Wednesday, July 31, 2013

Just try to read the small print

When I give a cortisone injection, I have to document it in our electronic medical records. I've always included the dose, how administered (intramuscular), and the lot number. This week my company added the requirement that we include the NDC number, as insurance companies wanted the information.

It's just one more administrative requirement, but what really makes it bad is trying to read the number off the bottle. As you can see from the photo, the font is very small! I suggested the policy was age discrimination, but that didn't get far.

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

The symptom or the problem?

"I don't know if I want to take this pain medicine," people have told me more than once. "I want to know what's really wrong with me and not just cover it up." Or: "I don't want to treat the symptoms. I want an MRI because I want to figure out the underlying problem."

There is a dichotomy often used, especially by the people who asked me these questions, between "knowing what's going on" and "not knowing what's going on." The more you think about these categories, of course, the more you realize that these conceal as much as they reveal. If we can determine that someone's lower back pain is not dangerous, but (as in most cases) we will never figure out to what specific tendon or muscle the pain is due to, what does it matter that we might always be in the dark about the cause?

Or take chronic kidney disease, which has recently been reclassified: the cutoffs in kidney function have been changed for some of the categories. Not significantly, but now there are new routes to become diagnosed with the conditions, and new guidelines to treat it. If you had one kind of kidney disease before, and were told, after some tests, you actually had the other one, what was known before and what wasn't? And what difference did it make?

You can never know everything. Treatment has to start sometime. And, since treatment can lead to a better picture of the underlying condition, it's never just covering up what is going on. Treatment and diagnosis always live in the creative ambiguity that is the organic muck of medicine. Sometimes I know what's going on even before a word has been spoken. Sometimes I won't know what's going on even when the patient feels 100% better because of something I did.

Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins School of Medicine. His research interests include doctor-patient communication, bioethics, systematic reviews, and the role of the primary care provider in cancer care. He is also the author of "Talking to Your Doctor." This post originally appeared at his blog.

QD: News Every Day--Back pain guidelines not influencing how doctors manage care

In stark contrast to guidelines for managing routine back pain, doctors are increasing their use of diagnostic imaging, referrals and narcotics, while nonsteroidal anti-inflammatory drug or acetaminophen use has declined and physical therapy referrals remain constant, a study found.

Researchers used nationally representative data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey from January 1999 through December 2010 to identify nearly 24,000 visits for spine problems. Results appeared online at JAMA Internal Medicine.

NSAID or acetaminophen use per visit decreased from 36.9% in 1999-2000 to 24.5% in 2009-2010, while narcotic use increased from 19.3% to 29.1%. The number of radiographs remained at about 17%, but the number of computed tomograms or magnetic resonance images increased from 7.2% to 11.3%.

Physical therapy referrals remained unchanged at about 20%, but physician referrals increased from 6.8% to 14%, and this increase "likely contributed to the recent increase in costly, morbid, and often ineffective outpatient spine operations observed in other studies. Recent meta-analyses and research of lumbar fusion surgery have not revealed improvement in patient outcomes and demonstrate that these procedures lead to significant adverse consequences, including 5.6% with life-threatening complications and 0.4% mortality."

In an editorialDonald E. Casey Jr., MD, MPH, MBA, FACP, wrote, "Whereas these guidelines promote use of nonopioid analgesics, avoidance of imaging tests, use of physical therapy-based exercises, and primary care for this population, the results of this analysis demonstrate recent significant decreases for these recommendations. The first step in addressing a problem is to admit that you have it, and in that regard the article by Mafi et al forces us to admit that development of clinical guidelines alone will not solve our problem in managing back pain."
Tuesday, July 30, 2013

New SARS-like virus: how big is the threat?

Reports of a new SARS-like virus have been trickling out of the Arabian Peninsula. SARS, you may recall, was a frighteningly severe viral illness that emerged in southeast China in 2003, spreading rapidly from human to human. Health care workers caring for SARS patients were especially at risk, with the doctor who discovered the illness dying of it a short time later.

SARS is caused by a virus known as SARS-CoV, a coronavirus that probably originated in palm civets, a raccoon-like animal native to Southeast Asia. Coronaviruses are common in humans, usually causing colds or "stomach flu." This particular coronavirus spread rapidly between people, causing the "severe acute respiratory syndrome" that gave the disease its name. Mortality, which was remarkably high, increased with the age of the victim, but even in younger, healthier people was quite deadly.

Ten years later no pandemic has emerged, perhaps due to a vigorous public health response, but probably also due to the biology of the virus. Like many similar viruses, its spread was facilitated by crowded living conditions and by the ease of international travel. Its demise is less well understood.

Since the early part of 2013, a new, similar illness has emerged in the Arabian Peninsula. Now called "MERS-Cov" (Middle East Respiratory Syndrome Coronavirus), there have been about sixty reported cases, all tied to the countries on the peninsula for which it was named. Several cases have been reported in Europe, but so far, the illness hasn't seemed to have caught fire the way SARS did. The case fatality rate for the illness is a terrifying 50%, but this will likely drop as milder cases become trackable.

The real concern here is what the future holds, and how we can affect it. As noted above, the vigorous public health response to SARS helped control the spread, and the disease is essentially no longer seen. I'm a bit skeptical that the illness was all but eliminated by public health efforts alone. What essentially amounts to a deadly cold virus should not be that easy to contain.

The tracking and control of MERS-CoV may also depend on a mixture of good public health and biologic luck, but there are certainly areas of obvious concern. The Muslim pilgrimages, especially the Hajj, bring people from all over the world to the epicenter of the outbreak, sending them back to their home countries after potential exposure. Prevention of a pandemic will depend on the openness of a number of traditionally authoritarian states, not a particularly comforting idea.

It may be that MERS-CoV disappears mysteriously before the next Hajj season. Or maybe not. There are certainly too many unknowns. Hopefully the governments of the Arabian Peninsula will be willing to work openly with other states and the World Health Organization to learn as much as possible before a potential explosion of cases.

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.

Hepatitis A outbreak linked to frozen berry and pomegranate mix

Hepatitis A is an illness which affects the liver and is caused by a virus. (You'll be shocked to learn it's called the hepatitis A virus.) It is usually transmitted through food and water contaminated by human feces, even in microscopic amounts. In the U.S. outbreaks have frequently been linked to food workers who have hepatitis A and contaminate food with their hands. The disease typically causes fatigue, abdominal pain, jaundice (yellowing of the skin and eyes), and dark urine. Patients typically recover completely without lasting damage to the liver. Unlike other forms of viral hepatitis, hepatitis A does not cause chronic infection. After the patient has recovered, the virus is cleared from the body and the patient is no longer infectious. Recovery is followed by lifelong immunity.

An outbreak caused by a negligent restaurant worker is bad enough, but we live in an interconnected international food marketplace. Contamination of the food supply can happen anywhere from the farm to the consumer's hands; the farther upstream the contamination, the more people may be affected.

The most recent food-borne hepatitis A outbreak has been sickening people since March. This week the Centers for Disease Control and Prevention (CDC) updated their findings from their ongoing investigation. The outbreak has been linked to Townsend Farms Organic Anti-Oxidant Blend frozen berry and pomegranate mix. As of this writing, 97 people have become ill in eight states including California. About half of those affected have been hospitalized. There have been no deaths. The berry and pomegranate mix is sold at both Costco and Harris Teeter, though all the affected people who recall eating the berry mix bought it at Costco.

The product has obviously been removed from store shelves. If you have any, discard it immediately. If you have eaten this product in the past two weeks and have never been vaccinated against hepatitis A, contact your doctor immediately. Vaccination may lower your chance of becoming ill.

