Monday, September 29, 2014

Do we model good lifestyle choices for our students and residents?

The Wall Street Journal has a very interesting Expert Panel comment on What Is the Most Common Piece of Advice Doctors Give—But Don’t Take?. Their opinions are worthy of a quick read, but I would like to challenge us in a different way.

Charles Barkley famously once said, “I am not a role model”. In our position (clinical educators), we are role models. Our students and residents aspire to become like us. Do we role model good health behaviors?

We do better than average. I almost never see physicians who smoke in 2014. We have accepted this advice in far greater numbers than the average person.

What about exercise and weight control? I do not have data, but truly obese physicians seem less common that truly obese people at the mall. Many physicians do exercise regularly.

We tend to work too hard and accept too much stress. Our learners see that, and often consider “lifestyle” fields.

When we embrace a healthy lifestyle, our learners take notice. As I have lost weight and taken up running, so have many residents.

Burnout remains our biggest risk. We must improve how we approach our profession to decrease burnout. My friend and colleague, Mark Linzer who works at Hennepin County Hospital in Minneapolis, has carefully researched this problem. Too few of us in academics have embraced his work, Doctor burnout: Nearly half of physicians report symptoms.

The burnout rate is nearly twice as high as in an earlier report by physician Mark Linzer, director of the Hennepin Healthcare System in Minneapolis. He is not associated with the Mayo study. He found 26.5% of doctors complain of burnout.

The doctors in the Linzer survey typically reported more than one symptom, but, if left untended, the doctors surveyed in the Mayo study could reach that point, too, he says.

“Control is the biggest predictor of burnout across the board,” Linzer says.

Among control issues that add to stress:
How many patients you see.
How much time you have with them.
How many different types of patients you might see in a short period.
When you might have to release someone from the hospital.

He adds team-oriented approaches could help ease the pressure: “It used to be all about the clinician caring for the patient. Now it needs to be the clinician, nurse, care coordinator and others. When you start expanding the numbers of types of people who are caring for a patient, that helps a doctor and patient a lot.”

As academicians we should embrace this research, and change how we teach and role model. We need help from administrators and physician leaders. We need to focus on teamwork. We need to focus on the person not the numbers.

We can help our learners the most when we address this issue strongly.

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.
Friday, September 26, 2014

The freedom to care

I got the following email a few weeks ago (details changed for confidentiality reasons):

Dear Sir,

I read about your unique practice online. I have a 91-year-old ambulatory father who will not go to a doctor. He definitely is not well and this is the only way I can get him the attention he needs. He is adamant about not wanting medical interventions; however, he still needs to be seen by someone. Despite his weakness, he has a strong will and cannot be made to go to a medical office. I told him I would try to find a physician to come to the house.

He lives in Augusta. I would retain you as needed. Thank you for your reply.

The son who wrote this lives in-state, but a few hours away, and was desperate for some sort of help. The details of his medical problems were very serious, and I seriously doubted this would be a long-term situation. It seemed pretty clear that he was dying and wanted to do so at home.

I responded:

Having an 87-year-old parent, I understand. I am also very much in favor of doing nothing when appropriate. I do wonder if hospice would be a good idea, as they focus (as would I) on quality of life. Do you think he would be open to having hospice (would free up a lot of money and resources from Medicare)? My focus would not be on doing anything that would not improve his quality of life (which is what he would probably want).

The son was happy with this approach, and I set a home visit to see this man.

The home was small but very orderly. A family friend answered the door and ushered us in. Pictures of family filled bookshelves, some of which showed people alongside of U.S. presidents, generals, and other important people.

The man was as expected: thin, frail, but with a very clear and sharp mind. He was also very suspicious of my intentions. I explained that I was there at the behest of his son and had no intent of putting him in the hospital, or even doing any tests if that was what he wanted. He relaxed a little at hearing this, allowing me to take a history.

91-year-old male with no previous medical problems. Abdominal distention and blood in BM for past 1-2 months. Getting weaker over past 1-2 weeks.

He had been hiding the details of his problems from family and friends, but his weakened state became obvious to everyone around him. The family friend added details where the gentleman was evasive. ”You fell down yesterday,” the friend said after the man had denied the same. ”What about last week when you couldn’t get to the car?”

He cast a scowl at the friend, but nodded. ”Yeah, I guess I have been falling some.”

I examined him, leading him to his bedroom so he could lie down and I could examine his abdomen. He required significant help even with the 20 steps it took to get to the bed. He let out a big sigh when he lay back on the bed. The diagnosis came quickly, as his liver was huge and had an irregular, lumpy feel.

I had little doubt. He had cancer in his liver, probably spread from his colon.

We went back to the den, where we initially had talked. ”I am going to be square with you. I think you have a very, very serious problem. I think you have cancer in your liver. I’m sorry to have to say this the first time meeting you, but you seem to be the kind of person who would want the truth, even if it is hard.”

He didn’t seem surprised at the news. ”Yeah, I figured it was something bad. Cancer, huh?”

“Yes,” I answered. ”Obviously there is no way to know without doing tests, but your son told me you don’t want any X-rays or labs done. I’m giving you my best guess, but I’d honestly be very surprised if it was anything else. I think it’s probably advanced enough that even if we did tests, there wouldn’t be much we could do.”

Again he nodded.

“I think hospice is the best thing to do at this point,” I said. “Hospice gives you access to much better nursing care, maybe a hospital bed, and other resources. They focus on your quality of life in the next few days or weeks, not on doing procedures that would extend this bad period of your life.”

His expression became negative. ”My mother was in hospice. I don’t want hospice.”

“What was the problem with hospice for your mother?” I asked.

“They took her out of the home and put her in that hospice,” he said. ”I am not leaving my home. I told you that.”

I explained that hospice usually didn’t involve leaving the home, and told him that I would do whatever I could to honor his wish to not leave home. He agreed to consider this and we wrapped up our conversation.

When I got back to the office I called the son, recounting my visit. He too wasn’t surprised at the cancer diagnosis. ”I’m coming to town this weekend, so I’ll try to talk to him about hospice. I agree that this is the best thing.”

Within 2 days hospice was set-up. This morning, 2 weeks after my visit, I got this email:

Dr. Lamberts and Staff,

My father passed away in his sleep yesterday. It was like every other night. He was still breathing at 6:00 a.m. An hour later, he had quietly passed. Thank you and your staff for your service and your kindness. Had you not made the home visit, I would not have had access to any medical services for him. The hospice was exactly what was needed.

I am grateful for the opportunity I had to help where help was not otherwise available. There is no way my previous practice would have offered me this freedom, the freedom to care for this man in his last days. I took 2 hours of my schedule to drive to his house and conduct the visit. From the business standpoint, this is not a big win for me. But who cares about business here when I have the opportunity to give help where it was most needed?

Thank you, sir, for letting me into your home. Thank you for trusting me when you didn’t want to trust a doctor. Thank you for letting me help you stay at home and live out your last days as you wanted them to be.

Thank you to my nurse who came along to share this experience. Thank you for the hospice for being sensitive and not using the word “hospice” around the man. Thank you to the son for contacting me. Thank you to the partners in my old practice who divorced me 2 years ago and set me free from the American health care system that would have shackled me. Thank you to my patients who have supported my practice and enabled me to keep the business open.

Thank you.

Good riddance to routine pelvic examinations

So much in medicine and in life is done out of habit. We do stuff simply because that’s the way we always did it. Repetition leads to the belief that we are doing the right thing.

In this country, we traditionally eat 3 meals each day. Why not 4 or 2?

We prefer soft drinks to be served iced cold. I’ve never tried a steaming hot Coke. Maybe this would be a game changer in the food industry?

Life gets more interesting when folks question long standing beliefs and practices forcing us to ask ourselves if what we are doing makes any sense.

In the medical profession, a yearly physical examination was dogma. Now, even traditionalists have backed away from this ritual that had no underlying scientific data to support it. Yet, patients would present themselves to this annual event believing that this ‘check-up’ was an important health preserver.

