they have a huge influence on our culture and economy. Look at any example of a "weight-loss miracle" presented by Dr. Oz. He may not endorse the products, but without any need for scientific evidence, quacks can say, "As Seen on Dr. Oz!" and sell, sell, sell.

The other threat to doubt comes from within the scientific establishment. It is seen in phenomena such as "publication bias," where "interesting" positive results are more likely to be published than negative results, giving a treatment a false veneer of success. Another is disturbing because it involves the corruption of individuals, the people we rely on to do the real work behind our discoveries.

The excellent blog, "Retraction Watch" works to bring to light studies and papers that have been published and then withdrawn or given an "asterisk." Normally, a scientific paper isn't retracted because it is wrong. Remember, doubt drives science, and finding out something is wrong is just as important as finding it is right. The problem comes when a paper's data is found to be in some way corrupted, either intentionally by manipulation of data, or simply by disastrous mistakes missed by editors. It's not always easy to prove actual "faking" of data, although the evidence is often clear, so a retraction or other sort of asterisk is a caution, not a legal action. It is an opportunity for the scientific community to police itself and potentially save money and time wasted in following red herrings.

To add a layer of "ick," there seems to be a trend of researches who have suffered retractions lashing out at the messenger. Twice so far this year, Retraction Watch has been threatened with legal action simply for reporting facts. The first regarded Dr. Bharat Aggarwal, a researcher who is under investigation by MD Anderson and who has been the subject of a number of retractions. The second is Ariel Fernandez, a researcher who had a paper given an "expression of concern," a sort of shot across the bow that there are questions about his work.

Both of these men lashed out at Retraction Watch for simply reporting the truth, a truth that helps the scientific process along. Doubt is the null hypothesis, the default state. It is up to a researcher to show why we should believe their suppositions. If they can't do it with good science, then their ideas may not be ripe, they may be wrong, or not yet provable. But to abandon doubt, to replace it with legal threats, essentially saying, "believe what I wrote, and if you don't, don't tell" corrupts this process. It also makes researchers who work may simply be wrong look like they might have something to hide.

Doubt isn't a weapon to be used until it slaughters all creative thoughts. It is a tool to help us avoid the very human instinct to believe what appears to be true, and what we wish to be true. Scientists, most of all, should know this.

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--Task Force mammography guideline didn't change screening rates

Mammography guidelines issued by the U.S. Preventive Service task Force may have had no impact in changing screening rates in average-risk women in their 40s, a study found.

To evaluate the effects of the 2009 recommendations, researchers conducted a secondary analysis of data collected in the 2006, 2008, and 2010 Behavioral Risk Factor Surveillance System surveys, comparing nearly 485,000 women ages 40-49 and women ages 50-74 before and after the recommendation.

Results appeared in the May issue of the Journal of General Internal Medicine.

Rates of mammogram use in the past year among women ages 40-49 and 50-74 were 51.8% and 64.3% in 2006, 53.2% and 65.2% in 2008, and 51.7 % and 62.4% in 2010, which was not a statistically significant change.

Researchers noted that rates of Pap smears fell during the same time period, leading them to conclude that patients and providers may have been hesitant to comply with the 2009 mammography recommendation.

"While cancer screening saves lives, practice should be informed by an understanding of the recommendations," researchers wrote. "Overuse of cancer screening tests, including mammography and Pap smear, in populations where evidence is lacking may contribute to the increasing cost of medical care and convey additional risks to individuals."

Reduce hospital readmission rates or else!

I attended a medical staff meeting recently. These are required meetings and attendance is taken, as was done when we were in kindergarten. While some folks are interested in these meetings' content, many are not and simply sign the attendance sheet and then slither out in a stealth fashion. Sly doctors grab their pagers and then leave hurriedly pretending that they were summoned to an urgent medical situation, when they are actually heading for Starbucks.

One of the community hospitals I attend initiated a dastardly procedure when administrators would not post the attendance sign-in sheet until the conclusion of the medical staff meeting. Under the threat of picketing, a massive walk out, letters to the local paper and other unspecified measures, the evil decree was rescinded. Who says that physicians have no power today?

