Friday, May 30, 2014

I still love being an internist

Many internists feel frustration over administrative burdens, a payment system that encourages you to decrease visit length (could we just ban productivity measures forever), maintenance of certification, the possibility of maintenance of licensure, and numerous regulations.

A recent Daily Beast article provides a very slanted view, How Being a Doctor Became the Most Miserable Profession. Multiple friends have sent me this article. I can only describe this article as hyperbolic.

This wonderful counter post expresses my feelings, Sorry, being a doctor is still a great gig, which reads: I think physicians complain far more, and far more publicly, than their situations warrant. For all their complaints, they still do incredibly well financially. They have more professional freedom than most working people. And they’re beloved.

I do know many happy physicians. These physicians focus on the positives in medicine.

Talk to most physicians and they still like interacting with patients. We all complain about various administrative issues, because we really do like spending our time with patients. We like the challenges that medicine provides.

I cannot imagine doing anything else. I cannot imagine a profession or a job that would challenge me intellectually and provides me the emotional satisfaction of knowing that I am trying to help.

We who are glass half full (or 3/4 full) people, focus on the positives and not the negatives. Obviously the half empty folks have greater focus on the negatives and no longer get great satisfaction from patient care.

We have problems in medicine, problems that we must identify and work hard to eliminate. But being a physician is inherently a wonderful life. I, for one, feel very fortunate to have this profession.

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.

Now what?

I really do not understand how Congress “works.” While it busied itself with passing a law that fails to fix the clearly broken Sustainable Growth Rate formula for Medicare physician payments, it added in a surprise for the entire health care industry: a provision that mandates a delay in the adoption of ICD-10 by CMS.

According to Modern Healthcare, it is not even clear which lawmaker added it to the bill.

It is no secret that several organizations, including the American Medical Association, strongly opposed the planned Oct. 1, 2014 implementation date. I was always ambivalent about ICD-10, for reasons that I have previously shared, but this delay seems like very bad public policy to me, for the following reasons:
1. It punishes the prepared who have hired and trained new coders, invested in new information systems and educated clinicians. The delay basically blows up work plans for a host of activities and leaves providers and payers in a bind. They can’t move forward, but they can’t easily suspend many of these activities either.
2. It creates uncertainty, which in many ways is the worst public policy. With every delay (this is just the latest of many) comes increased skepticism that the next deadline is “for real.” That, in turn, makes planning and preparing even harder.
3. The move to delay was a rider on a bill about something else. There was no transparency about who added it or why, and no opportunity for legislators to evaluate it on its merits. Not what I would call good government.

So, now what? I have no idea.

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--Prevention of secondary stroke also important during recovery

Low- to moderate-intensity aerobic activity, muscle-strengthening activity, reduction of sedentary behavior, and risk management for secondary prevention should be incorporated into the management of stroke survivors, a recommendation by the American Heart Association reads.

After stroke, 30% of survivors will have another one within their lifetimes, 18% of which will be fatal. “After stroke, health care professionals and stroke survivors tend to focus most of their rehabilitation on recovery, but the prevention of a subsequent stroke, as well as CAD and peripheral artery disease, is also an important task,” the authors wrote.

The scientific statement appeared online at Stroke.

Hospitalization and early convalescence should consist of low-level walking, self-care activities, intermittent sitting or standing, seated activities, or range of motion activities and motor challenges, the statement reads. The goal is to achieve increases in the resting heart rate of 10- to 20-beats per minute, using an interval or work-rest approach.

Inpatient and outpatient exercise therapy for aerobic improvement should target large-muscle activities such as walking, graded walking, stationary cycle ergometry, arm ergometry, arm-leg ergometry, or functional activities seated exercises. These can be done 3 to 5 days a week, in 20- to 60-minute sessions, or in multiple 10-minute sessions.

Inpatient and outpatient exercise therapy for muscular strength/endurance can include resistance training of the arms and legs, the trunk using free weights, weight-bearing or partial weight-bearing activities, elastic bands, spring coils, pulleys, circuit training and functional mobility. This can include 1 to 3 sets of 10 to 15 repetitions of 8 to 10 exercises involving the major muscle groups at 50% to 80% of 1 repetition maximum, for 2 to 3 days a week, with resistance gradually increased over time.

Flexibility exercises can include stretching of the trunk and extremities, using static stretches, holding for 10 to 30 seconds for 2 to 3 days a week.

Neuromuscular exercises can include balance and coordination activities, tai chi, yoga, paddles and balls to challenge hand-eye coordination, or computer games, 2 to 3 days a week.
Thursday, May 29, 2014

Getting granular about salt

In my prior column I made the case that worries about consuming too little sodium are substantially moot in the world where most of us do our eating. Sodium is an essential nutrient, and it is, of course, possible to consume too little. In much of nature (of the terrestrial variety), salt deficiency is a legitimate hazard, and the reason why many animals will make a pilgrimage to a salt lick. All of us who have completed medical training have seen hyponatremia (low sodium levels in the blood) in people as well, and it’s a very unpleasant condition to say the least. While more often due to a metabolic abnormality than low salt intake, cases of hyponatramia, which can be life threatening, vividly demonstrate that too little sodium is not a desirable alternative to too much.

So yes, we can consume too little sodium. And yes, we are rather uncertain at this point about what exactly the ideal threshold is, and just how universally it pertains. But despite any such distillation of misgivings and doubts, the present problem is clear enough. Whatever the optimal intake of sodium is, most of us in the modern world are well above it, with blatantly adverse health effects to show for it. A large aggregation of data from diverse sources indicates that human health improves when sodium intake is dialed down from the levels that now prevail.

So, since too much salt is one of the many ways the modern diet is broken, consuming less is the relevant fix. My argument is not that every question has been answered, but that we are better served to head productively toward the sweet spot than to let worries about overshooting forestall such progress altogether. Perfect is the enemy of good, and less salt would be good for most of us.

All the more so because most of our salt intake reaches us courtesy of processed foods that tend to carry other liabilities as well. The longer the ingredient list of a packaged food, the more sodium it is likely to contain, but also the more sugar (under whatever array of aliases); the more colorings; the more flavorings; the more food chemicals; and the more calories. A focus on eating less salt is no more necessary than a focus on eating less added sugar, or saturated fat, or trans fat, or calories. Rather, eat more “good stuff,” and the nutrient details tend to take care of themselves.

While true, that’s rather vague, and it may also seem a bit Pollyanna. That won’t do for a public health pragmatist like me, so I suspect a bit more granularity is in order. That, then, is today’s mission: getting granular about salt reduction.

Virtually all debate about optimal sodium intake refers to levels well below 2,500 milligrams per day, so we may comfortably accept that as a non-contentious target, apt to do us good. If we superimpose that sodium level on the prototypical diet of 2,000 calories, it gives us 1.25 milligrams of sodium per calorie. If the foods we eat average more than 1.25 milligrams sodium per calorie, our diet will provide more than 2,500 milligrams per day. If salty foods pull our average up, we must rely on non-salty foods to pull it down, so we land somewhere in proximity to the 2, 500 milligrams total.

But what are the salty foods that pull our average up? The usual suspects no doubt come to mind: soup, condiments, and everything in the “salty snack” aisle of the supermarket. If that were the whole story, we’d be in much less of a pickle. Alas, it is not.

Consider that America, purportedly, runs on Dunkin’. So a typical American day might begin with Dunkin’s bacon, egg, and cheese breakfast sandwich. If it does, it starts out with 460 calories, and 1,200 milligrams of sodium. That’s 2.6 milligrams of sodium per calorie, or well over twice as salty as you want your diet to be on average. If breakfast is pulling average salt intake up, what is the chance that lunch and dinner, where the truly salty foods tend to cluster, will pull it down?

Lest you think I am cherry picking my examples, note that most of Dunkin’s other sandwiches, both breakfast and bakery, are more concentrated in sodium than the example I chose. And there’s no reason to pick on Dunkin’; McDonald’s Egg McMuffin delivers 840 milligrams of sodium in 300 calories.

But then let’s presume that you are far too fastidious to have a fast-food sandwich for breakfast. If instead you have a bowl of, say, the seemingly quite virtuous Grape-Nuts cereal, you are getting 290 milligrams of sodium per 210-calorie service. That is, you guessed it, more than 1.25 milligrams per calorie. Grape-Nuts is saltier than our diets should be on average. And no need to pick on Grape-Nuts, either; the same is true of Cheerios, Life cereal, and even Frosted Flakes. Almost the entire inventory of America’s most popular breakfast cereals is saltier than our diets should be on average.

