Friday, November 29, 2013

Brain dysfunction persists long after a serious illness

A sudden life-threatening illness is every family's nightmare. A loved-one suddenly develops an overwhelming infection or is in a terrible accident. She is rushed to the ICU and is put on a ventilator. Many medications are started or she is rushed to surgery for her traumatic injuries. To the family, the first day or two is a blur of life-saving treatments, painfully waiting for the next update. The patient is on strong sedatives and non-communicative. She survives the worst days. The infection improves, or the surgeries fix the worst injuries. The ventilator is removed and the sedation is stopped. It looks like she's going to make it. Families are usually unprepared for this next stage. In the movies the patient might spring out of bed and return home or a musical montage would convey her complete recovery over the next few days.

In reality the patient spends days in the ICU weak, confused and agitated. She doesn't sleep. She recognizes loved ones only intermittently and has conversations with people who aren't there. Other times she's very lethargic and only answers questions with a word or two. Her family is terrified.

Doctors call this syndrome delirium, and it's very common in critically ill patients. Delirium manifests in disorientation, agitation and a level of alertness that can change quickly over time. Though delirium affects all mental process, the primary deficit is in attention. Delirious patients can't focus on a task or on a question from one moment to the next.

The brain is usually an innocent bystander in delirium. Delirium is almost never caused by a primary brain problem, a stroke or a brain tumor, for example. Delirium is caused by a problem elsewhere that is disorganizing brain function, respiratory failure that is sending the brain too little oxygen or too much carbon dioxide, kidney or liver failure that is sending the brain too many waste products, or an infection that is sending the brain bacterial toxins.

In my training I was taught that once the cause of delirium is found and treated, the delirium might take days or weeks to improve, but that the improvement would be complete. I've discussed with many families preparing to take home a loved one that the patient's periods of confusion would be shorter and the periods of lucidity would be longer, and over the next few weeks her mental status would return to normal. It turns out that's not true.

A study published in this week's New England Journal of Medicine (NEJM) sought to measure the long-term mental effects of critical illness. The study enrolled over 800 patients who were admitted to an ICU for respiratory failure, overwhelming infection, or cardiovascular failure (cardiogenic shock) for any medical or surgical reason. The vast majority of them had no cognitive deficits prior to this illness. Their average age was 61. This was an extremely sick group. They spent an average of 3 days on a ventilator and 10 days in the hospital. 74% had delirium, and on average delirium lasted for 4 days. The survivors were followed and underwent a broad battery of neurocognitive tests administered by psychologists 3 months and 12 months after their hospitalization. (For a sense of how desperately ill these patients were, 31% died between their ICU admission and the 3 month follow-up.)

The results were surprisingly poor. Three months after hospitalization 40% of patients had cognition scores that would be typical for a patient with a moderate traumatic brain injury. 26% were even worse and had scores similar to patients with mild Alzheimer's disease. Twelve months after hospitalization those percentages were only slightly better, 34% and 24% respectively. More shocking was that the rate of prolonged cognitive impairment did not depend on age; young people did as poorly as old. The deficits did correlate, however, with the duration of delirium while they were hospitalized.

This study highlights several gaps in our current care of critically ill patients. Measures are already taken in ICUs to minimize the likelihood and duration of delirium. These measures must be redoubled with the knowledge that delirium may harm patients' mental function even a year later. Ambulation as early as possible and re-establishing the sleep cycle with daytime alertness and stimulation and nighttime sleep (which requires darkness and quiet) have been two of the more promising methods to protect patients' mental status.

Patients and families should be warned that deficits in thinking and memory may persist for a long time. Just as we prescribe physical therapy for a weak patient going home from the hospital, perhaps we should also be recommending cognitive testing and rehabilitation. And we should keep in mind that patients and their families may require more help than we've appreciated for longer than we thought.

Learn more:

Intensive-Care Units Pose Long-Term Brain Risk, Study Finds (WSJ)
Delirium In The ICU May Pose Ongoing Risk Of Thinking Problems (Shots, NPR health news)
Brain problems can linger months after ICU stay (Reuters)
Long-Term Cognitive Impairment after Critical Illness (NEJM article)
Disability after Critical Illness (NEJM editorial)

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.
Thursday, November 28, 2013

An October birth: the Metastatic Breast Cancer Alliance

This week marks 11 years since my breast cancer diagnosis. My feelings are mixed. On the one hand, I’m keenly aware, and constantly appreciative, of the fortune of being alive and, as far as I know (knock on virtual wood), free of the disease. That’s great, of course, but I’m lucky – so far at least, still vying not to be cast off by some strange turn of statistical, informed roulette. I can’t help but think, especially today, of my countless breast cancer “sisters” with metastatic disease.

October 13 was Metastatic Breast Cancer Awareness Day. In 2009, the U.S. Congress voted to designate this day for attention to the particular needs of people with metastatic breast cancer (MBC). Although it’s been unofficial since that year, the day has been adopted by several breast cancer agencies as a time to rally in support the cause – and needed research – for people affected by MBC. For people who are living with MBC, the immediate goals are not so much to prevent breast cancer, or necessarily to cure it, but to find better treatments so they can live longer and fuller lives.

The number of women living with metastatic breast cancer is unknown. Almost all deaths from the disease occur in people who have advanced or metastatic (Stage 4) cases. This year, some 40,000 women and 400 men will die from breast cancer in the United States. According to the Centers for Disease Control, cancer is the number 1 cause of death in women between the ages of 35 and 64 years. Only lung cancer accounts for more cancer deaths among women. Almost all deaths from breast cancer occur in women with Stage 4 disease. The World Health Organization reports that approximately 458,000 will die from breast cancer this year, around the globe.

These are the kinds of numbers that can be hard for some people to face, or think about too much. Deaths from breast cancer amount to 110 people each day in the U.S., or 1,255 each day, around the globe. I’m thinking of a lecture room of women every day in the U.S., or a train’s worth, every single day, on average. Hard to envision. But it’s almost impossible not to get the message if just one woman, perhaps at the table over a lunch meeting, tells you about her daily life with relapsed or otherwise metastatic disease, and no end of treatment in sight.

If you break the deaths down by age group, as does the American Cancer Society in its most recent report on Breast Cancer Facts & Figures, you’ll find these numbers in Table 1: over 1,000 women die of breast cancer each year under the age of 40 years; an additional 4,780 die under the age of 50; almost 12,000 die between the ages of 50 and 64; the remainder of breast cancer deaths (nearly 23,000) occur in people age 65 and older. The overwhelming proportion of cases arises in women, although there’s a trend of more cases in men. The median age of a breast cancer diagnosis is 61 years; this is largely a disease of middle-aged women.

Some encouraging news on the research front, besides new drugs in the pipeline and ongoing trials, is the formation of a new, cooperative coalition of breast cancer charities that will work together to address the problem MBC. The new Metastatic Breast Cancer Alliance includes a spectrum of pink and gray agencies, young and old, working together. The main thing is to promote knowledge and research about breast cancer metastases – to reduce formation and growth of metastases, and to treat those affected with better, less toxic meds.

I’m delighted to see an example of breast cancer agencies working together, constructively. Sure, each group has its particular priorities and “personality,” if you will. But we all want to end misunderstanding, and we all hope to improve the lives of people living with Stage 4 disease. Breast cancer is not “easy.” It’s serious and life-destroying. The more research and scientific attention that we devote to men and women with metastatic breast cancer, the more likely will be an extension of their survival, and improved quality of what lives they’ve living, now and hopefully in the future.

This post originally appeared at Medical Lessons, written by Elaine Schattner, MD, ACP Member, a nonpracticing hematologist and oncologist who teaches at Weill Cornell Medical College, where she is a Clinical Associate Professor of Medicine. She shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology and as a patient who's had breast cancer.
Wednesday, November 27, 2013

QD: News Every Day--'Micropolitan' areas have little, no access to rheumatologists

Areas of the U.S. with less than 50,000 people (dubbed “micropolitan”) have very little or no access to rheumatologists, a study found. In some of these areas, individuals have to travel more than 200 miles to reach the closest rheumatologist, concluded a workforce study by the American College of Rheumatology.

