Monday, June 30, 2014

Return of the spirochete

“Example is the school of mankind, and they will learn at no other.”

—Edmund Burke

Syphilis has been around at least since Europeans arrived in the Western Hemisphere. It’s a sexually transmitted disease caused by Treponema pallidum, a member of a group of corkscrew-shaped bacteria called spirochetes. Sometimes it causes no symptoms at all, but typically it initially causes a painless sore on the mouth or genitals. Later it can cause a rash. Untreated it may lead to blindness, spinal cord and brain damage, and death.

After the discovery of penicillin in the 1940s syphilis was for the first time easily curable and the prevalence of syphilis in the U.S. dropped precipitously.

I trained in the bad-old-days of the mid-90s when HIV was killing tens of thousands of people in the U.S. every year. On every inpatient ward rotation I met patients hospitalized with an opportunistic AIDS-related infection. On every ICU rotation I met patients dying of AIDS. Back then medications to treat HIV were few, new, and only modestly effective. HIV was usually a rapidly fatal disease. It was scary. Counseling patients about condom use and monogamy was not moralistic or theoretical. It had all the practical urgency of yelling at someone to get off the train tracks.

I have no evidence that HIV and the response to it was responsible for the subsequent fall in syphilis infections, but in fact syphilis did decline during the 90s and in 2000 reached its lowest rate ever in the US and was on the verge of being eliminated. You would think that a disease that can be easily diagnosed with blood tests, can be cured with antibiotics, and can be prevented with condoms would be on its way to the dustbin of history. You would be wrong.

The Centers of Disease Control and Prevention (CDC) published a review of syphilis trends in the US from 2005 to 2013. The statistics are dismaying. The number of syphilis cases almost doubled during that interval, from 8,724 cases in 2005 to 16,663 in 2013. 91% of the 2013 cases occurred in men. The number of cases in women was about the same in 2013 as in 2005. Of the male cases in 2013, 84% occurred in men who reported having sex with men.

The report breaks down the trends geographically and by ethnicity but it’s the age breakdown that I found fascinating. From 2005 to 2009 men aged 20 to 24 had the greatest percentage increase in syphilis rates, and from 2009 to 2013 men aged 25 to 29 had the greatest increase. But of course those 2 age categories are actually the same group, men born in the 1980s. I couldn’t help notice that these are the men who grew up after the bad-old-days, the men who think of HIV as the treatable chronic illness it has become, not the death sentence it was 20 years ago.

The CDC report offers wise advice to physicians. We should be testing gay and bisexual men for syphilis at least annually. Men who have multiple partners should be tested more frequently. We should be counseling consistent condom use except in prolonged monogamous relationships in which both partners have been tested.

But perhaps that won’t be enough. I have zero evidence that the attitudes about HIV contributed to the decline of syphilis in 2000 or its resurgence now, but the time course certainly seems to fit. It’s a testament to scientific research and drug development that in such a short time a disease that had the mortality of stage 4 lung cancer is now more like diabetes. But to young men this progress must make our advice about avoiding sexually transmitted diseases sound a lot less urgent, less like getting off the train tracks and more like putting on their seat belt. That complacency is a terrific opportunity for a patient and ambitious spirochete.

Learn more:
US Syphilis Rate Up; Mostly Gay And Bisexual Men (NPR)
Syphilis Made A Big Comeback In 2013, CDC Warns (Forbes)
CDC Reports Syphilis is Increasing in Homosexual and Bisexual Men(Science World Report)
Syphilis (CDC fact sheet)
Primary and Secondary Syphilis — United States, 2005–2013 (CDC Morbidity and Mortality Weekly Report)
Syphilis—Reported Cases by Stage of Infection, United States, 1941 – 2012 (CDC)
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.

QD: News Every Day--Alcohol related to 1 in 10 deaths among adults, CDC reports

One of every 10 deaths among working-age adults can be attributed to excessive drinking, according to a CDC report released last week.

Researchers estimated total alcohol-attributable deaths and years of potential life lost across 54 conditions in the U.S. by age and sex among adults age 20 to 64 years, using the CDC's Alcohol-Related Disease Impact application for 2006 to 2010. During this time period, they found an annual average of 87,798 alcohol-attributable deaths and 831.6 years of potential life lost in the U.S. Overall, 9.8% of U.S. deaths from 2006 to 2010 could be attributed to excessive drinking.

The researchers noted that data on alcohol consumption were based on self-report and that deaths of former drinkers were not included, among other limitations. However, they concluded that excessive alcohol consumption has substantial consequences in the United States. They recommended that such interventions as raising taxes on alcohol could help decrease excessive consumption.

The full report is available online.
Friday, June 27, 2014

Better than new

If you were the right age to have been watching television in the mid-1970s, you probably remember “The 6 Million Dollar Man.” The show was about an astronaut who is critically injured in a test-mission gone bad, and is “rebuilt” with bionic (nuclear powered!) limbs and sensors to be “better than he was.” The campy intro, complete with scenes from the operating room, is, of course available on YouTube.

I was reminded of the old show when I read a recent piece in the New York Times about improvements in hearing aids. The newest models can now be controlled by smart-phone apps to adjust to different environments. Advanced filtering and other technology make it possible for wearers to hear better in noisy environments like restaurants. They can even stream audio directly from a phone or music player, like a Bluetooth headphone. Here’s the part that reminded me of the old show:

Today most people who wear hearing aids, eyeglasses, prosthetic limbs and other accessibility devices do so to correct a disability. But new hearing aids point to the bionic future of disability devices.

As they merge with software baked into our mobile computers, devices that were once used simply to fix whatever ailed us will begin to do much more. In time, accessibility devices may even let us surpass natural human abilities. One day all of us, not just those who need to correct some physical deficit, may pick up a bionic accessory or two.

I think we will see this play out first in competitive athletics. What if a golfer could embed a laser range finder and wind shear indicator in her sunglasses? What if a baseball player could wear contact lenses that allowed him to see the spin on the seams better? What if a tennis player could use a hearing aid that calibrated the amount of topspin off his opponent’s racket? If advantages can be had, athletes will seek them out, and it is going to be tough to “draw lines” around some of these technologies. If conventional contact lenses (not to mention refractive surgery) are commonplace, will it be possible to ban future “smart lenses” or “smart glasses?”

As the technology advances, making these “enhancements” more effective, less expensive, smaller and more wearable, I think we may all end up more like the 6 Million Dollar Man than we ever thought possible.

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.
Thursday, June 26, 2014

Ezetimibe (Zetia): Why are we still prescribing what appears to be a useless drug?

A health research company just released a list of the 100 top drugs in America according to sales. Twenty-ninth on the list, with sales of over $1.8 billion, is the cholesterol lowering drug ezetimibe, brand name Zetia.

This drug was released over 10 years ago because it worked really well in combination with statin drugs such as Zocor (simvastatin) to lower LDL cholesterol levels. It was released as a single agent and combined with simvastatin as Vytorin. The only problem was that in 2008 a study of the ezetimibe/simvastatin combination compared to simvastatin alone showed the combination did not improve measurements of arterial wall thickness, which correlates with things like heart attacks and strokes. Although cholesterol levels were lower in the combination arm, simvastatin was just as effective in achieving the more meaningful outcome.

Ezetimibe appeared to increase cancer risk in another study, evaluating patients with aortic stenosis. A study which compared adding niacin or ezetimibe to statin therapy in patients with coronary heart disease in 2009 showed that, even though ezetimibe was very effective in reducing LDL cholesterol levels, it also increased the thickness of the arterial walls when compared to niacin. Niacin wasn’t nearly as good at reducing cholesterol levels as ezetimibe, but there were more cardiovascular deaths in the ezetimibe group.