Here were some medical routines that were never questioned:
• Yearly ear drum examinations with the otoscope. Always exciting.
• Palpation of the abdomen.
• Listening to the lungs with a stethoscope.
• Testing your reflexes (Sure, this was fun, but did it help anyone?)

Keep in mind that I am referring to components of the physical exam that are performed on asymptomatic individuals who feel well. Obviously, listening to a patient’s lungs has more value if a patient has fever and a cough.

Yes, I recognize that there may be an intangible value in having a physician make physical contact with his patients, which some argue help to create a bond in the relationship. This may be true in part as patients have been taught to expect this from their doctors. Indeed, a “hands off” physician may be construed by patients as being an inattentive or even an incompetent practitioner.

Recently, the American College of Physicians issued a new guideline published in the Annals of Internal Medicine stating that routine pelvic examinations should not be performed. Why? Because there is no persuasive evidence that they do any good.

Sure, there will be pushback. In medicine and elsewhere, there is often resistance to change from those whose practices are being challenged. Review the following complex table that I have prepared.

Procedure Under Review and their Resistors

PSA: Urologists

Mammograms: Radiologists

Colonoscopies: Gastroenterologists

Term Limits: Politicians

Tort Reform: Take a guess

If all of the elements of a routine check-up were subjected to scientific scrutiny, we might be shocked at how little of the exam remained. This might create an unintended benefit. It would free up time that we physicians could use to talk more with our patients. So far, no scientific study has deemed this to be a waste of time.

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.
Thursday, September 25, 2014

Rabid opposition to Ebola: epidemiology meets hyperbole

To be quite blunt about it, Ebola is a very scary disease. Among those infected, the mortality rate is, as is perhaps now widely known, an appallingly high 90%. That would seem a very good reason to keep our borders closed to this scourge and the consequences to the poor souls who already have it be damned. That, apparently, was just the kind of thinking behind at least one rather high-profile tweet.

But perhaps we might characterize this thinking as the subjugation of epidemiology to hyperbole. And like all rabid opposition, it is the product of anxiety rather than analysis.

And speaking of rabies, that is a virus already well-established here in the U.S. with a case fatality rate of either 100%, or something very close to it. In other words, rabies is a more lethal virus even than Ebola. Yet we don’t live our lives in fear of rabies for an obvious reason: we are very unlikely to get it. Rabies is not the common cold; a sneeze is not going to transmit it.

The transmission of rabies almost always involves the bite of an infected animal. Most human cases involve dog bites, not because there is much rabies in dogs, but because humans are more likely to come into contact with infected dogs than the species in which rabies is more prevalent, including raccoons, skunks, bats, and foxes.

But let’s move on, because my aim here is not to wade into rabies esoterica but to make a general point. Rabies is a horrendously bad disease, but we don’t live in fear of it because we take some basic precautions, like vaccinating our pets, and know we are unlikely to get it. We do not deport those rare individuals infected with it to some foreign land in the name of homeland security; we treat them here. And, to my knowledge, even Donald Trump has not called for the deportation of our raccoons.

The Ebola virus is nearly as lethal, and thus nearly as scary, as rabies. Like rabies, it is rather hard to catch. Direct contact with infected body fluids is required. There is, to date, no known case of respiratory transmission, meaning Ebola is not spread by coughing or sneezing. Conceivably, the virus could evolve so that changes; but in theory, the same is true of rabies. Fear of an Ebola outbreak in the U.S. is only justified among those who avoid the woods for fear that a skunk might sneeze.

What makes Ebola such a devastating disease in Africa is the lack of medical facilities to contain it. When family members in remote villages tend to one another, there is, of course, routine and rather copious exposure to infected body fluids, including blood. This is the very thing the gloves and gowns in routine use in every hospital in the U.S. are intended to prevent. When isolation precautions are taken, the degree of personal protection is considerably greater still. When need be, we have recourse to even more extreme forms of quarantine. Tuberculosis patients, for instance, can be treated in negative pressure rooms that preclude the release of any potentially infected air droplet.

To my knowledge, there are no negative pressure rooms in Sierra Leone. More importantly, there are few modern medical resources of any kind. Ebola spreads, as it is doing now in West Africa, when unprotected family and village members do the best they can to care for one another without recourse to gloves, gowns, masks, or perhaps even clean water. It is neither feasible nor reasonable to bring every Ebola-infected person to the U.S. for treatment in a state-of-the-art facility, but if it were, the current outbreak would come quickly to an end. There would be some risk of infection among the health care professionals directly involved, but that has always been one of our occupational hazards, and the risk is very, very small with suitable precautions. There would be no risk to anyone else.

So there is certainly no basis for either fear of, or opposition to, the on-going treatment of an infected American doctor in Atlanta. We may instead all be thankful that in return for the courageous service he was providing in Liberia, Dr. Brantly is now receiving an American standard of medical care himself.

Perhaps the exaggerated fear of Ebola is in part due to the vanishingly remote likelihood of an outbreak here in the U.S., and the fact that there has never been one. When it comes to risks, familiarity does seem to breed contempt. We Americans routinely dismiss, for instance, the perils of eating badly or want of exercise, which will be the leading causes of premature death among us. We are dismissive about the threat of flu as well, because the virus is familiar. Our perceptions often distort risk, hyperbolizing the exotic and trivializing the mundane. As Jared Diamond pointed out, there is considerable risk involved in taking a shower, to say nothing of crossing a busy street.

If we were at all rational about health risks, we should certainly consider closing our borders to tobacco. We would close them to soft drinks as well if a considered assessment of net harm were the basis for our actions. And maybe we would even do something to stave the trade of high-capacity, semi-automatic weapons.

Exhortations about the risks of Ebola in the U.S. are not the product of rational assessment. They are the product of excitement and exaggeration, and fear of the exotic. They are born of hyperbole, not epidemiology. They represent opposition of the rabid, knee-jerk variety.

If you don’t avoid the woods for fear that a fox might cough, we have no basis to deny any small contingent of Ebola-infected Americans an American standard of care. An effort is under way to approximate those standards in West Africa, and I’m sure we are all hoping for its prompt success. The brave participants should be secure in the knowledge that while most of their countrymen might be disinclined to join them over there, we won’t be over here clamoring to close the border to them.

The current Ebola outbreak, bad as it is, will come under control. In the interim, we should all keep calm and carry on rendering the best care we can to those among us who bravely confronted risks abroad from which we are, thankfully, reliably defended here at home.

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.
Wednesday, September 24, 2014

Another legacy of Roger Ebert

Roger Ebert became a larger-than-life celebrity figure though his movie criticism (first to win a Pulitzer), his TV show(s), and finally, his cancer.

His memoir, “Life Itself,” is highly acclaimed, and was turned into a documentary that is now playing in selected theaters.

The movie was initially made to feature Ebert’s life and illness. But throughout the making of the film, Ebert’s health began to get worse, and he soon died.

He participated in the making of the film right up until his death. Both he and his wife Chaz gave the filmmaker intimate access to their lives.

What makes the movie so special, in addition to learning about Ebert’s career, are the stories of his battle with alcohol addiction and his cancer, treatment, and death.

I’ve never before seen a real film subject in such detail with his lower jaw removed, where his mouth is basically a flap of skin—it was that way for the last several years of his life. He could neither speak, nor eat or drink–ironic for a man known for his voracious appetites and weight.

The film shows him on two occasions being “suctioned,” where a reparatory tech uses a long probe to aspirate mucous from his windpipe. Again, I’ve never seen something so real and raw in a film. It’s unsparing. But it’s deeply moving. Throughout his illness, rather than becoming maudlin, Ebert continued writing, blogging and reviewing films all throughout his illness, right up until his death. No matter your opinion of him, his courage and perseverance in the face of serious illness and his impending death is something to behold.