Researchers analyzed the distribution of rheumatology practices across the U.S. using the association’s membership database. In 2010 there were nearly 4,000 practicing rheumatologists in the database, with 90% practicing in metropolitan regions, 3% in “micropolitan” areas of fewer than 50,000 people, and 7% in rural parts of the country.

In 50 of the 479 micropolitan areas, travel to the nearest rheumatologist was more than 100 miles. Several regions with populations of 200,000 or more people also had no practicing rheumatologist in the area. Researchers did report a higher concentration of rheumatology practices in more populous areas with higher median incomes.

An editorial pointed out that a previously published study from The Netherlands showed that delay in seeing a rheumatologist was associated with a hazard ratio of 1.87 for not achieving a DMARD-free remission and a 1.3 times higher rate of joint destruction. “For patients with autoimmune and inflammatory diseases, rheumatologists are specialist physicians who are central to early diagnosis and treatment, which evidence suggest is most important within the first few months of disease onset to limit joint damage, improve physical function, and induce remission.”

Suggestions included making newly minted rheumatologists aware of practice opportunities; increasing funding for fellow positions in areas that lack rheumatology services; and expanding the roles of nurse practitioners and physician assistants to help care for patients.

Don't BUGG me! (some more)

Recently I blogged about the BUGG study. This paper has generated a fair amount of media coverage, and as I looked through the headlines this morning, I was struck by the variability of the messages they seem to contain. Take a look at the headlines below all describing the BUGG study:
• Gloves, Gowns in ICUs Cut Down on MRSA
• Cheaper Way to Stop MRSA Adds No Patient Risk
• Widespread Glove, Gown Use In ICUs Could Reduce Spread Of MRSA
• Gloves and gowns use in ICU not completely effective against infection, says study
• ICU gloves and gowns may reduce infection
• Use of gloves, gowns by health care workers for ICU patient contact does not reduce MRSA infection
• Gloves, Gowns In ICU Reduces MRSA 40 Percent
• Gloves and Gowns Don’t Cut Hospital Care Infections, A Study Finds
• Universal gloves, gowns in ICU reduced MRSA acquisition
• Universal glove use not associated with reduction in acquiring antibiotic-resistant bacteria
• Widespread gown and glove use by health-care workers in ICU reduces MRSA 40 percent
• Gown And Glove Use In ICU Cuts MRSA by 40 Pct
• Gloves and Gowns Don’t Stop Spread of All Infections in Hospitals
• ICU Gloves and Gowns Might Reduce MRSA Infection, Study Says
• Universal Gown And Glove Use By Health-Care Workers In ICU Reduces MRSA 40 Percent
• Gloves and gowns do not protect against MRSA or VRE, study shows
• Study Examines Effect of Use of Gloves and Gowns For All Patient Contact in ICUs on MRSA or VRE
• Universal gown and glove use by health-care workers in ICU reduces MRSA 40 percent
• Wearing gown and gloves for all ICU patient contact reduces MRSA infections by 40%
• Study-Hospital Precautions Do Nothing to Stop Infections

Interestingly, if you examine each headline carefully you find that almost every one of them is technically correct, though if you had never read the paper you would likely be very confused. It’s a great example of how technical papers get translated for the general public. In this case it’s related to understanding the difference between colonization and infection, the differences between types of outcomes (are we talking about device-associated infections or pathogen-specific infections?), and combined vs. single outcomes (MRSA and VRE combined vs. MRSA and VRE evaluated separately).

Lastly, even if you read the paper and have a good understanding of its findings, the implications of the study will be different based on the value judgments of the reader. Despite all of the confusion, I think that you’ll seldom find a better designed or better executed study in health care epidemiology. In Facebook parlance, “It’s complicated.”

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.
Tuesday, November 26, 2013

Being a good doctor by working around prescription costs

This article should frustrate everyone, The Soaring Cost of a Simple Breath

Every day that I make rounds, we have discussions about prescription drug costs with the students and residents. We are all learning to become adept at finding low cost alternatives to high drug costs.

This particular article describes a most troubling problem, the ridiculous cost of asthma inhalers. I do mean the adjective ridiculous. This pricing is obscene. It leads to patients not being able to afford to treat their disease.

In the adult inpatient service we mostly see COPD patients. I almost never prescribe inhalers. Inhalers work well, but for price reasons we use nebulizer machines instead. Nebulizer machines are much less expensive than a single inhaler, and then we can prescribe generic asthma medication solutions to use with the nebulizer. They are inexpensive through Wal-Mart, Walgreens and other pharmacies. Often we can get patients a free nebulizer in our hospital, and then the costs become reasonable.

For hypertension, we have become adept at using generic drugs. We try the same for diabetes, left sided heart failure and even lipid medications.

We have a responsibility to our patients to weigh the costs of their medications. We should learn the unreasonable costs of prescription meds and work around those costs.

The pharmaceutical manufactures will lower their prices if they see that high prices lead to fewer profits. We physicians must lead the charge to think of the patient’s finances first!

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--Aspirin may not help colon cancer survival time

Low-dose aspirin in colorectal cancer patients did not increase survival time, a study found.

Researchers in England did a nested case-control analysis of nearly 4,800 patients who had been diagnosed with colorectal cancer from 1998 through 2007. There were nearly 1,600 colorectal cancer-specific deaths, each of which was matched with up to 5 risk-set controls (more than 7,500 total matched risk-set controls).

Results appeared online Nov. 18 in Gastroenterology.

Low-dose aspirin was not associated with colorectal cancer-specific mortality (25.3% versus 26.3%; adjusted odds ratio [OR], 1.06; 95% CI, 0.92 to 1.24) or all-cause mortality (adjusted OR, 1.06; 95% CI, 0.94 to 1.19).

And, there was no dose-response association. Low-dose aspirin use for more than 1 year after diagnosis was not associated with colorectal cancer-specific mortality (adjusted OR, 0.98; 95% CI, 0.82 to 1.19). Also, there was no association between low-dose aspirin and either colon cancer-specific mortality (adjusted OR, 1.02; 95% CI, 0.83 to 1.25) or rectal cancer-specific mortality (adjusted OR, 1.10; 95% CI, 0.88 to 1.38).

Researchers noted the results contrast with 2 previous published results, the Nurses Health and Nurses Health and Health Professionals Follow-up studies, and a Scottish study published in 2013. The likely cause was the statistical analysis used by the previous studies, a Cox model that would have allocated the cancer-specific deaths to the aspirin user or non-user group on the basis of whether the patient had an aspirin prescription that covered the date of death. This study would have had similar results had it used the same method (adjusted hazard ratio, 0.46; 95% CI, 0.39 to 0.55).

They wrote, “The marked drop in aspirin prescriptions prior to death (for instance, 9% of patients are on low-dose aspirin at death compared with 14% 6 months earlier) suggest that dying patients have aspirin prescriptions discontinued (and therefore that an unlagged analysis will artificially create/exaggerate protective effects) or that aspirin exerts a short term protective effect on cancer-specific mortality. Whilst the latter is possible, this seems unlikely as low-dose aspirin is thought to work by preventing metastasis.”
Monday, November 25, 2013

Inconvenient disagreement

As an advocate of patient-centered care, I have to recognize that some varieties of patient-centrism make me more comfortable than others. If I really want the patient to do X, and the patient doesn’t want to, I generally feel okay about that. Frustrated, sure, and often times convinced that my way is the right way and the patient’s way is some sort of detour. Most often, though, I am able to put aside those feelings and encourage the patient to make their own decision. I am a less-is-more kind of guy, after all. Plus, encouraging the patient’s decision making can leave behind the pleasing glow of low-grade self-righteousness.

But sometimes things go the other way. You have garden-variety back pain, I tell Ms. X, without any alarm signs that might indicate infection or cancer. Yet she still wants the scan. Or say you come to me and want to check your “basic labs,” to make sure “everything is okay with your blood.”