Sadly, most of these meetings have nothing to do with making us better doctors. The agendas are full of medical coding and billing issues. Hospitals are hyperventilating over an increasing burden of mandates issued from Mount Medicare to preserve reimbursement. At present, if physicians and hospitals somehow make it through the labyrinth of hoops intact, they will accrue a very modest increase in revenue. In the near future, failure to comply will result in punitive financial confiscation.

Every hospital is armed with utilization personnel that are trolling through the wards scouring charts trying to verify that the medical documentation supports the highest reimbursement possible. I don't fault the hospitals for this. We follow a similar path in our office. The hospital hoops we are forced through are described as a palladium to protect patients, although I continue to argue that the motivation is to control costs.

This blog has several posts that argue that the government's pay-for-performance initiatives are scams that ironically decrease medical quality, rather than enhance it as promised.

At this recent medical meeting, the speaker was instructing us that if patients with certain diagnoses are discharged and then readmitted within 30 days, that the hospital would be financially penalized. Obviously, there are many legitimate reasons that a sick patient would need to be re-hospitalized within a month, but this issue warrants a separate blog post.

Here's what I learned. If a patient returns to the emergency room within 30 days of a hospital discharge, all personnel will be notified that this is a "patient of interest" (my term). Every effort will be made to choose any pathway, except admission, for reasons unrelated to medical quality. In fairness, once patients are discharged, medical professionals will stay engaged with them to verify they are complying with medical appointments and medications which should prevent disease recurrence and readmission to the hospital.

I found it galling that strong effort would be undertaken to restrict admission of only those who were recently discharged from the hospital. Shouldn't stringent hospitalization criteria be used for every patient seen in the emergency room? Is it a wonder why cynicism is metastasizing widely?

This is but a single example of how the medical profession is being forced to game the system to comply with a punitive financial penalty system that is poorly disguised as a medical quality initiative. Hospitals are "teaching to the test" so that they and physicians look good on paper so more cash will trickle in. However, medical quality means more than checking off certain boxes required by an army of officials who don't practice medicine.

The public would be horrified how much time and resources are devoted to feed this bureaucratic beast. Is any of this making me a better doctor? This is easy to determine. Let me see if this box is checked off.

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.
Friday, May 24, 2013

Technology in medical education

I was given the privilege of presenting the keynote talk at a faculty development session for the Indiana University School of Medicine Department of Emergency Medicine earlier this week. The theme of the entire day was using technology in education. The opening speaker, Bart Besinger, MD, gave a phenomenal talk on "How to give a lecture with or without technology." It was one of the most engaging talks I have ever heard, and included practical information and tips for making one's didactics top notch! Later in the day, the topic I spoke about was the use of social media to communicate and teach in medicine. It was a wonderful opportunity to network with colleagues from outside of my own departments, and I found the faculty completely engaged and willing to try something new.

We discussed some of the literature on the use of social media in medicine and medical education, and how educators can leverage social media as a tool to disseminate medical information. The highlight came at the end, when we taught the faculty how to use Twitter. The goal was to have five new faculty join Twitter. Many more joined, and the discussion was nothing short of fabulous. It was clear that the faculty were wholly accepting of taking the plunge to use Twitter in medical education (the hashtag used was #IUEMFacDev).

Today, the learning that took place just two days ago was put into action. The faculty used a hashtag (#IUEMTalks) for their own lecture series. Kudos to Dan Rusyniak, MD, for putting on this great workshop. I appreciate so much the invitation to share and learn from emergency medicine faculty colleagues, as well as the willingness of so many to put into practice this new learning tool.

Here is a link to the workshop handouts.

In an upcoming venue, our institution is privileged to host (to have hosted, for some readers) the first inaugural Mobile Computing in Medical Education conference on May 31, 2013, in Indianapolis. In this conference, we will showcase several different ways in which medical students, residents, fellows and faculty utilize mobile tablets in medical education. We look forward to sharing the learning opportunities in this one-of-a-kind conference.

So how are you using emerging technology to further medical education?

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--CDC urges smokers to seek physician help when quitting

Because a doctor's advice and assistance more than doubles the odds that a smoker will quit successfully, the Centers for Disease Control and Prevention is partnering with ACP and four other physician groups on a "Talk With Your Doctor" campaign.

Get ready for the influx in your waiting room? Almost 70% of all smokers want to quit, according to the CDC cited in its National Health Interview Survey.

