Friday, January 31, 2014

Hypertension and the new Joint National Committee 8 recommendations for treatment

Doctoring is a practice based in science, but at its best, attempts to treat whole complex humans to achieve goals such as health and happiness which have no good scientific definition. Good doctors practice outside of boxes, and our success or failure is scrutinized closely according to very subjective criteria by our patients and colleagues. It is nice, in this situation, to have aspects of our work be based on clearly measurable variables; blood pressure, for instance.

The concept of high blood pressure as a clinical diagnosis began to be accepted at the beginning of the last century, correlated with the invention of the blood pressure cuff. It turns out that the pressure of blood in the arteries, when elevated, can lead to heart attacks, strokes, aneurysms and kidney failure and can be an indication of other serious medical illnesses including tumors of the adrenal gland and pituitary as well as narrowing of the blood vessels to the kidneys. Controlling the blood pressure has been effective in reducing heart attack and stroke rates, historically.

Blood pressure elevations are usually related to genetic factors as well as obesity, high salt diet, excessive alcohol intake. Lifestyle changes to reduce salt intake and obesity and increase activity significantly reduce blood pressure. The first consistently tolerable blood pressure medicine was produced in the late 1950’s and that class of medications (thiazide diuretics) is still one of the most widely used and effective ones available.

There are many classifications of drugs that can lower blood pressure and the production of new ones has been a staple of the pharmaceutical industry for many years. Since blood pressure medications frequently have unpleasant side effects or don’t lower the blood pressure very effectively, it was easy to produce new drugs that promised superior blood pressure lowering effects or less side effects or a more convenient dosing schedule.

A pleasingly simple and mutually enjoyable office visit for a patient and primary care physician in my experience included measuring the blood pressure, finding it to be just a bit too high, going to the sample closet, finding an attractively packaged new blood pressure medication with the placebo effect still firmly attached to the brightly colored capsules, giving it to the patients with instructions to come back in two weeks to see how well it worked. Unfortunately the shiny new medications were ridiculously expensive and usually too new to have been extensively tested to determine if they actually worked to reduce the target issues, stuff like strokes, heart and kidney damage, as opposed to just lowering the blood pressure.

Guidelines emerged from organizations such as the National Heart Lung and Blood Institute (NHLBI) to address which medicines to use and what blood pressure was too high and which patients to treat. There has been abundant research on blood pressure control and outcomes in different populations, fueled by both drug companies which wanted to prove their new blockbusters to be effective and experts in the field who wanted to find out what actually worked. Committees have attempted to digest this research, some good and some suspect, and come up with recommendations to guide practice.

The Journal of the American Medical Association published the Joint National Committee’s eighth set of guidelines, 10 years after the last set of guidelines came out. Guidelines are taken quite seriously by physicians and now by the people who pay us, who often scrutinize our adherence to them as a basis for performance based pay. These guidelines were 5 years in the making, I read, and were scrupulously discussed, based only on randomized controlled trials, and were delightfully succinct. There were three editorials in the same issue, generally approving them, though admitting that there is room for debate and improvement.

Briefly, and it is possible to be brief with these recommendations, the new guidelines recommend:
1. Treat all patients over the age of 60 with lifestyle recommendations plus medications if their blood pressure is over 150 systolic or 90 diastolic, aiming for a blood pressure just below this goal. Previous guidelines recommended a goal of 140/90 in this group. Patients who feel fine and are on medications with blood pressure significantly below this goal may remain on the same medications.
2. Patients between the ages of 18 and 60, start treatment with lifestyle measures and medications if the blood pressure is over 140 systolic or 90 diastolic, with a goal blood pressure of under 140/90. This same recommendation is true for patients in this age group with diabetes or kidney disease (which increase the risks associated with hypertension.)
3. Use drugs in only 4 classes to start, including diuretics, angiotensin converting enzyme inhibitors or angiotensin receptor blockers or calcium channel blockers such as diltiazem and amlodipine. Beta blockers are absent from the list of recommended drugs because of one well done study which showed an increase in death for patients on beta blockers, primarily due to strokes. Drugs can be started singly or in combination. For African-Americans use only thiazides or calcium channel blockers unless they have significant kidney disease, in which case angiotensin active medications are probably effective. Be sure to use doses of these drugs that are adequate but not toxic (there is a nice table.)
4. For patients with blood pressure above the goal after starting initial therapy, add another of the drugs in one of the 4 classes, but do not combine angiotensin receptor blockers with angiotensin converting enzyme inhibitors. If blood pressure still is not controlled, drugs in another class may be added, though it is unclear from evidence that this will make a difference in outcome.

These recommendations are not meant to entirely squelch creativity and do not address control of blood pressure in patients who have established heart disease, who may take other medications that control issues other than just the blood pressure and may interact with blood pressure medications.

I am generally very happy with these new guidelines. The fact that blood pressure goals for patients over the age of 60 are looser will significantly reduce the burden of treatment for these people, and reduce the number of fruitless visits in which both patients and physicians feel like failures because a number refuses to climb as low as we would wish. The standardization of blood pressure goals for patients younger than this, returning to the historical 140/90 as a goal of treatment will also simplify things. The treatment of blood pressure with reduction of disabling strokes and heart attacks that has been associated with this is a major success of modern medicine and simplifying treatment will probably make both patients and physicians more motivated to do it right.

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.

QD: News Every Day--Upper endoscopy may not be used where it's most needed

Upper endoscopy may be underused in patients at high risk for Barrett’s esophagus and certain cancers, and overused for symptomatic reflux, a study suggests.

As a result, overuse of esophagogastroduodenoscopy (EGD) procedures for uncomplicated gastroesophageal reflux disease (GERD) may crowd out detection of esophageal, gastric or duodenal cancers (E/GC), the study concluded.

Researchers conducted a retrospective cohort study using data from the VA. Patients were included if they had ICD-9 codes from 2004 through 2009 for uncomplicated GERD without signs of anemia, decompensated liver disease, gastrointestinal tract [GI] bleeding, celiac disease, any metastatic cancer or any chemotherapy.

Results appeared in a research letter published online first Jan. 27 at JAMA Internal Medicine.

Of nearly a half-million patients with newly diagnosed, uncomplicated GERD, 7.3% had an EGD within a year and 15.4% had an EGD. The yield was 10.1% for Barrett’s esophagus and 0.81% for E/GC.

Males 50 years or older with GERD were less likely to receive an EGD. But, these patients were more likely to be diagnosed as having Barrett’s esophagus or E/GC than women or those younger than 50.

Other factors led to more likelihood of receiving an EGD, including chest pain, dyspepsia, and use of drugs that inhibit gastric acid; the number of VA visits, GI clinic visits or having a rural residence; and receiving care at a facility that conducted a comparatively high number of EDG procedures. However, there was either no association or a decreased likelihood for detecting Barrett’s esophagus and E/GC.

The results suggest potential underutilization of EGD among high-risk patients and overutilization in low-risk patients. “Given the high Barrett’s esophagus and/or E/GC prevalence (11%) at the time of EGD, this mismatch between high-risk groups and likelihood of receiving EGD may contribute to missed opportunities for conducting effective screening EGD,” the authors wrote.

Instead, EGD is likely to be performed to address symptomatic GERD or other unclear complaints more often than screening for Barrett’s esophagus and cancer, even though the value of such a procedure for those symptoms is unknown. “The volume of EGD performed in this low-risk population may crowd out availability for screening and surveillance EGD in higher-risk patients,” the authors noted.

Hospice: mission creep

Doctors are asked to sign things all the time: prescriptions, home nursing care plans, death certificates, diabetic shoe forms.

Less frequently, hospice verifications.

Why was I asked to sign hospice orders for Mr. Taylor? Sure, he was old. 87.

He’d survived decades of high blood pressure, two major surgeries, unintentional weight loss, chronic pain, headaches, even a benign brain tumor. But I had never referred him to hospice.

I wouldn’t have diagnosed him as “terminal,” i.e. expected to live 6 months or less. As far as I could tell, he’d just keep on truckin’ for another year or 3.