From here, the news could readily go from bad to worse. The Center for Science in the Public Interest has published summaries of both processed foods and restaurant dishes that are not just highly concentrated in sodium, but in some cases deliver nearly a two-day supply (i.e., nearly 5 grams!) in just one dish.

But more bad news won’t help us, so let’s shake things up. Where is the good news?

You may be surprised. Consider, for instance, that Garden of Eatin’, one of my favorite chip brands (yes, I do think the nutritionally virtuous can occasionally eat chips!), offers yellow corn chips, ostensibly a salty snack, with just 70 milligrams of sodium per 140 calories. That’s just 0.5 milligrams sodium per calorie. So this so-called salty snack helps pull down, not up, the average salt level in our diets. Many other offerings in the salty snack aisle do the same. How can that be?

The matter reverts back to the overall degree of processing. The Garden of Eatin’ chips in question have just three ingredients: organic corn, oil, and sea salt. Breakfast cereals with much higher doses of salt taste less salty because other ingredients, notably sugar, mask the salt flavor. (They also taste less salty because our palates have acclimated to, and been desensitized by, the ridiculously high levels of salt and sugar in our diets. This process can be reversed!) When ingredients are few, and nothing obscures the taste of salt, it takes much less of it to impress our taste buds.

This is a generalizable theme. There are breakfast cereals made from short lists of wholesome ingredients that provide dramatically less sodium than the more processed popular brands. The popular Lucky Charms sports a long ingredient list that is not only home to at least 4 dyes and artificial flavors that help multi-colored marshmallows impersonate breakfast, but also provides cover for about 1.7 milligrams of sodium per calorie. So while sugar and chemistry are the obvious liabilities of this product, it is also far saltier than our diets should be on average. In contrast, one of my favorite breakfast cereals, Nature’s Path multigrain, has 1 milligrams of sodium per calorie.

Shorter, simpler ingredient lists are associated with less sodium in not just chips and cereals, but also breads, crackers, dairy products, snack bars, spreads, dressings, sauces, and even meats. These products tend to have less added sugar, too; to avoid harmful oils; to have more beneficial nutrients; and to help fill us up on fewer calories. Of course, to whatever extent you can prioritize foods with an ingredient list just one word long, apples, bananas, tomatoes, carrots, walnuts, broccoli, lentils, and so on, you reach the very pinnacle of this opportunity. Such foods don’t just help pull down our overall sodium intake, they help pull up the overall quality of our diets.

My colleagues and I developed, studied, published, and offer for free a food label literacy program called Nutrition Detectives designed to help kid and their parents trade up food choices in any given category. You can help yourself to the program if so inclined. Minimally, note that one of the 5 clues that constitute the program’s punch line is this: the shorter the ingredient list, the better. Better means much more than less sodium, but it tends to mean that into the bargain. For those with access toNuVal, the nutrient profiling system we similarly developed, studied, and published, higher scoring foods in any given category similarly offer better overall nutrition, and less salt as part of that formula. We have evidence as well that such trade-ups can be made using either approach without spending more money.

The copious excesses of sodium to which we are all exposed reside not just where we would expect them, but almost everywhere in the modern foodscape. The good news is that in all those same food categories there are alternative choices that are simpler, tasty, more nutritious, often no more expensive, and less salty besides. The very granular strategy of choosing foods with shorter ingredient lists allows for cutting out many superfluous grains of salt by way of improving overall nutritional quality. There should be no controversy in that.

QD: News Every Day--Circumcision associated with less prostate cancer in blacks, men over 35

Circumcision at birth may help prevent prostate cancer in black men, with a stronger association also noted among men of all races circumcised after age 35, a study found.

Canadian researchers conducted an observational study of nearly 1,600 prostate cancer patients diagnosed in a Montréal hospital between 2005 and 2009, as well as more than 1,600 healthy controls.

Results appeared at BJU International.

Circumcised men had a slightly lower but not statistically significant risk of developing prostate cancer than uncircumcised men (OR, 0.89; 95% CI, 0.76 to 1.04). Circumcision did have a protective effect in men circumcised after age 35 (OR, 0.55; 95% CI, 0.30 to 0.98). A weaker protective effect was seen among men circumcised within 1 year of birth (OR, 0.86; 95% CI, 0.72 to 1.04).

Men circumcised after age 35 may have had a pathologic condition of the foreskin that lead to them being circumcised, an author noted.

Black men had the strongest protective effect (OR, 0.40; 95% CI, 0.19 to 0.86, P-value for interaction, 0.02). No association was found among other races.

“This is a particularly interesting finding, as black men have the highest rates of prostate cancer in the world and this has never been explained,” an author noted.

Circumcision may reduce the risk of contracting and maintaining a sexually transmitted infection, which has been postulated to be a risk factor for prostate cancer. This may explain the reduced risk of prostate cancer observed in males circumcised at a younger age prior to any potential exposure to infection.
Wednesday, May 28, 2014

QD: News Every Day--Wikipedia may not be a reliable resource for medical conditions

Wikipedia articles for 9 of the 10 most costly medical conditions in the United States contained many errors when checked against standard peer-reviewed sources, a study found.

Physicians and medical students have been using social media and web-based resources as part of the care they deliver, leaving some experts “frightened.”

Researchers compared Wikipedia articles on the 10 most costly medical conditions with standard, evidence-based, peer-reviewed sources. Reviews were conducted by either an internal medicine resident or a rotating intern physician.

Results appeared in the Journal of the American Osteopathic Association.

The Wikipedia articles that contained assertions inconsistent with peer-reviewed sources included those on coronary artery disease, lung cancer, major depressive disorder, osteoarthritis, chronic obstructive pulmonary disease, hypertension, diabetes, back pain, and hyperlipidemia. The Wiki page for trauma-related disorders such as concussions was deemed OK.

An editorial by a medical librarian pointed out that there may be reasons why physicians choose Wikipedia over other more properly vetted resources. Subscription costs, convenience, popularity, ease of use, or a lack of information literacy skills might all play a role.

“Wikipedia has a place in literature searching, but it is best used as a starting point rather than an ending point,” the editorial states. “Wikipedia is attempting to upgrade its health content by offering a voluntary peer-review process. If physicians can make a commitment to edit Wikipedia content, then Wikipedia might have a chance at becoming a more reliable, peer-edited clinical decision tool.”

Get cancer. Lose your job?

Let’s start with this fact: If you are employed and get a breast cancer diagnosis, it’s less likely you’ll be working at your job 4 years later. A newly-published study of women in Los Angeles and Detroit found that among women less than 65 years with limited-stage breast cancer, 76% had a paying job at the time of their diagnosis. Based on follow-up surveys of the same women 4 years later, the number employed was reduced by 30%. That’s a huge drop.

The study was just published on-line in the Cancer Journal. The authors, including a corresponding and lead author in a department of radiation oncology at the University of Michigan, make a point in the paper’s title, Impact of Adjuvant Chemotherapy on Long-Term Employment of Survivors of Early-Stage Breast Cancer, that chemotherapy may be to blame. And there’s some truth in this. Chemotherapy causes fatigue and, occasionally lasting problems such as neuropathy, heart weakness, and chemobrain, that might limit or impair a person’s capacity to work effectively.

On the other hand, the likelihood of developing many of those chemo-related effects depend on the dose and regimen selected. Radiation, often, causes fatigue, and, when administered to the chest, can cause premature heart disease (atherosclerosis) and lung problems, besides secondary tumors as a late consequence of treatment. It happens, though, that hormonal treatments, like Tamoxifen, can cause chemobrain too.

As someone trained to give chemotherapy, I’ll point out that none of these options for adjuvant treatment (what’s given to patients with limited disease to lessen the likelihood of recurrence) is a walk in the park. Each bears the potential for short and long-term toxicity. So I don’t blame chemotherapy in particular, although the study authors emphasized that as a culprit based on a low-level statistical correlation.

This news comes as no surprise. I know too well how women at work may be treated after a breast cancer diagnosis. I am privy to the stories of dozens of women who say they were unduly turned down for promotions or good assignments, opportunities … Upon returning to work, if they took time off (which some didn’t, such as your author, during her breast cancer treatment), they, if they take pride in their work, find themselves missing their own doctors’ appointments, exercise and other aspects of survivorship care, just to “prove” that they’re still valuable to their office, team, and business.