The drive will be part of the "Tips From Former Smokers'' national television and online ad campaign through the end of this month, the agency said in a press release. Ads in the campaign end with the voice-over narration, "You can quit. Talk with your doctor for help."

"We hope doctors will offer evidence based counseling and medications to all patients who can benefit from them," the CDC director said.

Through partnerships, doctors will be offered training on tobacco interventions, and will receive information about the campaign through academic journals, newsletters, and digital communications. Besides ACP, participating medical societies include the American Medical Association, the American Academy of Family Physicians, the American Academy of Pediatrics and the American Congress of Obstetricians and Gynecologists.
Thursday, May 23, 2013

Time to redesign residencies

Once upon a time (actually when I did my residency), we worked long hours, were taught well and learned from our patients. Residency training had minimal rules. When we looked for a residency we took work load into consideration. Some residencies were more challenging than others. I choose a busy residency because I thought (back then) that I needed to see sufficient numbers of patients to become a good internist.

Our progress over the subsequent 35 years (since I finished my residency) is dubious. Pauline Chen, MD's wonderful article in the New York Times today, "The Impossible Workload for Doctors in Training," tells part of the story--no adjustment of work load as work hours have changed.

What does not make this article is the never ending paper work that program directors must document. What does not make this article is a reluctance to reconsider call schedules.

When the rules change, then the system must change. We have to adjust call schedules for the benefit of continuity. We need call schedules that value "ownership" and patient responsibility. We have to help our residents function as a team, with different members of the team working different shifts.

We who work in residency programs can do a better job at designing the residencies.

This will not solve the ACGME problems and will not solve the major problem of not enough funding to expand residency training slots. CMS has fixed the number of residency positions. Private insurers up to now have not made contributions to training--yet they benefit from well-trained physicians.

Residency is hard. It has always been hard. It is necessary if we want well trained physicians. But it does cost money. We do not have enough residency slots and that is a major societal problem. And no one is really addressing that problem.

For those who want to blame the AMA, the AAMC is responsible for medical student numbers, and they continue to increase quickly. They have increased so much that many U.S. graduates did not find an internship that past year (I have heard numbers ranging from 500-800). This does not count DO graduates, off shore graduates or IMGs. Can you find a new doctor? If you cannot, do not blame the AMA or the AAMC. Blame those who fund residency positions.

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--Dextrose injections for knee osteoarthritis aids pain, function

Prolotherapy injections of dextrose for knee osteoarthritis resulted in clinically meaningful sustained improvement of pain, function and stiffness scores compared with blinded saline injections and at-home exercises, a study found.

Researchers randomly assigned 90 adults with at least 3 months of painful knee osteoarthritis to blinded injection with dextrose prolotherapy or saline, or to at-home exercise. Extra- and intra-articular injections were done at 1, 5, and 9 weeks with as-needed treatments at weeks 13 and 17.

Outcome measures included knee pain, post-procedure opioid use for injection-related pain, and patient satisfaction. Results appeared in the May/June issue of Annals of Family Medicine.

No baseline differences existed between groups. All groups reported improved for a composite score on the Western Ontario McMaster University Osteoarthritis Index (WOMAC; 100 points) scores compared with baseline status (P less than <.01) at 52 weeks. WOMAC scores for patients receiving dextrose prolotherapy improved more (P less than .05) at 52 weeks than did scores for patients receiving saline and exercise (score change: 15.3 +/- 3.5 vs. 7.6 +/- 3.4, and 8.2 +/- 3.3 points, respectively) and exceeded the WOMAC-based minimal clinically important difference.

Individual knee pain scores also improved more in the prolotherapy group (P=.05).

Postprocedure opioid medication addressed injection-related pain, satisfaction with the procedure was high and there were no adverse events, researchers noted.

Researchers wrote, "Its use in clinical practice is relatively uncomplicated; prolotherapy is performed in the outpatient setting without ultrasound guidance using inexpensive solutions. The knee protocol is easy to learn and requires less than 15 minutes to perform; continuing medical education is provided in major university and national physician organizations settings."
Wednesday, May 22, 2013

How to learn bedside (point of care) ultrasound: tips for the interested internist

I first picked up an ultrasound transducer 17 months ago, at Vicki Noble, MD's emergency medicine ultrasound course at Harvard University. I had just barely heard about using ultrasound as a clinical tool and was vaguely interested. The course was three days long and cost a little under $700 and changed my life forever and made me a better doctor.