Neither of these is necessary. MRIs for garden-variety back pain, as we have discussed before in this space, can lead to real harm, as can blood tests for no good reason. And this, the asking for things that I don’t think have a point, is very difficult for me to deal with. I think this because it goes against the grain of my personality (I would rather do less, and avoid iatrogenic harm, than do more and cause it) and such requests reinforce a real, justified expectation that we all have when we go the doctor: we should leave with something, even if it is just a prescription slip. It’s as if the X-ray order or the antibiotic we leave the doctor’s office with is an objective correlative for the care they are supposed to give us.

When the patient asks for something that might harm them without discernible use to me, I try to explain my views – and then people, being who they are, sometimes want to make that same decision. Which leaves me with a range of unpalatable options. I can say no; I can say yes; or I can temporize. Saying no makes me feel good and dissatisfies the patient. Often, if the contraindicated care is provided by a broad range of providers anyway (e.g., antibiotics for viral upper respiratory infections), my refusal does no good. If I say yes I have implicated myself in the patient’s potential self-harm.

Part of a solution, apart from me biting the bullet and saying no more often, is to change expectation, so that leaving the visit “with something in hand” can be not just a script, or a procedure, but a plan of action or a symptom diary to be filled out. Until then, disagreement will still get my hackles up, especially if the patient wants something I don’t.

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

QD: News Every Day--Growing minority say doctors should do anything to keep patients alive

A growing minority of Americans said that medical professionals should do everything possible to save a patient’s life in all circumstances, according to a survey by the Pew Research Religion and Public Life Project.

Two-thirds of Americans (66%) say there are at least some situations in which a patient should be allowed to die, while nearly a third (31%) say that medical professionals always should do everything possible to save a patient’s life, according to a survey of 2,000 people. The balance of opinion has increased by 9 percentage points since 2005 and 16 points since 1990, the organization said in a report.

While 57% said they would tell their doctors to stop treatment if they had a disease with no hope of improvement and were suffering a great deal of pain, and 52% said they would ask their doctors to stop treatment if they had an incurable disease and were totally dependent on someone else for their care, 35% said they would tell their doctors to do everything possible to keep them alive with no hope of improvement and a great deal of pain. In 1990, by comparison, 28% expressed this view.

The increase stems from an increase in the share of the public that expresses a preference on these questions; the portion that had no opinion or declined to answer the survey question fell from 12% in 1990 to 8% in 2005 and 3% in 2013. Those who would choose to step treatments has remained about the same over the past 23 years.

Also, the survey reported that some opinions were closely tied to religious beliefs:
• 62% said that a person suffering a great deal of pain with no hope of improvement has a moral right to commit suicide, up from 55% in 1990;
• 56% also said this about those who have an incurable disease, up from 49% in 1990;
• 32% said a person has a moral right to suicide when he or she “is an extremely heavy burden on his or her family,” roughly the same share as in 1990 (29%); and
• 47% approve and 49% disapprove of laws that would allow a physician to prescribe lethal doses of drugs that a terminally ill patient could use to commit suicide, about the same as in 1990.

The majority of Americans reported they have not prepared for end-of-life decisions:
• 37% have given a great deal of thought to their wishes for end-of-life treatment,
• 35% have given some thought, and
• 27% have not given very much thought or have given no thought at all.

Even among Americans ages 75 and older, 1 in 4 said they have not given very much or any thought to their end-of-life wishes, 1 in 5 have neither written down nor talked with someone about their wishes for medical treatment at the end of their lives, and 1 in 3 who describe their health as fair or poor have neither written down nor talked about their wishes with anyone, according to the survey.
Friday, November 22, 2013

Performance measurement and the new cholesterol guidelines

Physicians face a consistent great challenge. As we learn more about pathophysiology and pharmacology, our recommendations can change dramatically. We do not really always know what we think we know. As physicians age, we all can give dramatic examples of changed beliefs. Here are some examples from my career. Beta blockers were initially contraindicated for systolic dysfunction; now they are indicated. Who would have thought that we could treat ulcer disease with antibiotics? We once gave estrogen to post-menopausal women to prevent heart disease, now we avoid them to prevent heart disease.

The new cholesterol guidelines have responded to a series of studies and analyses that have made clear that lowering the cholesterol is not the magic goal, rather statins (which clearly lower cholesterol) are “magic” but probably because of their pleiotropic effects.

Pleiotropic effects of a drug are actions other than those for which the agent was specifically developed. These effects may be related or unrelated to the primary mechanism of action of the drug, and they are usually unanticipated. Pleiotropic effects may be undesirable (such as side effects or toxicity), neutral, or, as is especially the case with HMG-CoA reductase inhibitors (statins), beneficial.

Pleiotropic effects of statins include improvement of endothelial dysfunction, increased nitric oxide bioavailability, antioxidant properties, inhibition of inflammatory responses, and stabilization of atherosclerotic plaques. These and several other emergent properties could act in concert with the potent low-density lipoprotein cholesterol-lowering effects of statins to exert early as well as lasting cardiovascular protective effects. Understanding the pleiotropic effects of statins is important to optimize their use in treatment and prevention of cardiovascular disease.

This major cholesterol guideline shift should quickly invalidate several major performance measures. We actually predicted this in 2006: Defining the proper guidelines—the case of cholesterol targets.

So for the past 7 years, we have used performance measurement to encourage lowering cholesterol and stimulating the use of drugs that had no outcome data. 7 years later we have a new guideline.

Should we write a new performance measure? We want to measure something.

What performance measure should we create? I favor using statins for secondary prevention, because the data there are very strong. I oppose measuring statin use for primary prevention, because the data are so much more controversial.

If we are going to measure performance, either to check our systems of care, or to “reward” physicians for doing their job, then we must have very clear measures. We must have measures without controversy. We have had the wrong measures for cholesterol for 7 years, even though we had data to show that only statins make a significant outcome difference.

Our underlying theory was wrong. I have taught for 7 years that only statins matter, because my reading of Rod Hayward’s paper convinced me that goals did not matter, being on a statin mattered. I, and others, taught against the performance measures and guidelines, because we believed the evidence. We were measured wrongly for 7 years, and only now are vindicated.

This story represents an example of just another hazard of performance measurement based on guidelines. We have wasted health care dollars prescribing expensive drugs for 7 years. The guideline just released may fix that problem. I fear that we have so convinced physicians to lower cholesterol that change will not happen as quickly as we want.

I hope that the Choosing Wisely campaign includes adherence to the new primary prevention guideline. Give statins, and only statins.

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.

Physicians fear online ratings when they don't have to

Many physicians continue to be fearful of online rating sites, despite evidence that they don’t have anything to worry about.

Multiple studies, including one from the Journal of General Internal Medicine (saying that 88% of physician reviews were positive), to a more recent one from the Journal of Urology (86% positive), say that the majority of physician ratings are better than most doctors would think.

Reconcile these findings with the recent study that shows that online ratings in general are influenced by the so-called herd effect.

From the journal, Science, researchers found that a person was 32% more likely to give a news story an up vote on an aggregated news site if it already had a positive rating. In other words: “… a positive nudge, [the researchers] said, can set off a bandwagon of approval.”

“‘Hype can work,’ said Sinan K. Aral, a professor of information technology and marketing at the Massachusetts Institute of Technology, ‘and feed on itself as well.’”

“If people tend to herd together on popular opinions, that could call into question the reliability of ‘wisdom of the crowd’ ratings on Web sites like Yelp or Amazon and perhaps provide marketers with hints on how to bring positive attention to their products.”

Let’s put aside whether online ratings can accurately ascertain the quality of the doctor, or not. The truth is, it doesn’t matter: They’re here to stay. 44% of patients online search the web to research their doctor, and a growing number will be influenced by the ratings that pop up when a doctor is Googled.

Now that we know the power of the herd mentality, the first rating on a physician review site grows more important.

Physicians should ask all their patients to rate them online. The aforementioned studies suggest that most of these ratings will be favorable. And once doctors get their first positive rating, we now know it holds sway over future ones as well.

Kevin Pho, MD, ACP Member is co-author of Establishing, Managing, and Protecting Your Online Reputation: A Social Media Guide for Physicians and Medical Practices. He is founder and editor of, where this post originally appeared.