So why was I being asked to sign hospice paperwork for him? How did this come about?

“Mr. Taylor, why are you in hospice? Are you dying?”

-Not that he knew of. He’d just been told that he’d get more “home services” that way.

“Who set this up for you?”

-It was one of those “home doctors.” Geriatric care providers that offer house calls to infirm seniors when it’s too hard for them to come to a doctor’s office.

Thing is, he was still plenty able to come to my office. And did so regularly.

Apparently, though, the opportunity to get more home services was too good to pass up.

The agency that was providing him at-home medical services referred him to a for-profit hospice firm, one that could collect the daily Medicare fee for a hospice enrollee.

Is it any wonder, then, that we’ve seen a surge in hospice enrollments in the last few years?

Finally, someone has written something about it. Thank you, Washington Post.

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.
Thursday, January 30, 2014

Ignorance can make you sick

In the 8 years I’ve been writing about medicine, I’ve chased down hundreds of articles presenting bad science as truth. Usually, I find bad medical information in alternative health websites, the Dr. Oz show, and other outlets that shouldn’t surprise most readers.

I recently stumbled on an OpEd piece in the New York Times that is so stuffed with medical misinformation it would be better published under “fiction.”

In it, Jennifer Berman, who freely admits to ignoring the science behind health, bemoans the consequences of her veganism. I have no problem with the vegan diet. Done properly, it’s very healthy and rarely leads to vitamin deficiencies. It probably helps prevent diabetes and heart disease. But it does not cause hypothyroidism or cavities as Berman writes.

Berman says that she was diagnosed with hypothyroidism, a common disorder in which the thyroid gland stops making enough thyroid hormone. She was apparently told that this was due to her ingestion of large amounts of kale and other cruciferous vegetables. While there is some scientific plausibility to the biochemistry of this, it’s not a thing. There is no medical literature to support kale, broccoli and other healthy vegetables as a cause for thyroid disease. A common cause would be an immune system attack on her thyroid, but one consideration would be poor dietary choices.

The element iodine is needed to make thyroid hormone, and can only come from diet. That’s why most table salt is “iodized”. It only takes small amounts to keep the thyroid going. People on limited diets who don’t use table salt can easily develop an iodine deficiency.

She blames her dental cavities on “juicing.” It is certainly possible for excessive citrus consumption to erode tooth enamel, but a better explanation came from her dentist: her avoidance of fluoride. Fluoride in water and toothpaste can help prevent cavities. While she may be getting excessive sugars in her diet, the fluoride would help protect her, but she was hesitant to follow her dentist’s advice.

I found Berman’s narrative an interesting read, but not for the reasons she likely intended. It shows how we as human beings make our health choices irrationally, relying on our friends and our guts rather than on science and doctors. If, as she humorously implied, she decides to go back to Twinkies and milk, it would be unfortunate. She can remain a vegan if she simply follows the science..

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.

Statins, static and the status quo: Is anyone getting the signal?

I rather doubt you need me to bring the roiling statin debate to your attention, given its prominence in scientific circles and mass media alike. In essence, a new set of guidelines for the use of lipid-lowering drugs to prevent heart disease was issued with considerable fanfare and then set off a firestorm of controversy. The old approach relied heavily on levels of LDL cholesterol, while the new approach relies on a calculation of overall cardiac risk that leaves LDL out of the mix altogether. At stake are statin prescriptions for millions of us.

So, as a physician specializing in preventive medicine, and with a long-standing interest in cardiac risk modification specifically, it makes sense for me to weigh in here. Perhaps some of my faithful readers—and my thanks for that, by the way—have been waiting for my verdict. So here you go: The answer may not matter a lot, because it’s the wrong question.

I guess it’s only fair to note that I have held back from entering this fray for two reasons, one lesser and one greater. The lesser reason is that we really don’t yet know the right answer. If it were truly clear exactly what criteria for statin use were best, there would be no controversy in the first place. There appear to be strengths and weaknesses to both sets of criteria, the old and the new. Either way, it’s clear that statins, which in fact are rather good drugs, can and do save lives when prescribed judiciously. The debate is all about what “judiciously” really means, and what is most judicious.

Frankly, I don’t think anyone knows for sure yet. To know with genuine certainty, we would need to randomize thousands of people to statin prescription by the old method, and thousands more to statin prescription by the new method, and see which group had less heart disease and premature death over time. Until or unless that is done—don’t hold your breath—we have competing expert opinions with no clear basis in empirical evidence to declare a winner.

As noted, that is the lesser reason for my apparent abdication. The greater reason is that I think it’s the wrong question. The right question is: How can a society look on passively at a situation that invites tens of millions of its citizens (no matter what criteria are used) to take a drug to fix what feet and forks could fix better, at lower cost, more universally, and absent the risk of side effects?

Statins really are good drugs, and under the conditions that now prevail, they do indeed save lives. And yes, alas, tens of millions of us are candidates for them. But such conditions need not prevail, and should not prevail. Why do we let them prevail?

As far as I’m concerned, the entire debate about statins is part of our societal static. It’s a background noise of cultural misdirection that favors the conflated interests of Big Food and Big Pharma while ignoring the compelling, consistent, signal of what lifestyle as medicine could do for us all.

We could prevent all those heart attacks, and more, without putting statins in the drinking water. We could add years to life, and life to years, and save rather than spend money doing it, if lifestyle were our preferred medicine. The signal has been there for literal decades that minimally 80 percent of all heart disease could be eliminated by lifestyle means readily at our disposal. There is a case that, but for rare anomalies, heart disease as we know it could be virtually eradicated by those same lifestyle means. And the same lifestyle medicine that could do this job would slash our risk for every other bad outcome as well, while enhancing energy, cultivating vitality, and contributing to overall quality of life. And unlike our statins, we could share these benefits with those we love.

But for the most part, we as individuals, and collectively as a culture, seem deaf to this signal. We watch our peers and parents succumb to heart disease, and wring our hands. We fret over the same fate overtaking us. We get prescriptions for drugs we wish we didn’t have to take, worry about serious side effects, suffer through minor ones, grumble about copays, and implicate ourselves in the unmanageable burden of “health” care costs.

And so our debate about statins, seemingly so important, plays out in the static of the status quo. No matter who wins the debate about statin indications, we the people—the tens of millions of people who, either way, are missing the signal and will wind up taking drugs to fix what lifestyle could fix better—lose.

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

QD: News Every Day--Vitamin D use questioned in general population for heart diseases, fractures or mortality

Vitamin D supplementation with or without calcium does not reduce skeletal or non-skeletal outcomes in the general population by more than 15%, a meta-analysis concluded.

Researchers in New Zealand did a meta-analysis of vitamin D trials, with or without calcium, to estimate the effects of supplementation on myocardial infarction or ischemic heart disease, stroke or cerebrovascular disease, cancer, total fracture, hip fracture, and mortality. They used a risk reduction threshold of 5% for mortality and 15% for the other conditions.

Results appeared online Jan. 24 at The Lancet.

The effect estimates all were within the futility boundary, researchers noted, showing that vitamin D does not alter the relative risk of any of these endpoints:
• Vitamin D supplementation alone did not reduce hip fracture by 15% or more (12 trials, 27,834 patients);
• Vitamin D co-administered with calcium reduced hip fracture in institutionalized individuals (2 trials, 3,853 patients);
• Vitamin D did not alter the relative risk of hip fracture by 15% or more in community-dwelling individuals (7 trials, 46,237 patients); and
• There was uncertainty whether vitamin D with or without calcium reduces the risk of death (38 trials, 81,173 patients).

Researchers noted that vitamin D with calcium reduced hip fractures in two trials of institutional settings, and that it supplementation had uncertain whether there were small effects on mortality. Yet, future trials with similar designs are unlikely to alter these conclusions because the results of several large trials were so heterogeneous, researchers wrote.