I've written previously about food-borne illness, about the lack of evidence that anti-oxidants have health benefits, and about the lack of evidence that organic food is healthier than food grown with industrial fertilizer and pesticides. This is an unfortunate story in which these topics intersect. The recent media coverage of the outbreak included an interview with the wife of one of the people sickened with hepatitis A. She expressed surprise that organic food could become contaminated. But there has never been any suggestion that organic food is less likely to bear infectious diseases than food grown with pesticides. Even organic food producers have never made such a claim. If anything, the withholding of industrial fertilizers may increase the likelihood of food contamination if animal waste is used instead and if it is not cleaned off the food.

So please wash all uncooked fruits and vegetables before eating them, even frozen produce. Please wash your hands after using the bathroom. And please feel free to buy organic food because you think it tastes better, or because you'd like to spend more money on food, or because you know it will impress the intriguing hipster checking out your shopping cart. But don't do it for health benefits.

Learn more:
Multistate outbreak of Hepatitis A infections potentially associated with "Townsend Farms Organic Antioxidant Blend" frozen berry and pomegranate mix (CDC)
Advice to Consumers (CDC)
CDC: 87 Now Sickened in Hepatitis A Outbreak (WebMD)
Hepatitis A victim shocked organic berries almost led to liver transplant (CBS News)
Hepatitis A (review article by the Mayo Clinic)

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

QD: News Every Day--Weekly debridement may heal wounds faster

More frequent debridements lead to shorter wound healing times, concluded a retrospective study of the largest wound data set reported in the literature and that was conducted by a corporate provider of wound healing services.

Researchers employed by the company, Healogics, collected data on a sample of nearly 313,000 wounds from all causes among nearly 155,000 patients from 525 wound care centers from June 2008 through June 2012.

Most wounds were diabetic foot ulcers (19%), venous leg ulcers (26.1%), and pressure ulcers (16.2%).

Results appeared online at JAMA Dermatology.

Just more than 70% of wounds healed with a median number of two debridements (range, 1 to 138). The highest heal rate was for traumatic wounds (78.4%) and the lowest rate was for pressure ulcers (56.6%).

Wounds that received weekly or more frequent debridement (P less than .001) healed in a shorter time, the study reported. For diabetic foot ulcers, the median time to heal for weekly or more frequent debridement was 21 days, compared with 64 days for 1- to 2-week intervals and 76 days for 2 weeks or more between debridements (log-rank test, P less than .001). For traumatic wounds, the median time to heal for weekly or more frequent debridement was 14 days, compared with 42 days for 1- to 2-week intervals and 49 days for 2 weeks or more between debridements (log rank test, P less than .001).

Study authors noted that significant variables for wound healing included male sex, physician specialty, wound type, increased patient age, and increased wound age, area and depth.

An editorial noted that chronic wounds require a consistent approach to remove inhibitors to healing, and also that wound centers such as those in the study use evidenced-based algorithms for care, resulting in improved outcomes.

The editorial stated, "In either case, these data provide a best-practice approach, to which most dermatologists likely do not adhere, and as such represent a practice gap. Because of a lack of either appreciation of the need for a consistent approach or understanding of the importance of debridement, many are likely not performing debridement enough."
Monday, July 29, 2013

The 'lethal placebo' and clarifying hormone replacement outcomes

Everyone seems to love a riveting conspiracy theory, except, of course, the victims of it. We enjoy the gathering momentum of our collective outrage and casting our passionate aspersions at some malefactor in the military industrial complex. In my world, that malefactor is often Big Pharma. Everyone loves to hate the harms that drugs do and the profits they generate along the way. Denigrating Big Pharma is a cultural pastime, and rollicking good fun.

And in the larger context of health care, it even makes sense. The prime directive of medicine, after all, is primum non nocere. Medicine becomes a legitimate target for scorn when it is a purveyor of net harm.

But what truly matters here is not the means, but the ends, the harm itself. What matters is life lost from years, and in the more extreme cases, years lost from life. And I have just such a tale to tell, but the means are peculiar. It's not the drug that's killing people, it's the placebo.

My Yale colleague, Dr. Phil Sarrel, has devoted his career in large measure to a detailed knowledge of the overall health effects, and in particular the vascular effects, of ovarian hormones. Ovarian hormones, estrogen and its metabolites, and progesterone, profoundly influence a woman's health from menarche to menopause, and then influence a woman's health some more by disappearing.

Dr. Sarrel was in the vanguard of those who saw serious problems with the large, randomized clinical trials, published just at the turn of the millennium, that refuted our prior faith in the disease-preventing potential of hormone replacement therapy. The HERS trial, and the massive and massively influential Women's Health Initiative (WHI), purportedly showed that we had been wrong about the advantages of hormone replacement, and that the practice resulted in net harm.

Even I was among those who noticed right away that the net harm was very, very slight, and grossly exaggerated in media headlines. But Dr. Sarrel was among those with the expertise to induce bigger worries.

Both trials had used the exact same form of hormone replacement, so-called "Prempro," a combination of Premarin and medroxy-progesterone acetate. Premarin is estrogen derived from the urine of pregnant horses, and thus not native to humans. Medroxy-progesterone acetate is a synthetic progesterone, not native to any species, and many times more potent than human progesterone. Most experts, including my colleague, had long preferred other forms of hormone replacement, considering Prem/Pro a dubious choice.

But when HERS and the WHI tarred the practice of hormone replacement, it was with a broad brush. The news was not that Prem/Pro, one questionable approach to hormone replacement, resulted in benefits for some women and harms for others, with a very slight net harm at the population level. The news was: hormone replacement therapy harms women!

We already had potentially serious problems at this point, but the plot thickens considerably. Dr. Sarrel was also among those to note that these clinical trials administered Prem/Pro to women a decade after menopause. They did this to be sure the women were not just merely but most sincerely post-menopausal. But we had cause to suspect then, and abundant reason to know now, that the benefits of ovarian hormone replacement accrue right at the time of menopause, and in the decade that follows. Timing is often crucial in medicine, as in life. Administer, for instance, a potent diuretic while a patient is fluid overloaded, and it can be lifesaving. Give just the same drug after they have already eliminated that excess fluid, and the result is apt to be hypotension and even death. Timing matters, and the hormone replacement trials got it seriously wrong.

All of this suggests that many women who might have benefited from good hormone replacement administered with good timing have missed out on those benefits because of the headlines engendered by HERS and the WHI. But the story does not end here, either. It ends, as noted, with a lethal placebo.

Quite a few months ago, Dr. Sarrel and I had the first of our recent intense flurry of meetings at my lab. He had brought me a paper published in JAMA in 2011, reporting on one particular subgroup included in the WHI: women who had undergone hysterectomy. The only reason to include progesterone in hormone replacement is to protect the uterine lining from overgrowth, so women who have had a hysterectomy are prescribed (or were, back in the days when hormone replacement was not the bogeyman) estrogen only.

Dr. Sarrel's read of this paper was that the younger women, those age 50 to 59 and therefore just on the far side of menopause, had a considerably higher mortality rate when given placebo, rather than when given estrogen. I am formally trained in biostatistics and epidemiology, so my colleague asked me to verify this impression, which I did. Our project, and the resulting publication of our paper in July in the American Journal of Public Health, grew from there.

Working with a team from my lab, we devised a very simple formula to translate the excess death rate seen in the estrogen-only arm of the WHI to the entire population of such women in the United States: women in their 50s, who had undergone hysterectomy. Hysterectomy is very common, arguably too common, so this population numbers in the many millions. We then needed to add into the formula the most reliable estimates we could find for the precipitous drop in estrogen prescriptions following the publication of the original WHI results back in 2002.

We, of course, had to run the details of our analysis through the gauntlet of peer review. And our paper now stands, in a highly-esteemed journal, on full display before a jury of peers. So I can spare you the details of our methods, and focus on the punch line.

We estimated that over the past decade, due to a wholesale abandonment of all forms of hormone replacement for all categories of women by both the women themselves and their doctors, minimally 20,000, and quite possibly more than 90,000 women have died prematurely. We were very careful to incorporate only reliably conservative figures into our formula, so the numbers might actually be higher still. Being extremely cautious, we report that over 40,000 women have died over the past 10 years for failure to take estrogen.