The harsh reality is that people who have had cancer treatment are sometimes perceived as a burden on a working group: a consultant who can’t travel quite so much, a sales rep who looks less beautiful, a nurse who has to take an occasional half-day off for a check-up. Some bosses worry, although you’d be hard-pressed to find this in writing, that an employee who had cancer treatment may suffer a recurrence, and so she can’t be counted on, no matter how capable and motivated she may be, to lead a fellowship program, or to complete an ambitious project.

What would help is for doctors to guide patients with more nuanced advice, to avoid over-treatment. And patients should ask their physicians, based on their circumstances, for the least therapy that makes sense based on the size and molecular details of their tumor, to avoid long-term toxicity. And for employers to treat their workers who have illness, and not just breast cancer, as potentially valuable workers, contributors, over the long haul.

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.
Tuesday, May 27, 2014

E-cigarettes and the FDA: Where should we stand?

People have smoked tobacco for centuries, possibly thousands of years, and cigarettes were first machine made in France in the 1880s. In the U.S., smoking peaked in the year 1965 when 50% of men and 33% of women smoked, with a per capita consumption of more than 4,000 cigarettes per year. When health effects of smoking began to be widely publicized, particularly its association with lung cancer, cigarette smoking began to decline.

Nicotine, the psychoactive ingredient in cigarettes, is addictive, producing a withdrawal syndrome that is at least partially relieved by nicotine replacement. Cigarette smoking, though, also has cultural meaning, which has contributed to its popularity. For decades therapeutic nicotine replacement has been available to people who want to quit smoking, first only by prescription, but now over the counter since the 1990s. The first product, a nicotine chewing gum, was released in the late 1970’s, followed by a patch, a nasal spray and finally an inhaler. The inhaler delivered an aerosol of a nicotine solution from a cartridge attached to a small plastic mouthpiece which is absorbed primarily through the mucus membranes of the mouth. My patients told me that it tasted nasty and it made them look like they were sucking on a tampon. It was a great idea, but not very well executed.

It always seemed to me that what was really needed was a device that looked like a cigarette and delivered nicotine to smokers without the toxic chemicals that were associated with burning tobacco. Nicotine itself, other than being addictive, is not particularly toxic and certainly doesn’t cause lung disease, atherosclerosis, or cancer. In 2003 a Chinese pharmacist Hon Lik (per Wikipedia) invented the first electronic cigarette, which vaporized a solution of propylene glycol and nicotine for inhalation. Within a year a similar device was marketed in China for helping people quit smoking.

Other technology has subsequently been introduced, mainly based on the aerosolization of a nicotine solution by a battery powered heated coil inside a vaguely cigarette shaped device. Flavors are often added, and some e-cigarettes have only flavor and no nicotine. European tobacco companies have been enthusiastic about inventing and developing their versions of e-cigarettes, and Phillip Morris, a U.S. tobacco company, has bought the rights to a nicotine delivery device based on the aerosolization of nicotine by pyruvate, which would not require a battery or produce smoke.

Looking online, I see that I can buy an e-cigarette starter kit for about $25, and the e-juice (nicotine solution) to fill it for about $1/mL, and it looks like 1 mL yields about 120 puffs. I can also buy a pack of FDA-approved Nicorette inhalers, 20 in a pack, for about $30, and according to the package, a smoker would use 3-6 cartridges a day. Sounds like about $7.50 a day. The forums on e-cigarette use are all over the place, but it sounds like a heavy user might inhale 4 mL a day or so, a more moderate one 1 mL, so $1 to $4. Disposable ones can cost more. Cigarettes, depending on where you live, cost upwards of $5 a pack, as much as $14.50 in New York.

E-cigarettes have developed quite the following, and have their enthusiastic and stylish supporters. Using an e-cigarette, or cartomizer, is called “vaping” and some people are excited not just about the nicotine, but also about the devices and flavors and overall coolness of the technology. Poisoning has been reported, primarily due to young children drinking the replacement solution. There is no significant evidence of toxicity related to using the devices as recommended. The Food and Drug Administration (FDA) does not presently regulate e-cigarettes, but recently announced a plan to categorize them as a tobacco product, requiring producers to register and to share with the FDA details about how they are made and what they contain. They also would not allow free samples or purchase by anyone under the age of 18. Manufacturers would not be able to say, without proof, that e-cigarettes are safer than cigarettes and would have to say that nicotine is addictive. These proposals are still being discussed it is not clear when or if they will be adopted.

Which brings up a very important point. We don’t actually know if e-cigarettes are safe or if they help people quit smoking. It seems likely that if there is a cheaper alternative to cigarettes that gives a person the same nicotine high, tastes like pomegranate (or strawberry or whatever) rather than burning leaves, can be used in public places and costs a fraction of what cigarettes do, people will tend to prefer it. But we don’t know this. It seems likely that a product that contains nicotine rather than burning leaves with associated carbon monoxide and carcinogens will cause less health problems, but we also don’t know this.

There are so many competing e-cigarette producers that none is likely to come up with the money to support research that would be convincing of the safety and effectiveness of the whole class of products, including those made by their competitors. Some small studies are mostly encouraging. Compared to cigarette smoke extracts, the extracts of e-cigarettes are much less toxic to mouse fibroblast cells. Air quality was not significantly affected by e-cigarette use for the compounds tested, including glycols (which would be expected to be found in e-cigarette smoke) along with other standard pollutants found in high levels when cigarette smoking is present. About 400 e-cigarette users were followed for a year, to look at use of both e-cigarettes and tobacco cigarettes. E-cigarette use was about stable over the year, and for former smokers there was a 6% relapse rate to tobacco, whereas about 46% of subjects who smoked tobacco as well as e-cigarettes completely ceased using tobacco at the end of a year. One study of smokers and nonsmokers showed no significant reduction in lung function acutely after using e-cigarettes briefly, but another slightly larger study of smokers only showed a restriction of airflow in smokers after using e-cigarettes for 5 minutes. No studies have addressed long term lung effects of regular use of e-cigarettes, and this information is much more relevant.

So where should we, as physicians, stand on the subject of e-cigarettes? First and foremost, not on the side of ignorance. I hear many physicians speak out for or against e-cigarettes without knowing anything about them. My own hospital banned them, as have many other hospitals, based on not very much real information. Countries around the world ban them or regulate them or ignore them completely, based primarily on opinion. They are legal in Germany. They are regulated as a medicinal product in Denmark. They are illegal with a heavy fine in Hong Kong, but legal in China. In Hungary it is legal to buy them and use them but it is illegal to sell the nicotine solution.

I tend to think that e-cigarettes are a good invention. I suspect that if they came out several decades ago our smoking related morbidity would be much lower. They have the potential to come pretty close to eliminating tobacco smoking, much more effectively than regulation and physician nagging has done. They will not reduce nicotine addiction and have the potential to increase it, but it is not clear that nicotine addiction is a public health problem. Clearly good research is important, and it is likely that convincing evidence of safety will not be available for years, and will have difficulty finding funding. Phillip Morris probably will be first to show their product to be safe, if it is, but it will be in their best interest to make sure that data is not generalizable to other e-cigarettes.

The FDA is right to regulate the e-cigarette industry and to require that the manufacturers be honest about what is in them, since there are quite a number of chemicals that make people sick when they are aerosolized and inhaled. Even if e-cigarettes aren’t exactly food or drug or tobacco product, they are somewhere in between all of these things and their popularity gives them tremendous potential to do harm if nobody is watching. Even so, creating excessive burdens that interfere with their ability to successfully undermine the tobacco industry (about which there is truly nothing good to say) would be an error.

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--The poor die from cancer; the rich, with it

Certain cancers are more concentrated in areas with high poverty, while other cancers arise more often in wealthy regions, according to a study that also concluded poorer areas had lower cancer incidence but higher mortality than wealthier ones.

Results appeared in CANCER.

Socioeconomic status may influence the type of cancer a person may develop, so researchers assigned nearly 3 million tumors diagnosed between 2005 and 2009 from 16 states plus Los Angeles, an area covering 42% of the U.S. population, into 1 of 4 groupings based on the poverty rate of the residential census tract at time of diagnosis. All cases were geocoded by the registries and 2000 census tracts. A poverty level was assigned to each case based on the percentage of individuals living below the poverty level: less than 5%, 5% to less than 10%, 10% to less than 20%, and 20% or more.

For all cancer types combined, there was a negligible association between cancer incidence and poverty. However, of 39 cancer types, 14 were positively associated with poverty and 18 were negatively associated.