This drug, whose only claim to fame is that it reduces a number on a chemistry panel, continues to be popular in both the U.S. and Canada. An editorial in the Journal of the American Medical Association 2014 wondered at the failure of very convincing evidence to make us stop prescribing it. The author concluded that it must be that the manufacturer (Merck) has been very effective at marketing ezetimibe and that patients’ and doctors’ fixation on reducing the cholesterol numbers has made it attractive in defiance of its lack of efficacy. Statin drugs, which also are not immune to controversy, may reduce the risk of heart attacks by reducing inflammation, not by reducing cholesterol levels per se. Since ezetimibe acts to reduce absorption of cholesterol from the gut, it may have no effect at all on inflammation or vascular health despite lowering cholesterol levels.

There are further studies still in the pipeline which may clarify the situation a bit more. It seems right now, though, that there is enough evidence that this is a bad drug for the Food and Drug Administration to rescind its approval. It would be nice to believe that physicians would take the initiative to change their prescribing habits, removing $1.8 billion dollars from our health care bill while reducing our patients’ pill burden, but apparently we are not stepping up to the plate.

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.

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.

Personal tech

My 87-year-old father broke his hip this past weekend. He was in Michigan for a party for his 101-year-old sister, and fell as he tried to put away her wheelchair. The good news is that he’s otherwise pretty healthy, so he should do fine. Still, getting old sucks.

During the whole situation around his injury, surgery, and upcoming recovery, one thing became very clear: technology can really make things much easier:
• I communicated with all of my siblings about what was going on and gave my “doctor’s perspective” to them via e-mail.
• I updated friends and other family members via Facebook.
• I have used social media to communicate cousins about what is going to happen after he’s discharged from the hospital and coordinate our plans.

All in all, tech has really made things much easier.

This reality is in stark contrast to the recent headline I read on Medscape: “Doctors are Talking: EHRs Destroy the Patient Encounter.” The article talks about the use of scribes (a clerical person in the exam room, not a pal of the Pharisee) to compensate for the inefficiencies of the computer in the exam room. Physician reaction is predictable: most see electronic records as an intrusion of “big brother” into the exam room. To me, the suggestion to use a scribe (increasing overhead by one full-time equivalent employee) to make the system profitable is ample evidence of EMR being anti-efficient.

Despite this, I continue to beat the drum for the use of technology as a positive force for health care improvement. In fact, I think that an increased use of tech is needed to truly make care better. Why do I do so, in face of the mounting frustrations of physicians with computerized records? Am I wrong, or are they?

Neither. The problem with electronic records is not with the tech itself, it is with the purpose of the medical record. Records are not for patient care or communication, they are the goods doctors give to the payors in exchange for money. They are the end-product of patient care, the product we sell. Doctors aren’t paid to give care, they are paid to document it. Electronic records simply make it so doctors can produce more documents in less time, complying with ever-increasingly complex rules for documentation.

When I say we need more tech, I am not saying we need more computerization so we can produce a higher volume of medically irrelevant word garbage. I am not saying we need to gather more points of data that can measure physicians and “reward” them if they input data well enough. The tech I am referring to is like that I used regarding my father. I want technology that does two things: connects and organizes. I want to be able to coordinate care with specialists and to reach out to my patients. I want my patients to be able to reach me when they need my help. Technology can do this; it sure did for my dad.

Yet people are incredibly reluctant to adopt this. They fear that using technology will inevitably make things less personal. I have patients who are still reluctant to use computers for this reason, and I definitely see this in my colleagues, who reject my pleas to communicate with me electronically.

My main communication tool, Twistle, allows me to communicate quickly and securely with my patients. Using it has greatly improved the efficiency of care and makes my patients feel more connected with me. Here are some examples:
• Patients routinely send me pictures of rashes/lesions. Sometimes I end up bringing them in to the office to get a personal view of them, but often I can give care based on the computer. One mother was out of state with her child and I could successfully diagnose and treat a yeast diaper rash. She was thrilled.
• I send actual copies of lab, X-ray, and procedure reports to the patients along with my explanation of their significance. Now the patient has a copy with them at all times (as long as they have a smartphone) and so can share the reports with any specialists they visit.
• One patient was having bad problems with an intestinal infection and was in the ER for the third time in a week. The ER doc was not taking her seriously and so she sent me a Twistle message asking for help. I replied with a run-down of what had been done and the reasons I felt she needed to be admitted for a work-up. She showed it to the doctor in the ER who grinned, nodded, and admitted her without any more questions.
• I often have a back-and-forth conversation using Twistle regarding symptoms and/or concerns a patient is having. This sometimes resolves the problem, but sometimes it results in an office visit. These visits, however, usually take less than 10 minutes of the patient’s time (from when they come in to when they leave) because I’ve already gotten the history on Twistle. This is normal in my practice, but is almost unheard of in the “real world.”

There are other examples, but clearly my patients who use this tool think it makes their care better. But what about those who are still reluctant? What about those who worry that this will push their care toward impersonal electronic communication? I finally figured out an answer to this: my daughter.

My daughter is in college in upstate New York (where I grew up, and where my parents live). She loves it up there (although has realized why few people retire and move up north), but the distance has been hard on us. We don’t get to see her nearly enough. The one thing that has helped us deal with this long distance has been technology. We use text messages, e-mail, FaceTime, and other technology to stay close to her. Does the technology replace seeing her in person? Absolutely not. But it does enhance our communication and connects us when we couldn’t otherwise do it.

This is what technology should do: it should enhance connection and improve relationship. Technology doesn’t have to add a layer of complexity or push people apart, in can simplify and connect. Technology doesn’t bring my dad or my daughter down to Georgia, but it can make the distance feel much shorter.

So I roll my eyes when people suggest paper medical records. Really?? I wouldn’t give up the ways in which tech has improved my communication and has brought me closer to the people who really matter. I think most of my patients would agree.

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.
Wednesday, June 25, 2014

Deadly virus meets deadly cancer with hopeful results

The history of the first hundred years of cancer therapy is that of a war, pitting bigger surgeries and stronger poisons against tumors, with patients caught in the middle. Over the last 2 decades, researchers have found ways of fighting cancer more precisely. One of the most successful examples is that of Gleevec (NYSE:NVS). Chronic myelogenous leukemia (CML), a kind of blood cancer, had been a tough disease to treat, even after the discovery of the genetic quirk responsible for its devastation. In the 90s, researchers discovered a chemical that specifically blocked the molecule produced by this abnormal gene and were able to treat CML specifically and effectively with a pill that caused minimal side effects (compared to traditional therapy).

The road to a unique cure for every cancer hasn’t been smooth–many cancers are much more complicated than CML, having many genetic abnormalities and other characteristics that make them hard to treat. As physicians we usually fall back to what we know: bigger surgeries, nastier drugs. But the search continues. This week, the Mayo Clinic reported two cases of another blood cancer that shrunk with a unique therapy: measles.

Measles can be a horrific childhood disease, but the virus has some interesting properties. Researchers have been able to modify the virus in 2 important ways: first, the virus can be made to latch on to a certain molecule on the surface of cells. Second, it can be made to suck up medical-grade radioactive iodine, making it easy to track with the right instrument.

The research that helped create the modified virus used the HeLa cancer cell line, derived from a woman from Baltimore named Henrietta Lacks, the subject of an excellent book by Rebecca Skloot. Mrs. Lacks died shortly after “donating” her cells, and her family never heard the full story of her contribution to science until Rebecca helped publicized it, leading to important discussions of medical ethics and law.