This death toll of estrogen avoidance, or better still, estrogen "aversion," represented some 4,000 women every year. Whatever the emotional impact of that figure, it should be greater, because any one of those women could be your spouse, or mother, or sister, or daughter, or friend. And the impact should be greater because the massively over-simplified, over-generalized, distorted "hormone replacement is bad" message continues to reverberate, and rates of all kinds of hormone replacement use continue to decline.

Stated bluntly, we think the mortality toll of estrogen avoidance is not merely a clear, present, and ongoing danger, it is a worsening one. More women are dying from this omission every year. And the next one in that calamitous line could be a woman you love; it could be you.

I write this column as my colleagues and I wrote our paper: with a sense of urgency, and even desperation. My career is entirely devoted to the prevention of avoidable harms and the protection of years of life, and life in years. This is as clear cut a case of preventable harms, and as readily fixable, as we are ever likely to see.

Here, then, are the take-away messages:

1) All forms of hormone replacement for all women at menopause was never right, but nor is NO forms of hormone replacement for NO women at menopause. There was always baby and bathwater here, and we have egregiously failed to distinguish between the two.

2) The millions of women who have undergone hysterectomy are candidates for estrogen-only hormone replacement at menopause, and when that treatment is provided at the time of menopause and for the years that immediately follow, it can both alleviate symptoms AND save lives. It could save the lives of thousands of women every year in the U.S., and no doubt many thousands more around the world where the tendency toward hormone replacement aversion also prevails.

Every woman who has had a hysterectomy should be open to the option of estrogen therapy at menopause and should discuss it with her doctor. Every health care professional needs to know that some forms of hormone replacement for some women at menopause remain potentially life-saving, and needs to address the topic accordingly.

3) Medical news is often translated into provocative headlines that abandon the nuances of the actual findings for the sake of maximal impact. This certainly happened when we learned that one form of hormone replacement resulted in a very slight excess of total net harm for one particular group of women, but is a far more systemic problem; it happens all the time. All of us plying our wares where medicine and the media come together need a bracing reality check: there are lives at stake! When headlines distort the actual state of medical knowledge and take on a life of their own, they can affect patient behavior and clinical practice, and the result can be the very harm medicine is pledged to avoid.

I call upon my colleagues involved in the reporting of medical news to embrace the great responsibility that comes with the great power of the press, and to deliver their headlines accordingly. How many avoidable deaths is a maximally titillating, but misleading, headline really worth?

We've all seen the commercials on television: Drug companies are required to report the various potential harms of their products, as they should be. But no one is required to report the potential harms of placebo. For the past decade, millions of women who might have enjoyed more life in years, and tens of thousands who might have enjoyed more years of life by taking estrogen, were, in essence, taking a "placebo" instead. And in this case, it was the placebo causing the harm. In this case, the placebo was, and all too often remains, lethal.

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.

8 tips on how to take a sabbatical

In October 2011 I left my job of 17 years, which I loved, mostly, and started a 2-year sabbatical. Since sabbatical implies that there is one year of rest every 7 years, I have built up at least 2 years since finishing medical school in 1986. Nobody in my office or medical community did sabbaticals, but we discussed that it would be a great idea when we first set up our practice. Various life changing events including 1 death, a retirement and the launching of 2 children required a response from me, and thus the sabbatical.

Physicians ought to do this. We are frequently overworked and burned out and rate ourselves as undercompensated for what we do despite the fact that we belong to one of the best paid occupations in the U.S. We develop a sense of duty and dread and get so busy trying to hold families and practices and administrative responsibilities together that we have neither the time nor the energy to figure out how to rejuvenate ourselves. We end up not loving the job that initially energized us through gruelingly difficult medical school and residencies. We were mostly the best and the brightest, the motivated high school and college students with a drive to serve others and the sparkle to get ourselves into competitive medical schools. We become hurried and harried, with compassion fatigue and dark circles under our eyes. We burn out and become worse doctors and serve our patients less well and burden our families with our ill humor.

I gave notice at my traditional internal medicine practice and got hooked up with various locum tenens companies. I found out that, as a hospitalist, I could make more than enough money to support myself. By working blocks of 7 day, 12 hour shifts at hospitals in various locations I could support various educational projects and travel since locums hospitalist medicine is so much better compensated than my regular job was. I wrote about how that process worked here.

I also did the things that I had regretted not being able to do for 17 years. I took lots of continuing medical education. Wherever there was a good class in something I wanted to learn, I went there. When my son went to college, I did a road trip with my husband across 4 states to deliver him and stayed with my sister. We camped along the way. I did a meditation retreat for a week. I went to the Republic of Georgia for 3 weeks and learned to sing new weird folk songs and performed with a small group at a symposium there. I learned to do bedside ultrasound and had enough money, through my lucrative locums jobs, to pay for a small ultrasound machine and a full month ultrasound fellowship in California.

I took off enough time to really study for my internal medicine boards and took the test to requalify, which for me was voluntary. I applied for fellowship in the American College of Physicians, attended their meeting and walked in the ceremony to get the fellowship. It was in San Francisco, so I got to walk to Chinatown and eat good Chinese food at the breaks and buy cheap Chinese underwear and tea. I spent some quality time with my dog, walking on the mountain near here. I am visiting friends on the east coast this next week, whom I have wanted to visit for years, but never took the time. I am also going to Tanzania in 2 weeks to supervise medical student researchers and teach ultrasound. On my to-do list are trips to India to see how their medical system works (perhaps I could teach bedside ultrasound there) and to South Sudan to work with a friend who treats visceral leischmaniasis.

I also saw over 1,000 patients, many of whom were very sick and all of whom taught me something. I saw the inner workings of 7 hospitals and met dozens of new colleagues, who have also taught me stuff I could never get from books or conferences. I learned how to sleep so I could function on night shifts, learned how to use about 5 different computerized medical record systems, how to apply for medical licenses and that I am very hard to fingerprint. I learned how to be very efficient with my time, and that I am not fast and don't care to be. I learned how to pack a suitcase or a car so I don't forget the important stuff, and various things about airport security, including the fact that it feels nice to be patted down when you are cold and tired.

So, some tips for the doctor who is interested in taking a sabbatical:
1) Do it. It's a good idea.
2) Do something difficult. If you do locum tenens hospitalist work, that counts. Intense work that taxes you, combined with a healthy amount of sleep deprivation leads to personal growth, so long as you don't do it all the time.
3) Do something that is not difficult. Maybe even just a few weeks where you only hang out and garden and go for walks.
4) Do something exotic. Once you are no longer burned out and overworked, this is really fun.
5) Do something that is not medicine.
6) Learn something. It's not a bad idea to take some sort of organized review that leads to a recertification, but there are so many interesting things to learn, in and out of medicine. Go for it.
7) If you do locums, set money aside for income taxes. You are an independent contractor and none of what you make is deducted ahead of time. April 15th can be surprisingly painful.
8) See to your family. They will miss you when you are out and about, pursuing your dreams.

So what, one may ask, about my patients who I have deserted, and those that other sabbaticalizing doctors will desert? What goes around comes around, and they will be better served eventually if we love what we do and are better at it.

I am not done with my sabbatical, but can now visualize a time when I will work here in my hometown and have a regular schedule. I will probably do some "moonlighting" since working away is still interesting. I would like to do both outpatient and inpatient medicine and use what I have learned to help move health care in the right direction, and haven't quite figured out what that is going to look like.

This, of course, is an issue with a sabbatical, the re-entry. I will have to design my job in such a way that it continues to allow me to do the things that, when I am on my deathbed, I will look back upon with satisfaction. Right now I'm thinking I'll buy an old ambulance, paint "Doc-o Truck" on the side (like the taco trucks that make those excellent tiny tacos), do mobile medicine in underserved areas, support this clearly financially untenable enterprise with hospitalist shifts, and write about what happens. More on the Doc-o Truck later.