Kaposi sarcoma and cancers of the larynx, cervix, penis, and liver were more likely in the poorest neighborhoods. Melanoma and cancers of the thyroid, other non-epithelial skin, and testis were more likely in the wealthiest neighborhoods.

Cancers more associated with poverty have lower incidence and higher mortality, and those associated with wealth have higher incidence and lower mortality, researchers said.

New technology makes it easier to link patient addresses with neighborhood characteristics, therefore making it possible to incorporate socioeconomic status into cancer surveillance, and this study shows the importance of including measures of socioeconomic status in national cancer surveillance efforts, researchers wrote.
Monday, May 26, 2014

Google hangouts on Air - a game changer for CME?

I recently had an opportunity to put together a CME course on Social Media and Web 2.0 in Medicine for the Cleveland Clinic CME department. After the participants had learned about and had a chance to experiment with Twitter and Google+ hands on, we wanted to organize a panel discussion with several social media experts in the healthcare arena. The budget for the CME course would not accommodate travel expenses to get panelists from out of town for a face-to-face discussion. In addition, it would be quite inconvenient to have people travel for a “one-hour” panel discussion. These factors would limit who we could invite to the panel.

So instead of compromising on our panelist selection, we decided to explore options for doing an online panel discussion. Since the course was on the use of social media the natural choice was to do a Google Hangout and broadcast it live on YouTube (Google Hangout on Air). What could be better than using the tools that you are learning about in the course!

The panelists were:
Vineet Arora (@FutureDocs)
Katherine Chretien (@MotherinMed)
Anne Marie Cunningham (@AMCunningham)
Michelle Kraft (@Krafty)

This is the YouTube video of our Hangout on Air. For a first time effort, it worked pretty smoothly. If you think you may want to do one of these yourself, read on.

The process of setting up the Google Hangout on Air the first time can be complex. So I am listing the steps here in case someone else wants to try this out.
• Make sure all the panelists are on Google+ and you have circled each other
• Make sure your YouTube account is linked to your Google account.
• Click Hangout from the menu on the left and click on Start Hangout on Air
• Give the Hangout a name and invite someone to it. This does not have to be the panelists or the audience. I have a couple of different Google+ profiles and I just invite myself to it.
• Now start the Hangout
• Click on agree to any notifications that come up
• Invite your panelists
• This part is still not LIVE. This is called the green room.
• You can talk to panelists, adjust lighting, microphones, go over the logistics etc.
• You can have everyone install the app Hangout tool box and enable the lower third (allows everyone to add their name and tagline or affiliation). This will look mirrored but will appear correctly oriented for the audience.
• From the bottom right grab the YouTube link (this is the URL where the broadcast will appear live on YouTube).
• Share this URL with the audience - either on Google+, in a private community or Twitter or Facebook.
• When they click on the link they will see a YouTube video with the message “Starting soon”.
• Now click on Start broadcast. In about 10 seconds the broadcast will go live. You can start your panel discussion as soon as it goes live.
• The moderator (the person who initiates the Hangout) can control which speaker shows up in the main window by clicking on their profile in the bottom of the hangout window
• The YouTube video shows up after a short delay (about 30 seconds) but then runs quite smoothly.
• Once the discussion is over, stop the broadcast
• You can debrief with the panelists and then end the broadcast.
• Afterwards you can edit the video adjust the title, description etc and then set the privacy settings in your YouTube video manager.

Several course participants were surprised learn about this functionality of Google+. Several wanted to know how they could do this. Our CME department wanted to discuss various uses for this technology both for live courses and for creating enduring material.

Consider the advantages of this technology for CME
1. Cost savings (Travel costs and free technology)
2. Convenience
3. Ability to invite best panelists/speakers without above limitations
4. Feasible to for live audiences both face to face and remote
5. Since YouTube automatically archives the session, you can also embed the videos into online enduring materials.

Google+ Hangouts on Air might just be a game changer for CME. What do you think?

Neil Mehta MBBS, MS, FACP, practices internal medicine at a large tertiary care hospital in Ohio. He is also the Director of Education Technology (Academic Computing) for his medical school and in charge of his hospital system's home grown Learning and Content Management System. He is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management. This post originally appeared at Technology in (Medical) Education.
Friday, May 23, 2014

Since knowledge evolves, what is the implication for performance measures?

Recently I had a wonderful conversation about how medicine changes. One colleague gave the example of ulcer disease. Those who trained in the 1960s and 1970s know most of this history, but it actually goes back to the early part of the 20th century.

Consider the Sippy diet, the Bilroth 2, highly selective vagotomy, the introduction of H2 blockers, the introduction of PPIs, and then the crazy idea that a bacteria causes ulcer disease.

At many points in time, one could now imagine a performance measure that would now create laughter.

In the early 80s we castigated students and residents for using beta blockers in patients with heart failure, now with systolic dysfunction we would castigate those who did not use beta blockers.

I think we are making progress in our understanding of disease and the management of disease. But what will we say 20 years from now.

We have performance measures based on rather weak evidence. Expert opinion does not substitute for strong evidence.

The naive believe that we can measure physician quality. We cannot. Quality has too many legitimate dimensions. Not all those dimensions are measurable.

In another discussion yesterday, several physicians discussed how history taking (the first, and perhaps most important step to correct diagnosis) requires a variety of skills. We must learn how to ask each patient the proper question. That question changes according to the patient’s background, education, and personality. We must become comfortable reading body language and facial expressions. We must have the patience to wait for the patient. We must convince the patient that we really are non-judgmental so that whatever they tell us is just information and does not induce a harsh reaction.

We are complex beings and we react to disease or diseases in various ways. We have different goals once we have a disease. The best physicians really do treat the patient rather than the disease.

Yet our performance measures focus primarily on the disease, not the patient. Our performance measures rarely measure our diagnostic ability. Our performance measures do not consider the patient’s disease burden and how we prioritize treatment.

Knowledge will continue evolving. We will continue our quest to improve patient care. But will performance measures based on weak evidence help?

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.

QD: News Every Day--Many women who underwent double mastectomies didn't have risk factors

Nearly 70% of women who underwent a double mastectomy didn’t have the major genetic or familial risk factors that would indicate contralateral disease, a study found, although having an MRI during the diagnosis did lead to more of the surgeries.

The growing use of MRI as part of the diagnostic workup in patients with breast cancer may detect occult lesions for which treatment is not likely to improve outcomes for patients, study authors noted, so they conducted a longitudinal survey of women newly diagnosed with breast cancer in Detroit and Los Angeles registries from June 1, 2005, to Feb. 1, 2007, and again 4 years later.

Results appeared in JAMA Surgery.

Of the more than 1,400 women in the analysis, 18.9% strongly considered double mastectomy, or contralateral prophylactic mastectomy (CPM) and 7.6% underwent the procedure. Of those who strongly considered double mastectomy, 32.2% received it. But, the majority of patients (68.9%) who received double mastectomy had no major genetic or familial risk factors for contralateral disease.

Among the rest of the 1,400 women who didn’t undergo double mastectomy, 45.8% underwent unilateral mastectomy and 22.8% received breast conservation surgery.

Undergoing double mastectomy was significantly associated with having undergone genetic testing (vs. unilateral mastectomy, relative risk ratio [RRR]: 10.48; 95% CI, 3.61 to 3.48 and vs. breast conservation surgery, RRR: 19.10; 95% CI, 5.67 to 56.41; P<0.001).

A strong family history of breast or ovarian cancer was significantly associated with double mastectomy (vs. unilateral mastectomy, RRR: 5.19; 95% CI, 2.34 to 11.56 and vs. breast conservation surgery, RRR: 4.24; 95% CI, 1.80 to 9.88; P=0.001).

Having undergone MRI was significantly associated with double mastectomy (vs. unilateral mastectomy RRR: 2.07; 95% CI, 1.21 to 3.52 and vs. breast conservation surgery, RRR: 2.14; 95% CI, 1.28 to 3.58; P=0.001).

Also, associated factors included higher education (vs. unilateral mastectomy, RRR: 5.04; 95% CI, 2.37 to 10.71 and vs. breast conservation surgery, RRR: 4.38; 95% CI, 2.07 to 9.29; P<0.001), and greater worry about recurrence (vs. unilateral mastectomy, RRR: 2.81; 95% CI, 1.14 to 6.88 and vs. breast conservation surgery, RRR: 4.24; 95% CI, 1.80 to 9.98; P=0.001).