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.
Tuesday, September 23, 2014

My golf lesson: Patient satisfaction really is in the eye of the beholder

Over the last year I’ve become rather addicted to golf. Having always been more into cardiovascular sports I’m actually quite surprised with how much I’ve taken to it. Fresh air, outdoors, lots of walking in beautiful nature and spending time with friends—what is there not to like? Anyway, I’ve frequented several different courses in the Boston area in just the last few months.

Last week we were due to play on one particular course which is actually situated in a less than prestigious area but happens to be pretty decently maintained. We found out about the course online where it had stellar reviews, and had already played on the course a few times. But on one evening last week we arrived to find that a tournament was taking place. In no mood to give up on our planned golf round, we quickly decided to go to another nearby public course. We debated where to go for several minutes, between a nice course that we already knew versus another closer course, but one that we both knew had quite abysmal online ratings (and had avoided before for this very reason). Due to time constraints we reluctantly opted for the latter. To our pleasant surprise when we got there it turned out to be an excellent course, indeed much better than the one we had just come from! Not that I’m by any means a pro, and my friend is no novice either—but we were really very impressed and wondered how the online ratings could have been so wrong?

But to the point. This got me thinking about patient satisfaction and reviews in the health care industry too. On deeper analysis of why the golf course could have got bad reviews—I think I got where the problem was. This course was in one of the most prestigious suburbs of Boston, serving a high-end population and surrounded by elite private golf courses. The mostly local people giving the ratings were obviously more demanding and seemingly had higher standards. Yet the original golf course which was clearly not as good, but in a much less desirable area, had glowing reviews from the local population.

This is exactly the same phenomenon that exists with patient satisfaction and their health care experience. There are huge variations depending on peoples’ socioeconomic status and geographical area. It’s well known that certain parts of the country, especially the South and Midwest, consistently outperform their Northeastern counterparts when it comes to patient satisfaction—despite no correlation with patient care standards (in fact many would argue that there’s sometimes a reverse correlation). I’ve even heard it said that in many parts of the country all a doctor has to do is stick their head through the door and wave at the patient, and that patient will be overjoyed with their care!

What my golf experience that day reinforced to me was that customer satisfaction is not a precise science and there are huge individual variables at play. Doctors, nurses, health care organizations, and even the government must keep this in mind as they digest data and look for ways to improve in this area. Whether it is golf or a hospital—satisfaction and a good experience really are in the eye of the beholder.

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.
Monday, September 22, 2014

Has the term 'evidence-based' lost its meaning?

During my career, evidence-based medicine has become a rallying cry for quality. Experts exhort us to use evidence to make better treatment and diagnostic decisions.

This movement’s founders had and have pure intentions. They champion a careful dispassionate analysis of data to answer important clinical questions. They critically evaluate the literature and work diligently to apply the data to the individual patient.

Unfortunately, theory too often trumps practice. Since the concept seems so pure and desirable, one might predict that some would use the term incorrectly. Of course they do. Claiming that a treatment is “evidence-based” makes it good.

Nietzsche apparently said, “There are no data, only interpretations.” Evidence-based medicine, while a great theory, too often falls apart in practice. How else can one explain the all too frequent guideline disagreements? One group views the evidence differently than another group.

Too many decision makers do not understand the concept of extrapolating beyond the data. As I often cite, the 4-hour pneumonia rule is the classic example, but likely so is tight control of diabetes and tight control of hypertension.

I personally believe that the term “evidence-based” has lost its cache. The idea is a good one, but in 2014 I fear that the term is overused and used inappropriately. I wish it still meant based on a dispassionate analysis of the evidence. It does not, so we should quit imagining that it does.

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.
Friday, September 19, 2014

Boom goes the dynamite

Oh yeah. Hot dang. All right. Groovy.

Boom goes the dynamite.

I had a very great day yesterday.

I saw 3 patients who had recent diagnoses of cancer. Yeah, those 2 statements seem to contradict. They don’t. Each person I saw gave me a clear view of how the practice I’ve been building over the past 18 months is making a difference. A big, big difference.

The first patient was a guy who is pretty far along in the treatment of his cancer. I sent him to a specialist about a year ago and he was diagnosed with a serious, but treatable form of cancer. While he’s happy with the overall outcome of his disease, he has lymphedema, which is making him very uncomfortable. Lymphedema causes swelling of soft tissue that is very difficult to treat, as it cuts off the normal drainage system for the fluid that is outside of blood vessels surrounding cells.

When he asked his specialists about this, they told him that nothing could be done. He expressed his frustration at the fact, so I did what every red-blooded person in 2014 would do: I Googled his problem. I immediately found a number of useful websites which talked about the exact problem he was facing, 1 of which was written by a physician who had dealt with his form of cancer (and has written a book chronicling his experience). While I read aloud from the website, he purchased the book from Amazon. I discovered that the pessimism of his specialists was not exactly right. In fact, I found out that there were important steps to take to prevent this problem from becoming permanent.

“Why didn’t my other doctors tell me this?” he asked.

I shrugged my shoulders. ”I guess they didn’t have the time to do it.” We had just spent about an hour together talking about his cancer experience and other non-medical things (computers, music). He nodded in agreement, acknowledging the reality the big advantage he has in my office: access to me.

The second patient, coincidentally, had the same kind of cancer. In fact, it was my experience with the first patient was just a few months before this second patient’s presentation that allowed me to quickly diagnose and treat his problem.

He had a peaceful expression as he sat across me in my office. ”This whole thing got me thinking differently about spiritual issues.” he explained. ”I just keep thinking about how many things worked out to get me diagnosed and treated. I noticed the lump and thought to myself: ‘I should make an appointment with Dr. Rob.’ and then you saw me the next day. Within a week I was diagnosed with cancer and things took off from there.”

I reminded him that before he got treatment, we had a discussion using secure messaging about “alternative” treatments for the cancer that were suggested by a family member. ”You remember when I told you about how Steve Jobs’ death was probably due to the time he spent going after alternative treatments before getting standard medical care?”

He nodded. ”Yeah, and I’m real glad I listened to you. Everyone has told me I’m doing amazingly well and have a good chance to be cured.” he told me. He looked away from me and took a deep breath. “I just wonder what would’ve happened if you weren’t in this office. I usually hate going to the doctor and put stuff off. I just wonder if things would’ve turned out like they did. It makes me feel like angels were around me.”

The third patient was a younger woman who was recently diagnosed with a very serious cancer. I saw her and her husband for the first time since the diagnosis. After tearful hugs and warm greetings, I asked how they were doing.

“Once we got over the initial shock of the diagnosis,” she explained, “we are doing much better.”

She had presented with symptoms not generally suggestive of cancer which persisted and grew worse. After going after the most likely causes, I got a secure message from the husband expressing his worry and asking me to do more to diagnose and treat her. After his message we immediately ordered the test that made the diagnosis. “She got really mad at me for doing that,” he said with a smile, “but I sure am glad that I did.”

She grudgingly agreed that he was right, and that (for once) a husband actually had an “I told you so” to hold over his wife. It’s usually the other way around. ”I would have waited much longer before doing that test. I’d probably have been nearly dead before making the diagnosis.” She paused and wiped away a tear. ”I’m just so glad you are our doctor.”

All 3 patients were significantly impacted by the different ways we do things in my new practice. Two of them may owe their lives to these differences. The main difference is the markedly better access my patients have to me. They don’t have a frustrating phone system to navigate, an army of office staff to convince, or a 2-hour wait to endure to get my time or attention. They needed my help, and they had easy access me when they most needed me.

One of the worst parts of the job of being a doctor is to diagnose people with cancer. At the same time, however, there is a sense of this being the highest honor paid to me as a person: I am the person who is there to help when the stakes are highest and the future looks darkest. I have the opportunity to be the right person at the right place at the right time. Bad stuff happens, and I will likely face many more sad yet meaningful days in the future where I am called on to stand beside people on the hardest days of their lives.