Emergency physicians have embraced the use of ultrasound at the bedside for many years and the vast majority of physicians who complete emergency medicine residencies are competent in using ultrasound for procedures and diagnosis. In bedside ultrasound, the doctor who examines the patient also does the ultrasound, often with a small portable machine, checking out the heart, lungs and other internal organs as part of the physical exam.

Internal medicine physicians have been very slow to pick up this technology, probably mostly because the equipment has been a little too large to be convenient and training to wield the probe and interpret the images takes time and is inaccessible. The American Academy of Chest Physicians (ACCP) is the professional organization that represents critical care and pulmonary doctors, and their journal, Chest, has recently adopted ultrasound education via an online section called the Ultrasound Corner. The editorial by Seth Koenig, MD, accurately describes the power of the technique in critically ill patients, and the educational offerings of the ACCP for intensivists.

So, first of all, why might an internist want to learn bedside ultrasound and how might it be merged effortlessly into patient care? When I see a patient now, instead of taking their pulse and placing my stethoscope on their chest and back, hearing the vague taps and clunks and bubbles and whooshes of the internal organs I have come to trust are in there, I open the ultrasound machine that lives in my white coat, squeeze a little gel from a tube I keep warm in my pocket, and the patient and I look at heart, lungs, liver, spleen, kidneys and bladder. Most of them, those not blind or in a coma, think this is incredibly cool.

At the end of this exam, which takes all of 5 minutes if I am thorough, I know whether their heart squeezes normally, whether there is excess fluid in the lungs or pericardial sack, whether there is fluid in the belly, whether the kidneys are blocked and whether the bladder is emptying normally. Sometimes I also see things like gallstones or tumors or blood clots. I can often evaluate whether the patient is dehydrated by looking at the inferior vena cava, the vein that returns blood from the lower body to the heart.

If a patient loses consciousness, like one of them just did today, I can quickly rule out a major heart attack as the cause of the problem. My little machine is not quite as sensitive as the huge expensive ultrasound machines, but it is pretty good and I can usually be sure about the answers to the questions that are most vital to treating my patients immediately. If a patient has chest pain and my ultrasound of their heart is good, I can be much more confident about whether the chest pain is due to a heart attack.

Several times since I have been doing this, I have found an unexpectedly poorly functioning heart in a patient whose story of chest pain was not particularly convincing for coronary artery disease and was able to advocate for quick or aggressive treatment which expedited treatment and saved heart muscle. The ability to evaluate bladder size is powerful. The ability to rule out hydronephrosis (urine backed up in the kidneys) allows me to avoid excessive imaging in patients who have a change in their kidney function. We often see patients with big bellies who may or may not have excess fluid due to cancer or liver failure or heart failure, and it is so very convenient to be able to make the distinction between fat and fluid without waiting for an imaging procedure to be done.

But how does a person learn how? I took three emergency ultrasound CME classes with live models and hands on instruction, one on line ACCP class in critical care ultrasound and bought the pocket Vscan ultrasound from GE, which I use at least once on just about every patient, friend and family member. The dog has barely escaped due to excess fur. I then took a mini ultrasound fellowship with the department of emergency ultrasound at UC Irvine under the direction of Chris Fox, MD. This involved 4 weeks of scanning in the ER, going over saved scans, teaching medical students and studying online material.

It was kind of expensive: $5,000 for the fellowship and 4 weeks off of work in a place where I had to stay at a hotel. But I am way better at it than I was, I know what the protocols are and can do ultrasound of things that internists don't usually examine that way, including eyeballs and uteruses and testicles and thyroids and skin structures. My Vscan doesn't have a linear transducer, so I haven't been able to improve as fast at procedures that need shallow scanning, such as blood vessels, muscles and joints. I'm thinking that I will need to have access to a machine that I can use whenever I want, so I will probably buy an ultrasound machine with a linear transducer from China where the technology costs about 1/10th what it does here.