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.

Considering the effective clinician

Last week I gave Grand Rounds at U.C. Davis with the title, "Learning to think like a clinician." As I considered my choice of words I realized that Philip Tumulty's essay and subsequent book influenced me greatly. This Johns Hopkins master clinician wrote the essay, "What Is a Clinician and What Does He Do?" [Tumulty P. N Engl J Med. 1970;283:20-24.]

Three years later he expanded on this essay and published his classic book that is no longer in print, "The Effective Clinician." Here is a quote from that original essay:

"He is meticulous in accumulating the historical and physical data from the patient. His questioning of the patient is searching and incisive, like that of a wise barrister. ... His special interest is any human illness. His care of the patient does not end with the correct diagnosis. ... He is inexhaustibly capable of infusing into his patient's insight, self-discipline, optimism and courage. Those he cannot make well, he comforts. ... The things he works with are intellectual capacity, unconfined clinical experience and the perceptive use of his eyes, ears, hands and heart."

His use of the phrase "clinician" raised the term in my mind. I owned his book, and read it several times. Unfortunately, like my comic books, it has disappeared. But I did get a copy of the original essay.

So I use the term clinician because not all physicians become effective clinicians. This phrase has magical meaning to me. It encompasses the various skills that our patients deserve. Even though the article is 43 years old, the meaning in the article has not changed. We must think, use various skills, and connect with our patients. I suspect that were he alive, Dr. Tumulty would write eloquently about what we are losing. He wrote this abstract back then:

"A clinician is one whose prime function is to manage a sick person with the purpose of alleviating the total effect of his illness. The multifocal character of the impact of illness upon the patient and his family is stressed. Clinical evidence is the material with which the physician works, and a meticulous history and physical examination are paramount. The availability of more specific forms of therapy requires a clinician to be more of a scientist and, at the same time, more expert in clinical methods. Ability to listen and to talk, so that valid clinical evidence is gathered, anxieties are dissipated, and understanding and motivation are instilled, are the clinicians' greatest assets."

We need more clinicians. Perhaps making that point is sufficient. I can only hope so.

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--Coffee drinkers may have lower suicide rates

Three large cohort studies support an association between coffee and lower risk of suicide (at least in health professionals).

To evaluate the association between coffee and caffeine consumption and suicide risk, researchers accessed data of nearly 44,000 men in the Health Professionals Follow-up Study (HPFS, 1988 to 2008), nearly 74,000 women in the Nurses' Health Study (NHS, 1992 to 2008), and 91,000 women in the NHS II (1993 to 2007).

Coffee and decaffeinated coffee use was assessed every four years by questionnaires. Deaths from suicide were determined by physician review of death certificates. Results appeared online at the The World Journal of Biological Psychiatry.

There were 277 deaths from suicide. Compared to those consuming one cup a week of caffeinated coffee or less, the pooled multivariate relative risk (RR) of suicide for those drinking two to three cups a day was 0.55 (95% confidence interval [CI], 0.38 to 0.78) and for those drinking four or more cups a day was 0.47 (95% CI, 0.27 to 0.81) (P for trend less than 0.001).

The pooled multivariate relative risk for suicide was 0.75 (95% CI, 0.63 to 0.90) for each two cups per day of caffeinated coffee and 0.77 (95% CI, 0.63 to 0.93) for each increment of 300 mg/day of caffeine.
Friday, July 26, 2013

Can we have an informed discussion about health care reform?

One of the responsibilities that I enjoy a great deal and take most seriously as an educator is getting people to think about and to look at issues from all perspectives. Yes I do have my own opinions about many things, but I genuinely try to get people to form their own opinions based on an informed analysis of the facts. I am also willing to change my opinions when the facts no longer support them.

In this vein, I find the national debate in the U.S. about health care reform very frustrating. While I admittedly support the Affordable Care Act (aka, Obamacare), I also know it is imperfect. If any health care policy wonk were designing health care reform from scratch, they would likely not come up with Obamacare. Yet I also recognize that health care reform is a political process, and that political outcomes, based on compromise and tradeoffs, never completely satisfy anyone. In addition, we cannot forget why we need health care reform in the first place, which is because our current health care system is wasteful, harmful, and not sustainable. Doing nothing is not an option, and I believe that Obamacare is preferable to maintaining the status quo.

One of the biggest ironies about Obamacare is that while most Americans oppose the overall law, they support most of the provisions in it, particularly the requirements denying lifetime limits on coverage or on preexisting conditions. They also see changes to their own health insurance plans, changes that would have come with Obamacare or not and are usually at the behest of their employers facing continued premium increases, and blame them on Obamacare. (And clearly those who have fundamental disagreements with Obamacare, or just want to see the President fail no matter what, exploit this to their advantage.)

Probably the main reason why I find the health care reform debate so frustrating is that most Americans do not understand many of the core issues around health care delivery and finance. In particular, they do not understand the difference between health insurance and health care expenditures. Very few Americans, only the very wealthy, can afford to pay for all health care costs. Instead, we all pay for health care insurance. Furthermore, free markets do not really work in most areas of health care, and it is debatable whether we should even try to make them work, as I noted in this blog during the height of the debate over health care reform legislation.

This ignorance is best exemplified by postings such as one on an anti-Obamacare site. The quote at the top of the women's health care portion of the site (reproduced as a picture below in case the site changes) lays bare how badly people misunderstand health insurance (private or public): "I had a hysterectomy, I have no need for maternity coverage, but I have to now pay for it. I have to pay not only my own premium but I have to subsidize everybody else." (Kudos to JD Kleinke for pointing out this site in one of his blog postings. I also agree with another posting of his that Obamacare is more conservative, i.e., less liberal, than Medicare.)

The person quoted on this site obviously misunderstands the concept of health insurance. How many people not needing a hysterectomy subsidized this woman's hysterectomy? She obviously does not understand that the whole idea behind insurance is that we "subsidize" each other's needed care, so that when we need it ourselves, it is available for us. If we start lopping off this condition or that procedure from health insurance, then we soon lose the whole concept of insurance. (This is one of the reasons why most Obamacare insurance exchange plans will be more expensive than cut-rate plans that offer meager coverage and can be terminated at any time.) Carrying this woman's logic to an extreme, does she now no longer support paying for women who need a hysterectomy, since she no longer needs one?

Another manifestation of this thinking concerns Medicare. The famous quote "keep your government hands off my Medicare" (last couple paragraphs of this Washington Post article) best demonstrates how little many people truly understand about Medicare. Less blatantly, however, many elderly people who think nothing of demanding anything and everything from Medicare are the same people who are opposed to other forms of government-run health insurance, especially Medicaid for the poor. Yet these seniors do not realize that they are getting several-fold more benefits from Medicare than the contributions they have made over their lives (Fried, J (2008). Democrats and Republicans - Rhetoric and Reality: Comparing the Voters in Statistics and Anecdotes. New York, NY, Algora Publishing.).

But I do agree with those who argue that we cannot provide unfettered access to any and all types of care to everyone, seniors or otherwise. We do need to make some decisions as a society about what constitutes adequate health care coverage, and who should pay what. There are some areas where competition and free markets work in health care, and those should be encouraged. But the notion that we can buy less costly insurance policies, covering only this or that, really does not make sense.

I am willing to explore all the possible options for health care reform. Some conservative ideas make sense. But before we can have those discussions, a good proportion of the population needs to understand some basic realities about health care and its financing, and be willing to have an honest discussion about them.

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.

Am I an indicator of a decline in hygiene?

