Friday, October 31, 2014

What would a straightforward referendum on nationalized health care look like in America?

The independence referendum in Scotland got me thinking. I must admit I was glued to the news over the last few days of campaigning. For those of you not following closely, it seemed as if the No camp had a comfortable lead right up until the last week, when the opinion polls suddenly showed the Yes camp pulling ahead. This rattled the establishment. The prospect of my country of birth splitting up rather saddened me as well, and I was fixated on the TV watching BBC world news late into the night as the constituency vote counts came in.

The result in the end was a fairly comfortable No vote. The Union remains intact. In the preceding week, a lot of people in my hospital asked me what I thought of the vote. I had a feeling that the No vote would prevail, if anything because when it comes to a big change, absent an economic catastrophe, people are usually quite conservatively inclined when they reach the ballot box (conservative as in keeping the status quo).

As someone who works in health care, a field where there is a lot of contentious debate at the moment, the Scottish vote also got me wondering what would happen if there was a straight referendum put to the American people about adopting socialized medicine? I found the thought intriguing. I can see both sides of a potential debate having very passionate opinions, as is the case with right versus left politics in general. Leaving aside any discussion on how it uniquely affects doctors and hospitals, I envision the two sides hinging their broad philosophical arguments on the following:

Vote: “Should the United States have a fully socialized, universal single-payer health care system?”

The Yes camp (probably coinciding with left wing politics):
• Every other Western industrialized nation has some form of socialized medicine;
• Older people generally like Medicare, so why not extend it to everyone?
• Health care should be a right and not a privilege;
• The free market does not work for health care; and
• It is the best way to control costs.

The No camp (coinciding with the right):
• Socialized medicine will restrict choice and personal freedom (it is a form of government control over a vital part of our lives);
• Socialized medicine takes away peoples’ own responsibility for their health;
• Socialized anything is very un-American;
• The free market always delivers the highest standards and best customer service; and
• The government does the worst job at controlling costs.

For the Yes camp, the assumption that Americans would want a European-style socialized health care system neglects the realization that the collective American culture and psyche is inherently very different from those countries. For the No camp, the assumption that the government cannot be trusted to deliver health care may not resonate with everyone. In a federal country as heterogeneous as the United States, the debate would be highly variable by region. I’m not even sure the federal government would have the legal authority to poll the American people in this way. Whatever the truth of the matter, it’d be a fascinating referendum. And I don’t think either side could take the result for granted.

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.
Thursday, October 30, 2014

Curbside consultation and hallway conversations

“Curbside consultation” is an interesting term in medicine. There has been an increasing interest in this term in the recent medical literature, specifically as it relates to patient care in medicine. I myself have often pondered how much one learns from curbside consults. I know that some specialists may frown upon them because of the potential for some to document recommendations in the chart without a “formal” consultation. As a primary care physician, I enjoy the camaraderie associated with a curbside consult, and in turn, try to help my colleagues out when they ask me a quick question.

The other day, I was on the way from my administrative office to my clinical office where I see patients. Just outside the parking lot, I saw a colleague I had been meaning to call but just hadn’t gotten around to actually contacting. In a five-minute conversation, I was able to get so much more helpful information about the topic at hand, and helped my colleague in understanding a concept with which he was not familiar. For the record, this actual conversation took place on the sidewalk, right next to the curb. If there was anything that was truly “curbside”, this was it!

I wonder how much one can actually “learn” from a curbside consult? In my example described above, I can honestly say that the “worth” of that curbside consult is much more than that of a one-hour “lecture” on the same topic by an expert. I’d be willing to say that my colleague felt the same.

The same concept can be applied to “hallway conversations” at regional and national meetings: the energy disseminated from a brief conversation with a colleague is itself a wonderful opportunity for learning for all (including disseminating to others who may not be a part of the conversation). So the next question becomes this: “If it is so helpful, how do we value curbside consults/hallway conversations?” I don’t know the answer, but it is certainly worth exploring. Yet one more thing ripe for future study!

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

Bedside ultrasound can diagnose kidney stones

I have been following the progress of bedside ultrasound (using ultrasound as a diagnostic tool during physical exam of patients) as it gets a foothold in standard medical practice. It has been part of my practice for almost 3 years now, during which time I have been repeatedly amazed by how helpful it is for guiding my clinical decisions. There is good research showing how useful it is for all sorts of applications, from heart problems to intestinal obstruction, but it is still slow to catch on.