QD: News Every Day--Statins may have positive effect on cardio events in critical limb ischemia

Statins are associated with less mortality and fewer major adverse cardiovascular and cerebrovascular events, as well as more amputation-free survival in patients with critical limb ischemia (CLI), a study found.

Corresponding author John R. Laird, MD, FACP and colleagues looked at 380 CLI patients, 246 (65%) of whom were prescribed statins, who were treated longitudinally at a multidisciplinary vascular center and who underwent diagnostic angiography or therapeutic endovascular intervention between 2006 and 2012.

Results appeared in the Journal of the American College of Cardiology.

The mean LDL cholesterol level was lower in patients prescribed statins (75±28 vs. 96±40 mg/dL, P<0.001). Patients taking statins had more comorbidity, including diabetes, coronary artery disease, and hypertension, as well as more extensive lower extremity disease (all P<0.05).

Statin therapy was associated with lower one-year rates of major adverse cardiovascular and cerebrovascular events (MACCE), defined as any death, myocardial infarction, or stroke, within one year post-procedure. Statins users had lower rates of major events (HR, 0.53; 95% CI 0.28 to 0.99) and mortality (HR, 0.49; 95% CI 0.24 to 0.97). There were non-statistically significant trends in favor of statins for MI (HR, 0.48; 95% CI, 0.16 to 1.44), stroke (HR, 0.18; 95% CI, 0.02 to 1.78), and amputation (HR, 0.68; 95% CI, 0.32 to 1.39). The risk of death or major amputation was also significantly decreased in those prescribed statins (HR, 0.53; 95% CI, 0.35 to 0.98).

Among patients treated with statins, the group with baseline LDL cholesterol levels greater than 130 mg/dL had the highest unadjusted one-year event rate (22%). After adjusting for variables, there were decreased levels of MACCE among patients taking statins with baseline LDL levels greater than 130 compared to levels of 100-130 (HR, 0.51; 95% CI, 0.32 to 0.80), 70-100 (HR, 0.54; 95% CI, 0.36 to 0.83), and less than 70 (HR, 0.71; 95% CI, 0.48 to 1.05).

Researchers wrote, “The improved rates of one-year MACCE with statin use strengthens the evidence supporting the guideline recommendations of statin therapy for all PAD patients, including those with even the most advanced stages of disease.”

In an editorial, Michael R. Jaff, DO, FACP, wrote, “It is exciting to learn through this retrospective single center propensity analysis that aggressive statin therapy may not only reduce myocardial infarction, stroke, and death, but may actually improve limb survival in the most advanced PAD patients. ... This certainly provides motivation for a prospective analysis of patients with all manifestations of PAD, including those with ischemic rest pain and non-healing ischemic ulcerations, treated with statin therapy to aggressively low LDL-cholesterol levels, and include imaging of treated arterial segments.”
Thursday, November 21, 2013

What do 400,000 deaths from medical errors look like from the inside of a hospital?

An article in the Journal of Patient Safety by a NASA toxicologist and patient safety advocate, John T. James, PhD, addressed the question of medical errors in hospital settings. Dr. James evaluated the results of 4 studies of patient adverse events (PAE) and extrapolated the results to estimate that 400,000 deaths yearly are associated with preventable patient harms. The Harvard Medical Practice study which reviewed records from several New York hospitals in 1984 estimated that deaths due to medical error numbered about 98,000 per year, and that number has been quoted widely and embraced as the truth by the Institute of Medicine, a nonprofit organization which seeks to advise patients and decision makers about important issues in medicine. This current article uses different methods and suggests that the number may be much higher.

After reading the article about the article on a public interest site on the internet, I perused the comments, which were primarily outrage, interspersed with a doctor or two who seemed pretty defensive and said unpopular things that were on the order of, “What do you expect? We’re doing the best we can!” My first reaction was to wonder what exactly the study meant, how was it done, and what were the definitions. I found the article and read it and came to some conclusions that probably ought to be part of the discussion.

How did they reach their conclusions?

The 4 studies that were evaluated were in hospitals in various areas of the country in which a “Global Trigger Tool” was used to identify patients who might have had an adverse event, something bad that happened in the hospital. This could have been a missed lab test, a procedure complication, a drug reaction or a hospital acquired infection. The charts of the patients who were identified this way were then reviewed by doctors and the doctors determined if it looked like the adverse event contributed to that patient’s death. Each of the studies was performed a little differently, but they shared this general method.

They found that about 0.65-1.4% of patients who were hospitalized had an adverse event that contributed to their death. Overall, in the 4 studies, 4,252 randomly selected patients’ charts were reviewed, and of that number, adverse events contributed to the deaths of 38 people. Based on other studies, 69% of these adverse events were felt to be preventable, and multiplied over the 34.4 million patients hospitalized yearly, they came up with 210,000 people yearly for whom preventable adverse events contributed to their deaths. Since their methods did not include errors of diagnosis or errors of omission, that is not figuring out what was wrong or not treating it according to accepted guidelines, and medical errors are not always well documented in the medical records, the author rounds this 210,000 up to about 400,000 patients who died partly because of medical error.

Why this is somewhat misleading

This is a big and very important issue. I see medical errors and, more often, adverse events from decisions that, in retrospect, were wrong, on a daily basis when I work in hospitals. But there is something very wrong in the way that this article is being reported. The author himself labels adverse events that contribute to death as “lethal errors.” Some of them are, but some of them just contribute to the lethal cascade of events, from life choices to decisions to pursue aggressive treatments, which end in death. The overdose of insulin that kills a patient is a rare event. The blood clot in the leg because of failure to order prophylactic heparin that leads to full anticoagulation that leads to gastrointestinal bleeding which leads to intensive care unit stay which leads to ventilator associated pneumonia and death due to drug resistant organisms because the patient was a diabetic who also dabbled in intravenous drugs, or some version of this narrative, is common. The failure to prescribe heparin in the first place should hardly be called a lethal error. In fact, the prescription of heparin in the first place, itself, might have led to a life-threatening complication.

The outrage which is beginning to erupt is taking the form of “Doctors kill 400,000 people a year in hospitals due to negligence.” That is not what this paper says. It says that 400,000 people who die each year in hospitals are made sicker by the things we do to them. Another issue brought up in this article is that 10 to 20 times this number of patients are significantly impacted by medical error in hospitals. These events might be a hospital-acquired infection or a surgical wound complication or a drug error from which a patient recovered, though not without suffering. If the estimate is correct, we are making 4-8 million people sicker in hospitals yearly in our attempts to heal them. We need to pay good attention to all of these things and identify the processes that make them happen and look for practical solutions. This falls under the heading of patient safety. Much is actively being done in hospitals to improve patient safety, but the complexity of what we do limits our ability to protect those in our care from harm.

An example from a hospital shift

I admitted 4 patients to the hospital yesterday and so had ample opportunity to make life altering mistakes in the lives of 4 individuals. The first was a morbidly obese woman with new diabetes who had developed a severe leg infection related to the fact that her legs were always swollen. The infecting organism was probably a staph or strep, and given the community in which I am working, it might be methicillin-resistant Staphylococcus aureus. I started her on two antibiotics, both of which might cause a life threatening allergic rash, and one of which might cause kidney failure. Both might also lead to a life-threatening Clostridium difficile infection of the colon. Starting insulin might lead to a hypoglycemic reaction that could result in death or disability. Simply putting the patient to bed might lead to bedsores, especially if I treat her pain with intravenous opiate medications which could lead to respiratory depression and death or disability.

I then moved on to the man who had been monthly to this hospital due to complications of ongoing methamphetamine abuse with diabetes for which he usually failed to take his medications and end-stage liver failure from hepatitis C. This time he wasn’t very sick, just had a very high blood sugar level and a very low potassium level. I gave him potassium first, because giving insulin would lower his potassium further and might cause a fatal heart arrhythmia. I gave lots of potassium, because the level was very low, and I risked raising the potassium level to a point where it might cause a fatal arrhythmia. The pharmacy called to see if I really wanted to give all of that potassium and I said yes, and thanks for checking on me. Pharmacy monitoring of physicians’ orders is standard, and they catch errors all the time and I really appreciate it. I had to decide whether to give intravenous fluid, and decided not to, despite some kidney failure, because of a long history of going into heart failure with just a little fluid overload.