There are other ways to learn bedside ultrasound, including year-long fellowships, which are usually based in emergency rooms. There is a program at Harvard that lasts 5 or 10 days that involves participating in scanning at the radiology department, and reviewing many scans every day. I would love to do that. The limitation of learning ultrasound techniques from real ultrasonographers and radiologists is that they do a more thorough exam than we usually have time for, and the perfect protocol for quickly determining relevant information in an internal medicine patient is not the same as what an ultrasonographer does when we order specific tests.

The ACCP has excellent courses with live patient scanning, which are apparently quite expensive. I would also love to take one of these. There are many for-profit groups that offer training as well. It's not hard to find a course that will get a person started, but it does take many hours of practice and the ability to review scans with experts in order to feel comfortable. If our hospitals or clinics decided to embrace bedside ultrasound, and radiologists bought into it (and I actually think they would) we could really benefit from the teaching of our radiology technicians and MD radiologists.

It continues to astonish me how much more effective I am as a doctor with an ultrasound than I was as a doctor without one. I make diagnoses I wouldn't have thought of, save patients radiation and hospital days and quickly have information I need to focus treatment. I understand why my busy colleagues haven't embraced this technology yet, but when they do they are going to love it!

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.

Uncomplicating matters on the way to health

On Monday of this week, my staff and I at the Yale-Griffin Prevention Research Center entertained a visiting delegation of colleagues from Korea. The visit was first proposed by a preventive medicine specialist there in an email to me some months back. Somehow, in the time since, the visit grew to a group of roughly 25, most working for public health agencies.

We were of course honored and delighted that a group would travel so far to learn about our health promotion programs. And we were also eager to explore the opportunities for translating programs that have proven effective here for application in another language and culture.

Translation, however, proved to have more general relevance to the meeting. Of the group, only three members spoke English. Thanks to years of Tae Kwon Do, I can count to 10 in Korean, but that was the extent of our group's collective vocabulary. So the day's discussions, which spanned some hours, required frequent pauses for translation from English to Korean (for the most part), or Korean to English.

So, there we were, a large group from the Prevention Center, Griffin Hospital, some of our partner agencies, and our guests, gathered around a big boardroom table for hours, wrestling with the challenges of health promotion in two languages.

A group this size, talking at length about how best to implement health promotion programming, might well have sucked all of the oxygen out of the room even without the language barrier. But with that additional encumbrance, and despite my frequent recourse to standing and walking around the perimeter of the room--by mid-afternoon I was feeling increasingly prone to a sudden onset coma.

So around that time, while we were discussing programs to promote physical activity as our rear ends molded to our chairs, I asked my staff to pick out and project one of our ABE for Fitness videos for the group. We did so, choosing from the library of roughly 60 videos one made for the office setting, lasting about four minutes, and providing a total body workout in the standing position.

We all followed along, and suddenly there were smiles on faces that appeared all but unconscious a moment before. Suddenly, we had oxygen in our lungs again, and it was actually reaching our brains! And suddenly, following the on-screen guide through the exercises, there was no language barrier, and no real cultural barrier, either. We were all just moving, together, and feeling a whole lot better for it.

There's no question that activity burst rejuvenated our meeting, but its ramifications went far beyond that. It illustrated how readily we can turn a simple action into a complex idea, when what we really want is to turn ideas into actions.

We could have talked for hours about the challenges of fitting physical activity into people's days while failing to fit any into ours. Or, we could have put our feet where our mouths were and, stood up and said, how about this? Which, thankfully, is what we did.

I am by no means suggesting that ABE for Fitness, or any one program, suffices to reverse all of the forces of modern living that conspire against physical activity or health in general. I am, however, saying that getting up and moving isn't very complicated. And it isn't even very hard.

And while eating better may be a bit more complicated than being active, I think that, too, can be fairly simple. Eat close to nature. Learn enough about nutrition and food labels so you can trade up your choices. Control your own food choices rather than letting others do it for you. And by getting used to better foods, come to love the foods that love you back. Admittedly, there is some effort here, but it's not a space mission.

I believe that many of the best defenses of the human body reside with the body politic. And consequently, I support an array of programs and policies that would help pave the way to health and place it along a path of lesser resistance for us all. Exploring just such opportunities was why our Korean colleagues traveled so far to confer.