“In view of our findings, there is little justification for prescribing vitamin D supplements to prevent myocardial infarction or ischaemic heart disease, stroke or cerebrovascular disease, cancer, or fractures, or to reduce the risk of death in unselected community-dwelling individuals,” researchers wrote. “Investigators and funding bodies should consider the probable futility of undertaking similar trials of vitamin D to investigate any of these endpoints.”

The study trails on the heels of findings that vitamin D may still have uses in other specific populations. Higher vitamin D levels appear to be associated with reduced disease activity and a slower rate of disease progression in multiple sclerosis patients treated with interferon beta-1b, according to the study.
Wednesday, January 29, 2014

Does the white coat make the doctor?

There’s a piece in The Atlantic entitled The Psychology of Lululemon (free full text here). I probably would not have read that article but for the fact that I was in Lululemon just a few days ago buying my wife some yoga clothes for Christmas. This turned out to be an interesting read. The premise of the piece is that athletic clothing makes people want to work out—that in some way, clothes have power over the wearer. Of course, I began to think about the implications of the white coat for doctors, particularly because I remembered a survey we did a few years ago where some physicians mentioned that wearing a white coat made them feel more confident. I must admit that at the time I thought that was fairly absurd.

The Atlantic article cites a study from the Journal of Experimental Social Psychology, which I reviewed. Turns out, a colleague blogged on this paper last year, so I won’t belabor all the details. In a nutshell, investigators at Northwestern University set up a series of experiments in which subjects performed cognitive tasks that measured selective or sustained attention. In one trial some subjects wore white coats and some didn’t; interestingly, those who did performed better by a factor of 2. In another experiment, all the subjects wore white coats but some were told they were wearing a doctor’s coat, while others were told they were wearing a painter’s coat. The doctor’s coat group scored significantly better. The results led the investigators to coin the term enclothed cognition, which they defined as the systematic influence that clothes have on the wearer’s psychological processes.

Rehashing this paper made me stop and wonder whether after being white-coat free for the past five years I should put that dirty old thing back on. It is true that I know some very smart physicians who are never to be seen without their white coats. On the other hand, I also know some white-coated doctors, probably just as many, that I hope to never meet on the other end of a stethoscope. Maybe I’m just too grounded in reality. As much as I wish that if I ensconced myself in Under Armour my athletic abilities would surge, there’s not enough magical thinking on earth to tear me from the bitter reality that my skinny, scrawny body would not perform any differently.

While I’ll have to bow to science and come to grips with the concept of enclothed cognition, I still believe that keeping patients from contact with contaminated coat sleeves trumps whatever small intellectual edge the white coat might provide. As the psychologists have shown, it’s all in your head. So here’s my recommendation: as you enter your next patient’s room, bare below the elbows in your freshly laundered scrubs, stop for a split second and imagine yourself sporting a shiny white coat in all of its radiant splendor with a Superman logo blazing above the chest pocket. Then strut confidently into that room, and bedazzle the patient with your diagnostic brilliance.

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--Poster-sized commitment to fewer antibiotics offers modest reduction for prescriptions

Displaying poster-sized commitment letters in the exam room to encourage proper antibiotic prescribing decreased inappropriate uses for acute respiratory infections, a study found.

Researchers set the study during a 1-year flu cycle. Prescribing habits were examined during a baseline period of three-quarters of the year, and then during an intervention period, when the poster was displayed during the peak of cold and flu season. The poster-sized commitment letters featured text about a commitment to avoid inappropriate prescribing for acute respiratory infections, and the clinicians’ photos and signatures, to hang in examination rooms for 12 weeks at 5 outpatient primary care clinics in Los Angeles.

Prescribers included 11 physicians and 3 nurse practitioners. A total of 954 adults had visits; 449 patients were treated by clinicians randomized to rooms with a posted commitment letter (335 in the baseline period, 114 in the intervention period) and 505 patients were treated by clinicians randomized to control rooms. (384 baseline, 121 intervention).

Results appeared online first at JAMA Internal Medicine.

Baseline rates were 43.5% for control rooms and 42.8% for poster rooms. During the intervention period of peak cold and flu season, inappropriate prescribing rates increased to 52.7% for controls but decreased to 33.7% when the poster was displayed, a nearly 20% absolute reduction in inappropriate antibiotic prescribing rate relative to control (P=0.02).

Researchers noted that the method was simple, low-cost intervention that had an effect comparable to costlier, more intensive quality-improvement efforts. Researchers wrote, “Our results show that active engagement in the form of public commitment need not involve extensive demands on provider time.”

An editorial compared the intervention to judo, a gentle redirection of intent relying on the concept of “public commitment” rather than an overpowering one.

“The authors developed a novel intervention that was based on a sophisticated understanding of how to overcome the psychology that drives behavior linked to inappropriate antibiotic prescriptions,” the editorialist wrote. “Rather than direct confrontation with the force of education or nagging, they sought a gentler ‘nudging’ approach that worked harmoniously with the underlying psychology of both patient and clinician.”
Tuesday, January 28, 2014

Do physician rating sites make the grade? Find a doctor on Angie's List

I’ve never logged onto Angie’s List, but I might be on it. Physicians are now routinely rated on various internet sites that the public can view before making appointments, or just as a parlor game. You can look up doctors just as you would check ratings on toaster ovens, snow blowers, cars and restaurants.

Are these sites truly useful?

Can a grading site inform the public about a physician’s medical quality?

Can a visitor to the site be confident that the view expressed is true and objective?

I’m skeptical.

I’ve thought deeply on the issue of medical quality since I was a medical intern in 1985. Indeed, it was my preoccupation with this subject that led to the birth of this blog years ago. Review the blog’s categories at the right of your screen and note how many labels include the term ‘quality’. A recurrent theme here is how difficult it is to measure medical quality, even for medical insiders who know the blood and guts of the business. Pay-for-performance is an example of the government’s feeble effort to measure medical quality. I have devoted several posts to exposing this sham and explaining its systemic flaws.

If physicians and health care experts can’t define and measure medical quality, then I am deeply skeptical that on-line rating sites can succeed where the medical profession has failed. That this sites are filled with advertising communicates that their true mi$$ion may be unstated.

Nevertheless, these programs are here to stay and we can expect more competitors to materialize. Let’s face it. The public loves rating everything. Each year, parents of high-schoolers race for the U.S. News and World Report annual college ratings, even though seasoned educators know that this is a poor resource for choosing quality higher education. Throughout the country, there are lists of our best doctors, hospitals, athletes, musicians and chefs. Sometimes, these lists defy logic. How many #1 cardiologists can one city have?

Just google the phrase “list of the 100 best” and see what pops up.

Doctor rating sites are likely to be sites where disgruntled patients express themselves. This creates an indelible stain on the reputation of the doctor, who cannot expunge the false claim. It is well accepted that dissatisfied customers are more likely to speak out, which creates an unbalanced record of performance for doctors and various businesses. I acknowledge that some on line criticisms may be valid, but others may false and defamatory. How can a reader discern the truth?

Consider the following hypothetical criticisms:

Keep away from this doctor. He’s only in it for the money.
Perhaps, this is a patient who wouldn’t pay his bill.
I’ve never seen a doctor so insensitive to my pain. After seeing him, I had to go to the emergency room for some relief.
Perhaps, this a patient who demanded narcotics, and the doctor declined to accommodate this request.

Warning! This doc is in the pocket of insurance companies. He was pushing me to try a different medication.
Perhaps, this patient was offered an inexpensive alternative that was medically equivalent.

Remember, one thing that on-line grading sites do not offer is both sides of the story. Readers are counseled to assume there is another side, which may be where the truth lies.

New companies are emerging that promise to combat on-line attacks against physicians and others. A component of their strategies is to encourage favorable comments to be added to the sites to provide balance and to suggest that a negative comment is an outlier. All this sounds more like a game to me than true quality assessment.

Who’s grading the grading sites? Will Angie take this on?

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.