I then headed to my third patient, a woman with chronic pain and ongoing alcohol abuse, a quart of whiskey a day, who was feeling like she was going into alcohol withdrawal again and also was short of breath because of her chronic lung disease and new pneumonia. She had just quit smoking but was using some kind of nicotine nebulizer she got in a tobacco shop. She was on warfarin, which she said had been perfectly stable for months. I ordered the antibiotic for her pneumonia which could cause tendon rupture and antibiotic associated diarrhea, the asthma meds which could make her heart beat erratically and make her delirious, decided against the sequential compression devices for her legs since she had known arterial occlusive disease with recent arterial clot which nearly resulted in amputation, even though I did risk her developing a clot in a vein. I ordered her regular warfarin dose and checked her protime. The pharmacy called a couple of hours later to tell me the protime was dangerously high, so I thanked them and discontinued the warfarin, asking the pharmacy to monitor it and restart when appropriate. I ordered high-dose lorazepam, which might lead to breathing problems with resultant need for a ventilator which could lead to pneumonia and ICU-related dementia.

Then up the stairs to the transfer patient, a 39-year-old man who used IV and subcutaneous methamphetamine and had developed abscesses all over his skin and a heart valve infection. He had been in hospital improving from this for 3 weeks, and now was in my care with a central line (intravenous catheter in his internal jugular vein) and open wounds on both hands and both legs after surgical treatments of his abscesses. He was on high dose pain meds and still complained of pain. He had a fever. His fever might have been from his known severe heart valve infection, from an internal abscess as yet undiagnosed or from the central line.

I ordered blood cultures which could only be obtained from the central line because he had no accessible peripheral veins and considered the option of replacing the central line with a new one which would not be a nidus of infection but the insertion of which could cause injury to an artery or puncture the lung, which might kill him. Another option would be a peripherally inserted central catheter which would have a pretty high risk of resulting in a blood clot in the arm which could migrate to the lung and cause his death.

I ordered most of the medications which had been working at the previous hospital. They included drugs that could cause kidney failure, respiratory failure and allergic reactions of all kinds. He was also on an antipsychotic medication that could cause a permanent neurological impairment called tardive dyskinesia in which the tongue involuntarily keeps sticking out of the mouth. When he didn’t take that, he had apparently been extremely anxious and agitated.

Keeping patients safer

And that wasn’t even a big day. Clearly protecting patients from harms in the hospital is a priority. The most important way to protect patients is to keep them out of the hospital and keep their treatments as streamlined as is possible without risking errors of omission.

Keeping patients out of the hospital means assigning priority to resources that keep people healthy. It also means having important conversations with patients about what they really want done and what being in a hospital means. Presenting every patient with the list of the all of terrible things our treatments can do to them is impractical, but we need to bring them in to the conversation. We need to have the time to do this, which means backing off on something else which fills our time. Deliberately simplifying care would help, and we could make this an item for action. If there were fewer medications prescribed, fewer specialists consulted, fewer intravenous lines inserted, fewer surgical procedures offered and performed, there would be fewer medical errors. We can make this happen, but it will involve a concerted decision by patients, families, doctors and hospitals that it is something we all value. Doing less will redirect the revenue stream which will be uncomfortable and disruptive, but so very worthwhile.

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.

Greatly improved new statin guidelines, with one exception

The Twitterverse blew up yesterday when they released the new lipid guidelines. I read many articles and finally think I am understanding the big progress these guidelines achieve.

My favorite review is on Medscape (free registration required) New Cholesterol Guidelines Abandon LDL Targets. I titled this post the statin guidelines, because these guidelines no longer focus on LDL levels, but rather the use of statins. We are no longer asked to treat to goal, rather to put appropriate patients on a statin.

“The four major primary- and secondary-prevention patient groups who should be treated with statins were identified on the basis of randomized, controlled clinical trials showing that the benefit of treatment outweighed the risk of adverse events. The four treatment groups include:

1. Individuals with clinical atherosclerotic cardiovascular disease.

2. Individuals with LDL-cholesterol levels >190 mg/dL, such as those with familial hypercholesterolemia.

3. Individuals with diabetes aged 40 to 75 years old with LDL-cholesterol levels between 70 and 189 mg/dL and without evidence of atherosclerotic cardiovascular disease.

4. Individuals without evidence of cardiovascular disease or diabetes but who have LDL-cholesterol levels between 70 and 189 mg/dL and a 10-year risk of atherosclerotic cardiovascular disease >7.5%.”

Obviously these groups differ in many ways from current guidelines. The writing panel acknowledged that they had no outcome evidence for any cholesterol lowering medication other than statins. So adding a second or third medication is no longer needed or desirable.

Group 1 is the most important because the benefit has the best evidence. For those patients, the new guidelines suggest either rosuvastatin or atorvastatin (high-intensity statins) unless not tolerated. They also recommend this strategy for the very high cholesterol patients (group 2).

For group 3 patients, they recommend moderate-intensity statins (we generally use pravastatin for price and less side effects).

Group 4 is a problem in my mind, and in the minds of some critics.

To heartwire, Dr. Roger Blumenthal (Johns Hopkins Medical Institute, Baltimore, MD), who was not part of the writing committee, said he agreed with 90% of the information in the new guidelines. “To put that in perspective, I probably only agree with my wife 85% of the time,” he said.

I don’t even agree with my wife 100% of the time.

Namely, he is a little troubled by the new atherosclerotic risk score. Derived from FHS, ARIC, CARDIA, and CHS, it hasn’t performed all that well when applied to other cohorts, such as the Multiethnic Study of Atherosclerosis (MESA) and Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, he said. The risk score does not take into account family history of premature cardiovascular disease, triglycerides, waist circumference, body-mass index, lifestyle habits, and smoking history.

“In my mind, we’re putting a lot of faith in this risk score,” said Blumenthal. “We’re probably going to be treating many more people, especially many more ethnic minorities, who get above this 7.5% threshold.”

Dr. Brendan Everett (Brigham and Women’s Hospital, Boston, MA) told heartwire that the expert panel is going “out on a limb” a little with regard to the new risk score. He said that while a risk-prediction algorithm was used in the ATP III guidelines, a number of large statin trials have been published to date, and none of these studies used a risk score to identify patients for inclusion.

“If the model performs poorly, of course, then it’s unlikely to do a good job separating patients at a higher rather than lower 10-year atherosclerotic cardiovascular disease risk, and it will thus lead to misallocation of statins,” commented Everett. “Even if it does perform well, using a risk score to identify individuals who will benefit from statin therapy, regardless of the etiology of their elevated risk, is not an approach that has been tested in any clinical trial.”

I downloaded the risk calculator yesterday. According the risk calculator I should have a statin discussion. My only risk are my age (64) and my Y chromosome. I get no credit for 0 family history, good waist circumference and regular exercise. I just do not believe the calculator.

I hope that when we translate this guideline into performance measures, we do not include group 4 – because we have no data to support its use. I have no problem doing primary prevention in patients with a very high risk, but believe that we should read the fine print very carefully here:

“In the primary-prevention-therapy decisions, we insisted that the patient and the physician have a discussion to determine what the benefits and risks are specifically for that patient,” said Stone. This discussion should focus on the patient’s characteristics and preferences to determine the best therapy.

Group 4 should not produce a performance measure. Rather these patients deserve thoughtful joint decision making.

Overall the panel deserves a strong B+. They could have received an A if they had not tried so hard to include large numbers of primary prevention patients.

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.

Contact precautions are so last year

I was going to post some thoughts on the BUGG Study (and I did put a quick summary into an F1000 recommendation). However, I have little to add to the authors’ own discussion, Preeti Malani’s editorial, and Mike’s previous posts. In short: a great study that advances the field, and given the mixed results (primary versus secondary outcomes) it will be hypothesis-generating but not practice-changing. I do, though, have a couple related observations.

First, we should stop conflating methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci, whether for study designs or for prevention strategies. They differ too much in preferred ecological niche, inherent and acquired resistance mechanisms, virulence, epidemiology, and almost certainly also in relative effectiveness of prevention strategies. The authors include some discussion of this point in the paper.