But yesterday made me happy. The hardest thing I’ve done in my life, giving up my old practice and starting something completely different, is succeeding. No, I’ve not yet earned enough to pay all of my bills (I am getting closer on that front). The success is measured in other ways: I’ve saved patients’ time, saved them lots of money, decreased their frustration, and restored some of their trust in doctors. This way of practicing medicine is not just different; it’s better.

Yesterday was the day when I saw its biggest success: My new practice saves lives.

Boom. Dynamite. Boom.

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.

Physicians lose right of free speech

I’m all for free speech and I’m very hostile to censorship. The response to ugly speech is not censorship, but is rebuttal speech. Of course, there’s a lot of speech out there that should never be uttered. Indecent and rude speech is constitutionally protected, but is usually a poor choice. We have the right to make speech that is wrong.

I relish my free speech in the office with patients. I am interested in their interests and occupations and sometimes even find time to discuss their medical concerns. I am cautious about having a political discussion with them, but patients often want my thoughts and advice on various aspects of medical politics, and I am willing to share my views with them. I don’t think they fear that politics or any other issue under discussion will affect their care. It won’t.

A Federal Appeal Court recently decided in a Florida case that physicians could be sanctioned if they asked patients if they owned firearms if it was not medically necessary to do so. Entering this information into the medical record could also result professional discipline. The court was considering such gun inquiries to be “treatment” and not constitutionally protected speech.

I am on the record in this blog more than once that I do not think we should look to the courts to make policy. Their task is simply to rule on the legality of a particularly claim. In other words, we should not criticize a legal decision simply because we do not like the outcome. Nevertheless, this decision is simply beyond wacky and could create a theater of the absurd in every physician’s office

Could the following examples of physician inquires be prohibited?
• A psychiatrist cannot ask about cigarette smoking as this is not relevant to the patient’s depression.
• An internist cannot ask what the patient’s hobbies are as this is not germane to the medical encounter.
• A gastroenterologist asks his patient who is a chef for a recipe and risks professional sanction for crossing a red line.
• A surgeon asks a patient’s opinion about the town’s new basketball coach and hopes that this patient is not a planted mole recording the conversation.

So for those physicians who practice in the 11th Circuit, no gun inquires unless you can demonstrate with clear evidence that it has direct medical relevance. The court left open for now asking patients about sling shots, fly fishing and skeet shooting, but medical practitioners are advised to consult with their attorneys regularly.

Apparently, idiotic judicial decisions can still be the law of the land.

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.
Thursday, September 18, 2014

Sodium studies, with a grain of salt

Another week, another roiling debate about nutrition. In the immortal words of Iago the parrot, I’m going to have a heart attack and die from that surprise.

Actually, heart attacks are directly germane to this topic; strokes even more so. The particular goal of guidelines addressing salt (or sodium) intake is to prevent ambient high blood pressure, a major contributor to cardiovascular disease and the leading cause of stroke. There are numerous other health effects of sodium intake as well, including an influence on bone density, but blood pressure tends to grab the spotlight.

And spotlight it is at the moment. Recent studies have reached almost shockingly divergent conclusions about the pros and cons of sodium restriction. Compounding matters, the studies in question appeared in the very same issue of the New England Journal of Medicine, published on Aug. 14.

Two articles, by the same large, international group of researchers called the “PURE investigators,” standing for “Prospective Urban Rural Epidemiology“ study, challenged the current emphasis on restricting sodium. Or at least, that’s what the related headlines say. One of these studies looked at variation in sodium excretion in urine and its association with blood pressure; the other looked at the same measure and its association with all-cause mortality and cardiovascular disease.

For both of these studies, the authors used a database of morning urine specimens from over 100,000 people in 18 countries to estimate 24-hour sodium and potassium excretion, and from those estimated values, to extrapolate daily intake of sodium and potassium. We may leave the methods at that, other than noting that as estimates are predicated on estimates, the error bars get pretty wide, pretty fast.

As noted, the inevitably hyperbolic headlines attached to these studies suggest they found that we should abandon salt restriction, and pour it on. But here are what the authors concluded in their own words. In the first of the studies, they stated: “In this study, the association of estimated intake of sodium and potassium, as determined from measurements of excretion of these cations, with blood pressure was nonlinear and was most pronounced in persons consuming high-sodium diets, persons with hypertension, and older persons.”

If you think that’s a long way from “pour it on,” well, I agree. Essentially, the researchers found that excess sodium was most likely to raise blood pressure in older people, and those already prone to high blood pressure. And, high sodium intake was most important when sodium intake was ... high. Well, alrighty then.

Moving on. The second study concluded with this: “In this study in which sodium intake was estimated on the basis of measured urinary excretion, an estimated sodium intake between 3 grams per day and 6 grams per day was associated with a lower risk of death and cardiovascular events than was either a higher or lower estimated level of intake.”

Superficially, that translates to: we can eat too much salt, and we can eat too little. That we have long known, since sodium is an essential nutrient. Too little can result in a life-threatening condition called hyponatremia. The study may have raised questions about how much is too much, since the 3-gram threshold is higher than current recommendations, although not higher than prevailing intake. But we have to be careful not to over-interpret that isolated finding. What does it mean if your intake of sodium is lower than average for the population of which you are a member? It means you are different. That might be good, but it could readily be bad. Being “different” might mean not fitting in with prevailing norms for any number of reasons, from poor health to social isolation. A lower daily intake of salt could result merely from a lower daily intake of food. Where any of these factors is operative, they might account for variations in both blood pressure, and mortality, quite independently of sodium.

Wherever these first two studies left us, we couldn’t stay there long, because the third study followed immediately after to shake things up some more. This one, by a different group of investigators, obtained data about sodium intake and cardiovascular death for over 70 percent of the global population of adults. What’s good for the goose is good for the gander, so here is what these researchers concluded: “In this modeling study, 1.65 million deaths from cardiovascular causes that occurred in 2010 were attributed to sodium consumption above a reference level of 2.0 g per day.”

They went on to note that excess sodium intake was responsible for one in ten of all deaths from cardiovascular disease around the globe. Associated headlines either indicated that our salt intake is, indeed, too high; or more bluntly, that too much salt is killing us.

A pretty confusing batch of papers to say the least, and that, too, has made headlines.

Here’s where I think it all shakes out.

There is no doubt it’s possible to consume too little sodium, and there is no doubt it’s possible to consume too much.

Not everyone is equally sensitive to sodium excess, and in general, it matters more as we age, and to those of us prone to high blood pressure.

A lower intake of sodium than prevails in a given population might indicate other important differences in behavior, health, or social integration. The current studies account for these imperfectly.

The studies purportedly raising questions about the importance of sodium restriction are actually only challenging the optimal threshold, suggesting it should perhaps be 3 grams daily rather than the current World Health Organization recommendation of 2 grams daily.

Missing from all headlines is this important tidbit: More than twice as many adults have a sodium intake above 6 grams daily as have an intake below 3 grams daily; and nearly 7 times as many have an intake above 4 grams, as have an intake below 3 grams.

This, in my view, leads to key point one: it is theoretically possible to consume too little sodium, but whether the relevant cut-point is set high or low, the vast majority of adults living in the real world consume too much. All three studies actually agreed on this point.

So, yes, I presume if you fill a house with water, it might cause drowning. But I’m not sure that theoretical concern is of great practical value when putting out a fire.

The second key point, certainly for those of us in the U.S., is this: More than 75% of the sodium we consume comes from processed foods. This figures in the manipulation of recipes to maximize our calorie intake.

The implications are rather clear. Any shift from a diet of more to less processed foods will result inevitably in a decrease in sodium intake. That shift is advisable because of the decisive health benefits associated with it, and regardless of the specific contributions of sodium reduction to that benefit. A typical American diet tends to be too high in sodium whether the higher or lower cut-point is invoked. But its more important liability is likely the fact that it is a typical American diet, in which a third or more of calories routinely come from “junk.” There is no debate about the value of eating food in place of junk.