It's time to establish order amid this hospital medicine chaos

Following rapid growth in the last couple of decades, hospital medicine is set to become the largest specialty in American health care. Hospitalists work in almost every hospital across the country. Being in the field myself, I know that we are uniquely placed to get a complete view of the system from admission to discharge and to lead quality improvement initiatives. We treat a full range of medical illnesses, often coordinating care between a number of specialists as the “captain of the ship”. The close bonds that are formed with patients and their families make the job very unique and special. Hospital doctors are truly practicing frontline medicine in the purest form. At its best, this is one of the most rewarding professions anyone can ever hope to have.

Given this, members of our specialty have to ask ourselves why the job is not as popular as it should be? Most programs around the country are struggling to hire hospitalists, and those programs that are well established suffer high rates of turnover, as much as 20% to 30% per year. No organization can succeed with such high rates of attrition.

A friend once remarked to me, “In my hospital, it always seems like the hospitalists really hate their job”. As someone who had been in practice several years, this observation really made me think. I know that a lot of hospital doctors don’t like their jobs, have plans for fellowship, or view it as a temporary career move. But why? Many hospitals take it as a given that their programs will see a “revolving door” of staff turnover. This is an incredible shame and I don’t think it’s the job per say that is making this happen. It is actually the way programs are set up and the circumstances that hospitalists are expected to work under. Poor organization and inattention to optimal workflow basically ensure that the doctor will be subjected to complete chaos during the typical work day. Why should we assume hospital medicine has to be like this?

Fortunately, I have worked in the better programs which are well ahead, but it’s obvious to me from looking around and talking to other colleagues what the issues are. Here is the typical scenario for a significant proportion of hospitalists. The doctor will start the day with a list of patients to see. As they diligently get to work, they will simultaneously be getting paged with questions from nurses about their patients. Some urgent, some not so urgent.

In between, the doctor will be taking calls from the emergency room for new admissions and other hospital floors for new consults. The pager will be going off constantly. Trying to spend a few minutes talking to patients and their families, the precious time will regularly be interrupted. There is simply no rhyme or reason to the day. One patient may get seen at 7 am and another 3 pm. The new admission from the ER that was taken at 8 am may not be seen until 4 pm. The patient that was waiting to go home all morning is finally discharged at 5 pm. Sounds crazy? These scenarios play out in most hospitals on a daily basis.

The job of a hospitalist is one that requires significant multitasking. However, lack of organization makes the typical workday for a lot of jobs out there intolerable. No wonder there’s so much burnout. Nobody—not anyone—who is diligent, thorough and wants to do a good job, could work like this.

Moreover, it’s also dangerous for patients. At a time of increased focus on quality and safety, the hospital medicine doctor needs to work in an environment that affords time for focus and high quality care. Take even the best job in the world and make it completely unorganized and chaotic—people will soon dislike it. Of course being a doctor in most specialties is anything but predictable, but the situation is made much worse than it should be.

What we need to do is to create a defined framework to the day. The workflow of a hospital medicine doctor is actually one that can be somewhat planned (it’s very different for example from that of an ER doctor, which has a continuous workflow of “one patient after another” not knowing what’s arriving through the door next). In many respects, the day should be more similar to a primary care or office-based physician who will attempt to have a set clinic schedule. In these settings it wouldn’t be acceptable to have the patients coming in at random times and to also keep slotting in extra patients during the day. The same goes for a surgery schedule too. Yet this is what happens every day in hospital medicine.

Here’s the broad strategy that every hospitalist program needs:
• The doctor has their list of patients to see in the morning;
• Have expectations for rounding on patients before a certain time utilizing a full multidisciplinary rounding model;
• Institute a system of geographical rounding, which means that the hospital doctor is always near their patients and spends less time walking between floors. This also reduces the frequency of paging the doctor;
• Nurses and Case Managers should know approximately what time they will be able to convey their concerns and questions to the doctor;
• A focus on discharging patients as early as possible;
• Afternoons should be spent on reviewing patients, documentation, and family meetings; and
• An on-call doctor should be based in the Emergency Room, tasked with seeing all new admissions. The same applies to any new medical consults.

Standardizing systems isn’t designed to take away individuality, but rather to establish order to what is now chaos. Working in an organized fashion will also mean more emphasis can be put on important metrics such as reducing length of stay, earlier discharge times, and improving patient satisfaction. We already have some excellent programs across the country that are leading the way. In addition, to avoid monotony, variety can be added to the program by having doctors rotate around different floors and the Emergency Room every several weeks.

The success of a hospital medicine program can make or break the institution—it’s vital we get this right. Hospital leaders should be putting their heads together and working out how to make this the best job in medicine (it’s already shaping up to be one of the most important). Put more order into the day and watch hospital medicine doctors and our health care system flourish. And ultimately, happier patients will be the real winners.

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.

QD: News Every Day--CDC tells doctors to avoid basing flu decisions on rapid results tests

Physicians should rely on neither test results nor laboratory confirmation of influenza to make decisions about starting antiviral treatment, the CDC advised.

Rapid influenza diagnostic tests have low sensitivities, generally 40 to 70% (range 10 to 80%), and high specificities of 90 to 95% (range 85 to 100%), agency physicians said at a press conference.

The agency cautioned physicians that a negative rapid flu test result does not exclude a diagnosis of influenza and should not be used to make treatment or infection control decisions. Instead, when there is clinical suspicion of influenza and antiviral treatment is indicated, antiviral treatment and appropriate infection control strategies should be started as soon as possible.
Monday, January 27, 2014

Graduate Medical Education: successes despite challenges

In a post a few days ago, Dr. J. Russell Strader, in a post entitled “Why graduate medical education is failing,” described concern over graduates of residency in the current era, compared with those who trained in a different era. He opines that many current residents feel, in his words, “woefully unprepared” for the realities of practice and have a “lack of ability to work independently.” While his specialty of cardiology, a mix of a “procedural specialty” and a “cognitive specialty,” is slightly different from mine (primarily cognitive), I have a few thoughts about graduate medical education (GME) that paint a different picture.

The current residents in training now did not “ask” for the duty hour restrictions. The duty hour restrictions were placed on them, not the other way around. Program directors themselves are in a quandary to produce competent graduates while still adhering to restrictions with which they may or may not agree. For example, what should I do when a resident chooses of her own volition to stay over on duty hours by 25 minutes to finish discussing end-of-life concerns with a family of an ill intensive care unit patient? I personally applaud such residents for understanding the bigger picture (for the record, a scenario such as this IS allowed by the current duty hour regulations).

Current program directors have to make the following statement on every one of their graduates and “sign off” on each resident at the time of graduation: “This graduate is competent to practice [SPECIALTY] independently without supervision.” The current era of competency-based medical education, administrated through the Milestones initiative will likely demonstrate that some residents need longer training times while others will prove appropriate competency earlier. The focus, of course, is to produce physicians who truly are ready to practice unsupervised, as the Accreditation Council for Graduate Medical Education (ACGME) is accountable to the public.

The current generation of residents seem to describe a greater interest in caring for the underserved and global health initiatives than previous generations (this is purely anectodal based on applicants I have interviewed over the past 10 years). This may be multifactorial, due to factors such as newer curricular opportunities in these areas that may not have existed many years ago.

The current residency and fellowship training programs still place great emphasis on “thinking like a doctor” and other clinical decision-making curricula, and have many novel curricular tools to evaluate residents in this regard.

So what might we take from all of this?

First, I believe that the current generation of trainees is as dedicated as any other to the provision of outstanding patient care. This generation has many competing demands and barriers to that care that simply did not exist 10 or more years ago, and they are handling it as best as they can. They are not lazy!

Second, the concept of supervision, which has always existed, has nevertheless evolved over the years, necessitating more oversight by current attendings. Attitudes such as “If I had to call the attending for help, it was a failure,” might now be (and should be) a minority opinion, as the field of patient safety now demands more intensive supervision from attending physicians.

Third, the ACGME has moved towards a concept of “graded supervision”, meaning PGY1 residents should have more oversight than those 3 months from graduation. The amount of supervision diminishes as time progresses through the training program. This is different from the mentality of “Let’s crush them during intern year so that they are REALLY ready as upper level residents” which was likely the pervasive mentality. Of course a consequence of this may lead to some residents taking longer to feel comfortable as a supervisory PGY2 resident.