Second, the hypothesis being tested in the BUGG study is definitely swimming upstream, against what I perceive as slow movement away from contact precautions. Mike has posted about their new approach at VCU, but other centers have also moved away from the CDC’s Management of Multidrug-Resistant Organisms guidance regarding use of contact precautions.

I’m on an informal e-mail group of academic hospital epidemiologists, and last week one of them asked whether centers were still using contact precautions for Escherichia coli-extended-spectrum β-lactamase producers. The responses provided further evidence for a move away from isolating for E. coli-ESBLs, MRSA and VRE in some large academic centers. I suspect this represents the tip of the iceberg, particularly as hospitals seek to improve their patient satisfaction scores.

Of course, there’s a big difference between an ICU-specific universal glove-gown intervention and hospital-wide, microbiology-driven contact precautions use, and it is easy to hypothesize why the former would work better than the latter.

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--'Sudden' cardiac arrests often preceded by noticeable warning signs beforehand

Potential warning signs of a sudden cardiac arrest can occur up to a month ahead of time in half of men, a study found.

Among 567 middle-age men in Portland, Ore. who had out-of-hospital cardiac arrests, 53% had symptoms prior to the cardiac arrest. Of those with symptoms, 56% had chest pain, 13% had shortness of breath and 4% had dizziness, fainting or palpitations.

Almost 80% of the symptoms occurred between 4 weeks and 1 hour before the sudden cardiac arrest, he said.

The research was presented at the American Heart Association’s Scientific Sessions 2013 as an abstract.

The new research is part of the 11-year-old Oregon Sudden Unexpected Death Study, which involves 1 million people in the Portland metro area. Researchers gathered information about the symptoms and health history of men 35 to 65 years old who had out-of-hospital cardiac arrests in 2002-12.

Most men had coronary artery disease, but only about half had been tested for it before their cardiac arrest.

About 360,000 out-of-hospital cardiac arrests are reported each year in the U.S., according to the American Heart Association, and only 9.5% survive.
Wednesday, November 20, 2013

Ted Cruz filibuster misses the mark

Even the most casual Whistleblower reader is aware of my hostility toward Obamacare, which appears destined for incremental implementation. Ted Cruz’s paper mache weapons were no match for the Democrats’ artillery brigade. When the Chamber of Commerce, corporate America and organized labor are all on the same side of this issue, it suggests that healing this forerunner of socialized medicine will take more than a tweak or two to smooth it out.

There’s nothing unexpected or unfair here. Romney campaigned hard against Obamacare. The country had an opportunity to elect him, and declined to do so. Did we expect that Obama would dismantle his signature legislative first term achievement in his second term? When Romney lost, Obamacare won. The Affordable Care Act was legally enacted, albeit without a single Republican vote. The Supreme Court determined that the law was constitutional. Elections matter. So, a flawed program, whose ultimate consequences are not yet entirely visible, was legally enacted and will be nearly impossible to derail.

Of course, serious reform was needed. I written throughout this blog that our health care system was not enjoying optimal health. There were glaring deficiencies and inequalities that I could never satisfactorily explain to my patients.
• Why are drugs in Canada so much cheaper than the same drugs purchased here?
• How can a hospital charge exorbitant fees for simple items that would cost a few bucks at CVS?
• Why did it take so long for colon cancer screening to be a covered benefit, when colon cancer was always paid for?
• Why is our per capita health care cost so much higher than other nations who demonstrate superior health outcomes?
• Why can’t patients receive medical bills that they can understand?
• Shouldn’t patients and their families have some skin in the game as a brake on the profligate spending of other people’s money for health care?
• Why do physicians permit, if not encourage, futile medical care?
• Why is it possible that so many working Americans can’t afford medical insurance coverage?

Obamacare emerged because the dysfunctional system demanded a response, and no prior president since the Truman administration was able to move the ball down-field. Had Obamacare antagonists passed reform measures incrementally during past decades, then we wouldn’t be subjected to the clumsy and heavy hand of government healing now.

I don’t like Obamacare and I wish it could be repealed. But, the program didn’t emerge from nowhere. Those who coasted along for decades clinging to the status quo, created a target so large that you could hit it without aiming. In Ted Cruz’s 21 hour and 19 minute speech, he never explained what brought us all to this moment. We can’t blame Obama for this. His aim was wild, but the target we all created was so large, that he couldn’t miss.

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.

The Devil Wears Scrubs

We are in a boom time for news and information about all things medical. The same democratization of information that allows us to look up information on our own (hello, Drs. Google and Wikipedia) has also brought myriad new voices to the public’s discourse through multiple outlets: blogging, social media, podcasting, etc.

Medical bloggers and influencers, people with a proclivity for making complicated concepts clear, have many opportunities to straddle the worlds of old and new media as they hone their voices and build their brands. New media exposure can lead to more traditional tracks like book publishing.

Medical books have always been a popular genre. With the rise of self-publishing, this is no doubt even more true today. Medical books most often take the form of self-help (“what you need to know about this diet or disease”), odysseys (“my cancer story”), predictions (“The Creative Destruction of Medicine”) polemics (“why the U.S/Canada/U.K./Obamacare is so good/bad/other) and, of course, memoir (“how I survived internship/residency”).

Memoirs usually are good for their shock value, some laughs, and some broader life lessons learned by the subject/author. I’ve read many “I survived internship” stories, and they invariably contain a scene involving a rectal exam, stool and shame. (Guilty as charged.)

The most famous tell-all memoir of internship is Samuel Shem’s (aka Stephen Bergman) fictionalized version of his first year at Boston’s Beth Israel hospital, or what he called “The House of God.” Bergman blew the lid off of the inhuman culture that exists in medical training, where we expect trainees to become indoctrinated in the ways of the system and turn students’ idealism on its head.

The most recent internship memoir I’ve come across is “The Devil Wears Scrubs,” by Freida McFadden. It’s a self-published, slightly fictionalized account of the first month of McFadden’s internship. She had a rocky start.

My belief is that people think medical memoir has staying power as a genre because of the vicarious thrills of what it takes to become a doctor. In reality, I think the fascination is much more of along the lines of, “Holy crap! I can’t believe someone’s life could be so awful.”

Dr. McFadden (also a nom de plume, like the aforementioned Dr. Shem) writes well and is a good humorist, both in eviscerating the evil resident who lords over her (“Alyssa”) and in being self-deprecating as she realizes to her horror that she is unable to muster feeling for patients that die (though not always), as it’s one less work item on her to-do list.

Dr. McFadden is alternatively known as Dr. Fizzy, Fizzy McFizz, and Doctor Cartoon. As a cartoonist, she has lampooned the medical profession and its system of training for years in her brutally honest cartoons. They were collected in a previous book, “A Cartoon Guide to Becoming a Doctor.”

I’d recommend “The Devil Wears Scrubs” to anyone in or considering going to medical school. It’d make a good gift for any family member thinking along those lines. If you’re a lay reader and enjoy the medical memoir genre, you’ll find the book accessible. McFadden does a good job of showing how one can maintain her humanity in a system designed to squeeze it out of us.

I asked Dr. McFadden if she thought “Alyssa” would see her book. “Unlikely,” she wrote back to me. “Although if I had her address, I’d anonymously send her a copy!”

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.

Life at Grady: A reminder

The air was cool. Too cool to be outside with only a paper thin white coat and wintry enough for this Grady elder passing me by to give me a tiny head shake when I tried to pull that same inadequate coat closer to my body for warmth. But the walk wasn’t far. I was only heading out of the hospital door and half a block to our office building. Two minutes, tops. And sometimes the threat of chilly air isn’t enough to make you deal with the hassle of schlepping a winter coat onto the hospital floors.

For me, that is.

As I crossed the street, I saw a young woman walking briskly. She was holding what appeared to be a baby that couldn’t have been more than a few weeks old. Fortunately, she’d checked the weather and dressed her baby and herself appropriately. Unlike the doctor approaching them.

“Good morning,” I spoke.