Multiple myeloma (MM) is a nasty disease which can shut down normal blood cell production, produce proteins toxic to the heart, kidneys and other organs, and create painful tumors in bone and soft tissue. It can often be treated for a while, but is rarely cured.

The team at Mayo came up with a clever idea: could the modified measles virus, which likes to kill cancer cells, be made to kill specific cancer cells? As luck would have it, the virus (called MV-NIS) is particularly attracted to a cell surface molecule that MM makes a lot of.

They found 2 patients, both of whom were dying of myeloma, having undergone all of the most rigorous therapies available. Both patients showed little immunity to measles, meaning they were less likely to fight off the virus before it could get to the tumors (although an argument might be made that the immune response could kill off infected tumor cells, but that’s not what this study looked at).

The 2 patients were enrolled in a “Phase I” trial, the sort of experiment in which no promises are made of any success. It is simply an experiment to see if the patients can tolerate or even survive a new treatment. These patients did, sort of. After being given large doses of the modified measles virus, they developed very high fevers and low blood pressure, but survived this “septic” phase. In one patient, tumor masses melted away and she had a complete remission that lasted about 9 months. The other patient responded to the treatment but only incompletely.

This study exemplified scientific cleverness on several levels. A nasty virus was altered to make it less harmful to normal tissue (it seemed not to infect normal tissue around tumors). The virus was also altered to suck up iodine so that it could be tracked by external scans. As a bonus, radioactive iodine sucked up by the virus can kill tumor cells by zapping them with radiation.

This is a promising proof of concept, but a very early one. This has been tried in 2 patients, neither of whom are cured, and the therapy was not without dangers. Many experts (and laypeople like Mrs. Lacks) contributed to each step that led to this therapy. This may be a promising treatment, or perhaps just one more step toward an eventual treatment. Either way, it’s good 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.

5 ways to make hospitals into a more calm and healing environment

The very basic definition of a hospital is a place of healing and recovery. Health care is in a tumultuous state of flux at the moment, with the universal drive for quality improvement and the need to rein in costs. These issues, along with the desire to enhance our patients’ satisfaction and overall health care experience, were barely even talked about a decade ago. Now, they are all the buzz around every hospital administration table across the country.

The problem that we have, however, is that the whole topic of making hospitals better places to be has become a bit of a bumper sticker, with lots of convoluted and complex ideas being put forward, that often border on being nothing more than expensive gimmicks. At the same time, most hospitals are missing a lot of the common sense measures that really make hospitals places where people can actually comfortably get better. In terms of going back to these fundamental basics, here are 5 of the most straightforward ways we can get there:

1. Make hospitals as quiet as possible
This should go without saying, but is so commonly overlooked. If patients cannot get a decent rest, especially at night, how can they possibly feel better? It’s often the first complaint I hear in the morning when I enter a patients’ room—either due to a noisy neighbor or activity outside the room. While it may be impossible to eliminate all nocturnal noise in a busy environment, we can do so much better. I call this the “rough and tumble” atmosphere in most hospitals.

2. Single-bed rooms
This also links to the noise problem, but is just as much an issue with hygiene and infection control. The trend over the last few decades is for fewer and fewer patients to be grouped together in rooms. Although the United States is ahead of the curve compared to most other countries, there’s little doubt that in the not too distant future, sharing a room with another patient will be viewed as just as unacceptable as finding out you are sharing a hotel room with a random stranger when you check-in!

3. Staffing ratios
We need to ensure that all frontline health care staff, especially doctors and nurses, have adequate time with patients and their families. The more rushed and frantic the atmosphere is, the less a hospital becomes a place of healing and instead more like a factory floor. So many of our problems in health care, whether they are to do with improving patient safety or enhancing patient satisfaction, would be solved with the right numbers of frontline clinical staff. Think it’s expensive to have more doctors and nurses? Imagine the cost benefits in terms of reduced medical errors and the organization gaining a better reputation with patients and their families.

4. Hospital design
As new hospitals are being built, and those that are already here add to their campuses with new building wings, let’s put maximum thought into the right internal (and for that matter external) design for a hospital. Utilize an open plan design as much as possible, minimize the old-fashioned style long corridors, and pay attention to other important design aspects such as the flooring. You know when you’re in a nice and classy restaurant, hotel or airport, and you feel good about it. The same rules apply to hospitals.

5. Ambulate patients and take them outside the room
One clinical aspect of medical care that we don’t address enough is the need to ambulate patients as much as possible during their recovery. It’s the worst thing for patients to be stuck in bed for most of the day, barely sitting up. Not only does this increase the risk for deep vein thrombosis (a blood clot in the leg), but also leads to a higher risk of infection and generally prolonged recovery. The inpatient medicine world can actually learn a lot from orthopedics in this respect, because orthopedic surgical floors are among the best at ambulating their patients post-operatively. All hospital units need to be stricter about protocols for making patients get up out of bed, ambulating them whenever they can, and even taking them around the hospital—in a wheelchair if necessary. This can increase patients’ motivation and give them a welcome change of scene. The most positive feedback I’ve heard has been in hospitals with beautiful external areas, where patients can be taken outside on nice days, often to garden-like areas.

These are just 5 ways that we can make hospitals into the “healing temples” that they are supposed to be. We all know from our experiences of even having a simple cold or viral infection, that nothing helps us more than a good rest in a comfortable and quiet environment. Until we get this most basic requirement right of what a hospital should be like, it’s really futile to be discussing a lot of other things. The world of health care needs to remember that aside from good medicine, a nice environment can be just as sweet a pill.

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.
Tuesday, June 24, 2014

On orchestrating change

Change causes distress for most people. In medicine we have a hierarchy that disdains most change. Medical students, residents, attending physicians all seemingly reject change. Practicing physicians dislike change. Yet change occurs and is necessary. I learned a great deal about change from my mother. This anecdote may help put change into perspective.

Many years ago, over 50 years ago, we lived in a 3-bedroom house. In the evening we all sat in the family room watching our small TV. One evening, as my father sat in HIS chair, and my sister and I sat on the floor, my mother comes into the room and announces that a couch would look good against one of the walls. I remember my father rolling his eyes and mumbling something about another campaign. Nine months later he gladly bought a couch.

My mother understood patience. My father was not ready for change, so she started a campaign to change minds.

Many years later, I was a new internal medicine program director. I was full of ideas, but quickly learned that my ideas were often way ahead of the program. Once we had to rethink our clinic schedules. I had the idea of having interns come to clinic in the morning and residents in the afternoon. This plan would allow someone from the team to always be around during the day. This plan would take interns out of rounds 1 day each week, making a strong statement about the importance of outpatient training.

When I first presented this plan, it was roundly rejected. Over the next few months I gently made the case to reconsider this strategy. Eventually, the chair had this great idea of having interns in morning clinic. The idea triumphed after enough time for everyone to accept the logic.

Too often change in medicine occurs without involving those affected. Too often students or physicians reject well-meaning change because they were not involved in the process.

Change challenges us. We become used to the status quo. But we must change at times.

When we advocate change, we need to carefully understand the consequences and especially the unintended consequences. We cannot ignore those whom the change impacts. They must be part of the change process, or else the resistance will grow and grow.

Leaders forget these principles too often. We have seen many changes imposed on physicians without a clear understanding of how those changes will impact practice and their lives. They forget these principles and cause great angst.

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.
Monday, June 23, 2014

You can chew it. You can swallow it. But is it food?

There is, of course, stuff we can chew and swallow that isn’t food. Play-Doh comes to mind. As does Silly Putty.