Fourth, the concept of life-long learning means that someone does not know “everything” once she/he begins practice. It is, after all, the “practice” of medicine, and we all are always learning (even many years after training is completed). This concept of lifelong learning can even be taught. There is nothing wrong with newly minted clinicians thinking: “Can I run this patient care scenario past you?” In fact, it is probably safer for patients to have another opinion when one clinician is doubtful as to diagnostic or therapeutic plans. This is best described as “knowing when you don’t know something”. The danger of course lies in the physician who “doesn’t know what she/he doesn’t know.”

My colleague Teresa Chan also outlined her thoughts on this same post earlier today, and provides a truly compelling argument why graduate medical education is succeeding in producing competent physicians ready to practice independently and unsupervised. Like Dr. Chan, I am very proud of the “products” of the current GME environment, and feel that patient care has improved over the years as the graduate medical education community has evolved in not only what it teaches to residents but also how it teaches.

Alexander M. Djuricich, MD, FACP, is Associate Dean for Continuing Medical Education and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis. This post originally appeared at Mired in MedEd, where he blogs about medical education.

Can you have your colonoscopy and endoscopy on the same day?

I’ve heard it dozens of times:

My gastroenterologist says s/he can’t do my endoscopy and colonoscopy on the same day.

Sometimes it’s because it was considered too “dangerous.” Occasionally it’s because “That’s not the way we do it”. Sorry, that doesn’t fly with me. And it shouldn’t with you.

Yes, there are true medical reasons that some people shouldn’t have an upper endoscopy and a colonoscopy (sometimes called “bidirectional endoscopy” or a “double dip“) on the same day. But these are few and far between.

Years ago, my mother told me the same thing … after her procedures. I nearly flipped out.

The real reason is that (in the USA) the doctor and/or the facility gets paid less for doing them on the same day than when they do them on different days.

What does having your 2 procedures done on separate days mean for you?

 2 days away from work or your personal life

 undergoing anesthesia/sedation twice

 getting someone else to drive you to and from the procedure on 2 days

 more money out of your pocket (or out of your insurance company’s)

If you do need to have both done, think carefully. A patient-center doctor would usually have no problem doing them both on the same day, instead of caring more about the bottom line.

Ryan Madanick, MD, is an ACP Member, a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain. This post originally appeared at his blog, Gut Check.

QD: News Every Day--Hormone therapy associated with 40% less need for repeating joint replacement surgery

Hormone replacement therapy (HRT) taken regularly for 6 months after a knee or hip replacement was associated with a 40% reduced risk of needing repeat surgery, a study found.

A population-based study based on national data for England and Wales found that more than 2% of procedures typically have to be repeated within 3 years, primarily because of osteolysis (75% of cases).

Researchers assessed the likelihood of repeat joint replacement surgery among women who required a first knee or hip replacement between 1986 and 2006. Matched samples were created of 2,700 HRT users and 8,100 women who had not used HRT to compare the risk of repeat surgery over a period of 3 years.

Results appeared online first Jan. 22 in the Annals of the Rheumatic Diseases.

Failure incidence was 2.61/1,000 person-years-at-risk (95% CI, 1.79 to 3.61) in HRT users, and 4.25 (95% CI, 3.81 to 5.02) among HRT non-users. Those who had taken HRT regularly for 6 months or more after their surgery were 38% less likely to require repeat surgery than were those who had not done so (95% CI, 0.41 to 0.94; P=0.023). Those who regularly took HRT for 12 months or more after their procedure were 52% less likely to need further surgery during the 3-year monitoring period (95% CI, 0.29 to 0.78).

Higher adherence and therapy duration were associated with further reductions in revision rates. Taking HRT before surgery, however, made no difference to the risk of implant failure, the findings showed (hazard ratio [HR], 1.06; 95% CI, 0.66 to 1.70; P=0.80), but a strong protective effect was present for those with a first prescription after surgery (HR, 0.24; 95% CI, 0.10 to 0.55; P=0.001). The findings held true even after taking account of other influential factors, including use of drugs that can impair bone turnover (HR, 0.61; 0.40 to 0.92; P=0.019).

Low estrogen levels have been implicated in bone thinning and loss, while HRT is thought to help conserve bone thickness. But this is the first study to show that it can help prevent repeat surgery in women who have undergone hip/knee replacement, noted the authors.

“As the rate of revision at 7 years is under 5%, it is likely that any antiresorptive drugs would be used in a targeted manner to patients identified as being at high risk of failure,” they wrote. “Given the risk of venous thromboembolic events with HRT, HRT should be stopped 6 weeks before and after surgery. This is supported by our observation that the protective effect of HRT was only evident when started after and not before the primary arthroplasty.”
Friday, January 24, 2014

Does health care spending equal moderating? David Blumenthal et al explain

David Blumenthal and others published a paper in the New England Journal of Medicine entitled “Health Care Spending—a Giant Slain or Sleeping?” In it they look at the ongoing, and rarely discussed, phenomenon of slowing of health care spending, which has persisted over several years.

Health care spending grew remarkably after the establishment of Medicare and Medicaid in the 1960’s, resulting in the fact that health care costs now equal about 18% of our gross domestic product (GDP) when they were only 5% before these programs were introduced. This was no coincidence. A third-party payer, even one we expect to value frugality such as the government, will increase utilization of services because they are already paid for, and will increase prices for the same reason unless the prices are negotiated.

In Europe, prices for procedures and medications are frequently negotiated, but in the U.S. powerful drug companies and device manufacturers successfully resist this, resulting in relatively free-floating prices. In the past few years, however, overall health care costs have slowed their growth considerably and now actually lag behind the increase in GDP. We have had a much slower economy since 2008, which could be expected to slow health care spending, but this effect has been beyond what economists would expect based on this.

The authors discuss the many factors that may be involved in slowing health care costs, and also present some strategies that might help encourage this trend. They suggest that some of the provisions of the Affordable Care Act, including establishment of health care models that make providers of health care more financially responsible for the health of patients rather than profiting from their illness, may already be having a positive impact. Movement towards having patients be more involved in their own health, including making informed choices about treatment and testing may reduce unnecessary costs. The article is definitely worth reading. They conclude that health care, despite the encouraging trends, is still overpriced and can stand to be more frugal without sacrificing patient care. This is true.

In my experience, testing and treatments are still ordered without adequate attention to necessity or cost. Preventive strategies to reduce grave illness are still underutilized and drug companies still overcharge for their products and convince us that their value is higher than it really is. We continue to use the very newest and most expensive technologies to delay the moment of death for patients who are genuinely dying and ought to be allowed to do so in comfort and with dignity. All of these things come with huge price tags.

The article ends with a couple of very important points, and then misses a few more because the authors are most likely not practicing physicians. Dr. Blumenthal, the first author, is the president of the Commonwealth Fund, a philanthropic organization which researches social and health policy. He has been a primary care physician, but has been influential in policy and administration for many years, suggesting that he probably no longer takes care of patients in the hospital or clinic. His coauthors, Kristof Stremikis and David Cutler are in public policy and economics, respectively, and are not MDs.

The points that are particularly important that they did mention in the article are that consumers can be a powerful force for improving both quality and in reducing costs if, and only if, they are given data about quality and costs. Also, that the way we presently pay for medical care, especially the way we bill, is incredibly inefficient (also, in its complexity, so prone to fraud and inaccuracies, though they didn’t mention this.)

What they did not mention is that physicians can be a powerful force in improving quality and reducing costs if they, also, are given data about these things. Doctors still do not know how much a given test or procedure costs, what portion will be paid by a patient out of pocket, and mostly do not have guidelines that help them not to order excessive testing or treatment. Billing is only a small part of the problem of administrative burden. The increasing demand on nurses’ and other caregivers’ time by electronic health records which appear to be endlessly hungry for valueless detail that must be entered on a computer not only reduces all of our abilities to do good bedside patient care but clouds our minds with trivia and chases experienced staff, both nurses and doctors, to early retirement because of inadequate (and irrelevant) data entry skills.