But I also believe that most of us are quite capable of acquiring new skills we deem important and applying that skill-power to good effect. I believe that people who manage mortgages, student loans, tax forms, and 401(k)s can figure out how to have a healthy dinner if it matters to them. I believe people who can navigate across the country through a maze of airports can, if so inclined, acquire the skills to fit some fitness into their daily routines.

Sometimes we mistake hard for complex. Lifting a rock, for instance, can be hard if the rock is heavy, but it's not complicated. A deliberating committee is unlikely to help.

And sometimes we get carried away with how hard something might be, instead of just doing it -- and discovering it's actually fairly easy. That activity burst was easy. One of those every hour, and we could all have gotten that recommended 30 minutes of physical activity without ever leaving the board room.

Getting to health doesn't need to be all that complicated. And it also doesn't need to be about "should." Don't pursue health because it's an obligation, or because someone says you should. Pursue health because health is a currency you can spend on living better. Pursue health because healthy people have more fun. Pursue health if it matters to you, because it matters to you.

I genuinely believe that most of us can get to health in the pursuit of pleasure and get more pleasure in the pursuit of health. I believe that making substantially better use of our feet and our forks every day need not be very complicated, might not even need to be hard, and can even be fun.

I believe we can uncomplicate getting to health. All we really need to do is decide that health truly matters, and start acting accordingly.

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

QD: News Every Day--Patient education materials written above nation's average reading level

Patient education materials are written for grade levels higher than the average American can read, a study found, and may require medical specialty societies to reconsider how they draft and present such handouts.

The average American adult reads at approximately a seventh to eighth grade level, prompting government and medical societies to call for patient education materials to be written at a fourth to sixth grade reading level

Researchers downloaded the body text of online patient education materials from 16 medical specialties into Microsoft Word and performed readability statistics on them. ACP materials were included in the analysis.

Results appeared online May 20 at JAMA Internal Medicine.

After using the many tools available in Word to analyze the readability of text, patient education materials from all 16 medical specialties were too complex for a sixth grade reading level. Among the specialties near the recommended grade level when measured by New Fog Count were: dermatology, 4.3; obstetrics and gynecology, 6.0; plastic surgery, 6.1; and family medicine, 6.6.

New Dale-Chall readability formula test showed that dermatology, family medicine, and obstetrics and gynecology met the average American adult reading level. Flesch Reading Ease readability analysis showed that patient resources were considered to be "difficult." The Flesch-Kincaid grade level readability test showed that family medicine was the only specialty satisfying the average adult reading ability. Fry graphical analysis test results ranged from the eighth grade level in family medicine to unclassifiable in dermatology because materials were beyond the 17th grade level.

Researchers wrote, "One simple adjustment is to write more clearly, which may increase comprehension regardless of the reader's health literacy capabilities. The use of pictures and videos may also be an effective way of increasing a patient's comprehension of health information that is too complex to fully explain through pure text."
Tuesday, May 21, 2013

Medical office efficiency - the times they are a wastin'

Medical practices, particularly private businesses like mine, strive for efficiency. This has become more necessary as medical reimbursements inexorably decline while overhead and other expenses rise. This may be the point in this post when a reader will jump to the comment section below and carp how I and every other doctor are only in it for the money. Not so fast here. Yes, I would like to make a living and I believe that I deserve a decent one. In my case, I do not seek, and have never sought wealth. For small private medical groups, particularly in northeast Ohio, we are aiming to survive more than to thrive.

These days wasted time during the work week can be the tipping point that buries a private practice.

Where are the time sinkholes in medical practice?

No show patients. This is the Wonder Bread of medical practices. It torments doctors in 12 different ways. Younger readers may need to Google to get this reference.

Late patients. While these folks are less sinful than Wonder Bread patients, they mangle the schedule and suck up physician and staff time. Should these patients be told that they need to reschedule? How late does a patient have to be before he is ejected from the office? Should he be told to sit tight in the waiting room until all of the on-time patients have been seen? Are we comfortable playing hardball with a 90-year-old woman who hobbles in on her walker 20 minutes late?

Delays in receiving requested medical records. Even in the electronic era, it can be mind boggling how much work is required to get a few papers faxed over. For doctors, this task becomes a competition where we gird our loins to beat the system.