My thoughts turned to those substances, among others, when my friends at Time magazine asked me to opine on the suggestion that “junk” foods should carry warning labels. My first inclination was: No, that’s too much. But then it dawned on me: Is anything that is a legitimate candidate for a warning label a “food” in the first place?

I looked up the definition of food, and the first one I found was: “any nutritious substance that people or animals eat or drink, or that plants absorb, in order to maintain life and growth.” That in turn implies that non-nutritious substances that, say, gum up our coronary arteries, pad our adipocytes, or rot our teeth might not qualify.

So, in some ways, a warning label on a food would be like a warning label on a computer that says: “Not To Be Used For Computing.” So how can it be a computer? Or a label on a car indicating it is “Not Suitable For Transportation.” Well, then, is it a car? You see where I’m going.

The suggestion about warning labels came at the World Health Organization’s 67 World Health Assembly, now ongoing in Geneva. The case was made that junk food is even more damaging to public health today than tobacco, and that warning labels should be posted accordingly on the implicated foods.

The argument that junk food (whatever, exactly, that is) does more damage globally than tobacco is far more defensible than it may at first seem. As far back as 1993, we knew that the combination of eating badly and lack of physical activity was just behind tobacco on the list of leading causes of premature death (and chronic disease) in the United States. When the analysis that produced that original list was repeated a decade later, that gap had narrowed, due both to less smoking, and ongoing neglect of both feet and forks, with worsening epidemics of obesity and diabetes to show for it.

Related studies have been published with regularity ever since, showing again and again and again, in populations around the globe, that eating badly and inactivity are exacting an enormous toll. Both have now been implicated among the leading causes of premature death and chronic disease worldwide. So that case can be closed.

What, then, of warning labels?

Well, the libertarians among us, and that portion of libertarian in all of us, are likely inclined to balk. In fact, the balking began before ever the talking on the subject had concluded. The basic gist here is: don’t tell me what to eat! And, of course, resistance to intrusions by Big Brother inevitably invite slippery-slope paranoia: If the government can tell me what food I shouldn’t really eat, what’s to stop them from telling me what food I must eat? The next thing you know, breakfast is prescribed by the Feds and administered by military police.

I understand the objections. But I don’t think they hold up. And in fact, I want to make the case that a skull and crossbones on a package of “toaster pastries” or multicolored marshmallows masquerading as part of a complete breakfast (what part, I’ve always wondered?); or a day’s supply of sugar dissolved in caramel-colored liquid; or something that once resembled animal flesh that has now been processed into a concoction of meat, sugar, salt and carcinogens, does not go nearly far enough.

After all, we are talking about food. And food should be … well, food.

Tobacco is tobacco, there is no way around that. None of us has to smoke, and those of us who do are exposed to the intrinsic harms of tobacco. We deserve to know what those are, and how significant. This is really no different than providing just such information about pharmaceuticals. I doubt even the libertarians object to disclosures about the potential side effects of Big Pharma’s offerings. In fact, I suspect the libertarians may feel particularly entitled to just such information.

Tobacco and alcohol are the same. They are drugs, albeit drugs used recreationally. They come with intrinsic dangers, and the consumer has a right to know about them.

One might argue to extend just such thinking to “junk” food, and thus counter the libertarian argument. Indeed, I think that could be done: being told what’s what is not being told what do to! We can be told what is in our food without being told what food to put in our mouths.

But as noted, I don’t think the “unless you want to die slowly and painfully, don’t eat this food!” label goes far enough. Because unlike tobacco or alcohol, or drugs used to treat disease, food is supposed to be good for us, not bad. It is supposed to be sustenance, not sabotage.

We are, truly, what we eat, using the nutrient components of food to reconstruct ourselves from our molecules on up every day. Consider, in particular, that food is the one, only, literal construction material for the growing body of a child you love. How we ever got the notion that “junk” food, out of which we are growing our children, was cute, or innocent, I have no idea.

You can’t smoke tobacco and avoid tobacco. You can’t drink alcohol and avoid alcohol. But you can eat food and avoid junk. There is, in fact, an impressive range of overall nutritional quality in almost every food category, so we could abandon junk food altogether, and quickly learn not to miss it.

In my opinion, that’s what we should do. Despite thinking at first that warning labels might go too far, I wound up realizing they wouldn’t go nearly far enough. Junk should never have been glorified as a food group in the first place. So sure, let’s apply some objective method to determine what foods warrant a scarlet “J,” but then, let’s eradicate them, because they aren’t food. We can sell them for something else, like spackling, for instance. But food ought to be food, not junk. It’s silly to have “don’t buy this food” labels on food we keep selling as... food. If it warrants the warning, it really doesn’t qualify. There are alternative products that do in every case.

Which might, I suppose, put me at odds with the libertarians. What else is new.

But frankly, even they should object to the false advertising involved in marketing junk as food. Besides, they can still smoke and drink.

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.
Friday, June 20, 2014

Meager and unsatisfactory

It’s nice to see antimicrobial resistance featured in a Sunday New York Times editorial—nothing that we haven’t already covered in a recent post by Eli Perencevich, MD, ACP Member on the WHO report, but worth reading nonetheless.

If you believe that “you can’t improve what you can’t measure,” the most disheartening sentence in this editorial about the WHO report is “… few countries track and monitor antibiotic resistance comprehensively, and there is no standard methodology for doing so.”

This saying is a paraphrase of Lord Kelvin, who also said: “When you can measure what you are speaking about, and express it in numbers, you know something about it; but when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind.”

“Meager and unsatisfactory” is a great description of the status of our current response to the antimicrobial resistance threat.
Thursday, June 19, 2014

MERS: a primer

The CDC reported the first case of Middle East Respiratory Syndrome (MERS) in the United States. The patient is a health care worker who flew from Saudi Arabia to Chicago (via London), and then traveled by bus to Indiana, where he is currently hospitalized.

I suspect this is the first of many posts on this topic. In case you have not been following the MERS story, I put together a summary to get you up to speed.

• Approximately 400 cases have been reported since the first case was reported in 2012.
• All cases have been acquired in 6 countries in the Arabian peninsula, though some cases became symptomatic after travel to other countries.
• The virus (a novel coronavirus) appears to have originated in bats, but antibodies to the virus have been found in camels.
• Transmission dynamics are not completely understood. Human-to-human transmission does occur, and some cases are associated with contact with camels.
• About 1 in 5 cases have been healthcare workers who cared for patients with MERS.

Clinical (excellent reference by Hui et al here)
• The incubation period is 2-13 days (median, 5 days).
• The illness is characterized by pneumonia, which in most cases is severe (80% require ventilatory support).
• Typical cases begin with fever, cough, chills, sore throat, myalgia and arthralgia, followed by dyspnea and rapid progression to pneumonia.
• Severe cases may be associated with ARDS, septic shock and multiorgan failure.
• Fever is almost always present.
• GI symptoms (nausea, vomiting, or diarrhea) are present in 1/3.
• Chest imaging is always abnormal; findings include bilateral hilar infiltrates, patchy infiltrates, segmental or lobar opacities, ground glass opacities and small pleural effusions.
• Routine laboratory abnormalities are variable.
• Mortality rate is ~30%. In fatal cases, median time from presentation to death is 11.5 days.
• Asymptomatic infection can occur.

Diagnostic Testing (detailed instructions by CDC here)
• In the US, all testing is performed by public health laboratories.
• PCR is available for BAL fluid, tracheal aspirate, pleural fluid, sputum, NP/OP swabs, NP wash/aspirate, and serum.
• Antibody testing: acute (first week of illness), convalescent (≥3 weeks after acute sample obtained).

• No specific antiviral therapy is currently available.
• Treatment is focused on supportive care.