A few weeks ago I was seeing patients at a clinic in an affluent suburb. My first patient of the day was a professional woman. At the end of the encounter, she said: "Can I ask you a question?" I had no idea where this was going, sensing that this was probably not going to be a medical question, but said, "of course." She then proceeded to ask me how I liked my Toms, as she wanted to buy her husband a pair. I was in my typical summer clinic attire, which consists of a polo jersey, khakis, and Toms (no socks). Now I think Toms are great. They're comfortable, not made of leather (i.e., animal friendly), and for every pair sold a pair is given away to a child in need. But this post isn't really about Toms.

The Toms question from my patient was a great segue for me to ask the patient about doctor's clothing. I asked her what she thought about how I was dressed and her expectations of how physicians should dress. She said that she saw me walk into the clinic and knew I was her doctor because she had Googled me before the visit. She noted the way I was dressed and thought I would probably put a lab coat on (by the tone of her voice I could tell she didn't like the lab coat concept).

She went on to tell me that my clothes made me "a real human" and it made her more comfortable in interacting with me. I suspect that some other patients may feel differently, but I carefully follow my patient satisfaction scores and must admit that if my clothes are problematic, it's not reflected in my scores. Patients don't really care how their doctor is dressed, as long as the doctor demonstrates empathy, communicates well, and ensures that the patient has access to him/her when they have a problem.

There's an essay in this week's BMJ by Dr. Stephanie Dancer, former editor of the Journal of Hospital Infection. It's entitled, "Put your ties back on: scruffy doctors damage our reputation and indicate a decline in hygiene." In her poorly argued essay, which I think is sexist and borders on crazy talk, she attempts to link the bare-below-the-elbows concept to lower standards for infection prevention. She writes: "No tie"--along with stubble, spitting, picking your nose, and gravity defying trousers--symbolize the real status of hygiene in today's society."

In one paragraph she discounts the role of clothing in infection prevention:
"Given that bed linen and pajamas are habitually contaminated with their owners' personal microbial flora, the focus on transmission from what staff are wearing seems disproportionate and perhaps even irrelevant."

This, of course, fails to distinguish between endogenous and exogenous pathogens. A paragraph later she chastises doctors for wearing the same clothes for several days as it "showers the environment with millions of skin organisms." However, the vast majority of clinicians who wear white coats wear the same coat for days to weeks without laundering them.

I continue to believe that bare below the elbows is useful in infection prevention as it reduces clothing contamination and makes compliance with hand hygiene easier. And I wholeheartedly believe that doctors should appear neat and clean. But I'm still trying to determine biologic plausibility for how banning neck ties has led to nose picking ... Maybe it's because neckties function as handkerchiefs!

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--ACE inhibitors may slow cognitive decline of dementia

ACE inhibitors may slow the rate of cognitive decline typical of dementia, a small study found.

Researchers at two university centers in Ireland compared the rates of cognitive decline in 361 patients who had either been diagnosed with Alzheimer's disease, vascular dementia or a mix of both from 1999 to 2010. Eighty five of the patients were already taking ACE inhibitors. Cognitive decline was assessed using either the Standardized Mini Mental State Examination (SMMSE) or the Quick Mild Cognitive Impairment (Qmci) screen.

Results appeared online at BMJ Open

There was a significant difference in the median, 6-month rate of decline in Qmci scores between those taking ACE inhibitors and those not taking them (1.8 points vs. 2.1 points; P=0.049).

The researchers also assessed the impact of ACE inhibitors on the brain power of 30 patients newly prescribed these drugs during their first six months of treatment.

Median SMMSE scores improved by 1.2 points in the first 6 months of newly taking ACE inhibitors, compared to a 0.8 point decline for the group already receiving them (P=0.003) group and a 1 point decline for the group not taking them (P=0.001) group over the same period.

Researchers noted that the results may results from better adherence to the medication regimen, better blood pressure control, or improved blood flow to the brain.

"This [study] supports the growing body of evidence for the use of ACE inhibitors and other [blood pressure lowering] agents in the management of dementia," the authors wrote. "Although the differences were small and of uncertain clinical significance, if sustained over years, the compounding effects may well have significant clinical benefits."
Thursday, July 25, 2013

Culture, power and personal responsibility for health

Our culture, at least the movie-going part of it, seems to have embraced the adage: With great power comes great responsibility. Somehow, at the same time, it seems to have ignored the inevitable, underlying principle: Power and responsibility are conjoined. This, in turn, implies a corollary our culture also neglects routinely, if not universally: Before anyone can reasonably be expected to take responsibility, they must be suitably empowered.

After all, if great power brings great responsibility, then presumably modest power brings more modest responsibility. And, by extension, utter lack of power would bring, you guessed it, something very much like utter lack of responsibility.

There is something almost viscerally objectionable about the renunciation of responsibility. We just don't like it! But before you let your viscera coopt your view of this matter, let's consider how consistently we already do accept the notion that in the absence of power, there is no responsibility.

Newborns aren't responsible for anything, not even personal hygiene, because they have no power, no control, and none of the relevant skills. Newborn babies can't take care of themselves, and aren't expected to do so. As children grow, they are expected to take on responsibilities little by little, as they acquire the skills to do so. Let's be clear about the sequence: Power comes first, responsibility after. Only after potty-training do we expect our kids to take on responsibility for this most basic need, and even then, we anticipate accidents early on. There is the basic power associated with any given ability, but then only practice makes perfect.

We can't, and don't, ask someone to be responsible for acting on some set of instructions they don't have the literacy to read. We don't ask 3-year-olds to follow written guidelines. We don't ask the average literate American to take responsibility for instructions written in Armenian. In the absence of power, responsibility is a non-starter.

We can't, and don't, expect someone to ride a bike they haven't been taught to ride. And we can't, and don't, expect someone who knows how to ride a bike to ride a bike, unless they have a bike! There are many ways to be disempowered. Among them are a lack of aptitude, and a lack of relevant resources.

There is, as I have noted before in a series to which I return now after a pause of several months, a prevailing tendency in our society to associate obesity and the illnesses attached to it to some deficit of personal responsibility. This could be true, but only if the requisite empowerment prevailed, and were being squandered. If the actual problem is a lack of power, then invoking a lack of responsibility implicates the wrong suspect altogether. This matters, because one is unlikely to fix what is broken while focusing on what isn't.

There is, to my knowledge, no scientific evidence that the current cohort of Homo sapiens is less endowed with personal responsibility than all prior cohorts. I've looked. If the evidence is out there, I can't find it.

Perhaps, nonetheless, your convictions cause you to believe that we are now less personally responsible than our forebears, even in the absence of evidence. Perhaps you feel compelled to believe that obesity must be about personal responsibility. But obesity is now hyperendemic not only among adults, but also children under 10. Are we truly inclined to believe that the average 6-year-old today is less personally responsible than all 6-year-olds through history? If not, but today's 6-year-old is apt be fatter, then something else is going on.

I think we know what it is, and it's all about power, and culture. Culture is a powerful influence on us all. When personal responsibility involves defiance of the prevailing forces of one's culture, it becomes a very tall order indeed.

Unfortunately, that is just the order associated with personal responsibility for health. Obesity and chronic disease are not just prevalent in the modern world, they are so prevalent as to constitute the new normal. To remain free of them is to be ... abnormal. Abnormal, for good or for ill, is always hard.

In a commentary published in The Lancet in February of this year, a group of scholars made the very point that the power of culture, and profit, is all too often oriented in opposition to health rather than in support of it. We might ask people to take responsibility in spite of it all, but that's a bit like pitching someone off our boat and assigning them responsibility for keeping afloat, whether or not they've ever learned how to swim. Relevant power is prerequisite to responsibility.

If you know it's important to control your weight and attend to your health, but almost everything in your environment and your culture conspires against such efforts, how responsible are you, personally? If as a child you get brief, tepid messages about eating well in school, but are then bombarded with state-of-the-art advertisements on screen and online encouraging you to do otherwise, are you truly personally irresponsible if you go with the prevailing flow?