“G’morning,” she replied, still hustling.

I craned my neck over to catch a glimpse of baby as we crossed paths. It warmed my heart when she paused for two seconds to pull down the fuzzy pink fleece covering her cherubic face. I stood on my tiptoes to get a better look. Reflexively, I smiled and placed my hand on my chest. “Congratulations. She’s beautiful,” I said. And then, since I knew she appeared to be in a hurry, I added, “Have a great day!”

“You, too, ma’am!” She was already four or five steps away by then and almost into the County Health Department--which is conveniently located across the street from Grady and is also a necessary destination for parents of new babies seeking birth certificates.

I kept walking and picked up my pace. On the steps of the Glenn building (also across from the hospital), I saw this rotund fellow sitting down and preparing to smoke a cigarette. He appeared to work in construction of some sort, as he was wearing a reflective vest and steel-toe boots. He looked up, made quick eye contact with me, and gave me the nod. I returned the favor.

In that glance, I also gave him some uninvited admonishment about the cigarettes. Since my expression was decidedly playful, his reply was, too. He held up his index finger and beat it in the air a few times--his nonverbal way of saying, “This is the last one!” I narrowed one eye, pursed my lips and pointed at him as passed. My way of saying, “I got my eye on you!” And then we both laughed. Which was cool because I didn’t know him yet we’d just had an entire exchange without saying a word.

At this point I was just a couple of strides away from the entrance to our faculty office building. I rummaged around for my access card to get in. It wasn’t clipped to my jacket and wasn’t in my pockets either. . . . hmmmm.

I thought for a few seconds and then. . . . Shoot! I remembered in that instant that I’d left it sitting on my office desk earlier that morning. Man. It was too cold for all this. Pulling my coat together once more, I decided to make a break for it around the corner to the public entrance.

I usually try not to run while wearing my white coat unless it’s an emergency. I know it always alarms people to see doctors rushing anywhere. This was no different; I could tell by the group of people standing catty-corner by the hospital who all stopped to watch me. When I noticed them, I stopped running and resorted to walking as quickly as I could instead.

Now, I was at the door. Finally. But just before I could escape the cool air, I paused. I was hearing something unusual.

“What is that?”

I turned around and stepped back out on the sidewalk to look around. I couldn’t see where it was coming from, but that sound was getting louder and louder. I looked over my shoulder to see if, perhaps, it was coming from our building. But it wasn’t.

Louder and louder. Closer and closer. And finally, I saw what it was

A man perfectly playing a flute. Not looking for money or applause or any such thing. But I was so entranced by its perfect pitch that I gave him all of those things.

“Beautiful!” I said while clapping my hands. It really was.

“Today, Grady, tomorrow, The Apollo!” And then he laughed out loud a bit before playing an up-tempo little piece right then and there for me on that sidewalk.

And I clapped and tapped my foot the whole time, forgetting about the cold and even why I was going back to my office in the first place. The song was short and sweet. And before I could say anything else, he’d tipped his hat and thanked me for listening. And I thanked him right back for blessing me with his gift.

I watched him long after he’d passed me by. On he went—walking and playing. The sound of his heels clicking the concrete were his makeshift metronome and I could see his shoulders hunching in concert with each note. I squinted my eyes to try to take in the expressions of those under the sound of his flute. And from what I saw, they all seemed to be blessed, too. And I swear to you, all of it was magical.

Eventually, he turned a corner and was out of my line of sight. Just then, I felt the chill of November on my chest again. I opened the door and went on up to my office.

So that was what happened in the two minutes that it took me to walk across the street from Grady Hospital to my office. But it was a reminder. A reminder of what can happen when I remember to open my eyes and notice the moments, the music, and the magic swirling around the most ordinary parts of my day.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.

QD: News Every Day--Better medical adherence may not translate to acute coronary syndrome outcomes

A 4-part intervention for acute coronary syndrome improved medication adherence but not clinical outcomes in the first year after a hospitalization among patients, a study found.

253 patients from 4 VA medical centers across the U.S. who were admitted with acute coronary syndrome were randomized to the intervention group or usual care before discharge. The 4-part intervention lasted for 1 year and involved pharmacist-led medication reconciliation; patient education; collaborative care between the pharmacist and a primary care clinician and/or cardiologist (The clinician was told of the intervention, and cosigned the pharmacists’ notes in the computerized medical record); and voice messages reminding patients of educational lessons and medication refill reminders.

Researchers assessed medication adherence, defined as mean proportion of days covered greater than 0.80 in the year following discharge for clopidogrel, β-blockers, statins, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers [ACEI/ARB]). Results appeared online Nov. 18 in JAMA Internal Medicine.

241 patients (95.3%) completed the study, 122 in the intervention group and 119 in the usual care group. 89.3% of patients in the intervention group were adherent, compared with 73.9% in the usual care group (P=0.003). Mean adherence was higher in the intervention group (0.94 vs 0.87; P<0.001). More patients in the intervention group were adherent to clopidogrel (86.8% vs 70.7%; P=0.03), statins (93.2% vs 71.3%; P<0.001), and ACEI/ARB (93.1% vs 81.7%; P=0.03), but not β-blockers (88.1% vs 84.8%; P=0.59).

Despite the better medication adherence, there were no statistically significant differences for patients who achieved blood pressure (P=0.23) and LDL cholesterol targets (P=0.14). There was a non-statistically-significant trend toward greater blood pressure control (58.6% vs 48.9%), decline in systolic blood pressure (−12 vs −4 mm Hg), and decline in diastolic blood pressure (−5 vs −3 mm Hg) for intervention patients. And, there were no statistically significant differences between the 2 groups for rehospitalization for myocardial infarction, revascularization or death. Researchers noted that more research is needed into understanding how medication adherence translates into better clinical outcomes before expanding the program.
Tuesday, November 19, 2013

Beating on wheat and raining on grains

Beating on wheat and raining on grains is very much in season. But I don’t think that’s what’s making us fat and stupid. I am pretty convinced it’s the paperclip. And, possibly, the Post-it note.

First, I have it on decisive authority that our paleolithic ancestors had no paperclips. And they had no Post-it notes. That probably clinches the argument right there, but there’s more.

The paperclip was reportedly invented in 1899. Since epidemic obesity, diabetes, and dementia have ensued, I think it’s rather clear that paperclips are to blame.

The Post-it note was invented, more accidentally than not, in 1974 or thereabouts. Just look at all the hell that has done broke loose since then! Not just all these epidemics of chronic disease, but climate change, overpopulation, desertification, and the wholesale death of bats and bees if not yet birds. Clearly, then, paperclips could only do so much damage on their own. Post-it notes put us over the edge.

Having established these indelible links among paperclips, Post-it notes, and all manner of calamitous mayhem, the prosecution is really tempted to rest on its laurels, but there’s still more. The innocent must be exonerated.

And to that end, there’s a defense of grains. Grains allegedly make us fat and stupid. But what about all those agonizingly skinny people in U.N. food relief lines living just about only on grains? What about the notorious “bread and water” diet for poor souls wasting away in dungeons and prisons? My understanding is that obesity is not the salient problem there.

OK, that’s feeble stuff, you’re right. But how about the fact that grains figure, often quite prominently, in the diets of all of the healthiest, leanest, longest-lived, most vital peoples on the planet? Look through the inventory of Blue Zones, and you find grains everywhere. The Okinawans ate them; the Seventh Day Adventists eat them; they figure in all of the best variations on the theme of the Mediterranean diet.

And they have fared pretty well in clinical trials, too. Grains were part of the dietary pattern shown to reverse coronary atherosclerosis. They were part of the diets, more than once, shown to prevent heart attacks 70 percent of the time in high-risk people. They were part of the diets shown to lower blood pressure, and prevent diabetes in almost two-thirds of high-risk individuals. There’s more, but that really ought to do it if you’re still reading.

As for the adverse effects of grain intake on brain function, I am aware of no reports indicating that Sir Isaac Newton avoided them. Or Goethe. Or Bach. Or Shakespeare. Or Einstein. And I’ve read of Julius Caesar dipping his grainy bread in olive oil, even as I do myself, meaning no disrespect to any Picts or Gauls listening in. I enjoy whole grain bread in olive oil, but harbor no malice toward Picts or Gauls. I draw the line!