Infection Control and Prevention (CDC guidance here)
• Contact and airborne precautions are indicated for patients under investigation, and suspected and confirmed cases (see CDC case definitions here).
• Eye protection (goggles or face shield) is specifically recommended.
• At this time, there is no available vaccine or chemoprophylaxis.

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.
Wednesday, June 18, 2014

When you demand antibiotics, you hurt us all

The discovery of penicillin was a perceived as a miracle. Men mortally wounded in war survived. Pneumonia, the Captain of the Men of Death, got a demotion. Infectious diseases were a major cause of death and the war metaphors continued.

But penicillin and the antibiotics that followed moved quickly from treating war wounds and pneumonias to the everyday treatment of just about everything. No doubt millions were cured of meningitis, pneumonia, strep throat (with the probable prevention of rheumatic fever), limb-threatening infections. But as vaccination and other public health measures improved, antibiotics became more commonly seen in severely ill hospitalized patients (often used appropriately under the supervision of experts) and doctors’ offices (often inappropriately).

Antibiotics are losing their miracle abilities, and quickly. Natural selection, with its arsenal of genes and mutations, eventually wins every time, and bacteria develop resistance.

It’s my fault, and yours. Despite the medical facts, our perception of antibiotics as miracle drugs persists. They don’t cure colds, bronchitis, most ear and sinus infections. There are few reasons to use them for everyday ailments. But people being people, the greater the urgency, the stronger the belief in miracles. I cannot make your sinuses better before your trip by giving you a “Z-Pak.” If your cough started yesterday, there’s not a helluva lot I can do to help you that your grandma hasn’t already told you.

But doctors want to help people and frequently succumb to patient demands. So this is on all of us. If your doctor thinks antibiotics will help you, take them, all of them, to avoid breeding resistance. If your doctor says you don’t need any, say “thank you” for the good news.

Together we can try to salvage our supply of useful antibiotics and stem the tide of super-bugs resistant to everything.

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.

Designing a better hospital

Let’s face it. A hospital is a place where nobody wants to be. By its very nature, it is somewhere scary and not too nice.

Those of us who work every day in hospitals can easily forget this fact: Those who we serve would rather be anywhere else (and so they should). Think of all the things our patients would rather be doing: enjoying a leisurely afternoon with the family, out in the shopping mall, or at a dinner party with friends. Because of this, we have to think of hospitals in slightly different terms than many other institutions.

For all the talk of patient satisfaction and improving the health care experience, hospitals will always be inherently different from hotels, restaurants, and airports, which are associated with excitement and a good time. But that doesn’t mean that we can’t put more thought into how we could make them more inviting and tolerable from a basic design perspective. As comfortable and healing as possible. That is, after all, the basic function of a hospital: to allow patients to rest and recover.

As someone who has worked in several different hospitals, all very different in terms of location and appearance, I have gained a fair idea of what a good hospital looks like, architecturally, both internally and externally. Here are some of those qualities:

1. An open lobby
The hospital entrance should be as open-plan as possible. Make use of as much natural light, greenery, water (I’ve worked in a hospital with a small waterfall in the lobby), and background music. Along the same lines, make use of an open space feeling everywhere, including on hospital floors. The more cramped and enclosed a hospital feels, the less welcoming it will be

2. Glass exterior
This is being used by new hospitals, and imparts a more modern and “futuristic” feel. The worst external designs use a lot of concrete, dull in color, and bland from the outside

3. Rethink corridors and don’t let them be too long
Traditionally hospital floors are based on a “corridor” design. Generally the longer the corridor, the more “detached” and monotonous a hospital can begin to feel. Some of the older hospitals have extremely long corridors, which was the old-style way to build hospitals. Most intensive care units do not utilize this design, and will have patient rooms distributed around a central area (more circular design). That’s for a reason: Corridors don’t promote vigilant patient care

4. Flooring
Flooring is very important to the design of any area, and an often overlooked aspect in hospitals. Think carefully about the type and color of the floors. Avoid drab and dull colors. Carpets may be also be a good idea, but are tricky because they are difficult to clean. While we can’t obviously have carpets in patient rooms, we can maximize their use elsewhere. Wooden floors also look good, and can be glossed over to make them hygienic and bleachable

5. Single-bed rooms
Multiple occupancy rooms are on the way out. Most hospitals now have two to a room, and the trend is for more isolation. We are way ahead of the curve in the United States, because most hospitals in Europe still have much larger numbers of patients per room. No doubt one day we will find it unacceptable that we have to share a room with anyone at all when we are in hospital, a place that is supposed to be hygienic and restful

6. Minimize clutter
This gets back to an open space design, but it’s very important to minimize the amount of clutter that is located in corridors and patient rooms. Equipment that is not being used should be placed in storage areas

7. Outside campus
New hospitals should only be built in places that are detached from the outside “hustle and bustle.” The problem with downtown hospitals, aside from the noise from outside, is that it’s often difficult for visitors to get there and parking can be a whole different story. Ideally hospitals should be located a bit out of town and have plenty of parking outside

8. Quiet and healing
Patients need to be able to recover in a comfortable and healing environment. One of the biggest complaints I hear when I enter a patient’s room first thing in the morning is how they couldn’t sleep—either due to noise from staff, equipment, or a noisy neighbor! It should go without saying that if we don’t let sick people rest, they cannot possibly feel better. The layout and design of the surroundings plays a large part in the sound-proof nature of the patient’s room

The above design points are common to many of the best performing hospitals and those that usually get the best ratings. Obviously it is more difficult for hospitals that are already established. They can’t just change their whole design. But as we build new hospitals, and those that are already here build new wings, we must think of these. Input is required not just from architects, but everyone involved in the hospital. The internal design of a hospital can make a massive difference to patients’ health care experience. It also makes a huge difference to how everyone who works in the hospital experiences their workday. We can never make hospitals exciting and thrilling places to be—they shouldn’t be! But while we guide patients through a tough and low time in their lives, we can at least give them the best possible environment in which to get better.

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--Heavy computer users, dry eye sufferers may share tear film abnormality

Office workers who spend long hours at computers, as well as those with an increased frequency of eye strain, had a low concentration of a mucin in their tears that was similar to patients with dry eye disease, a study found.

To determine the relationship between mucin 5AC (MUC5AC) concentrations in tears among those who used computers extensively and the frequency of ocular symptoms, researchers conducted an institutional, cross-sectional study of the eyes of 96 young and middle-aged Japanese office workers. MUC5AC helps clear the ocular surface of debris and also helps hold fluids to the ocular surface.

Participants completed questionnaires about their working hours and the frequency of ocular symptoms. Dry eye disease, defined by subjective symptoms, tear fluid abnormalities, and keratoconjunctival disorder, was diagnosed as definite or probable, or it was not present.

Results appeared online June 9 in JAMA Ophthalmology.

Mean duration of VDT use was 8.2 (1.9) hours per day. The mean MUC5AC concentration was lower in the tears of heavy computer users with definite dry eye than in those with no dry eye (P=0.02; Hodges-Lehmann estimator, −2.17; 95% CI, −4.67 to −0.30). The mean MUC5AC concentration in the group who worked more than 7 hours was 5.9 [SD, 6.1] ng/mg; 86 eyes), which was lower than that in the group working less than 5 hours: 9.6 [12.3] ng/mg; 38 eyes) (Steel test, P=0.049). The estimated difference was −1.65 (95% CI, −3.12 to 0.00). Furthermore, MUC5AC concentration was lower in participants with symptomatic eye strain than in asymptomatic individuals (P=0.001; estimated difference, −1.71; 95% CI, −2.86 to −0.63).