Worry about recurrence appeared to drive decisions for double mastectomy although the procedure has not been shown to reduce recurrence, the authors noted.

“Educational materials and decision tools for average-risk patients making initial breast cancer treatment decisions typically do not include information about CPM, actual risk of contralateral breast cancer, or interpretation of genetic test results. Such information could be useful for women making these decisions,” the authors wrote. “However, our findings that CPM was strongly associated with higher educational attainment suggests that improved knowledge may not be sufficient to address patient factors, such as worry about recurrence, motivating strong consideration of the procedure. Furthermore, the association found between diagnostic MRI and receipt of CPM indicates a need to consider strategies for educating both patients and clinicians about the impact of extensive testing on treatment decision making.”

An invited commentary stated that decisions about double mastectomies are made at an emotional time that make it difficult to balance the true risks and benefits. Better shared-decision making is needed. “While CPM might be considered overtreating women without clinical indications, it might still be the right choice for some women for risk reduction, cosmetic, and/or emotional reasons.”
Thursday, May 22, 2014

Of salt, 'saltation' and salience: the case for fixing what's broken

We have long had abundant reason to believe that most of us living in the modern world consume too much sodium and would benefit from consuming less. But whether the topic is salt, or saturated fat, or calories, or even the health effects of consuming vegetables and fruits, saltation (the jumping from one position to another) seems to be the prevailing inclination in modern nutrition. Certainly it is the inclination that predominates in the popular press. Salt is just the latest nutrient to get caught up in that proclivity.

This isn’t the first time salt claimed its 15 minutes of notoriety. Just less than a year ago, I was prompted to address this issue by an Institute of Medicine report questioning the gospel of “less is better” with regard to sodium intake. Two recent studies compel me to revisit the topic now. For those who like the punch line up front, I can tell you my conclusion is much as it was. I remain convinced that most of us consume too much salt, and would benefit from reducing our intake. And yes, of course, it’s possible to consume too little.

Of the 2 recent studies on salt intake and health outcomes, predictably the one that challenged the prevailing view garnered more media attention. That study, published in the American Journal of Hypertension in early April, was a meta-analysis examining sodium intake in populations around the world and its association with both all-cause mortality and cardiovascular disease.

The authors concluded that mortality and heart disease rates were higher among those with both low and high sodium intake, and lower for those with intake in the middle range. Because dietary guidelines from the relevant authorities, including the IOM, the CDC, and the U.S. Department of Agriculture all emphasize a reduction in our customarily excessive salt intake, the more provocative message in this study was the potential danger in consuming too little. So “salt guidelines are too low“ was the common pop culture assessment.

But there are a few problems with that conclusion. First, as the study authors stated, the increased risks of both heart disease and mortality were greater with high sodium intake, than with low. So if we were ranking our concerns based on this study alone, excess sodium would still be the bigger problem.

Second, the authors noted their meta-analysis was based almost entirely on observational, not intervention, trials. This meant studies simply looked at variation in sodium intake and compared that to variation in health outcomes. Studies like that beg the question: What accounted for the sodium variation in the first place? Some health conscious people may have a very low intake of sodium, but others likely to land there are people with maladies affecting the heart or kidneys, people who are under-nourished for any reason, and so on. The authors attempted to account for such considerations, but acknowledged a limited ability to do so. In other words, this study had limited capacity to tell us whether low sodium intake resulted in poor health, or whether poor health resulted in low sodium intake. Chances are there was some of both in the mix.

The more recent study, just published online in the British Medical Journal, took headlines in the opposite direction: Too much sodium is the problem after all. For this study, investigators tracked dietary patterns, including sodium intake, and sodium excretion, in representative samples of the population of England. Over the past decade, they tracked a number of dietary changes, and conducted analyses to determine the association of each with health outcomes. The particularly noteworthy findings were a reduction in sodium intake and excretion, associated with a population-wide reduction in mean blood pressure, in turn associated with a marked reduction in the mortality rate from both stroke and heart disease.

This study is subject to limitations of its own. But it does not suffer the problem of temporal association that bedevils the first. The gist is clear: A population-wide reduction in sodium intake over the past decade is almost certainly at least part of the reason for a population-wide reduction in blood pressure, and cardiovascular mortality.

But conclusions about sodium in our diets should not be based on any one study, whatever its strengths or weaknesses, but rather the overall weight of evidence. That remains rather clear. Average sodium intake levels in the U.S. and much of the modernized world are higher than advised. Intervention studies, such as DASH, that have lowered levels to approximate prevailing guidelines, have lowered blood pressure as a result. Blood pressure reduction in turn has been strongly and consistently associated with reduced risk of both heart disease and stroke.

But there is more. Paleo diet enthusiasts rightly note that our native dietary intake pattern is likely to be “good” for us, since it is the pattern to which we are adapted. That adaptation is a powerful influence. It’s why koala bears should eat eucalyptus leaves, and lions should eat wildebeest. It stands to reason that adaptation is relevant to our species as well. There are many implications of “native” eating for Homo sapiens, but one of them is a much higher intake of potassium than sodium. The modern diet typically reverses this ratio. Arguments for sodium reduction thus derive from both modern science, and paleoanthropology.

Finally, the source of sodium is a relevant consideration. Roughly 80% of the sodium in the typical American diet comes not from personal use of a salt shaker, but from salt processed into our food before ever we get our hands on it. This implies that sodium intake tends to come down with consumption of less processed foods overall. While reduced sodium intake is likely beneficial in such context, the context of a less processed diet is apt to be beneficial in a variety of ways. With sodium, as with other nutrients of concern, if we get the foods and dietary pattern right, nutrients tend to take care of themselves.

Of course, the contention that we should reduce ambient sodium intake not by focusing on sodium, but by eating “food, not too much, mostly plants,” invites the customary rebuttals: That’s elitist, unrealistic, too expensive, and too hard. I disagree with these assertions and have addressed them in very practical terms. My group has studied the costs of trading up to better, less-processed, and among other things, less-salty options in any given food category, and found that it can generally be done without spending more money. We have developed and studied a nutrition guidance system and a free food label literacy program, showing that both can help people get there from here. Of importance to everyone who isn’t a card-carrying member of the foodie elite, it is possible to trade up nutrition (and dial down sodium) without swapping out chips for chard; it’s possible to make meaningful progress by eating better chips.

Sodium is an essential nutrient; of course we could, in principle, eat too little. We could, as well, drink too much water. Or exercise too much. Or sleep excessively. Or spend too much time fortifying bonds of friendship. I suppose we might devote too much of each day to hugging.

But really, what are the odds? We sleep and hug too little, work and stress too much. The theoretical dangers of overshooting are not a good reason to neglect what is currently broken.

Average sodium intake in the U.S. hovers well about 3,000 mg per day. While there is legitimate debate about health effects at levels below 2,300 mg per day, there is little about levels between here and there. Just to hit the targets in which we do have confidence, we have a long way to go. So it seems very premature to start encouraging people to worry about overshooting.

The prevailing fashion in nutrition, if not all of health news, is contrarianism. Cutting back on salt was yesterday’s news. If today’s news were the same as yesterday’s news, we might not be confused, and desperately in need of tomorrow’s news to help sort it all out. We can’t have that! So as never before, contrarians and iconoclasts own the headlines.

But they don’t really own the science, which is, as ever, a product of the gradual accumulation of data and genuine understanding over time, not the single study that grabs 15 minutes in the spotlight. And they don’t own our common sense, which should tell us that worrying about doing too much is not a good reason to avoid doing enough.

The “salutatory” headlines notwithstanding, an excess of sodium is the salient, clear, and present danger for modern societies. While allowing for the hypothetical hazards of going too far, we should focus for now on fixing what we know to be broken.

Hospital medicine: Driving the future of health care

Hospital medicine has rapidly become one of the largest specialties in the United States. As the number of practicing hospital medicine doctors soars above the 30,000 mark and healthcare reform takes hold, the specialty finds itself at the forefront of American medicine. And for good reason. It is a young, dynamic, varied and flexible specialty that can be practiced in a number of different settings. Hospital medicine doctors are no longer just the “stand-in” for the patient’s primary care physician. Hospitals all over the country are increasingly looking to hospitalists to drive quality improvement forward. Having been in practice for over 5 years, I feel that the best and most committed hospital medicine doctors (that I myself have used as role models) have been the ones who enjoy patient care above all else, and then find a particular niche that they become expert in.