If there is logic and value in such musings, I believe they all distill down to this: How can the whole of our collective responsibility for health be so much less than the sum of what we expect from its parts? Do we truly expect every individual, adult and child alike, to compensate with personal responsibility for the collective abdications at the level of culture, and corporation?

In his famous song of that very name, John Mayer laments that we keep on "waitin' on the world to change." But since the world changes slowly, and health can fall apart a whole lot faster, none of us can afford just to wait. We can seek out the skills we need to become empowered, and then express our personal responsibility. We can, and for better or worse, we must.

But that's not a reason to accept the world as it is. The world can change, and since the modern world conspires against our health it should change. We can't change it alone, but we can change it together. And there is no reason to choose between defending the health of your own body, and being part of the body politic, working to make the world a healthier place for us all. Collectively, we can put health on a path of lesser resistance so no one of us needs to work quite so hard to get there from here.

Taking responsibility requires empowerment. But even when empowered, leaping tall buildings in a single bound is asking a bit much of the mortals among us. The power and responsibility for lowering that bar, reside with our culture. Power over culture, in turn, resides with us.

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.

Addiction and substance abuse can strike anyone

Over the course of a year, I have an alternating pattern of caffeinated coffee ingestion. As readers should know, I will not swallow Starbucks 'Joe' as I do not think that I have sufficient stomach acid and other bodily defenses to successful prevail against this corrosive elixir. Of course, everything has a benefit if one is resourceful enough to discover it. For instance, I have found their coffee to be quite useful as a paint remover or shark repellent.

The best coffee in Cleveland is found at Dunkin' Donuts. Perhaps, one of the reasons their java is so smooth is that my order of coffee with cream is mixed at a 1 to 1 ratio. Cream at Dunkin' Donuts is no half and half concoction; it's the real thing.

As I write this, there is an environmentally unfriendly Styrofoam cup beside me. I'll down this coffee every day for weeks reaching a point where if I skip a day, I will enjoy the pleasure of an ice-pick, throbbing headache at 4 p.m. It's a pounder that stays with me for 3 hours, until it fades allowing my neurons to regain some level of function. At this point, I am aware that I have developed a physical addition to the stimulant, and need to resume daily use if I am to avoid the afternoon cranial crusher.

I now face a choice. Resume the daily caffeine or break it off and tolerate the withdrawal phase until I am successfully detoxified.

In general, I opt for the latter and survive on decaf for several weeks until I convince myself that a single caffeinated morning brew can't hurt me. And so, resumes the cycle.

While this is a real addiction with real withdrawal, it is a mere wraith of the addictions that I confront as a physician. While the tobacco habit is most common, there's an abundance of alcohol abuse in my practice, which I am sure is substantially underestimated. I surmise that most of the alcoholics in my practice are unknown to me. I see a fair amount of pain medication addiction, which was initiated for short term pain control, but over time has morphed into a new disease.

It's a sad reality to recognize how difficult it is for alcoholics and other addicts to recover successfully, even when they strive to do so. Booze and cigarettes over time become tentacles that wrap around their victims, squeezing tightly, such that most addicts don't have the strength or the will to remove them. It is humbling to appreciate the power that these substances exert over the users. These are folks who simply cannot throw these chains aside, despite suffering profound personal and professional losses and serious medical consequences. And, no one can do this work for them, as I have witnessed time and time again.

There is no comparison of these tragic and recalcitrant conditions to a coffee fling, which poses a small challenge to the afflicted individual, as I know. While some addicts manage to slay the dragon, most will serve as prey to the beast.

I've got a few more swigs of Dunkin' Donuts left this morning. Addicted? Of course not. I can stop anytime I want. Maybe tomorrow, or the next day ...
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--FDA will allow fecal transplants after all

The Food and Drug Administration will back off its previous stance that fecal transplantations will require an Investigational New Device (IND) application.

The FDA said in a guidance for industry that it will not require physicians to apply through the regulatory process, "provided that the treating physician obtains adequate informed consent from the patient or his or her legally authorized representative for the use of FMT [fecal microbiota for transplantation ] products. Informed consent should include, at a minimum, a statement that the use of FMT products to treat C. difficile is investigational and a discussion of its potential risks. FDA intends to exercise this discretion on an interim basis while the agency develops appropriate policies for the study and use of FMT products under IND."

Fecal transplants have been widely discussed as a way to treat recurrent Clostridium difficile colitis, and the agency's decision was unpopular among internists.
Wednesday, July 24, 2013

Orthopedic dialogue

Six months ago I posted a story about a demented 94 year old patient who'd fractured her hip. She'd lost more than thirty pounds in the preceding months and had already had a collarbone fracture from a previous fall.

Her son wanted her to be made "comfort care only," and avoid a trip to the operating room since she was likely within six months of death and was immobile (bedbound) even before her hip fracture. She was going to be referred to hospice. We called off the orthopedic consultants who had been kind enough to recommend (and set her up for) hip stabilization.

I felt like this was the right course of action, and the family members (the ones I'd met) supported this decision. The patient appeared comfortable, able to sit up in bed and hold conversations (albeit demented ones), and not in any distress from her fracture.

The next day, I came to the hospital to find out she was already on the operating room table to have her hip "pinned." No one had called me to discuss the change in plan.

I was furious. I felt betrayed by my orthopedic colleagues, who hadn't seen fit to discuss their thinking or the change in planning (or the subsequent conversations with the family) with me. After all, I was the physician 'in charge' of the case; the one legally responsible for the decision-making and the outcome.

The blog post generated attention: commentary, multiple reposts (e.g. here and here) and some white heat.

I've learned a lot from the case, and from my posting of something so 'fresh' and full of emotion: Namely, that with the perspective of time, I now see that it was inappropriate of me to:
--blog about something so recent;
--"call out" my orthopedic colleagues without discussing the situation with them first;
--use profanity in a blog post about something important and meaningful, thereby likely putting off the audience I would hope to capture.

I apologize for my boorishness. I was quite angry, and I let it get the best of me.

Many people wrote asking what the resolution of the case was, and what the upshot of my post-hoc conversation with orthopedic colleagues would be.

I spoke with the department chair, after he'd had ample time to review the case and hear from the "players."

I respect his approach and fact-finding, and he acknowledged that the communication over the patient's fate (and consent to surgery) was mishandled. But he also helped me see the situation through the eyes of an orthopedic surgeon, which addressed my concern about their motivation(s). I will tackle his points one by one.

Hip fractures are an endemic problem. With our aging population and the thinning bone that comes along with it, hip fractures are an inevitability in communities and growing as a problem along with our aging loved ones. Primary care doctors do a lousy job treating osteoporosis.

Hip fractures are a local problem. At this one 500-bed hospital in a medium-sized American city, there were more than 800 hip fractures last year--more than 2 per day. The weekend before I spoke with the chairman, there had been seven hip fractures.

Orthopedic surgeons are not motivated by money when it comes to hip fractures. Unlike much of orthopedics which provides elective surgeries, hip fractures are a form of trauma, and therefore do not conform to surgical scheduling. Orthopedists perform fracture repairs as add-ons to their regular cases, and most surgeons don't like to perform them as they occur at off-hours, over and above their regular caseloads. Medical outcomes in hip fracture improve the sooner they are repaired; therefore the addition of time pressure to these cases is another stressor for surgeons.

In the case I blogged about, the orthopedic group collected $819.27 in professional fees (i.e. the doctor's charge) for the pinning of the 94 year-old patient's hip. "Half of that goes to taxes, another quarter to overhead," the chairman told me. That leaves a collection of about $205 net for the procedure. The implication is that no one is getting rich repairing hip fractures.

Communication is a two-way street. Much as I was displeased with the lack of communication in this case, the chairman provided several examples of where internists had simply not communicated with his team regarding a patient's care. He's absolutely right about this. It's a fail for all of us.