Patient paperwork. Our new patients fill out medical surveys that our staff then uploads manually into our EMR (electronic medical record) system. Although these folks are told to arrive early, it never seems to be early enough. I often find myself in solitude in the exam room while the expected patient is in the waiting room pushing paper. In time, this clumsy process will be compressed and expedited, but our practice is not there yet.

Down on the Pharma. This is the improvised explosive device of medical practices. I cannot calculate how much time is vaporized re-prescribing medications that are not, or no longer on, the preferred list. If we guess the right medication, then we err on the number of pills permitted. If we opt for the mail order pharmacy, we learn that the local drug store was the proper destination. And, of course, if we were insane enough to memorize a particular patient's proton pump inhibitor prescription pathway, it changes at year's end.

There may be other reasons that challenge medical office efficiency. Perhaps, for instance, there is the rare instance when a physician is late. In this instance, any of my patients who are reading this post are invited not to comment.

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.

How red meat leads to heart disease

We have known for decades about heart disease and the effects of red meat and saturated fats being a cause of elevated cholesterol. But we've also known that is not the whole story and now surprising new research is pointing to gut bacteria and the actual chemical that is produced by meat as the culprit for heart disease.

Carnitine is found in red meat and is also used by body builders as a supplement for energy. Researchers have found that in the intestinal tract, bacteria convert carnitine into a metabolite called TMAO and TMAO promotes thickening of the arteries. Steak consumption caused subjects in the study to immediately produce large amounts of TMAO. Vegetarians did not produce the chemical.

Many people who become vegetarian say that they can no longer digest red meat. It turns out that they actually lose the ability to metabolize carnitine over time because they do not develop the gut bacteria that meat eaters have.

How did the researchers know it was the gut bacteria? They gave the study participants large doses of antibiotics to wipe out the normal flora in the intestinal tract and then none of the meat eaters or vegetarians produced TMAO after eating steak or taking carnitine pills.

The researchers from Cleveland Clinic, examined record of 2,595 patients who had undergone cardiac evaluations and found that patients with high levels of TMAO and carnitine were the most likely to develop heart disease, heart attacks, strokes and death within the next three years.

"Cholesterol is still needed to clog the arteries, but TMAO changes how cholesterol is metabolized-like the dimmer on a light switch," said lead author Stanley Hazen. "This may explain why two people can have the same LDL level, but one develops cardiovascular disease and the other doesn't."

It would appear that carnitine alone is not the problem but a regular diet of meat creates the gut bacteria that break carnitine down into TMAO. Vegetarians and meat eaters have very different gut bacteria. TMAO may be a waste product but it is significantly affecting cholesterol metabolism and deposition into arteries.

What should you take from this study?
--The Mediterranean diet is still the most heart healthy diet. (Small amounts of meat and red wine; grains and vegetables in large amounts. Avoid processed foods.)
--Try to eat only organic local farmed meat and chicken. It takes an effort but is worth the time and money to avoid antibiotics, growth hormones and horrible animal conditions.
-- Never take carnitine supplements or energy drinks.
--Small amounts of meat means no more than 4-6 oz. Think about that the next time you think about steak.

This post originally appeared at Everything Health. Toni Brayer, MD, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

QD: News Every Day--Wording change affects surrogates' end-of-life choices for loved ones

Small wording changes made big differences in end-of-life decisions for surrogates of critically ill patients, a study found.

Researchers conducted a web-based simulated meeting to discuss code status using 256 volunteers randomly assigned to consider a hypothetical scenario in which their spouse or parent was receiving life-sustaining treatment in an intensive care unit. An actor portrayed an intensivist, who at the end of the interview discloses a 10% likelihood of survival in the event of cardiac arrest requiring cardiopulmonary resuscitation (CPR). The actor then asked surrogates to decide the patient's code status.

Results of the study, co-authored by Robert M. Arnold, MD, FACP, appeared online at Critical Care Medicine.

While emotional triggers didn't influence the outcomes, researchers noted that three framing manipulations that mattered included implying the social norm was not to choose CPR, phrasing that the decision was the patient's vs. the surrogate's, and describing the alternative to CPR as "allow natural death" vs. "do not resuscitate [DNR]."