As ever, competing headlines propagating confusion are partly a result of the legitimate nuances associated with the incremental advance of scientific understanding, and partly the machinations of media profiting from hyperbole and intrigue. But we can bypass the potential confusion altogether if we take it all with the proverbial grain of salt.

Whether the topic du jour is sodium, or fructose; wheat or meat; gluten or saturated fat, we are subject to the impasse of perpetual confusion if we fixate sequentially on each successive study of each particular nutrient. If instead we embrace what we reliably know about healthful eating in general, sodium intake will tend to fall in the sweet spot, along with the intake of all other nutrients. In other words, we could reliably defend ourselves against hyperbole and headlines, malnutrition and misinformation alike, with wholesome foods, in sensible combinations.

Tune in next week when that news ... will be exactly the same.

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.
Wednesday, September 17, 2014

Physician drug testing

The New York Times reported on a ballot initiative in California that would mandate random routine drug and alcohol testing of physicians, and targeted testing after major adverse patient events. The full text of the proposal is available here.

Proponents of the measure (Proposition 46) highlight the danger posed by impaired physicians and the ubiquity of drug testing for other professionals such as airline pilots and public safety officers. They also endorse the other “patient safety measures” included in the proposition, including mandating that providers check a controlled substance database similar to the New York State I-STOP database before prescribing. Their arguments are summarized here.

Predictably, the California Medical Association opposes the measure, mostly they say because it would also raise the current cap on “pain and suffering” payments in malpractice suits, and lead to higher malpractice insurance costs. Interestingly, the CMA website opposing the proposition doesn’t mention the drug testing provision.

My first reaction when I read about the drug testing initiative was one of sadness. What a shame that we have failed to maintain the public trust in our profession. But I was also reminded of a case I was involved in years ago in which a physician’s careless act led to a patient’s death. I have long regretted that I failed to insist that the physician be tested for drugs or alcohol at the time. If the death had been caused by a plane crash or a bus accident, we would all expect such testing to take place, and its omission would never be tolerated by the National Transportation Safety Board.

The mission statement of the CMA is: “Promoting the science and art of medicine, the care and well-being of patients, the protection of the public health and the betterment of the medical profession.” Seems to me that if they really mean it, they ought to be in favor of drug testing.

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.
Tuesday, September 16, 2014

A letter from a medical patient to the hospital CEO

We are at a pivotal moment in health care. It’s changing so rapidly even the people leading the change can barely keep up. One of the biggest paradigm shifts over the last decade is the focus on quality over quantity. Improving the health care experience and patient satisfaction are also being talked about in boardrooms across the country (largely due to the link with reimbursements, but still unthinkable a few years ago).

As someone who has worked up and down the East Coast in a variety of different settings—from large academic centers to more rural hospitals—I have found the broad challenges to be the same everywhere you go. Unfortunately it’s also been my experience that hospital leaders often lose the forest for the trees, and are overly focused on unnecessarily complex solutions to simple problems. I’ve treated thousands of hospitalized medical patients over the years, and with my interest in quality improvement and improving the patient experience, I’ve noticed very similar patterns in what our suffering patients report back to us as their best and worst feelings towards the hospital.

While I don’t presume to be putting words into anybody’s mouth, here’s what I suspect a letter would look like from a large majority of patients who are hospitalized in America:

Dear Hospital CEO/Health care leader,

Thank you for asking me about my hospital experience during my recent bout of pneumonia. Overall I found the commitment and dedication of the frontline staff to be highly commendable. Their sincerity and professionalism was without question. However, I would like to point out a few observations (in fact, I will list them to make it easier to read).
1. I spent a lot of time in the Emergency Room waiting for my hospital bed. I know how busy it was and I’m sure everyone was doing their best, but I wanted to mention this. It’s very noisy down there and sometimes felt a little too overwhelming for me (it’s my first time in hospital).
2. There was a lot of confusion when I was admitted about my medication list. The ED and the hospital doctor both had different lists, neither of which was my actual one. I’m sorry I couldn’t remember my exact medication regimen, I’m on several different pills, but is there a better way to get an accurate list, perhaps directly from my primary care doctor or pharmacy? This nearly resulted in a small medication error on my second hospital day.
3. The nurses that saw me on the medical floor were great, but I noticed they were fixated on their computer screens and pushing around their carts more than they were looking at me or other patients! One nurse remarked to me that she agreed completely with my sentiments and proceeded to tell me all about the enormous data entry tasks that nurses now have to do. While I can’t comment on that, my mother was a nurse and my vision of a good nurse was always one who was with their patient at the bedside, talking to them regularly, consoling, and trying their best to make their sick patients feel better. I’m sure things have changed over the years, but I do hope nurses still have time to be nurses.
4. I thought the doctors were very good. Maybe a bit rushed, but again I know how busy they are. One thing though, I was seen by several different doctors in the mornings—the intern, resident, Attending, and then other specialists. All of them asked me the same questions and did the exact same examination. I was confused at first with who was in charge, but got it after a bit (some of the doctors also said opposing things to me, which needed to be clarified).
5. I found it very difficult to sleep at night. On my first night, my roommate kept calling out, and on the second night, there was a lot of commotion outside. Also, when I was already getting better, did the nursing assistant really need to wake me up at 3 a.m. to check my blood pressure? Just a thought. I’m sure I don’t need to tell you, but sleep and a good rest is one of the most important things the human body needs, and it’s especially true when we are sick. It should go without saying that hospitals should be calm, quiet and comfortable places.
6. I had 2 tests done which required me to be NPO. On the morning of each test, nobody could tell me what time the test would be. Have you ever been NPO before? I can tell you, it’s not pleasant. It would be good to have at least some idea how long it will last!
7. A couple of the scans I had, nobody told me beforehand what they were for. A transporter just walked into my room and announced he was taking me downstairs. There were also a couple of occasions where a phlebotomist suddenly showed up during the afternoon to take blood. I’m an educated person, and it would have been good to know the reasons why.
8. My family was extremely concerned about me, and asked on a couple of occasions roughly when the doctor would be around to speak with them. The nurse gave them an 8-hour window! Is this normal?
9. I know it’s a cliché, but the food! I’m not saying we need to have gourmet 5-star food, but I wasn’t a fan. Sorry, but you did ask me what I thought.
10. When I was discharged, the whole process seemed to happen very abruptly. I think we need to be more thorough and go through all the medications and follow-up very carefully. It’d also help if all the appointments were made for me. And while we are on the subject, on my second day in hospital, someone called my family at home and started talking about my “admission status” and when I was going to be leaving. This was before anyone even knew what was wrong with me! More tact please, my family got a bit worked up.

Having given you this list, I still want to tell you that the doctors and nurses did a pretty awesome job. I’m very grateful for that and understand that a hospital is not a hotel. Although you asked me honestly what could improve, that doesn’t mean I didn’t overall receive an excellent service. For that I thank you and your hospital’s dedicated staff.

Yours sincerely,

Medical Patient in America

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.
Monday, September 15, 2014

Touching all the bases

Internal medicine requires knowledge, deduction, and many skills such as history taking, physical examination, and analyzing diagnostic tests. When confronting a new patient problem, we use our brains to work on finding a diagnosis. Much like police detectives, we would like to have brilliant diagnostic epiphanies, but often we make our diagnoses by painstakingly collecting all the clues and doing the necessary boots on the ground work.

We had a woman admitted to our service with confusion, decreased appetite and weight loss. In the ED, they diagnosed CKD Stage V, creatinine >5, and BUN >90. She had a 10-year history of type 2 diabetes mellitus. She had a history of ingesting high doses of salicylates and had a mildly elevated level.

The next morning as we are making rounds in the ICU she was on the bed pan. We asked the nurse to check a residual urine, because that is what we must always do with an unknown elevated creatinine. In fact her residual urine was 245 cc, despite no hydronephrosis on renal ultrasound.

The next day her appetite had returned and she no longer was confused. Three days later her creatinine was 1. Urological evaluation is the main plan now.