I have had the opportunity to work in a number of different hospitals up and down the East Coast, ranging from large urban medical centers, to more rural community hospitals. The challenges faced in many of these places are almost identical. I would like to identify 5 areas to focus that will take our specialty to the next level:

1. Rounding models

Currently, most hospitalists typically have patients scattered around the hospital on different floors. Their patients will be seen at completely random times. One may be seen at 7:30 a.m. and another at 3 p.m., often with no rhyme or reason behind the times. The solution to this problem is to institute good old-fashioned ward rounds, ideally multidisciplinary rounding within the patient’s room. This should be accomplished on all the patients by mid/late morning, with a definitive plan in place that is clear and succinct. Such a system works best when all patients are kept on one floor, in a geographical rounding model. This has a whole host of additional benefits, including vastly improving efficiency and reducing the volume of pages.

2. Program organization

Unfortunately most hospitalists work in a system of “hospital medicine chaos.” I use the term endearingly, because it’s not the fault of any doctor or even hospital. It’s the fact that our specialty is still new and largely disorganized. Hospitalists need to be able to focus on each patient, and not be multitasking to an unsafe degree. As well as more organized rounding models, programs can do this with other techniques such as utilizing a dedicated “admitter” in the emergency room and making sure that any additional call coverage is manageable. This will enable a better focus on metrics such as early discharges, reducing length of stay, and higher patient satisfaction.

3. Transitions of care

Two particular problems are admission medication reconciliation and the discharge process. The former has been a problem in every hospital I’ve worked in. It often seems impossible to get a complete and accurate medication list. There are a number of reasons why this eludes us, including the patient themselves not knowing what they are taking, and the admitting doctor having several different lists available to them! We need to get a “no ifs, ands, or buts medication list.” Studies are increasingly proving the value of pharmacists stationed in the emergency room to hand hospitalists this list when patients are admitted. Think this is expensive? Consider the reduced medication errors and improved patient safety.

The discharge process is another big area for improvement. By its nature a risky process and fraught with potential problems, we need to make every hospital discharge as thorough and seamless as possible. The role of the hospitalist is invaluable in making this happen.

4. Focusing on the patient

The drive to enhance patient satisfaction and improve the healthcare experience is really not rocket science. We need to listen to patients and take on board their concerns. The most common complaints I hear from my patients are usually quite straightforward, and I’m sure similar to what other doctors hear up and down the country—among them are a good night’s sleep and better hospital food! Not far behind is patients simply wanting more time with their doctors and nurses. We need to get back to the fundamentals of good medicine in a comfortable, healing environment.

5. Integrating health care IT with frontline hospital medicine

Meaningful use implementation has meant that hospitalists are having to work more than ever with information technology. This will only increase with time. Unfortunately, most of the current IT solutions are slow, inefficient, and cumbersome. They take time away from our patients. Hospital doctors should insist on IT that is optimized to our unique workflow. Rapid order entry (ideally using mobile technology) and efficient EMRs are the way of the future.

Ahead lies enormous opportunities for process improvement and making a real difference in our patients’ lives. We must remain fully engaged and more importantly lead in these hospital processes. The old attitude of many administrators that “hospitalists don’t make any money for the hospital” is rapidly turning into “hospitalists are crucial for our organization’s success.” The first few years have been a bit of a rocky road, and most programs around the country are still disorganized and can’t achieve the metrics that are needed to take things to the next level. Once we organize the specialty better, there’s no limit to high hospital care can soar.

This is a tremendously rewarding career. There are very few specialties left where you are the “captain of the ship”, guiding patients through their illness, forming strong relationships with both them and their families. Being a good old-fashioned doc with solid clinical and reasoning skills that are applied on a daily basis. Hospital medicine is one of them, and I feel blessed to be practicing it.

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--Therapy for painful hip arthritis may be no better than sham treatment

Twelve weeks of physical therapy for painful hip osteoarthritis did not result in greater improvement in pain or function compared to sham treatment, a study found

To determine efficacy of physical therapy on pain and physical function in patients with hip osteoarthritis, researchers conducted a randomized, placebo-controlled, participant- and assessor-blinded trial among 102 community volunteers with hip pain levels of 40 or higher on a visual analog scale of 100 mm and hip osteoarthritis confirmed by radiograph.

Forty-nine patients in the active group and 53 in the sham group underwent 12 weeks of intervention (10 treatment sessions) and 24 weeks of follow-up from May 2010 to February 2013. Active treatment included education and advice, manual therapy, home exercise, and gait aid if needed. Sham treatment included inactive ultrasound and inert gel. For 24 weeks after treatment, the active group continued unsupervised home exercise while the sham group self-applied gel 3 times weekly.

Results appeared online at JAMA Internal Medicine.

The between-group differences for improvements in pain were not significant. For the active group, the baseline mean (standard deviation) visual analog scale score was 58.8 mm (13.3) and the week-13 score was 40.1 mm (24.6). For the sham group, the baseline score was 58.0 mm (11.6) and the week-13 score was 35.2 mm (21.4). The mean difference was 6.9 mm favoring sham treatment (95% CI, −3.9 to 17.7) and function scores were not significantly different between groups.

The baseline mean (SD) physical function score for the active group was 32.3 (9.2) and the week-13 score was 27.5 (12.9) units. The baseline score for the sham treatment group was 32.4 (8.4) units and the week-13 score was 26.4 (11.3) units, for a mean difference of 1.4 units favoring sham (95% CI, −3.8 to 6.5) at week 13.

There were no between-group differences in average pain or physical function at week 36, or in impairments, physical performance, global change, psychological status, and quality of life at weeks 13 and 36. Nineteen of 46 patients (41%) in the active group reported 26 mild adverse effects, compared to 7 of 49 (14%) in the sham group who reported 9 mild adverse events (P=0.003).

The results raise questions about the importance of physical therapy for painful hip osteoarthritis, the researchers wrote.

“The absence of significant between-group differences despite use of skilled therapists and excellent adherence rates to home exercise (85%) suggest that the active physical therapy program was truly ineffective,” they wrote.
Wednesday, May 21, 2014

Still beating that dead horse, contact precautions edition

Regular readers know that we’ve long been posting about the unintended adverse consequences of contact precautions, most recently with Mike Edmond, MD, FACP’s post on the added associated costs.

A research letter was published online in JAMA Internal Medicine, reporting results of a time-motion study of interns (using RFID badges) to compare time spent with isolated versus non-isolated patients. You guessed it, the interns visited the isolated patients less often and for shorter periods of time.

To quote the authors, “[these] results support a growing body of literature suggesting that contact precautions may impede patient care”. We are long overdue for a rethinking of our use of contact precautions. I’ll end with another quote from the authors, one that nicely sums up the take-home message:

“Further research is needed, both to better define the patient population for whom the benefits of contact isolation outweigh the risks and to develop strategies to ameliorate those risks for those who must be placed into isolation.”

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--E-cigarettes may help smoking cessation attempts

People attempting to quit smoking without professional help are about 60% more likely to succeed if they use e-cigarettes than by using over-the-counter nicotine replacement therapies such as patches or gum, or by quitting cold turkey, reported a survey of smokers in England.

The study, published in Addiction, surveyed more than 5,800 smokers between 2009 and 2014 who had attempted to quit smoking without using prescription medication or professional support. In the study, 20% of people trying to quit with the aid of e-cigarettes reported having stopped smoking conventional cigarettes. The results were adjusted for age, nicotine dependence, previous quit attempts, and whether quitting was gradual or abrupt.

The research, chiefly funded by Cancer Research UK, suggests that e-cigarettes could play a positive role in reducing smoking rates. The study’s senior author said in a press release that e-cigarettes could substantially improve public health because of their widespread appeal and the huge health gains associated with stopping smoking. But the strongest evidence remains for use smoking-cessation services, such as those offered through England’s National Health Service, which nearly triple a smoker’s odds of successfully quitting compared with going it alone or relying on over-the-counter products.

While there is little evidence about the long-term effects of using e-cigarettes, and some public health experts have expressed concern that widespread use of e-cigarettes could re-normalize smoking, the author noted that smoking rates in England are declining, quitting rates are increasing, and regular e-cigarette use among never smokers is negligible.

An editorial published May 5 in the same journal called for more research into the field of e-cigarettes, citing the misperception that nicotine replacement product contain tobacco, the wide variety of products labelled as e-cigarettes, and questions about whether the products act as a gateway product to smoking.

“E-cigarettes may offer a way out of the smoking epidemic or a way of perpetuating it; robustly designed, implemented and accurately reported scientific evidence will be the best tool we have to help us predict and shape which of these realities transpires,” the editorial concluded.