Emotional triggers--seeing pictures and scenarios with the loved one as opposed to seeing neutral scenes before making the choice about CPR--did not impact CPR choice. But framing the social norm as not choosing, rather than choosing, CPR resulted in fewer decisions to resuscitate (48% vs 64%; odds ratio [OR], 0.52; 95% confidence interval [CI], 0.32 to 0.87), as did framing the alternative to CPR as "allow natural death" rather than DNR (49% vs 61%; OR, 0.58; 95% CI, 0.35 to 0.96).

Researchers wrote, "[W]e provide the first empiric evidence that this phrase, which has been integrated into the language of several health systems, may directly influence code status decisions."

Angelo Volandes, MD, ACP Member, tells The Atlantic that unwanted end-of-life treatments are "wrongful care." He describes a project that will teach patients and surrogates How Not to Die.

An experience he had as a medical resident showed him that patients needed to see examples of end-of-life care--what a CPR attempt is really like--for them to understand what's involved in that decision. He and Aretha Delight Davis, MD, ACP Associate Member, are now creating videos to show surrogates who may face such decisions.

Dr. Volandes told The Atlantic, "Videos communicate better than just a stand-alone conversation. And when people get good communication and understand what's involved, many, if not most, tend not to want a lot of the aggressive stuff that they're getting."
Monday, May 20, 2013

Is your doctor relying on bad information?

When I was a medical student, my friends and I wore white coats so stuffed with reference books we could barely move. When we were taking care of patients, a trip to the library simply wasn't practical, and that whole internet thing wasn't really up and running yet. Now my pocket contains only my smart phone.

Sure, I know more than I did then, but I also know that I am fallible. I like to look things up, and from my phone I can access a world of medical information. Certain resources have become more popular than others, but there is no way to gauge the quality of these resources other than relying on my opinions and those of my colleagues. Online references are a tempting but risky resource for doctors.

Two of the more widely-used resources are UpToDate and eMedicine. UpToDate is just that: a resource of practical medical knowledge that is updated frequently by experts. It's also very expensive (about $500/year last time I checked). eMedicine from Medscape is free, and usually quite reliable. Last week, though, I stumbled upon a something disturbing.

Moraxella catarrhalis is a common bacterium causing disease in humans. It causes sinus infections, bronchitis, ear infections, especially in children, but in adults it can be quite deadly. It's a serious bug. Thankfully, it's usually pretty responsive to antibiotics. But here's were eMedicine loses me:

Numerous different antimicrobials have been employed to treat M catarrhalis infection (see below). In addition, among the medicinal plants, garlic, cinnamon, and avocado leaves have all been found to be antagonistic to M catarrhalis.

This makes it seem as if antibiotics and medicinal plants are on equal footing here: They are not. M. catarrhalis can cause serious, life-threatening illness. There is no reason to think that avocado, garlic, or any other plant can be used in place of or even as an adjunct to antibiotics.

Most doctors know this. Many patients who stumble upon this information may not, leading to delay of therapy. I'm going to be keeping an eye on Medscape products looking for similar problems, but the real lesson here is that even with the entirety of medical knowledge in the palm of your hand, the guidance of a professional is important in interpreting and using this knowledge.


A reader pointed me to the study that was likely the source of the claims about treating M. cat with avocado, etc. As expected, it is an in vitro look at the effect of these substances on the bacteria. In my into to microbiology course, we would often grow out cultures of various bacteria, setting, for example, a slice of garlic on the medium to see if it would inhibit growth (we also did much more sophisticated versions of this experiment. While interesting, these studies say nothing about the clinical utility of these substances. The human body is very different from a Petri dish. For these plants to be used as treatments, they would have to be "weaponized," creating a way to deliver useful doses of the plant without, for example, having the putative active ingredients destroyed in the acidic environment of the stomach.

When researching antibiotics, candidate substances are identified either by computer modeling or good old-fashioned trial and error in the lab. After that comes years of testing to see if there is a way to make it useful in human beings. The study authors' conclude that (emphasis mine): "Garlic, cinnamon and avocado leaves extracts represents alternative source of natural antimicrobial substances for use in clinical practice for the treatment of cases of M. cattarhalis."

This is irresponsible and just plain wrong. The study doesn't lead us to conclude anything about clinical practice and to claim otherwise is bad science and bad medicine.

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.