We had no good reason to suspect urinary obstruction, but we often are surprised with apparently newly elevated creatinine levels. We see such patients all too often. Finding obstruction when we did saved many resources.

While we love our diagnostic eureka moments, more often we get to the diagnosis through a deliberate process of touching bases and seeing what clues arise on our journey. Too often I see practicing physicians and residents skips steps. Too often I skip steps. When we skip steps we can miss the diagnosis in our omissions.

We owe our patients the deliberate process that leads to success. We need to touch all the bases.

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.
Friday, September 12, 2014

Occam's Razor burn

I don’t like to brag, but if there is one area of my skills as a doctor about which I am proud, it would be my skill as a diagnostician. I like to play Sherlock Holmes and figure out what’s going on with people, and I think I’m pretty good at it.

So I lied. I do like to brag … a little.

In most people’s mind’s eye, the role of diagnostician is this:

Doctor: “So Mrs. Smith, what brings you in today?”

Patient:”I feel like I am dying. I have trouble catching my breath, I am running fevers of 108 every day for the past two months, my fingers are turning black, I pass out at least two times every hour, and I’ve been vomiting up blood.”

Doctor (puts his hand in beard in a thoughtful expression): “Hmmm … sounds serious. Are there any other symptoms you have been having over the past 2 months?”

Patient: ”Well, yes, now that you mention it, I’ve got this strange rash on my feet and they’ve really started to smell bad.”

Doctor (turns to nurse with knowing expression): “Just as I suspected. That last bit of information was crucial in tying this all together. There is a rare foot fungus that causes all of your symptoms. That’s why I always need you to tell me everything so we can find the right diagnosis.” (Doctor pulls out a vial of oil from his white coat). ”Let me put this oil (which comes from the moss of a tree that only grows in Tasmania) on your feet.”

The rash vanishes and the patient’s color returns to a healthy pink glow.

Patient: “I am healed! Thank you doctor! How did you know that was the problem?”

Doctor: “Give me all the facts and I can figure out what’s wrong. Never forget the wisdom of Occam’s Razor: ‘The simplest explanation is usually the right one.’ I look for the one explanation that ties all of the symptoms together and that is usually the answer.”

As a clinician, I fantasize about being the heroic detective who notices those obscure facts that others would miss, coming up with the life saving diagnosis when all others had failed. This, unfortunately, is not how it usually works when dealing with real human patients, and my desire to find a single diagnosis to explain what is going on can actually distract me from finding the answers my patients need.

Here’s how the real interaction often goes:

Doctor: “So, Mrs. Smith, what brings you in today?”

Patient: “For the past 6 months I’ve gotten more and more tired. I just have no energy at all.”

Doctor: “Are there any other symptoms?”

Patient: “Yes, now that you mention it, I’ve been losing a lot of my hair, I am gaining weight, I’m constipated, and my skin is real dry.”

Raise your hand if you think you know the diagnosis? If you said “low thyroid,” you fell into my clever trap. Even though these symptoms are classic for hypothyroidism, I have some information you don’t: Mrs. Smith just had a battery of blood work that was completely normal, which included thyroid testing. I also know some other facts about Mrs. Smith:
• She’s married to an alcoholic.
• Her mother recently died suddenly.
• She had a hysterectomy 3 months ago.
• She has a history of bad environmental allergies.

It turns out that Mrs. Smith isn’t sleeping well at all (related to her marital situation and loss of her mother), which explains her fatigue. Inexplicably, a large percentage of my patients who don’t sleep well fail to mention this fact, instead focusing on their extreme fatigue. I point out that there is a well-established link between lack of sleep and fatigue, and that fixing sleep will go a long way in improving fatigue.

The hair loss is related to her recent surgery and the loss of her mother. There’s a condition known as telogen effluvium where a person can lose up to a third of their hair following a particularly stressful event (such as surgery or a large psychological trauma). It accounts for the vast majority of acute hair loss in my office.

Her dry skin is related to allergies, which everyone in my town seems to have, and the constipation is irritable bowel syndrome she’s having related to stress in her life.

This is not the solution Hugh Laurie would’ve uncovered on an episode of House, nor is it the glamorous deduction Benedict Cumberbatch would’ve made on Sherlock. This would make really dull television, to be sure, but it is by far the rule as to the answers I uncover as a diagnostician.

Occam’s Razor be damned.

This is frustrating. It frustrates patients who have thoroughly researched their symptoms and have come up with the “1 diagnosis to rule them all” which explains (and fixes) everything. It frustrates doctors in training who get excited when they hear the patient say “all the right things” that point to a particular diagnosis, only to be turned back by negative lab tests. Finally, it frustrates experienced doctors like me when we have patients for which only one clinical diagnosis makes sense but the data rule out the only explanation we’ve got. Yet this is reality, and we must always bow our knee to the facts before us.

Here’s how I approach diagnostic problems in the real world (you may call this “Rob’s Razor” if you want):
Listen to the story. Patients will usually tell you what is wrong with them. Pay attention to the entire history, and don’t make theories until you’ve heard everything.
Don’t assume you’ve heard everything. Even after you’ve heard everything, you are inevitably missing important information. This may be “chapter 1” of the patient story, and simply the passage of time will make a confusing story begin to make sense.
First focus on the things that pose the largest risk. Make sure chest pain is not the heart, fever and cough is not pneumonia, and abdominal pain is not appendicitis. This can be done simply by getting a clearer history, or it may require further testing.
Then address problems that are common. Common problems presenting in uncommon ways are more common than weird stuff. I look for patterns: episodic abdominal pain suggests gallbladder. Constant chest pain lasting for two days is never ischemic heart pain. Weird chest pain in a 50-year-old diabetic smoker is more worrisome than classic pain in a 20-year-old female.
The older people get, the less likely you find a single diagnosis. Pediatrics is usually simple, as kids are usually sick with one thing. Adults, on the other hand, often have multiple problems at once. You will usually be wrong if you assume all symptoms are related in an adult.
When in doubt, blame medications. I had a person recently with itching in the ear that would not stop. We tried multiple things to relieve this, but couldn’t get it better. She was taking a blood pressure pill (ACE inhibitor) which sometimes causes a relentless cough, and I remembered that chronic cough could also be caused by irritation of the ear canal. So we stopped the medication and the symptom went away. To be certain, I had her restart it, and her symptoms quickly returned. The more medications a person takes, the more likely they are having side effects.
Be willing to wait for an answer. Stories develop, and sometimes you hear things differently when you’ve heard it the 5th time. Be patient.
Accept little victories. While I like to put oil on a patient and cure their symptoms, I usually don’t hit the home run. It’s often better to aim for a 10% improvement, or improvement of a single symptom, than to fix them all at once. Over time, a bunch of 10% improvements can make a big difference.
Remember: some problems go away on their own. Some things need Father Time, not Dr. Rob, to get better.

This all gets back to my role as a physician as a helper, not a healer. I like to be the medical magician who pulls a diagnostic rabbit out of the hat, but more often I’m the hand that helps people up when they are down, making the most out of a tough situation. It’s not glamorous, but it’s the way things usually work. Accept this fact and be pleasantly surprised on the occasion when Occam is actually right.

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.

Testing doctors for drugs and alcohol

I read recently that the left coast state of California is contemplating requiring physicians to submit to alcohol and drug testing. Citizens there will be voting on this proposal this November. I do think that the public is entitled to be treated by physicians who are unimpaired. Physicians, as members of the human species, have the same vices and frailties as the rest of us.

I have no objection to this new requirement, if it passes. This will not be a stand-alone proposal on the ballot, but is a part of the ballot initiative. Why would trial lawyers in the Golden State want to include it? The meat of their ballot effort is to reverse effective tort reform that had been in place there for several years. Click on the Legal Quality category on this blog for a fuller explanation of why the medical malpractice system has been screaming for reform, and is slowing getting it. Sure, there are always two or more sides to every issue. But, when the different points of view here are fairly weighed, trial lawyers’ self-serving positions are overtaken. They offer a different spin, of course. While I acknowledge the validity of some of their arguments, I believe that the system they advocate helps very few at the expense of many more innocents.