I commend the authors of this article for clear writing and excellent synthesis. The fact that health care spending is already going in the right direction is fascinating and almost entirely neglected in the press, probably because it doesn’t support the more popular story that everything to do with health care in America is going rapidly to hell in a handbasket. I expect the ongoing vigorous debate about health care reform will keep people discussing costs which will make both physicians and patients more likely to pay attention and reduce frivolous expenditures.

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.

Providers in the insurance game

I have come to believe that fee for service (FFS), at least in its current incarnation, is an unsustainable model of financing health care. Pick up any newspaper or journal and you are likely to see that I am not alone. The reasons are as numerous as the faults of the present health care landscape: high costs, poor quality of care, unhappy patients and unhappy providers.

In fairness, not all of the current mess can be laid at the feet of FFS, and there are some pretty attractive ideas out there about how to improve care and lower costs within a FFS framework. Most of these alternatives center on paying providers for episodes of care instead of specific elements of care. For instance, CMS has experimented with bundled payments that incorporate physician and hospital fees, as well as pre- and post-operative care for certain surgical procedures, and it is poised to do so again. Michael Porter has written extensively on how providers should be reimbursed based on the value of their services (defined as their quality divided by their cost) instead of the volume of services, as is typically the case now.

A more radical approach is for providers to take on the role of insurers. The basic idea is to “go upstream” in the typical payment cascade of employers (or individuals) to insurers and insurers to providers. It is a classic strategy of disintermediation—cutting out the middle-man—with the promise of a bigger cut of the economic pie, which in this case is the pool of premium dollars. The strategy has the additional appeal of freeing providers from the controlling influence of payers on the delivery of care, and from the seemingly relentless reduction in FFS rates. It is actually an idea that has been around for a very long time, embodied in the old health cooperatives and in more contemporary examples such as UPMC and the Geisinger Clinic.

That is the fundamental business motivation behind the creation of North Shore-LIJ CareConnect a wholly owned insurance company of our health system. The company is up and running, selling health insurance on the New York State exchange and in the commercial market. It could simplify the lives of patients and providers alike, by eliminating the contentious relationship between payers and providers. I think it is a good bet.

What do you think?

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.

QD: News Every Day--Can cooler buildings prompt healthier weight?

Frequent exposure to mild cold over sustained periods, such as by turning down the thermostats in buildings, may prompt people to burn more calories, and possibly maintain a healthier body weight, researchers wrote.

The idea is that rodent studies have shown that nonshivering thermogenesis consumes brown adipose tissue, and in humans, the response increases anywhere from a few percent to 30% when young, healthy adults are exposed to mild cold temperatures, such as from 64 to 66 °F.

The researchers, who reported their work in Trends in Endocrinology and Metabolism, are now hypothesizing that prompting large amounts of people to spend more energy to maintain thermal balance may positively affect health on a population scale, and also that regular exposure to mild cold keeps the peripheral vascular system in motion.

“Maximal thermal comfort in the built environment may increase our susceptibility to obesity and related disorders, and in parallel requires high energy use in buildings,” the authors wrote. “Mild cold exposure increases body energy expenditure without shivering and without compromising our precious comfort. Hence, rethinking our indoor climate by allowing ambient temperatures to drift may protect both health and bank account.”

This group of researchers from The Netherlands has been working on the idea for years now, having reported in one study that people can adapt to cooler environments and in another study that the cooler environment can burn brown adipose tissue in humans as well as rodents.

“More frequent cold exposure alone will not save the world, but is a serious factor to consider in creating a sustainable environment together with a healthy lifestyle,” they concluded.
Thursday, January 23, 2014

Retrospethics [Updated.]

A few weeks ago I wrote about dubious medical research from the 1950s involving prostate biopsies on skid row alcoholics. The research had been brought back to life by an expose in the New York Times.

In what is arguably becoming a trend, the Wall Street Journal has added to the genre. The Journal’s project is well worth a look, not only because of the first-rate reporting by Michael M. Phillips, but also because the digital presentation of text, photos, and video is arrestingly beautiful (if haunting). In all, some 22 people were involved in creating this project, as the credits at the end reveal.

The series opens with a short video of an archivist (reporter? researcher?) wheeling a box of old records to a library table and unearthing Department of Veterans Affairs memos about the practice of lobotomizing mentally ill soldiers.

The accompanying investigative reports by Phillips center on one still-living lobotomized veteran, Roman Tritz, who underwent “pre-frontal lobotomy” in 1953 at the VA hospital in Tomah, Wisconsin. Tritz, now 90 years old, still receives his medical care at the same facility.

Here’s an excerpt from Part I that well captures the state-of-the-art in psychiatry for ‘shell shocked’ vets at the time. I include it because it mentions several other therapies that seem absurd and unethical to us today (notable exception: electroshock, which is still performed): “During eight years as a patient in the VA hospital in Tomah, Wis., Mr. Tritz underwent 28 rounds of electroshock therapy, a common treatment that sometimes caused convulsions so jarring they broke patients’ bones. Medical records show that Mr. Tritz received another routine VA treatment: insulin-induced temporary comas, which were thought to relieve symptoms.”

“To stimulate patients’ nerves, hospital staff also commonly sprayed veterans with powerful jets of alternating hot and cold water, the archives show. Mr. Tritz received 66 treatments of high-pressure water sprays called the Scotch Douche and Needle Shower, his medical records say.”

When all else failed, there was lobotomy.”

“You couldn’t help but have the feeling that the medical community was impotent at that point,” says Elliot Valenstein, 89, a World War II veteran and psychiatrist who worked at the Topeka, Kan., VA hospital in the early 1950s. He recalls wards full of soldiers haunted by nightmares and flashbacks. The doctors, he says, ‘were prone to try anything.’”

Lobotomy perhaps had its most famous treatment in the book and Oscar-winning film “One Flew Over the Cuckoo’s Nest.” The Journal’s project will add greatly to the historical record of the abandoned practice.

The comments by readers are worth a look, too, and highlight the inherent tensions in such a project: It’s work that’s stunning, haunting, and probably prize-winning. The project raises the level of multi-media digital reporting to a higher level. Many commenters are laudatory, finding great value in the information and artful presentation. But many vociferously criticize the project, accusing Phillips and the Journal of applying modern ethical standards to practices that were medically acceptable at the time. Moreover, the critics question the motivations of the Journal and suggest that Mr. Tritz, who still suffers with paranoia and delusions, has been exploited to sell, er, newspapers.

I believe it’s incumbent upon us to support this type of work. Rediscovering lost history helps us fill in the composite about where we’ve come from and what we value as a society. Collective memory on behalf of those that have suffered also provides catharsis and ties us to our past and our very humanity.

I also think the Journal (and other online publications) have raised the bar in terms of answering the question of how what we used to think of as ‘newspapers’ can more fully realize their digital potential. [Author’s Update: You can click here and hear an interview with Michael Phillips of the WSJ.]

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.

Expertise and work hours

Pauline Chen has once again written a brilliant piece in the New York Times, Are Today’s New Surgeons Unprepared? While many comments miss her underlying question, her exposition makes the problem clear.

How do we gain expertise? Current theory supports the idea of deliberate practice. How do we conceptualize deliberate practice? Start with a sports analogy. You are trying to learn to make a 6-foot putt. In scenario one you practice putting 6 feet, but you have no hole for the ball. You putt 100 times—excellent practice. We then add a hole, and you still have mediocre performance.

In scenario 2, you practice putting the ball into the hole 100 times. On the test you do much better.

In scenario 3, you practice putting the ball into the hole 100 times, but you also have a coach how gives you feedback on your form. The coach gives instruction, and now you practice a modified putting stroke. On the test you do even better.

I hope this makes the principles of deliberate practice clear. You must do repetitions with feedback and immediate instruction.