“Our data indicate that MUC5AC mRNA expression is not altered in VDT (video display terminal) users,” the authors wrote. “However, a previous study has shown that MUC5AC mRNA levels are significantly reduced in patients with moderate to severe DED (dry eye disease). Because most of the definite DED in the present study was mild, we hypothesize that the difference in DED severity between the 2 studies accounts for the discrepancy in MUC5AC mRNA expression.”

Editor's Note: QD: News Every Day will resume on Monday, June 30.
Tuesday, June 17, 2014

The New York Times says we pay administrators too much

A friend sent me a link to a New York Times article on the ridiculous amount that insurance company executives and hospital administrators make. So the reason that American health care is so expensive is not because doctors earn too much, or drug companies charge too much or device manufacturers are making ever more expensive devices with ever expanded indications. Except that it is all of that and more.

Hospital administrators and insurance company executives do make lots of money. They make more than I ever will, unless I do their jobs. But it’s also pretty easy to make a comfortable living as a physician working for a hospital or even a nurse practitioner in one of the specialty or acute care areas. By “easy” I mean that it is easy to make money, not that the job is easy. The creation of the Affordable Care Act has set into motion some mechanisms for decreasing costs, but it doesn’t come close to dealing with the fundamental dynamic that makes health care expensive. Jobs that are indispensable for the functioning of the strange and overly complex and ridiculously fragmented health care industry are paid very well, both because they are difficult jobs which not everyone can or will do, but also because there is very little pressure to reduce the costs or complexity.

We built it this way. Because it has always been financially terrible to get sick or injured we created insurance which made it less financially devastating. We paid a little every month and then, if we needed care, the insurance company would pay our bill. But that changed incentives. Because we had paid an insurance company to cover our costs, it was more financially shrewd to get expensive medical care so as to recoup the cost of the insurance. Insurance companies would recoup their costs by raising rates, which allowed them to become larger and hire more staff. The vast majority of medical costs are paid that way, through a third party, but with our approval as consumers. Medicare, our large government insurance company, acts the same way.

Hospitals receive the bulk of health care spending and are more successful when they do more business. Costs like administrators’ salaries and new wings and fish tanks and flat screen TV’s are handed on to the consumer, with our permission, because our insurance pays for it. Administrators that can keep hospitals financially successful are worth their salaries to the companies that pay them, so they make a lot of money. Hospitals are businesses. If they are successful it is because they spend their money in a way that increases their profits.

Health care has grown unfettered for a very long time as insurance has become more universal and costs have lacked natural controls. Salaries of bigwigs and doctors have grown and more people in the US support their families on health care dollars. We have reached a point, though, where it is painful to pay for insurance and so we are looking for ways to lower health care costs without the incentives that would be present if we had to pay them by ourselves. Transparency, that is, knowing where the money goes, is an important step. Thanks, New York Times, for publishing information about what hospital administrators and insurance executives make, but I don’t think that being outraged about it is very useful.

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.

Case of caring

I have long been a fan of the “Case Records of the Massachusetts General Hospital,” which is published weekly in the New England Journal of Medicine. For many years, I made a point of recommending them to medical students and internal medicine residents as a model of concise yet comprehensive case presentations. No wasted words, no missing information, and none of the filler that trainees often added when they presented cases, such as “on heart exam …” or “the sodium was high at …” As I always reminded them (often not as gently as I should have), if they were reporting a heart murmur, I knew it part of their examination of the heart, and if the sodium was 149, I knew that was high.

Over the years, the Case Records have evolved from the old “stump the chump” format, where some oddball “zebra” was presented, “the medical students” always got it right, and the discussant often made an idiot out of himself. Those were admittedly fun to read, but probably not all that helpful to practicing physicians. An atypical presentation of tsutsugamushi fever? Really? I also had a warm place in my heart for the old CPC format, since I was once long ago one of those medical students (we were given a few hints by the chief resident that really helped) and, later, a discussant (NEJM 1994;330:126-34) who, luckily, did not make an idiot of himself, but was convinced for weeks that he was about to.

The medical students stopped offering their diagnoses a long time ago, and the mystery cases were dropped more recently. The current format is less detective story and more narrative, an explanation of the presentation and treatment of an interesting case.

One case was obviously chosen to coincide with the first anniversary of the Boston Marathon bombing. It detailed the care of a young man grievously wounded in the blast, from the time he arrived in the Massachusetts General Hospital emergency department 31 minutes after the bomb went off (“covered in ash and smell[ing] of smoke”) until his discharge weeks later to a rehabilitation facility.

A few things really struck me about the case discussion. First, the methodical accounting of the patient’s various wounds, including a traumatic amputation of his right leg and the presence of intracardiac shrapnel, was a vivid reminder of just how evil the attack was. Second, the imaging modalities used to assess his injuries and guide his treatment were almost eerie in their clarity. Third, the teamwork evident in his care was really impressive. From the first responders who probably saved his life by applying a tourniquet at the scene, to the physicians, nurses, therapists, psychologists and others who directly cared for him in the hospital, it clearly “took a village” to restore him.

Finally, I was really impressed by what the patient himself had to say about his care. It really is worth reading, but he cites three things in particular that stood out: “just being personable makes a huge difference in a person’s recovery … my family and I always felt included in every discussion with the doctors” and the control of his pain was critical to his recovery.

This Case Record retaught old, but important lessons. Being personable, being generous with information, and being attentive to physical comfort are things we can and should do for every patient.

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.
Monday, June 16, 2014

The well-chewed calorie

Many of you have doubtless already seen the commentary in the New York Times by my friend and colleague, Dr. David Ludwig (with Mark Friedman, whom I don’t know), entitled: “Always Hungry? Here’s Why.” If you have not read the piece, I commend it to you.

Regarding Dr. Ludwig, he is indeed both colleague and friend, and I am proud to call him both. He is a prolific, insightful and accomplished researcher, and one of those rare individuals whose intellect sends out sparks to ignite better thinking by those around him. For whatever my opinion is worth, I consider Dr. Ludwig one of the best in the business of both learning what we need to know about diet and health, and putting it to good use.

Regarding the New York Times piece, and the more scholarly commentary in JAMA on which it is based, I have a number of favorable impressions. The commentary essentially posits that we are not fat because we overeat, but overeat because we are fat, exploring the inner life of the adipocyte and its interactions with an array of hormones, insulin salient among them, to make that case. The commentary is thoughtful, well-reasoned and provocative. Dr. Ludwig’s excellent research, focused on glycemic index and load in particular, is cited for support.

But I am worried that even commentary of this caliber is subject to the law of unintended consequences, which has been the bane of public health nutrition for far too long already. In particular, I searched the text of both the pop culture and scholarly versions of this essay, and in neither case found any of these four words: survival, culture, satiety or synthesis. I think these are crucial considerations, and potentially grave omissions.

On Survival:
Drs. Ludwig and Friedman posit that we overeat because we get fat, but that merely begs the question: Why did we get fat in the first place? They address this to some extent, but fail to emphasize what I think is the essential, and obvious answer: survival. Throughout most of human history, calories were relatively scarce and hard to get, and physical activity was unavoidable. We are adapted to that world. But we have devised a modern world in which physical activity is scarce and hard to get, and calories are unavoidable. Houston, we have a problem.

In a world of relative caloric scarcity and fairly constant demands for physical exertion, appetite for salt, sugar, fat, calories, variety, all fosters survival. In nature, you eat what you can when you can, and you don’t get fat not because you are trying to avoid it, but because survival is challenging and conspires against it. In an unnatural world of constant abundance of tasty calories and labor-saving technology, you behave as you always have, but wind up with very different results.