The California ballot initiative aims to increase the financial cap for a medical malpractice award from $250,000 to $1.1 million. Trial lawyers and other supporters were concerned that the public may reject raising the cap as they have been enjoying the benefits of tort reform. Focus groups supported the notion that the public would find the drug and alcohol testing proposal appealing, which would raise the probability of passage of the bill.

There’s nothing evil about any of this. Every player in every issue uses polling and focus groups to create and tailor their message. (Ever notice how politicians claim they never read polls whenever poll results are against them or their positions?) I’m sure that the insurance companies who champion tort reform are using the same techniques to manage their message.

But, voters there and the rest of us should recognize why the drug and alcohol provision is included. It was just a spoonful of sugar to make the legal medicine go down. Why not just include the medical malpractice vote on the ballot by itself,? We’ve seen our politicians use this same technique over and over again. Add a popular poison-pill provision to an unpopular piece of legislation. When it’s properly voted down, criticize those who voted against it by pointing out their opposition to the popular add-on provision. Follow this example.

Legislator A: I am adding an amendment to the Quadruple the Minimum Wage Bill that would give all veterans and their families free First Class seating on all domestic flights.

Legislator B: I am voting against the bill because I think that quadrupling the minimum wage is bad economic policy

Legislator A: Shame on Legislator A for trashing our veterans who have sacrificed so much for this country.

Should other professions be subjected to random drug and alcohol testing? Which would you suggest?

Will Californians see through the smoke here? We’ll find out this November.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

QD: News Every Day--Cardiologists should consider comorbidities, study says

A quarter of adults in the U.S. have 2 or more chronic medical conditions, as do more than two-thirds of seniors, yet there are few clinical practice guidelines for cardiologists that take such comorbid conditions and their treatment into consideration. An put some numbers to how much comorbidity exists.

The authors of an article jointly developed by the American College of Cardiology, the American Heart Association, and the U.S. Department of Health and Human Services, reviewed Medicare claims for 2012 to determine the extent to which cardiovascular patients were filing claims for a range of other conditions such as pulmonary dysfunction, diabetes, arthritis and mental health disorders.

As was expected, hypertension and high cholesterol were the most common comorbidities for most of the major cardiovascular conditions. Notably, diabetes and arthritis were also very common in individuals with these conditions. For example, diabetes was a comorbidity in 41.7% of those with ischemic heart disease, 47.1% among heart failure patients, 37.1% in atrial fibrillation patients, and 41.5% in stroke patients. Arthritis was a comorbidity in 40.6% of those with ischemic heart disease, 45.6% among heart failure patients, 41.7% in atrial fibrillation patients, and 44.2% in stroke patients.

The analysis also revealed the presence of comorbidities such as chronic kidney disease, chronic obstructive pulmonary disease, Alzheimer’s disease/dementia, and depression among individuals with these cardiovascular conditions. For example, 26.3% of heart failure patients had Alzheimer’s disease/dementia, and 29.7% of stroke patients had depression.

The increase in so many comorbidities in aging patients with cardiovascular disease is an important clinical problem and makes developing new guidelines critical, the authors noted.

“We must try to better address many of the comorbidities that require special consideration,” said Jeffrey L. Anderson, MD, MACP, chair of the ACC/AHA Task Force on Practice Guidelines, and associate chief of cardiology at Intermountain Health Care, in Murray, Utah. “For example, arthritis is very common in older individuals who take analgesics that can make them more vulnerable to stomach bleeding, and blood thinners can cause serious consequences if stomach bleeding occurs, as can bladder complications.”

He said the ACC and AHA are working to provide cardiologists with a better understanding of how many drugs used to treat many conditions in older patients might react with current cardiovascular medications.

“Physicians often do not address these other conditions in making treatment decisions,” Dr. Anderson said. “This is intended as a wake-up call, since therapeutic decision making is getting more complicated because so many new drugs, devices, and therapeutic strategies for these other conditions are constantly coming into clinical practice. There is a lack of general awareness and even good clinical evidence available on possible interactions with cardiovascular and non-cardiovascular drugs.”
Thursday, September 11, 2014

Your doctor's knee-jerk reflex: how not to get kicked

We are, I trust, all but universally familiar with the knee jerk, or patellar, reflex. A doctor taps the patellar tendon with a rubber mallet, and our leg kicks forward in response.

The reaction is famously unthinking. In fact, it is literally so. What makes a reflex a reflex is that the brain is substantially uninvolved. The stretch of a tendon by the mallet is transmitted to the spinal cord, and the compensatory command to move against the stretch is sent right back out from the spinal cord to the muscles. The brain only gets involved as chaperone, pointing out to the nerves and muscles in question that the tap of a mallet is far from a dire threat to life and limb, and the response need not be unduly vigorous. In the aftermath of a stroke that damages the brain’s involvement in this network, and removes the calming influence of a rational assessment, reflexes become hyper-intense.

Since reflexes are reflexive, unthinking, and even a bit silly, we use them as a metonym for other actions of that sort. When we act without thinking, we admonish one another against such “knee jerk“ behavior.

Bringing this full circle, then, from reflex hammers in medical context to metonyms in the context of popular understanding, I write to offer a precaution: beware your doctor’s knee jerk reflex.

There are three particular prompts for this warning at this time.

First, I recently saw and began treating a patient for the fluoroquinolone syndrome. Within just a couple of weeks, I heard from a friend who had classic symptoms of it as well, following treatment with Levaquin. In both cases, there was a valid indication for antibiotic use. But there was also good reason to doubt the need for such a high-powered, broad-spectrum antibiotic in both cases. Often, the easiest way for a busy clinician to be sure to “cover the bases” with an antibiotic is to go after a fly with an elephant gun. The collateral damage can, predictably, be considerable; a consequence of knee-jerk prescribing.

Second, a paper published in JAMA indicates that cancer screening tests are routinely ordered in both men and women with life expectancies less than 5 years (due either to advanced age or serious illness, or both). The tests in question are all good tests, recommended by the United States Preventive Services Task Force. But the whole point of screening is to look for trouble early so it does not progress over time. If there isn’t much time left, looking for potential future trouble not currently causing any is very unlikely to do any good, and can, as the authors note, do harm. Why order the test then? Reflex.

Third, and finally, a study was just published in Critical Care Medicine indicating that demonstrably futile care in the intensive care unit is not merely futile, but potentially as bad as fatal. As the rate-limiting resources of intensive care are allocated to cases where they cannot do any meaningful good, those more likely to benefit are denied access. The misallocation of resources in this case is again the product of inertia, going with the prevailing flow, or reflex.

And so it is that while we might all submit on occasion to the knee jerk test, we should not submit to the knee jerk tendencies that all too readily drive behavior, even in clinics and hospitals. Self-defense is simple, and accessible to us all.

1) Always ask “why?” This seems obvious, but even in this modern era, many patients take it as an article of faith that a doctor’s recommendation is thoughtful and well informed. It may well be; but on any given occasion, it could also be a knee jerk, born of prevailing tendencies, distractions, and want of time. The question “why” is easily addressed by those who have already thought it over; and is a necessary reality check for those of us who have not.

2) Always ask “what else?” In the case of the fluoroquinolone syndrome, it’s bad enough when a fluoroquinolone was a genuinely thoughtful, warranted choice. It’s downright tragic when a much-less-potentially-toxic, narrow spectrum antibiotic would have served at least as well. “What else?” is a reminder that there is generally more than one way to test or treat, and the one we want is the BEST of them: most likely to help, least likely to hurt. It prods our providers to do the extra work of getting us there when we remind them we want to know the options, and comparison shop them.

3) Always ask “then what?” This would certainly defend against a screening colonoscopy in an 85-year-old with congestive heart failure. If I have this test, then what? The answer would have to be: we can find potential cancer early, and fix it now so it doesn’t cause you trouble in ten years. That would invite all concerned to revisit the relevance of that “help” 10 years in the future of someone exceedingly unlikely to live that long.