Becoming a surgeon (or any other physician specialty) requires deliberate practice. Volume matters. Following the patient from the beginning to the end of the clinical incident makes a difference. Let’s imagine the problem of abdominal pain due to appendicitis.

To really learn about appendicitis, the surgical novice must examine many patients with abdominal pain, learning to recognize the “surgical abdomen.” The novice must then learn the evaluation of the surgical abdomen. In the best scenario the novice goes to the OR with the patient and learns first the cause of the pain (nothing like actually looking at the inflamed appendix), and the learning step-by-step how to remove the appendix. Of course, sometimes the problem is not the appendix, and learning that and what to do next becomes part of the education. Finally the novice must care for the patient during the post-operative period to totally understand the disease and surgical process.

While that seems complex, the above paragraph actually is a bit too short and incomplete.

Medical interns must learn to recognize community acquired pneumonia and clearly know when the patient does not have that diagnosis. They learn the usual response to antibiotics, and hopefully understand that when the response is not usual, perhaps the initial diagnosis is incorrect.

Too often, in an attempt to meet somewhat arbitrary work hour restrictions, training programs unlink the steps of the disease process. We have one group of trainees admitting the patient, another group following the patient, and a different group seeing the patient after discharge. All three groups have decreased learning as a consequence.

We have developed systems to hopefully improve the resident’s quality of life, but have we designed those systems to allow adequate deliberate practice. We who trained in the “bad old days” worry about the current training model. We have a responsibility to raise these questions.

How do we provide our trainees with satisfactory volume and satisfactory continuity? How do we help them with their deliberate practice? The answers are not easy, despite the protestations of those who did not go through the old process.

Congratulations to Dr. Chen for clearly outlining the problem.

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 Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.
Wednesday, January 22, 2014

CRE decolonization: Can we? Should we?

A paper in American Journal of Infection Control poses an interesting question: can CRE (carbapenem-resistant Enterobacteriaceae) be eradicated from the gut? Given the increasing problems with these organisms, decolonization could play an important role in their control.

This study was performed at a large tertiary care hospital in Israel where active surveillance is performed on admission and weekly in targeted populations. Unfortunately the design of the study makes it difficult to interpret. There were 4 study arms: treatment with oral gentamicin, treatment with oral colistin, treatment with oral gentamicin + oral colistin, or no treatment. In part, the susceptibility of the colonizing strain dictated the study arm (e.g., patients with a colistin-resistant, gentamicin-susceptible strain were treated with gentamicin, unless they did not consent to treatment, in which case they were assigned to the control group). If the patient’s isolate was susceptible to both drugs, they were randomized to either drug or to combination therapy.

Treatment was given for 60 days or until eradication (defined as 3 consecutive negative rectal cultures with PCR performed on the 3rd negative sample), whichever came first. In the end, 26 patients received gentamicin alone, 16 colistin alone, 8 received both, and 102 were untreated. Eradication occurred in 42% for gentamicin, 50% for colistin and 37% for combined treatment. Only 7% of the untreated patients spontaneously decolonized.

What conclusions can we draw?
1. Spontaneous decolonization is a rare event.
2. It appears that some patients (one-half or less) can potentially be decolonized or at least suppressed while on treatment. Of note, 2 patients in the gentamicin arm, 4 in the colistin arm, and 2 in the combo arm relapsed. It would be interesting to know whether patients who had CRE eradicated remained culture negative for the long-term (e.g., 3 months or 6 months after treatment).
3. Given that colistin remains one of the most important drugs for treatment of these infections, it worries me that widespread use of this drug for decolonization could result in resistance. Indeed, colistin resistance was reported in 1 of 16 treated patients, and 6 of 26 patients in the gentamicin arm developed gentamicin resistance.

In the end, how do we use the data from this study? I suppose if I practiced in a hospital with high rates of CRE colonization, I would be tempted to try decolonization for very high risk patients (e.g., neutropenic leukemic patients). I would favor use of gentamicin if the isolate were susceptible. But it would make me very nervous.

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.

The microbiome's profound effect on health

I am fascinated by the new research and information on the gut microbiome. These microorganisms (germs, bacteria, microbes) live harmoniously in every part of our body and especially in our gastrointestinal system. It wasn’t even really discovered until the late 1990s and we now know that these microbial communities affect our health in ways we never dreamed. The human microbiome may play a role in obesity, immune response, diabetes, irritable bowel syndrome, and maybe even anxiety, depression and autism.

Anything that is this new has many possibilities the science is just starting, but there is clearly something very important here. The Human Microbiome Project is a NIH initiative with the goal of identifying and characterizing the microorganisms which are found in association with both healthy and diseased humans. They intend to test how changes in the human microbiome are associated with human health or disease.

A study published in Nature showed that adaptation to the gut microbiome can change in a day. This is important because dietary changes can have a huge immediate effect on disease. The researchers showed how immediate changes occur, depending upon subjects eating a plant based or animal based diet. They fed the volunteers either plant (grains, legumes, fruits and veggies) or animal (meats, cheese, eggs) diets for 5 consecutive days. They tracked food in the digestive tract, how the subjects felt and bowel movements.

The researchers analyzed 16S ribosomal RNAs to identify microbiome components in fecal samples, which were collected for several days before the dietary changes and each day during the study.

The animal-based diet clearly had a greater effect on the microbiome than the plant-based diet. Even after 1 day, the microbiome of those eating the animal-based diet differed significantly from baseline analyses.

The researchers found fecal bile acid changes in the animal based diet that are associated with liver cancer and Irritable bowel disease. These bile acids change the bile tolerant bacterium that is associated with IBD.

There is no cause-effect found here and the study size was too small to know what is actually occurring. But the fact that changes could be found in the gut microbiome in such a short amount of time is compelling. It is simply another potential explanation why diet is so important to health, and how changing our diet can have an immediate effect on our health.

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

QD: News Every Day--Half of hospitalized patients need surrogate decision making

Nearly half of hospitalized older adults need surrogates for at least part of their decision making, with a quarter of them depending entirely upon the surrogates, a study found.

Researchers conducted a prospective, observational study of more than 1,000 hospitalized seniors identified by their physicians as requiring major medical decisions while staying for longer than 48 hours in the medical and ICU units of 2 hospitals.

Results were published Jan. 20 in JAMA Internal Medicine.

While hospitalized, 47.4% (95% CI, 44.4% to 50.4%) of older adults required at least some surrogate involvement, with 24.4% (95% CI, 21.9% to 27.0%) making joint decisions between the patient and surrogate and 23% (95% CI, 20.6% to 25.6%) requiring all decisions made by a surrogate.

In the ICU, surrogate decision making was even more common. Surrogate involvement occurred in 71.1% (95% CI, 63.8% to 77.5%) of cases, with 27.7% (95% CI, 21.5% to 35%) of patients making joint decisions and 43.4% (95% CI, 36.1% to 51%) requiring all decisions made by a surrogate.

Among patients who required a surrogate for at least 1 decision, 57.2% required decisions about life-sustaining care (mostly addressing code status), 48.6% about procedures and operations, and 46.9% about discharge planning.

Patients who needed a surrogate required greater use of:
• ventilators (2.5% of patients who made decisions and 13.2% of patients who required any surrogate decisions; P <0 .001),
• artificial nutrition (1.7% of patients and 14.4% of surrogates; P <0 .001),
• length of stay (median, 6 days for patients and 7 days for surrogates; P < 0.001), and
• discharge to an extended-care facility (21.2% with patient decisions and 40.9% with surrogate decisions; P <0 .001).

Patients who needed a surrogate also had higher hospital mortality (0.0% patients and 5.9% surrogates; P <0 .001).

Most surrogates were daughters (58.9%), sons (25%), or spouses (20.6%). Only 7.4% of patients had a living will and 25% had a health care representative documented in the medical record.

Researchers noted that early family meetings in the ICU or giving families increased time to speak during the meetings should be built into the hospital structure as a central element of good patient care.