You get fat. And then, sure, being fat may propagate the problem in a number of ways, but the bedrock explanation for overeating is not being fat; that is an obvious chicken-and-egg conundrum. The bedrock explanation for getting fat is: we have made it fun (e.g., tasty food; sedentary recreation) and easy to get fat and hard (e.g., a need for constant restraint; hectic schedules; etc.) to avoid it.

On Culture:
Culture is bigger than any one of us. Cultural variation in behavior and health outcomes tells us rather indelibly, whether we like the message or not, that the basic care and feeding of the human body is highly dependent on actions of the body politic.

The Blue Zones have longer lives, better health and more happiness than the rest of us not because of a preferential focus on calories, or refined carbohydrates, but rather on living well. When pleasure is derived from strong social connections, there is less need to get it from toaster pastries. When culture normalizes good use of feet, forks and fingers; and encourages attention to sleep, stress mitigation and love, health and long life result, all around the world.

Our inclination to keep chewing calories into ever smaller bits of academic grist may be the very opposite of what we really need: the big picture. Our culture marketsmulti-colored marshmallows to our kids, and tells them they are “part of a complete breakfast!” Highly paid advertising executives engineer the angle of gaze on cereal boxes by iconic cartoon characters to influence, maximally and subliminally, the responses of children and adults alike. And we need to ask why are we fat? Come on! Maybe “hypocrisy” should be on my list of missing key words, too. Our culture seems to have no shame of it.

On Satiety:
Satiety refers to a feeling of fullness, and implies something about its duration as well. We have long recognized, all but intuitively, that the satiety attached to diverse foods is highly variable. For instance, we have referred in the vernacular to some foods as “stick to the ribs,” meaning they make, and keep us, full.

But now, again, welcome our cultural hypocrisy. We invite the likes of Dr. Ludwig to debate the origins of obesity, even as teams of Ph.D.’s work for Big Food companies to engineer foods that maximize the calories it takes to feel full. Michael Moss is only the most recent to tell us this tale; others have before. In a world where functional MRI scans and teams of scientists design foods so that bets that we “can’t eat just one” are entirely safe, the relevant question is not why so many of us are fat, but how on earth any of us manage not to be!

The key issue here is that inattention to satiety invites us to debate the relevance of calories, and carry on as if there is a choice to make between the laws of thermodynamics and the machinations of appetite. Why choose? The quantity of calories figures relevantly into energy balance and the hegemony of thermodynamics, while the quality and character of those calories determine how many it takes to feel full. The prevailing tendency in our culture is to maximize the calories it takes to feel full, making epidemic obesity little less than a fait accompli. We can reverse engineer this process to astonishingly good effect, but few in our society have the relevant skills.

On Synthesis:
And finally, the dualistic view advanced here, calories must be about quantity, or quality; obesity must be cause, or effect, may obscure a truth that is both moreholistic, and more actionable. In other words, what we get in the commentary is another hypothesis, while in my opinion, what we most need is synthesis.

Consider, for instance, the work of another friend and colleague, and another exemplar of the academic method, Dr. Brian Wansink. Dr. Wansink’s research has shown that substantial variations in both the quantity and quality of foods consumed can be achieved by influencing such factors as lighting, placement and packaging, before ever even addressing the composition of the food itself. Instead of a seemingly endless parade of competing hypotheses about what truly matters, why not consider the possibility of a truth that is greater than the sum of its parts: Just about every aspect of modern culture that makes it modern is obesigenic, and if we want to fix the problem, we have to fix it comprehensively.

Calories count, but counting calories is tedious business. And besides, few people are willing to spend their lives hungry when they have the option of fullness and satisfaction. So the answer is to reduce the calories it takes to feel full. That means eating better food, which in turn requires knowing what “better” food is (we do); being able to find, choose and afford it (all possible, but how much better we could do!); combining better eating with routine physical activity; and shutting down the forces of cultural hypocrisy that invite us to wring our hands about epidemic obesity even while actively propagating it.

Drs. Ludwig and Friedman talk about the research we need. Maybe among it is a study of how a predilection for highlighting our doubts and debates as publicly as possible forestalls any meaningful action based on what we do know. Again, it would be as if your foot catches fire, and you feel compelled to read competing theories about combustion point, flammability, flame retardants, the partial pressure of atmospheric gases, wound care and skin grafting, before ever you fetch that pail of water. I say: Go for it!

We must, of course, parse and debate, explore and question to advance our understanding, which is far from complete, and farther still from perfect. But then again, how perfect does our knowledge of combustion need to be to fetch a pail of water if our foot catches fire? There is a point at which debating the subtleties of what we don’t know while failing to act on what we do know may come dangerously close to fiddling while Rome burns.

In other words, as good and erudite as Dr. Ludwig’s insights are, maybe the calorie has been sufficiently well chewed already. And maybe endless rumination paves the road to procrastination and ruin.

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.

There has never been a better time to have diabetes

The danger of diabetes is not only the immediate risk of very high blood sugar. Diabetes also has many dreaded long-term complications. (In this post I am referring to both type 1 and type 2 diabetes mellitus. For an explanation of the differences between these 2 very different diseases see the first half of this post.) Diabetes greatly increases the risk of stroke, heart attack, and amputation. In the U.S. it is the leading cause of kidney failure and of blindness in adults.

A study performed by researchers at the Centers for Disease Control and Prevention and published in the New England Journal of Medicine tracked the frequency in the U.S. of 5 serious complications of diabetes over the 2 decades from 1990 to 2010. This was not an experiment in which a medication or diagnostic test is evaluated. This was simply counting how many people had diabetes in the US, and how many of them suffered heart attacks, strokes, kidney failure, amputations, or death due to very high blood sugar.

The results were very encouraging. The rate of heart attacks among diabetics fell by two-thirds, as did the rate of death due to very high blood sugar. This parallels a similar but smaller drop in the frequency of heart attacks in the general population. Stroke and amputation rates both declined by about half. The risk of permanent kidney failure declined by about a quarter.

What accounts for these favorable trends? Part of the credit lies with earlier detection and better treatment of diabetes. Screening for early complications of diabetes by checking for early signs of kidney injury and for the first signs of skin sores helps prevent amputations and kidney failure.

But much of the credit for these positive trends has nothing to do with diabetes, but with general improvements in preventing cardiovascular disease. Fewer people are smoking. Statins have revolutionized treatment for high cholesterol and have drastically reduced the incidence of strokes and heart attacks in the general populations. Improved use of blood pressure medications have also contributed to stroke and heart attack prevention and have prevented kidney failure. And all of these measures have helped reduce the frequency of amputations.

So as cardiovascular risks have declined in the general population, people with diabetes who are at very high risk have benefited most. That’s great news.

The one bit of data in the study that is terrible news is that from 1990 to 2010 the number of people with diabetes in the U.S. grew from 6.5 million to 20.7 million. So the frequency of terrible complications from diabetes is declining, but the number of people subject to these complications has more than tripled. This is terrific news for the individual with diabetes. Diabetes has never been less scary or more manageable. But for the society as a whole, the news is mixed.

To make further progress in decreasing complications from diabetes we must figure out how to stem the tide of the diabetes epidemic. For type 2 diabetes this may mean earlier detection of risk factors and expanded use of weight loss surgery for appropriate patients. It may also mean working to reverse the epidemic of obesity3—a quixotic task. For type 1 diabetes this may mean further work on an artificial pancreas and on immunotherapy that might arrest the disease in its very early stages when some pancreatic function remains.

We’ve come a long way. We’ve got a long way to go.