Clinical assessment that includes a test of the knee jerk reflex is fine. Clinical decisions driven by it are not, but they too, are out there. Forewarned, I hope, will prove to be forearmed.

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

QD: News Every Day--Internists losing 48 minutes a day to EMR use

Internists lose an average of 48 minutes a day to electronic medical record (EMR) use, including data entry and note writing, a survey found.

ACP members and staff sampled 1% of its membership, including attending physicians, residents, and fellows, from its research panel. Researchers then used random sampling to ensure balance and added nonmember internists. The 19-question survey was sent to 900 ACP members and 102 nonmember internists who provided ambulatory care; 411 responded. While 3 of 4 were attending physicians, trainees were more likely to respond. Respondents were experienced EMR users, as 70.6% used all of the EMR functions, and 82.5% had EMRs for more than 1 year. Researchers honed in on free time to learn more about the EMR’s overall effect on internist’s time, including nonclinic time.

Results appeared online Sept. 8 in a researcher letter in JAMA Internal Medicine.

The physicians reported using 61 EMR systems and came from a broad range of practice types. Researchers reported that 9 EMRs were used by 20 or more respondents, accounted for 324 (78.8%) of all users, and among these systems, users lost free time (P<0.05 for all). Of these 9, the Veterans Affairs’ EMR system was associated with the least loss of free time (−20 minutes) (P=0.04).

Researchers wrote, “Among all respondents, 89.8% reported that at least 1 data management function was slower post-EMR adoption, and 63.9% reported that note writing took longer. Surprisingly, a third (33.9%) reported that it took longer to find and review medical record data with the EMR than without, and a similar proportion, 32.2%, that it was slower to read other clinicians’ notes.”

Among all respondents, attending physicians lost a mean of 48 minutes per clinic day (P<0.001), compared to trainees, who lost a mean of 18 minutes per day (P<0.001). Among the 59.4% of all respondents who lost time, the mean loss was 78 minutes per clinic day.

“The loss of free time that our respondents reported was large and pervasive and could decrease access or increase costs of care,” the researchers wrote. “Policy makers should consider these time costs in future EMR mandates. Ambulatory practices may benefit from approaches used by high-performing practices—the use of scribes, standing orders, talking instead of e-mail—to recapture time lost on EMR. We can only speculate as to whether better computer skills, shorter (half-day) clinic assignments with proportionately less exposure to EMR time costs, or other factors account for the trainees’ smaller per-day time loss.”
Wednesday, September 10, 2014


The trend-spotting New York Times published a front-pager about the growth of urgent care clinics nationwide.

These are the places that are often referred to as “minor emergency rooms,” or “doc-in-a-box” outfits. Their value proposition is simple: You don’t need an appointment. The costs are “reasonable,” and much more transparent than usual medical care at a doctor’s office, emergency room, or hospital. Best of all: They can treat a majority of acute conditions and have you in and out in under an hour. No ER can make that claim. Heck, not many doctors’ offices can make that claim.

As the article makes clear, urgent care centers have one tremendous advantage over emergency departments: They can cherry pick patients. ERs are required by a federal law called EMTALA (1986) to see and stabilize every patient, regardless of their ability to pay. Urgent cares have no such obligation. And they don’t take Medicaid. To be seen, you must have either private insurance or pay cash.

Seeing a money-making opportunity, big money (i.e. Wall Street, health insurers, hospital chains) are investing big in urgent care centers.

Naturally, skimming the straightforward acute cases out of the medical morass makes some unhappy. The article quotes one physician: “The relationship I have with my patients and the comprehensiveness of care I provide to them is important,” said Dr. Robert L. Wergin, a family physician in Milford, Neb., and the president-elect of the American Academy of Family Physicians. “While there is a role for these centers, if I were sick I’d rather see my regular doctor, and I hope my patients feel that way.”

As a doctor, I very much see Dr. Wergin’s point of view. I believe in the importance of a relationship with a doctor (or, heck, a “medical home“) over the long term. But as a patient and “consumer,” I can certainly see the value in a place that can handle acute stuff on a walk-in, cash basis. My own patients who try to see me for minor maladies are often disappointed to find I’m not available for same day appointments much of the time.

I think the article gets it right. Urgent care is a trend likely to grow at least until the market is saturated. What will keep them afloat is the value they provide, until doctors’ offices (“medical homes”) can offer truly expanded hours and availability, and come up with more transparent pricing and same day efficiencies.

Doctors and traditionalists will continue to wring their hands over this upstart economic/delivery model, but as the industry moves from cottage to corporate, this is just one more stream in a raging river.

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.
Tuesday, September 9, 2014

Taking patient engagement to the next level in hospital care

Improving “patient engagement” is a subject that’s being talked about in hospital boardrooms across the country. It’s become the in-fashion political buzz phrase. Certainly sounds very well and good, but what exactly does it mean? Likely different things to different people depending on what angle they approach it—all the way from a care assistant up to the hospital CEO. In a nutshell, it’s all about allowing the patient to take center stage in their health care, and being fully informed and understanding each step of the way. It’s about education, encouraging healthy behaviors, improving health outcomes, and lowering health care costs. The ideal state is to allow the patient to feel that they are in the driving seat and full participants in their own care. As things currently stand, most health care systems across the world are way off from this place. It’s not just the health care that’s to blame either, because the biggest part of patient engagement involves the patient stepping up to the plate themselves. And there are some very real barriers to this including education, demographics and motivation. There’s also the reality that most 90-year-old chronically unwell patients in hospital will have difficulty taking care of themselves. The issue is thus a complex one.

No one has a better understanding of where the opportunities for improvement lie than the doctors and nurses working at the coalface. We get to see all the problems up close and personal on a daily basis. I’m going to talk about how this pertains to my own specialty of hospital medicine, and where we have enormous room to engage patients better while they are in hospital. Here are 5 areas to focus on:

1. Encouraging patients to ask questions when they see their doctor every day
As simple as it sounds, this is not done nearly enough, and is a big missed opportunity to make a difference to patients’ understanding of their illness. There are a number of reasons why this doesn’t happen, ranging from a “rushed” hospital environment, to patients sometimes feeling embarrassed to ask certain questions. I’m actually surprised by some of the questions I hear when I ask my patients if they have anything they want to ask me, and there’s no way I would have guessed what they were unsure about unless I encouraged them to speak up.

2. Giving patients all the knowledge they need about their medical condition
Writing details such as blood count numbers on the whiteboard at the end of their bed is one way to do this. In the future, patients will likely be able to pull up some of their own data on computers. The more that patients know, the more empowered they will be to make important health care decisions.

3. Involvement of families
Just as important as the patient, is the family. This is true for any patient who is too unwell to speak for themselves, and particularly applies to the elderly. Doctors and nurses have to ensure that family is completely on board with the plan of care and what their role is in the recovery process. I’ve always said that if you want to make sure that something is done after discharge, tell the patient’s daughter. It’s been my observation everywhere!

4. Involving the patient fully in the discharge process
The discharge process by its’ very nature is a risky endeavor. Typically there are medications that have been changed, tests pending, or even an uncertain diagnosis. All this at a time when the patient is still very frail. It is a crucial transition point, more important than almost any other to get right.

5. Follow-up care
All hospitalized patients must follow-up in a timely manner after being discharged. Nipping a potential problem in the bud can help reduce readmissions and potentially serious complications. Reminders should be sent to the primary care physician and a post-discharge follow-up call from a nurse or administrator would not go amiss—and also shows that we care.

There is no one magic formula for solving the issue of patient engagement in hospital medicine. It will require a multifaceted and multidisciplinary approach. Whichever arena we are in, it is vital for a number of reasons. Whether we are talking about raising the quality of health care, improving outcomes, or lowering health care costs—there’s a great deal to play for. The more knowledge and opportunities to participate in their own health care, the better it is for both patients and doctors.

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.