“In the hospital, family members are considered ‘visitors’ rather than crucial participants in their family member’s care,” the authors wrote. “In-depth interviews with surrogates conducted as part of the current study found that surrogates often have trouble contacting hospital staff and struggle for information about the patient. Clinicians also frequently report making decisions with surrogates to be highly stressful.”
Tuesday, January 21, 2014

Should HIPAA compliance guard all protected medical information?

Everyone is familiar with the acronym HIPAA, which is the 1996 edict called the Health Insurance Portability and Accountability Act. Isn’t that a smooth and melodious name?

These are rules and regulations that are designed to protect your confidential protected medical information. I support the mission. I don’t think that your medical records should be deliberately or inadvertently shared with those who are not lawfully permitted to view them.
• Medical charts (remember when there were medical charts?) should not be left open on the counter.
• A physician should not yell to front desk personnel within earshot of others to give the patient a psychiatric referral.
• Elevators are not proper venues to have medical discussions about specific patients.
• Medical information should not be disclosed to inquiring friends and family without permission.

I maintain that HIPAA has been OperationOVERKILL for many physicians and staff. Keep in mind that doctors, at least in my generation, have been imbued with a culture of confidentiality. For me, HIPAA has not changed my personal practices as I’ve always kept protected information private. There are entire industries now whose function is to assure that billing software, electronic medical records (EMR) and various medical vendors are ‘HIPAA compliant’. Of course, I recognize that the EMR era has unique privacy concerns that must be addressed. Yes, privacy and protection are necessary, but HIPAA often extends further than it should and is often the grist for office eye-rolling banter.

But, as is often the case with bureaucratic mandates, common sense is left at the curb. Clearly, there are circumstances where absolute compliance should be relaxed even if this is a technical violation. Do we really want 100% HIPAA compliance? Do we ever want 100% compliance in any sphere? If we insist on a policy of zero tolerance of weapons in our schools, for example, do we support suspending a second grader who fashioned a gun out of a Pop-Tart? Zero tolerance invariably leads to absurd situations.

A woman fell and was sent by her doctor to the emergency room so that ankle X-rays could be done. Fortunately, there was no fracture. Afterwards, the doctor’s staff called the hospital to have the relevant records faxed, but the request was denied. The heavy hand of HIPAA was firmly raised. They would need a signed release by the patient to authorize transfer of records to the very doctor who sent the patient to the emergency room in the first place. The reason given was to be faithful to HIPAA. The woman does not have a fax machine and had to hobble from her condo to the front desk for the signing and faxing ceremony. Luckily, this forced ambulation did not further damage her ailing ankle.

Readers might be wondering how I am knowledgeable about an individual’s private medical information. The patient is my mother. I share the vignette even though I did not obtain her signed release authorizing me to disclose her protected medical information to my millions of readers. I now live in fear that a middle-of-the-night knock on the door will be the HIPAA police. If this blog and its author disappear, then you will know what happened.

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 informatics lessons of

The debacle of the Health Web site rollout will serve as a case study in curricula of business, political science, informatics, and other fields of study for years to come. It is unfortunate that the toxic politics of health care reform obscure other interesting lessons to be learned about large-scale IT initiatives applied to complex problems, such as trying to match individuals to health insurance plans available in their area and determining who is eligible for federal subsidies.

I count myself among those who have waited years for health care reform, seen an imperfect (but better than the status quo) plan signed into law, and then observed its rollout botched from both a technical as well as a communications standpoint. My views on the Affordable Care Act (ACA, aka Obamacare), not the focus of this post, are that it was the best that could be achieved politically at the time, and that it will hopefully be improved over time. The goal of providing health care to all Americans, including those who are not insurable by market-based mechanisms, is still a laudable goal. I am also dismayed by those who want to see the ACA fail at all costs, almost as if the fact that real people will be losing real health care coverage (or not having it in the first place) did not matter.
,br/>I also agree with those who note we cannot attribute blame of everything bad happening about health insurance to the ACA, i.e., health insurance costs continue to rise for reasons unrelated the ACA and employers would likely continue scaling back health insurance benefits regardless of whether or not the ACA were repealed. Well, maybe I did want to get some commentary in about the ACA after all, but the bottom line is that the pre-ACA status quo was not sustainable.

Nonetheless, what can we learn from the rollout from an informatics standpoint? One problem is clear, which is the federal procurement process for IT, about which even President Obama joked. This is issue is addressed well in context in a blog posting by Dr. David Blumenthal, the former Director of the Office of the National Coordinator for Health IT (ONC) who was appointed shortly after the first election of President Obama. Dr. Blumenthal noted the major differences between a typical large-scale federal IT procurement and the selection of an electronic health record (EHR) system for the large and venerable Partners Health System, which is anchored by two of the large Harvard Medical School teaching hospitals.

For the federal IT procurement, the agency (in this case, ONC) provides the specification and then in essence turns the process over to a separate contracting office in the government. This is in contrast to the Partners EHR decision, which was reached by a process that involved leadership guided by diverse expertise within the organization. This sounds to me like an informatics approach, from gathering the needs of the organization and giving voice to different stakeholders within it, to then seeing the entire selection process through to making a decision. Whether or not we call it "informatics," implementing a large complex IT project "takes a village" within organizations.

Another insightful blog posting comes from Clay Shirky, a well-known Internet commentator. He noted how the planning and rollout process defied well-known best practices for undertaking large, complex IT projects. Political necessities cannot bypass the reality of the incremental requirements gathering, setting reasonable timelines, and testing. Part of the problem, of course, is that the ACA needed to roll from a political standpoint in October 2013. Delaying longer would push implementation into the middle of the 2014 elections, which would make those elections potentially more unpredictable.

But political timelines aside, everyone with knowledge of complex IT projects knows that no amount of political or other wishful thinking can make a project happen faster than is possible. John Halamka, a well-known informatics blogger, rightly pointed out that few people remember a project launching somewhat late, whereas more people remember for a longer time when projects go poorly and caused disruption, as Health has. I myself have always believed that one of the major limitations of the HITECH program was its highly compressed timeline, mostly related to its being funded by a short-term federal economic stimulus. This was certainly true for many of the grant-funded activities under HITECH, such as the regional extension centers (RECs) and the workforce development program. The RECs, which were funded at about the same as the workforce development programs, needed trained personnel immediately. Yet the workforce development training programs needed some lead time to be developed, and even furthermore the curriculum for those programs should have had enough development time before those.

In conclusion, while not everyone uses the word "informatics" in their descriptions of what happened and what should have been properly done with Health, it is clear that the type of approach advocated by most who are trained in informatics would be more likely to achieve the outcome resembling the Partners EHR implementation than the Health debacle. This is not to say that projects led by informatics experts never fail. However, the involvement of stakeholders, glued together by informaticians who understand health care, IT, and their interactions, would likely have a probability of greater success. I acknowledge the previous sentence is not evidence-based, since one cannot carry out randomized controlled trials in these sorts of complex interventions. But there is plenty of accumulated knowledge and wisdom on the best practices that emanate when sound informatics principles are applied [1-4], and these should guide any type of complex health IT implementation.

I am sure there will be more lessons that emerge from the Health experience, and hopefully honest scholars will be able to peel back the toxic politics and truly allow learning to take place. I also hope we can achieve sensible answers in our quest to provide basic, high-quality, and affordable health care to everyone in the United States.


1. Barnett, GO (1979). The use of computers in clinical data management: the ten commandments. Society for Computer Medicine Newsletter. 4: 6-8.
2. Bates, DW, Kuperman, GJ, et al. (2003). Ten commandments for effective clinical decision support: making the practice of evidence-based medicine a reality. Journal of the American Medical Informatics Association. 10: 523-530.
3. McDonald, CJ, Overhage, JM, et al. (2004). Physicians, information technology, and health care systems: a journey, not a destination. Journal of the American Medical Informatics Association. 11: 121-124.
4. Sittig, DF and Singh, H (2012). Rights and responsibilities of users of electronic health records. Canadian Medical Association Journal. 184: 1479-1483.
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.