They have created a center of excellence. One of the doctors who read my initial post works at the hospital in question. He pointed out, correctly, that NOT pinning the elder woman's hip (even though she was emaciated, demented, and fragile) would be cruel. She would have pain with any position changes and likely develop bedsores. The standard of care is to repair hip fractures, not let them heal (they actually can!) over time. The time cost (and risk) is too great. That physician (an internist) has partnered with the orthopedic group to form a center of excellence in hip fractures, devoting resources to tackling this growing and costly problem in a systematic fashion. This is a great response–and I'm pleased to work and teach at a hospital that's ready to tackle problems like this.

At the end of our chat, the chairman handed me copies of pages from the patient's chart. "Is that your note?" he asked me. I nodded.

"I can't read a word of it," he told me.


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.

Considering the differences between alternative, holistic and integrative medicine

Recently a patient of mine brought in a bottle given to her by her acupuncturist. She had turned to acupuncture with my encouragement after traditional medicine fell short at addressing her chronic pain. Indeed, there is data to support the efficacy of acupuncture in the management of chronic pain. I was encouraged to hear that this treatment, often labeled as "alternative," seemed to be helping her substantially.

However, my patient's questions had to do with the ingredients of the herbal medication she was given to help with weight loss and phlegm--a potpourri of botanicals translated from Chinese to English. She asked for my assessment and blessing, reminding me that I was a self-proclaimed "holistic" doctor.

Quickly I scanned the product's label. It contained, among other things, Raphanus Semen, something I immediately felt that I personally would not care to ingest. Despite my initial concern, I promised to research the herbal supplement to the best of my ability. Later, I discovered that Raphanus Semen was radish seed, which at least seemed less disgusting than what I had imagined.

This patient interaction brought to light two topics worth discussing:
1. What is meant by "Holistic Medicine?"
2. How does one assess the safety of complementary and alternative therapy, and more specifically, of botanicals and natural supplements?

I am fairly certain that "holistic" does not carry the same meaning to me as it does to many Americans. In my view holism in medicine implies having a whole person view. That is, seeing each patient, not just as a constellation of physical symptoms to diagnose and treat, but also within their psychosocial context. After all, a person's unique psychology and cultural background determine how he or she reacts to physical illness, diagnosis, medical advice, and treatment prescribed. A doctor who makes attempt to understand these parts of his or her patients is apt to be more successful at treating them.

However, most Americans tend to think of a "holistic doctor" as one who is well-versed in alternative therapies and who bucks standardized approaches endorsed by the medical establishment, including the pharmaceutical industry and the FDA. This is not true of my practice, though I am aware of the existence of bias and limitation within the scientific process.

As of late, the term "holistic medicine" has actually become antiquated and has been replaced by the contemporary field of "integrative medicine." As defined by the wise Dr. Andrew Weil, one of its best known proponents:
"Integrative medicine is healing-oriented medicine that takes account of the whole person (body, mind, and spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative."

By this description I am an advocate of integrative medicine, though, the key point here is "use of all appropriate therapies." The unfortunate truth is that many physicians who profess to practice integrative medicine treat multiple diagnoses that are not at all well-established by science, for example, "adrenal fatigue." In addition, many advocate use of products that lack sufficient evidence for safety and efficacy, for example DHEA or bio-identical hormones, and disavow standard FDA approved drugs for unclear reasons. This business too can be a money-making operation, as some of these physicians do not bill health insurance for their services, run a multitude of diagnostic lab tests of uncertain significance, and may even sell their non-approved "natural" products for significant profit.

Which complementary and alternative therapies are safe and reasonable to try? There are a number of resources that can help to guide both doctors and patients, such as NIH's National Center for Complementary and Alternative Therapy page on Herbs at a Glance. Unlike prescription drugs, the manufacturers of medicinal herbs and botanicals are not required to prove the safety and efficacy of their products prior to marketing them. In addition to the definite possibility that these substances might be ineffective, there are two major safety considerations--their potential for causing drug interactions and the risk of product contamination. If you are researching for negative reports on a particular substance you may find the NIH's index "How Safe is this Product or Practice?" to be useful.

In the case of my patient, she is on a fairly long list of medications for several serious health conditions. For example, she has a history of pulmonary embolus and also has an inherited condition that makes her prone to clotting. For this she takes a blood thinner. Her other drugs include strong pain medications and several psychotropic drugs with narrow therapeutic indices. My immediate concern was for the possibility of botanical-drug interactions, which might increase or decrease levels of her prescription drugs and cause toxicity or adverse medical events.

It turns out that my research was unable to shed light on any reliable information whatsoever about Raphanus Semen, nor the remaining six ingredients of the herbal medication that she showed me. I was left to shrug my shoulders and advise her, in this case, "probably not a good idea." On the other hand, I support the use of acupuncture for chronic pain and have been known to advise melatonin for sleep, probiotics for various digestive ails, and even strontium for osteoporosis.

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

QD: News Every Day--Many 'medical advances' eventually overturned

Offering no treatment can still be the best option a physician has, because the latest and greatest in medical advances are so often later discovered to be no better than doing nothing, a study concluded.

Reviewers classified all original articles that tested a new medical practice or therapy published from 2001 to 2010 in the New England Journal of Medicine into four types: "replacement," a new practice that surpasses standard of care; "back to the drawing board," a new practice that is no better than current practice; "reaffirmation," an existing practice that is better than a lesser standard; and "reversal," an existing practice that is no better than a lesser therapy.

Results appeared in the Mayo Clinic Proceedings.

In the study, about 40% of the studies that tested an existing medical practice found it ineffective compared with a previous standard, 38% upheld the practice, and about 27% were inconclusive.

Authors noted that this study, along with similar efforts such as the projects done by medical journals and medical societies, supports the idea that many "advances" are eventually overturned.

Researchers wrote, "The reversals we have identified by no means represent the final word for any of these practices. Simply because newer, larger, better controlled or designed studies contradict standard of care does not necessarily mean that older practices are wrong and new ones are right. On average, however, better designed, controlled, and powered studies reach more valid conclusions. Nevertheless, the reversals we have identified at the very least call these practices into question. Some practices ought to be abandoned, whereas others warrant retesting in more powerful investigations. One of the greatest virtues of medical research is our continual quest to reassess it."

An accompanying editorial outlined the impact of these results across not just one journal but across all of them.

"Despite better laboratory science, fascinating technology, and theoretically mature designs after 65 years of randomized trials, ineffective, harmful, expensive medical practices are being introduced more frequently now than at any other time in the history of medicine. Under the current mode of evidence collection, most of these new practices may never be challenged," the author wrote.

But there's hope if clinicians review the medical reversals and realize that the urge to treat isn't always the right choice.

The editorial continued, "The data collected by Prasad et al offer some hints about how this dreadful scenario might be aborted. The 146 medical reversals that they have assembled are, in a sense, examples of success stories that can inspire the astute clinician and clinical investigator to challenge the status quo and realize that doing less is more. It is not with irony that I call these disasters 'success stories.' If we can learn from them, these seemingly disappointing results may be extremely helpful in curtailing harms to patients and cost to the health care system."
Tuesday, July 23, 2013

Doctor Scum Bag

A post I wrote nearly three years ago has recently gone viral, bringing tens of thousands of readers and a huge number of comments. It's a letter I wrote to my patients who do something that all but guarantees a bad relationship with many (if not most) physicians: they don't get better. There are basically two responses I get to this post: either readers are grateful to have a doctor admit to our flawed humanity, or they are furious that I would suggest that patients, the ones with the disease, should see physicians as needy and flawed humans and therefore watch how they act around them.

If you haven't done so, read the comments to this post and hear the deep frustration and anger brought out by a letter that sympathizes with their pain and (apologetically) tries to help.