This post is dedicated to my nephew Elliott who has type 1 diabetes. His parents, Matt and Violet, have become very active with the Juvenile Diabetes Research Foundation (JDRF), an organization that funds research seeking a cure for type 1 diabetes. They are being honored for their indefatigable support of JDRF at a gala next month. Please consider supporting JDRF’s important work with your involvement or a donation. Thank you.

Learn more:

For Diabetics, Health Risks Fall Sharply (New York Times)

Study: Diabetic heart attacks and strokes falling (Washington Post)

Diabetes complications show significant decline in past two decades(Reuters)

Changes in Diabetes-Related Complications in the United States, 1990–2010 (New England Journal of Medicine article, abstract available without subscription)

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

QD: News Every Day--U.S. health care system last among 11 industrialized nations

The United States ranks last overall among 11 industrialized countries on measures of health system quality, efficiency, access to care, equity, and healthy lives, according to a new Commonwealth Fund report.

The U.S. spent the most per person on health care in 2011, or $8,508, compared with $3,406 in the United Kingdom, which ranked first overall.

The report attributes the United States’ ranking to deficiencies in access to primary care and inequities and inefficiencies in its health care system, according to “Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally, 2014 Update.” Data for this report drawn from previous Commonwealth Fund reports.

Key findings related to the U.S. include:

Healthy lives: The U.S. does poorly, ranking last on infant mortality and on deaths that were potentially preventable with timely access to effective health care and second-to-last on healthy life expectancy at age 60.

Access to care: People in the U.S. have the hardest time affording the health care they need. The U.S. ranks last on every measure of cost-related access. More than one-third (37%) of U.S. adults reported forgoing a recommended test, treatment, or follow-up care because of cost.

Health care quality: The U.S ranks in the middle. On 2 of 4 measures of quality-effective care and patient-centered care-the U.S. ranks near the top (third and fourth of 11 countries, respectively), but it does not perform as well providing safe or coordinated care.

Efficiency: The U.S ranks last, due to low marks on the time and dollars spent dealing with insurance administration, lack of communication among health care providers, and duplicative medical testing. Forty percent of U.S. adults who had visited an emergency room reported they could have been treated by a regular doctor, had one been available. This is more than double the rate of patients in the U.K. (16%).

Equity: The U.S. ranks last. About 4 of 10 (39%) adults with below-average incomes in the U.S. reported a medical problem but did not visit a doctor in the past year because of costs, compared with less than one of 10 in the U.K., Sweden, Canada, and Norway. There were also large discrepancies between the length of time U.S. adults waited for specialist, emergency, and after-hours care compared with higher-income adults.

The authors noted that provisions in the Affordable Care Act that have already extended coverage to millions of people in the United States can improve the country’s standing in some areas, particularly access to affordable and timely primary care.

“Now that millions more Americans have good coverage, we have to invest in our health care delivery system to be sure all patients-and especially those with the greatest need and whose care is the most costly-can get the high-quality, well-coordinated health care they need,” said Commonwealth Fund President David Blumenthal, MD, FACP. “Those kinds of improvements will go a long way toward improving peoples’ health while making efficient use of our precious health care dollars.”

The report was also produced in 2004, 2006, 2007, and 2010, with the U.S. ranking last in each of those years. The other countries included in the study were Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom. Countries added this year were Switzerland and Sweden, which followed the U.K. at the top of the rankings, and Norway and France, which were in the middle of the pack. Australia, Germany, the Netherlands, New Zealand, and Norway also placed in the middle, while Canada was just above the U.S. at the bottom.
Friday, June 13, 2014

Are emergency rooms admitting too many patients?

This blog has discussed conflicts of interests. Indeed, every player in the medical arena has found itself challenged by conflicts where one’s self-interest competes can skew what should be pure advice. This issue is not restricted to the medical universe. Every one of us has to navigate through similar circumstances throughout the journey of life. If an attorney, for example, is paid by the hour, then there is an incentive for the legal task to take longer than it might if the client were paying a flat fee.

The fee-for-service (FFS) payment system that had been the standard reimbursement model in medicine has been challenged and is being dismantled because of obvious conflicts that were present. (This is not the only reason that FFS is under attack, but it is the principal reason offered by FFS antagonists.) Physicians who were paid for each procedure they performed , performed more procedures. This has been well documented. Of course many other professions and trades still operate under a FFS system, but they are left unmolested. Consider dentists, auto mechanics and plumbers and contractors.

FFS is not inherently evil. But, it depends upon a high level of personal integrity which, admittedly, is not always present. In my own life, I often hope and pray that the individual who is offering me goods or services is thinking of my interests exclusively. Am I living in fantasy land?

The Rand Corporation released a study in May 2013 that demonstrated that emergency rooms accounted for about 50% of hospital admissions during the study period from 2003-2009. When I have posted on Emergency Medicine in the past, it has stimulated a high volume of responses, some good, some bad and some ugly.

I think it is inarguable that emergency room (ER) care wastes health care dollars by performing unnecessary medical care. As a gastroenterologist, I affirm that the threshold for obtaining a CAT scan of the abdomen in the ER is much lower than it should be. And, so it is with other radiology tests, labs, cardiac testing, etc.

I understand why this is happening. If I were an ER physician, I would behave similarly facing the same pressures that they do. They face huge legal risks. They are in a culture of overtreatment and overtesting because they feel more than other physicians that they cannot miss anything. They argue that they have only one chance to get it right, unlike internists and others who can see their patients again in a follow-up visit. If an ER physician holds back on a CAT scan of the abdomen on a patient who has a stomach ache, and directs the patient to see his doctor in 48 hours, what is the ER physician’s legal exposure if the patient skips this appointment and ends up having appendicitis?

Keep in mind that we should expect that ERs to have higher hospitalization rates of their patients, since their patients are much more likely to be acutely ill.

But even accounting for the sick patients in the ER, I think there is a significant percentage of ER patients who should be sent home and are sent upstairs instead. This would be an easy study to perform. Compare the intensity of testing between the emergency room and a primary care office with regard to common medical conditions. I would wager handsomely that the ER testing intensity and admission rate would be several-fold higher than compared to doctors’ offices. Want to challenge me on this point?

Even though I understand why ER docs do what they do, it is a bleeding point in the health care system that needs a tourniquet.

It is clear that ER physicians are incentivized to admit their patients to the hospital. Of course, they might be ‘encouraged’ to do this by their hospitals who stand to gain financially when the house is full. Leaving the financial conflict aside, when an ER physician admits a patient, he is completely free of the risk of sending a patient home who may have a serious medical issue. I am not referring here to patients who clearly should be admitted, but to the large group of patients who most likely have a benign medical complaint, but the ER physician advises hospitalization ‘just to be on the safe side’. These same patients if seen in their own doctors’ offices would never be sent to the hospital to be admitted.

Where’s the foul here? Here are some of the side-effects on unnecessary hospitalizations.
• wastes gazillions of dollars,
• loss of productivity by confining folks who should be working,
• departure from sound medical practice which diminished the profession,
• emotional costs to the individuals and their families, and
• unnecessary exposure to the risks of hospital life.

How can this runaway train be brought under control? First, let’s try a little tort reform. Second, pay a flat rate for an ER visit. Under this model, if the ER physician orders an MRI on a patient with a back strain, the hospital swallows the cost. Finally, when hospitals are penalized financially for hospitalizing folks who should have been sent home, we will witness the miracle of a runaway train performing a U-turn on the tracks.

While the Rand Corporation’s results are not earth shaking on its face, my intuition, insider’s knowledge and a tincture of cynicism all converge on the conclusion that for too many patients the ER has become a portal of entry in the hospital. Is the greater good served if the ER is a revolving door or barricade?

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.