None of this is an argument for refined starches, obviously. Just because whole grains have a pretty good track record doesn’t mean the same pedigree extends to what’s left behind when we’ve stripped off the hull and ripped out the germ. That would be like inferring that since Earth’s atmosphere is good to breathe, it would still be good to breathe if we sucked out all the oxygen. I wish you, the baby, and the bathwater good luck with that one.

Of course, it’s true that there were no “grains” per se in our native, paleolithic diet. That’s pretty damning.

But of course, there were no grain-fed cattle either. There was no bacon. There was no mustard. There was no ketchup either. There was no marinara sauce. Heck, there were no tomatoes. There were no beans, no lentils, no chickens as we know them now. No ground beef, and certainly no sausage. No deli meats. No hummus. There was mammoth, though.

The reality is that we can’t eat the foods our Stone Age ancestors ate, because their foods don’t exist now, and our foods didn’t exist then. The best we can do is approximate the native. And while the native did not include grains, it did reportedly achieve something like 100 grams of fiber daily from a wide variety of plant foods. There is little hope of getting to 100 grams of fiber daily even with whole grains filling in for the high-fiber plant foods our ancestors ate, and probably no hope of doing so without them. So those who consider eating grains a departure from the native should concede that not eating 100 grams of fiber per day is another.

Of course, if you do aim for 100 grams of fiber, permit me to recommend excellent reading materials in your bathroom; you’ll be spending a lot of time in there.

Still, the recent arguments against wheat and grains do seem really convincing. But then again, not all that long ago, arguments against dietary fat seemed really convincing. Then arguments against all carbohydrates, not just grains. Then arguments against all high-gycemic foods. And arguments against dairy. And arguments against eggs. And arguments against meat. And arguments against all animal products. And arguments against salt. And arguments against saturated fat. And arguments against tropical oils. And arguments against trans fat. And arguments against sugar in general, and fructose in particular. And arguments against gluten. And arguments against GMOs. And … well, you get the idea. All made persuasively, and with an application of religious zeal.

Of course, if any one of these arguments was truly valid about the one thing truly wrong with our diets, it would mean all the others are wrong. Of course we could account for that; eating the wrong foods has clearly made all the “other” guys dopey.

But maybe the only truly safe thing to do is assume they are all right. That’s what I’m going to do.

I’ve been sitting here on my fat tush long enough, and I’m off to start my next diet. I suppose I might attribute my excess poundage and listless mind to the hours in this chair in front of this screen, but there’s no popular book telling me to do that, so to hell with it. It’s the damn grains/sugar/carbs/wheat/GMOs/animal foods/etc.

My plan is to head on over to the fast food restaurant, and buy just about anything they sell. It doesn’t matter, because I intend to dump out the alleged food anyway; clearly nobody should be eating that crap. I intend to eat the Styrofoam.

Being a responsible, if dull and pudgy, parent, I will indulge my child in a Happy Meal. We will, of course, throw away that rubbish, too; my kid can eat the toy.

At least I would be setting out to the fast food restaurant now, if I could. I put my car keys on a paperclip, and for the life of me can’t remember where I left the damn thing. If only I had stuck a Post-it note reminder to the family mammoth, or the wall of my cave …

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.

Ward rounds ... does style matter?

Over the past few weeks I have had several discussions about the style of ward attending rounds. Medical educators who I respect greatly have argued strongly that they have the best way to do rounds. The more variations that they report, the more I am convinced that we have many ways to skin that cat.

When we started our ward attending round research over 10 years ago, we wanted to discover something about the style of rounds. We discovered a great deal, but nothing about the style of rounds. We learned the characteristics and domains of successful rounds.

Quoting from our recent letter to the editor of JAMA: “We learned that successful attending rounds required a multidimensional skill set comprised of 5 distinct domains: learning atmosphere, clinical teaching, teaching style, communicating expectations, and team management. As Wachter and Verghese explained, current work hour restrictions and hospital expectations create a demand for team management skills, one of our domains. This domain includes timeliness, efficiency, and accommodating absences required for administrative demands.”

“While team management is an important domain, it did not outweigh clinical teaching, learning atmosphere, teaching style, or communicating expectations. Trainees valued teaching. They rated ‘sharing of attending’s thought processes’ as the top attribute for successful rounds. They also valued bedside teaching and role modeling. These less precise attributes of clinical wisdom trumped the teaching of evidence-based literature. Students and residents felt they could read books and medical literature, but they wanted and needed attending physicians to demonstrate clinical reasoning, patient communication, physical examination skills, and professional physician behavior.”

There are many successful styles of attending rounds. We should not debate the proper structure of rounds. We should understand that our personalities influence how we like to run rounds. Learners care less about structure than they do about sharing ones thought processes, having some bedside teaching and role-modeling.

I encourage all ward attending physicians to develop their own structure and style for making rounds. Structure and style are less important than content. Our job is to use rounds to insure superb care for our patients and give our learners the opportunity to gain expertise. We should understand that our learners need us to provide role-modeling, not just through words, but also through observation. How we interact with patients matters. That we make certain that patients understand what is happening in the seemingly hostile atmosphere of a hospital matters. That we share our thought processes matters. And these activities trump style and structure.

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--Careful what you say about low back pain

Doctors can have a long-lasting impact on how patients perceive their low back pain, according to a study that concluded even an off-hand comment can have a lasting effect.

Researchers in New Zealand interviewed 12 people with acute low back pain of less than 6 weeks and 11 participants with chronic low back pain for more than 3 months. The patients had varied histories of low back pain, diverse exposure to health care professionals, and wide-ranging disability levels and fear avoidance beliefs.

Results appeared in the Annals of Family Medicine.

All participants with chronic low back pain and 9 of 11 participants with acute low back pain made one or more specific connections between something their clinician had said and their subsequent behavior, often coming away with a belief that they had to protect their backs from further strain.

Participants reported that their clinicians told them to adopt certain postures and strengthen specific muscles to manage their low back pain, which reinforced their belief that their spine was vulnerable. They tried to limit movement, reduce spinal load, maintain structural alignment and prevent injury, focusing constantly upon their backs even though trying to do so actually can lead to poorer outcomes and to lower expectations for recovery.

“Such information and advice could continue to influence the beliefs of patients for many years,” the researchers noted.

“Our findings show that clinicians can contribute to avoidance beliefs directly by focusing upon what patients should not do and indirectly by providing management advice and pathoanatomic explanations, which are interpreted as meaning the spine is vulnerable and requires protection,” the researchers wrote. “Nearly all participants reported receiving pathoanatomic explanations for the cause of their back pain, despite guideline recommendations against doing so. Such explanations may be provided to justify self-management recommendations; however, they influence not only evaluation of current symptoms but also appraisal of future episodes.”
Monday, November 18, 2013

'Am I a hypochondriac?'

There’s one question I get asked a lot: “I research my health problems on the Internet. Am I a hypochondriac?”

First, we should ban that word when talking about ourselves. No one wants to be called that, and doctors who use that word are committing malpractice. Everyone has some range of complaints and worries in life, often physical and mental together, and this is our job as doctors: to hear them out. I firmly believe that no complaint is illegitimate.

Nor, for that matter, is looking stuff up on the Internet a problem. Given that the advice proffered by doctors is most often not consonant with the scientific evidence (to quote this much-cited paper, “Even those physicians who are most enthusiastic about EBM (evidence-based medicine) rely more on traditional information sources than EBM-related sources “), I doubt that seeking information on the Internet is any worse. (Of course, there is already considerable literature on the topic.) Nor do I know of evidence that seeking health information on the Internet increases worry, another common concern mentioned to me.

I think the relationship between physical symptoms and worry actually go in another direction, at least as I see it. A subset of those who have common physical complaints sometimes have a lot of them, and with some frequency these are due to undiagnosed anxiety disorders or other psychiatric ailments, which often go untreated.

In short: physical complaints are never to be dismissed, no matter what their cause, and having recourse to publicly available information is not to be looked down on either.

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