Amidst the dichotomy of reactions, both of which I understand, is the obvious question: why has a relationship that exists for the purpose of healing and helping become one of frustration and anger? The corollary to this question is perhaps more important: what can be done to heal this broken relationship? A reader of my last post (about viewing patients from a different perspective) asked me point blank: "Dr. Rob, for the 99.999% of us who do not have a primary care doctor who is thinking as progressively as you, what advice can you give so that we can get our doctors to be treating us in the manner in which you are treating your own patients?"

I must admit, I get a bit uncomfortable with this, as it sounds like I am putting myself above my colleagues morally. Ironically, it is my deep understanding of my own huge flaws, coupled with an upbringing that scorned conformity, that rips me away from the survival self-centeredness most docs eventually adopt. Putting myself on any moral high ground only invites a very public (and deserved) fall back to the low ground I usually inhabit. No, I'm also not putting myself down out of false-modesty; I've made peace with my flaws, embracing them for what they are: a lens with which I can understand my fellow human scum-bags. Of course, as my best friend (and best man) used to remind me: "remember, I am doctor scum bag to you."

Now, I don't lay the whole problem at the feet of the fallen nature of mankind. I believe that our system of "health care" doesn't just fail to counter the flaws of our nature, it actively promotes bad relationships. It does this by:

Reducing patients to "problems." The payment system requires we use "problem codes" to classify patients and justify visits. The problem-oriented approach is not just a byproduct of the payment system, though, it is at the very core of medical education. Despite a 100% ultimate failure rate, we are still taught that death and disease are the opponents we need to outsmart or out-procedure. Perhaps its analogous to the public infatuation with the tawdry and grotesque (the more gruesome the murder, the more news shows cover it), but we physicians love "interesting cases." But nobody ever wants to be an "interesting case." Ask any of the people who commented on the blog post. Boring is better.

Rewarding sickness. Having a full office pays the bills. If everyone got healthy, the system would collapse. This means that anything that would help patients get healthy stands against the financial wellbeing of doctors and hospitals. If doctors communicate poorly with my patient, they will be less likely to get well, and will hence be more likely to need their services. I don't think docs actually use that sickening logic, but it is the ugly truth about our system. This is why tools that should make care better are not adopted: doctors are penalized when they improve care.

Making doctors targets. I am not talking about patients, I'm talking about payers targeting physicians (and hospitals) as the cause of the problem. It would seem that the best strategy to fight unnecessary cost would be to simply stop paying for unproven, unnecessary, and/or harmful procedures. Better yet, why not pay docs like me who are motivated to keep patients well and happy? But payers instead target doctors through small financial rewards and huge sanctions. "Quality measures" are not out there to reward high quality, their purpose is to expose and shame the bad doctors and hospitals. Am I exaggerating? Perhaps; but I can say that one of the best parts of being out of the insurance-oriented system is to no longer feel the passive-aggressive eye of big brother waiting to catch me not following their rules. All docs feel this, and it puts them in a position of defensiveness, which is not good for patients.

Killing time. One of the most remarkable differences in my new practice is the amount of time I can give each patient. I can answer the phone and handle their problems. I can sit and chat with them if they stop by to pay their bill. In the old system I was always late, always pressured to move on to the next patient, and rarely had time to do the most important thing: communicate with my patients. Good care takes relationship, and relationship takes time. Nobody has time anymore because the system seeks and destroys time, either by filling it with meaningless clerical tasks or by punishing those who take extra time with lower pay.

In our health care system we have a business where both ends of the transaction are miserably unhappy. 99% of doctors hate the health care system, and the 1% who like it are the ones to avoid. Patient dissatisfaction is nearly as high, skewed downward by people who have grown so used to the terrible system we have that they now see "terrible" as "average." Is there any other business where both consumer and those providing the product are so unhappy? The reason for this is that someone else is shaping the system: the payers.

I must admit, I am not sure how this can be fixed in any way other than a total disruption of the current system and replacement with one that is centered on people, not problems, on communication not documentation. Until we have a system that doesn't reward sickness, sickness will be the reward we reap. I left the system because I didn't think there was any way to continue practicing good care in it. While my new practice is far from perfect (consider the source), at least I am rewarded for taking time with people.

To have any chance at building better relationships between doctors and patients, we need to face the painful reality that our system corrupts even those with the best intentions. So, I guess that would make it a "scum-care" or "health-scum" system? The sooner we face our ugly reality, the more the chance of bringing the focus back to where it should be: caring for patients.

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.

Broad Street chump

We now revere John Snow, the father of modern epidemiology, for his brilliant work in tracing (and eliminating) the source of a cholera epidemic. Back in the day, though, Lancet founding editor Thomas Wakley was, to put it mildly, not a big fan. Here is John Snow's obituary, published in Lancet on June 26, 1858:
"This well-known physician died at noon, on the 16th instant, at his house in Sackville Street, from an attack of apoplexy. His researches on chloroform and other anaesthetics were appreciated by the profession."

Well, last month Lancet decided to right this wrong by publishing a "corrected" obituary. Read the interesting backstory for an explanation of why Snow had so many critics at that time. Note his private life, which mirrors that of many present-day epidemiologists:
"He took no wine nor strong drink; he lived on anchorite's fare, clothed plainly, kept no company, and found every amusement in his science books, his experiments and simple exercise"

h/t to the Iowa Dept of Public Health for including the Lancet link in their weekly update

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--83% of radiologists overlooked a gorilla inserted into a CT scan

This zebra was a gorilla, actually.
Researchers asked 24 radiologists to examine five CT scans for lung nodules, with full control over the scans. But, the researchers inserted into the one of the scans an image of a gorilla that was 48 times larger than an average nodule. They used eye tracking to assess what happened next.

Results appeared online July 17 at Psychological Science.

Eighty-three percent of the radiologists did not see the gorilla, and eye-tracking revealed that the radiologists who missed the gorilla spent an average of 5.7 seconds looking at that CT scan and 250 milliseconds looking at the spot where the gorilla was located.

Inattentional blindness has been well-documented over the years, and a famous demonstration illustrates how easy it is to overlook the obvious when a person is focused on some other activity.

Monday, July 22, 2013

Why wonks should read physician-written blogs

Obviously this post is a bit self-serving. However, it does involve some first guessing, rather than second guessing.

Talk to practicing physicians and these two concepts really drive them crazy. (There are others, but today I am just focusing on these two).

Performance measurement has grated on our nerves for a long time. This blog and many others have screamed about the flaws in the concept. We have pointed out the problems repeatedly. Finally, the "leaders" are seeing the light.

Experts in quality improvement developed an important paper for the Robert Wood Johnson Foundation. (I blogged about this on June 6.) In that paper, Achieving the Potential of Health Care Performance Measures, the authors point out many of the flaws that bloggers have noted for many years. Our concerns now are getting serious attention.

Now in the Annals of Internal Medicine, Koppel writes about "Demanding Utility From Health Information Technology."

Their results suggest that EHRs currently fail to meet the anticipated goals, an observation that is particularly disheartening when one recognizes that the study population likely reflects the views of more enthusiastic EHR users.


They had to do a study. They could have read many blogs and suspected the same thing. Koppel finished his commentary:

"In light of these findings, addressing health information technology's Tower of Babel will require redirection of our focus on data standards and integration. The U.S. government pays approximately 52% of all health care dollars, which can provide robust motivation for such refocusing. Regulators already have authority to demand data standards and interoperability. Ideally, vendors will cooperate. Current policy puts faith in market processes, incremental changes, and regulatory hints to achieve data standards, interoperability, and usability. DesRoches and colleagues reveal that such faith is chimerical. The necessity to improve care and reduce costs is too compelling to allow the current chaos to continue. This study shows that if EHRs are to fulfill their promise, we must shift from cheering health information technology implementations to demanding health information technology utility."

The wonks should talk to some real physicians to get an idea about unintended consequences. The good physicians who see patients daily understand practice very well. Why don't the beltway boys listen to them?

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.