ACP Internist addressed the use of e-cigarettes in a cover story in the March issue, and in recent coverage from Internal Medicine 2014.
Tuesday, May 20, 2014

Pocket ultrasound machines: 'Why doesn't everyone have one?'

For about 2 years now a tiny ultrasound machine has been part of my standard physical exam tools as I take care of patients in the hospital and in the outpatient clinic. In November 2011, I first picked up an ultrasound transducer in a continuing medical education course on bedside ultrasound for emergency physicians. I am an internist, not an emergency physician, but I was interested in bedside ultrasound and it was the emergency physicians who were giving the most interesting course. It was transforming for me. I was able to see internal anatomy and physiology and eventually, with lots of practice, I was able to make diagnoses more quickly and accurately. I bought a pocket ultrasound machine so I could make bedside ultrasound a seamless part of my practice

It was an unexpected and welcome bonus that my patients and their families loved it. I would share the moving ultrasound pictures with them, often having them hold the machine so I could point out how beautiful their internal organs were and what we could see that helped give us a clue about their disease process. Many of these same patients also got full, detailed ultrasounds or other imaging by radiology technicians, but since the technicians aren’t supposed to discuss findings with the patients and often they couldn’t see the screen, it wasn’t nearly as gratifying.

The most common comment I get from patients is, “Wow, that’s really cool!” ”I agree!” I answer. Then they will ask, “Why doesn’t everyone have one of these things?”

That is kind of a difficult question. “They’re pretty expensive,” I usually say. They are. At least for now. The little machines (I use Vscan, by GE) retail for over $8,000, though you can buy them cheaper used or overseas. Physicians balk at spending this amount of money on a piece of equipment. Most of the expensive gadgets we use are owned by hospitals or by our group practices. Musicians, however, who make a fraction of what we do, buy their own musical instruments, which often cost in excess of $10,000. I’m not sure the cost ought to be a serious consideration.

Other doctors often ask me if I bill for my exams. I don’t, because billing and the detailed documentation and posturing that would be necessary to prove to an insurance company that an ultrasound was necessary would take more time than I have. I report the results in my narrative of the physical exam, much as I do the findings of my ears or my hands or eyes. There are billing codes for limited ultrasounds, and if I were able to record and store my images easily I could probably boost my revenue, but that would make me feel just a little bit conflicted every time I did it. I would have to tell the patient that I was charging for it, which would probably make them feel conflicted as well, or maybe choose to forgo the exam, which would mean that I would know less about what was going on and would be more likely to make a mistake.

“It also takes a long time to learn,” I add. I have spent hundreds of hours in learning from good teachers, mostly in person, but also online. I have done many thousands of exams and have reviewed a fair number with experts. But it is actually pretty quick to get good enough to be sure of a handful of different things that make a huge difference in making clinical decisions. After that, much like most of the things we do in medicine, learning expands exponentially with on-the-job experience. Many students in medical school now are learning how to use ultrasound at the bedside as part of their standard training, which is really the best way to do it.

“When did those things come out? I’ve never seen anything like it!” say my patients. The little pocket model I have has been available for at least 5 years, and there have been portable ultrasounds for considerably longer. The company that makes mine has not been aggressive in marketing it, even though it is potentially as huge a deal as the introduction of the stethoscope, and other ultrasound companies have been incredibly slow in developing competitive models. Maybe it’s just difficult to develop the technology, but I think it’s a little less wholesome than that.

Ultrasound is a huge part of what radiology departments in hospitals and clinics do. It has grown as we have become aware of the dangers patients are incurring with the expanding use of imaging based on X-rays, such as CT scans. Full scale ultrasound exams are performed by radiology technicians using machines costing hundreds of thousands of dollars, are read by radiologists or cardiologists and billed out for thousands of dollars each. If physicians at the bedside are doing these exams for free, or even for cheap, this has the potential to negatively impact huge revenue centers. It is not in the financial interests of the whole industry for the manufacturers to produce an awesome pocket machine. A bedside ultrasound, which takes minutes, is hardly the same as a full scale ultrasound or echocardiogram which can take almost an hour to perform by a technician who does only this. In some cases we may order more ultrasounds because of what we see, or think we see, at the bedside, but for some questions our brief and focused exam will be enough and will supplant imaging by the radiology department.

There is also abundant controversy about adding routine ultrasound to the way we practice medicine. It is a “disruptive technology” which means that it potentially changes things in far reaching ways, many of which can’t be adequately predicted. We may see things inside patients that are best left unseen or are difficult to interpret. We may thus end up chasing findings that are nothing and costing patients more money and anxiety than we should. I have not found this to be true, however. Imaging of all kinds, especially the detailed kind that comes out of radiology departments, is often misleading and anxiety provoking. Think about the majority of mammogram abnormalities that turn out to be nothing or adrenal “incidentalomas,” the small meaningless lumps we see on the adrenal glands when CT scanning the abdomen. Combining bedside imaging with examining the patient, talking to them and reviewing laboratory data has been much less likely to lead me to misdiagnoses than to appropriate ones.

Many older physicians are trying to adjust to changes that make them feel that they are losing the profession that they used to practice skillfully in the past. We are asked to learn to use computer systems to document patient visits, review medical histories and order treatments. We start to become data entry technicians, and we aren’t very good at it. We are asked to learn continually changing algorithms for treating a myriad of diseases. We are required to provide excellent preventive medicine for our patients so they don’t have heart attacks or strokes or get cancer, when research on the proper way to do this makes what was wise 1 day stupid the next. On top of this people like me with our tiny little ultrasound machines come along and say “Hey, there’s this other thing you should do too.” But I would love for my overworked and stressed out colleagues to know that this is different. Data entry is not inherently fun. Robots or trained monkeys could probably stay on top of the preventive to-do list better than we do, and algorithms don’t give us much job satisfaction, even if they do help us deliver evidence based treatments. Bedside ultrasound, though, is terrifically fun and despite the time and effort required, brings back some of the joy of being a real doctor. I say this after a quarter of a century of practicing internal medicine. I am an “older physician.”

So, “Yes,” I tell my patients. “I agree. It is incredibly cool. We are looking at the inside of your body together and learning things. It’s unusual now, but I’m pretty sure it’s not going to be too long before it’s part of what most of us do.”

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.

Keep the beard

There’s a new paper in the Journal of Hospital Infection that takes a look at the bacterial ecology of facial hair. In this study, 408 male health care workers had two areas of their face cultured. About half of the men had facial hair and the other half did not. Interestingly, the men with facial hair were significantly less likely to have skin colonization with Staphylococcus aureus (lip: 34% vs 45%; cheek 41% vs 52%). When the facial skin was scratched with a sterile swab there was no difference in bacterial shedding between the two groups.

These findings are consistent with what we know about S. aureus. Colonization rates are higher in persons with chronic breaks in the skin (e.g., patients with eczema, dialysis patients, diabetic patients who require insulin injections, and IV drug users). Shaving causes micro- (and sometimes macro-) abrasions and lacerations. And cosmetic body shaving has clearly been associated with MRSA infections.

Based on this study, I would grow a beard, if only I could. Mine is too mangy. It would scare my patients. But for $8500, I could get a facial hair transplant, which is now all the rage in New York. Maybe there’s hope ...

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--Interns spend less time with patients in isolation rooms

Patients in isolation rooms may feel a little more lonely, as internal medicine interns spent less time with them than other patients, a study found.

To measure differences in time spent with patients in contact isolation rooms compared with those in nonisolation rooms, researchers used tracking devices attached to hospital identification badges to collect continuous real-time data on the location of 15 internal medicine interns from October through December, 2012.

Results appeared in a Research Letter at JAMA Internal Medicine.

Interns visited isolated patients less often (2.3 visits per day compared with 2.5 visits per day, P<0.001) and spent less time per visit with isolated patients (2.2 minutes per visit compared with 2.8 minutes per visit, P<0.001), the study found. Interns spent an average of 5.2 minutes per day with each of their isolated patients, compared with 6.9 minutes per day with each of their nonisolated patients (P<0.001).

“We were surprised to discover that interns spend little time in direct contact with their patients, and even less time with those patients in contact isolation,” wrote corresponding author Cody N. Dashiell-Earp, MD, ACP Resident/Fellow Member, and co-authors. “[T]he fact that trainees spend less time with isolated patients might explain why these patients experience more adverse events and have lower overall satisfaction, particularly if senior residents and attending physicians exhibit the same behavior.”

Infection prevention strategies should minimize the barrier between physicians and patients, including hand hygiene, antimicrobial stewardship, and universal decolonization, because these methods may be more effective at reducing the spread of resistant organisms and less disruptive to patients, the authors concluded.
Monday, May 19, 2014

Fatal error

The janitor approached my office manager with a very worried expression. ”Uh, Brenda …” he said, hesitantly.

“Yes?” she replied, wondering what janitorial emergency was looming in her near future.

“Uh … well … I was cleaning Dr. Lamberts’ office yesterday and I noticed on his computer …” He cleared his throat nervously, “Uh … his computer had something on it.”

“Something on his computer? You mean on top of the computer, or on the screen?” she asked, growing more curious.

“On the screen. It said something about an ‘illegal operation.’ I was worried that he had done something illegal and thought you should know,” he finished rapidly, seeming grateful that this huge weight lifted.

Relieved, Brenda laughed out loud, reassuring him that this “illegal operation” was not the kind of thing that would warrant police intervention.

Unfortunately for me, these “illegal operation” errors weren’t without consequence. It turned out that our system had something wrong at its core, eventually causing our entire computer network to crash, giving us no access to patient records for several days.

The reality of computer errors is that the deeper the error is—the closer it is to the core of the operating system—the wider the consequences when it causes trouble. That’s when the “blue screen of death” or (on a Mac, the “beach ball of death”) show up on our screens. That’s when the “illegal operation” progresses to a “fatal error.”

The fatal error in health care

We have such an error in our health care system. It’s absolutely central to nearly all care that is given, at the very heart of the operating system. It’s a problem that increased access to care won’t fix, that repealing the SGR, or forestalling ICD-10 won’t help. It’s a problem with something that is starts at the very beginning of health care itself.

The health care system is not about health.

Yes, the first word, “health” is inaccurate. Our system is built to address the opposite of health, sickness, exchanging money for addressing illness. The clinician is paid for matching diagnosis with procedure (ICD for CPT, in code). Economically, more (or more serious) diagnoses and more (or more complex) procedures result in more pay. Last I checked, more/more serious diagnoses and more/more complex procedures are not in the definition of “health.”

So is this just a case of bad nomenclature, or not wanting to use the term “sick care system” for public relations reasons? What does it matter what it’s called? The problem is that health is what the patient wants (although it’s hard to call someone a “patient” if they are healthy), but the system does nothing to help people each this goal. In fact, our system (as constructed) seems to be designed to discouraging providers from helping people toward the goal of health. After all, the system itself becomes unnecessary in the presence of health.

Getting what we pay for

So what do you get from such a backward system, one that rewards the outcomes people are supposed to avoid? You get what you pay for:
1. A premium is placed on making diagnoses, since they are rewarded.
• Unnecessary tests are done to “fish” for problems to treat. I got my vitamin D level drawn at my last doctor’s visit, but was not displaying any symptoms/signs of a deficiency and know of no evidence that treating it in someone like me would do any good. To what end do I have this diagnosis? I am not sure.
• New diseases are created to promote intervention. ”Low T” syndrome is a perfect example of this, not only rewarding the provider by adding complexity for the visit and the lab for the test run to make the diagnosis, but also the drug company who brought the “disease” to the public consciousness.
2. The likelihood of a person being considered “healthy” is much less.
• Obesity, depression, poor attention at school, social maladjustment - things that used to be considered different points along the range of normal human existence - are now classified as diseases. Risk factors, such as high cholesterol, are made in diseases to be treated. The end result is a diagnosis for everyone.
• Overdiagnosis leads to overtreatment with medications that themselves can cause problems (which is rewarded by increased pay for doctors, hospitals, drug companies, etc).
3. Little effort is made to do things that would lead to health.
• Spending more time/resources on people to educate them about their health is bad business, as it decreases the number of diagnoses and procedures a clinician can do in the course of the day.
• Since there is no motivation to prevent little problems from becoming big ones, they tend to be neglected. Patients often report the need to be “sick enough” to go to the doctor’s office, and seem embarrassed when their concerns are found to be “nothing serious.”

Why payors won’t change

So why don’t payors just stop paying for unnecessary medications, tests, and procedures for invented diagnoses? The did once, actually. Back in the early days of HMO’s, when most doctors and patients were used to getting any medication, test, and procedure without question, the payors changed: they stopped paying for everything. ”No, sir, you don’t need an MRI scan for back pain.” ”No, ma’am, you don’t need the brand name drug that costs 20 times more.”

This attempt to control cost was not met with praise, but instead by the demonization of payors by both doctors and patients. Insurance companies quickly became public enemy #1, said to be denying care to those in need. In reality, they were not denying care; they were simply refusing to pay for it. Patients could get the MRI or brand medicine if they wanted, they’d just have to pay for it themselves. But that wasn’t in the discussion.

In the end, they did what every God-fearing person does with a problem they don’t want: they passed the buck. Instead of refusing to pay for unnecessary procedures, they did 2 things:
1. Required authorization by providers. This meant that the denial was because of the provider’s inability to justify it, not the payor’s unwillingness to pay for it.
2. Started penalizing/reporting “bad” providers. This started with the use of “pay for performance,” and has come to full fruition recently by the “transparency” movement, where doctors’ and hospitals’ utilization are publicly reported.

The analogy I’ve used in the past is that of an alcoholic who blames their spouse for their inability to control their drinking. ”If only those damn doctors would stop ordering those unnecessary tests and prescribing those unnecessary drugs, I wouldn’t have the need to irresponsibly pay for them.”

Rethinking reform

The root financial arrangement in the health care system is to promote more: more diagnosis, more disease, more tests, more interventions, and more medications, with each of these being rewarded with more revenue. It seems the obvious cause of our out-of-control spending, spending which does not yield better health.

Attempts to reform the system have ignored this root problem, instead focusing on other things:
• Improving access to care (a la the ACA) - which addresses the real problem of uninsured/underinsured people, but ignores the fact that care became inaccessible for a reason: it costs too much.
• Measuring the care of providers and hospitals, attempting to manipulate them into reducing the cost of their care. The HITECH act (and our old pal “meaningful use”) does this via computerizing and capturing the data of clinicians, as do the ACO’s (accountable care organizations) for hospital systems. While there is a small shift of financial incentives in these arrangements, they greatly increase the complexity of the system, creating huge areas of spending that did not previously exist (yes, I am talking about the EMR companies, with Epic at their head).
• Changing who is in charge, either by privatizing Medicare and Medicaid or by going to a single-payor system. If a ship is sinking, the priority is to fix the hole, not to change captains.

Warning! This is where I get on my soap box.

For any solution to have a real effect, this core problem must be addressed. The basic incentive has to change from sickness to health. Doctors need to be rewarded for preventing disease and treating it early. Rewards for unnecessary tests, procedures, and medications need to be minimized or eliminated. This can only happen if it is financially beneficial to doctors for their patients to be healthy.

What a coincidence! That’s what my new practice does! Who’d have thought it? The healthier my patients are, the less of me they need and the larger my patient panel can get. I am motivated to keep problems small, to avoid complexity, and to think in terms of true prevention rather than the invention of diseases.

Obviously, the system still must address the inevitable/unpreventable medical problems that arise despite my best efforts to prevent them. This is where the high-deductible plans come in: covering problems that the patient cannot afford. Yet my job will always be to prevent patients from spending that deductible, wherever possible, avoiding unnecessary tests, medications, or ER visits. Why? Because in doing so I justify the monthly payment. It turns out that this is not very hard. This is a win/win/win, as patients are healthier, I make more money, and insurance companies don’t have to pay for nearly as much.

The bottom line

Any significant change, whatever the means, won’t happen until there is an even more basic shift, a shift in the very center of health care: we must focus again on people. The patient (or the person trying to avoid becoming a patient) has moved from the center of the health care transaction and has become the raw-materials for what we call “health care.” The doctor/hospital needs the patient to generate the codes necessary to be paid by the payor, which is the bottom-line reason for our problems. A system that has incentives to create disease and procedures, will be satisfied (and even happy) with a lack of health. But a system which rewards health will be radically different.

Changing the focus of care to this is more than just emotional idealism, it is good business. Care should not be about codes, procedures, medications, tests, or interventions, but instead about helping people live their lives with as few problems as possible. We need an economy that thrives when the patient costs the system less.

Any attempt to reform without this change will ultimately fail.

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