An article came out just recently in the New England Journal of Medicine, which has a large circulation and should make a bit of a splash. This multi-center study looked at the option of having patients (excluding the very obese, pregnant and critically ill) with abdominal and flank pain suspected of having kidney stones evaluated first by emergency physicians with ultrasound of the kidneys and bladder before considering getting a CT scan. Normally a patient with suspected kidney stones (crampy pain in the back or abdomen, blood in the urine, suggestive history) will be referred for an abdominal and pelvic CT scan, which costs more than $3,000 and carries a significant amount of radiation exposure.

In perfect circumstances performing the test and getting the results takes an hour, but it can end up taking several hours due to the usual delays. Sometimes patients with kidney stone type symptoms are referred by the emergency physician for an ultrasound by the radiology department, which takes about the same amount of time as the CT which takes the same amount of time, but costs a bit less and delivers no ionizing radiation. CT scans have beautiful pictures and can often find the kidney stone, if it’s in there, and not finding the stone is strongly suggestive that the diagnosis of what is causing the pain must be sought elsewhere. Ultrasound can show if the kidney is blocked by showing lack of flow into the bladder or buildup of fluid in the kidney (hydronephrosis) but rarely actually visualizes the stone. This information, however, is adequate to make the diagnosis in most cases, when combined with a good clinical history, physical exam and lab tests.

It turns out that the bedside ultrasound exam done by emergency room docs (in this study they were from multiple medical centers including University of California at San Francisco, Cook County and Rush Medical Centers in Chicago, Group Health in Seattle and many more high quality locations) is adequate in cases of abdominal or flank pain as a first evaluation to rule in or out kidney stones. It is much more focused than an ultrasound performed by the radiology department and it only takes about 5 minutes or less to perform. Since it is done by the physician examining the patient it is also a time to take more history and do more general observation, which is always a good thing. About 40% of the patients initially evaluated this way got an official radiology ultrasound or CT scan which were felt to be necessary by the ER physician to clarify what was going on.

About a million patients with kidney stones visit emergency rooms each year in the U.S. and more than 10 times that many visit ERs with symptoms that sound a bit like kidney stones and have to be evaluated for them. If all of them got bedside ultrasound as the initial evaluation of their kidneys, my back-of-the-envelope calculations suggest that multiple billions of dollars could be saved on imaging costs and lives could potentially be saved due to reduced radiation exposure. The study showed no significant increase in complications in the patient who first received bedside ultrasound. Actual cost savings were calculated, but not reported in the study (why?)

We can’t just start doing this because not all ER doctors are yet comfortable performing and interpreting bedside ultrasound of the kidneys and bladder. But they could be. It is not hard. Pretty much anybody could learn to do this in maybe an hour and could certainly be competent after doing 50 exams. The implications of this are bigger than the article points out. When ER physicians start doing regular bedside (or “point of care” as it’s sometimes termed) ultrasound they are going to get better at it. They will start to use ultrasound more and develop some pattern recognition skills that can’t be predicted which will likely lead to more accurate diagnoses of other diseases, and possibly less dependence on ionizing and expensive radiation in the form of CT scans.

Unfortunately CT scans for abdominal pain in the emergency room are an important source of revenue for both radiologists and hospitals, which puts a little kink in the clear path toward adopting bedside ultrasound as a diagnostic procedure of choice. It’s not clear what to do with this, because we could surely use the expertise of radiologists and radiology technicians in training physicians to be good bedside ultrasonographers and presently that would be a pretty big conflict of interest for them. Still, there is so much good stuff going on in the field of high tech ultrasound that is not in the scope of bedside ultrasound that radiologists and technicians could be kept gainfully occupied by doing things that other physicians can’t and shouldn’t do.

In the journal of the American Institute of Ultrasound in Medicine there were several articles about amazing and technically challenging imaging applications that non-radiologists might be wise not to try. There were articles about ultrasound of the midbrain to evaluate Parkinson’s disease, ultrasound of the liver to look at severity of cirrhosis, ultrasound of children with intestinal intussusception (telescoping of the bowel) to follow the success of noninvasive treatments and detailed prenatal evaluations for conditions I didn’t even know existed. Ultrasound to diagnose appendicitis has become nearly standard now, but is really hard to learn and ultrasonographers and radiologists do it well (some ER physicians do it well too, but it’s far from an entry level skill.)

Looking at the kidneys in 5 minutes in the ER is clearly fine for evaluating possible kidney stones. An abdominal ultrasound in the radiology department with their big powerful machine with the gorgeous images combined with the stunning command of anatomy of radiology professionals is a different and differently beneficial thing. This recent article may help move us as hospitalists, ER physicians and primary care providers toward doing more bedside ultrasound, which could be a very good thing. Perhaps more radiologists will find peace with that and can bring themselves to help teach other medical staff who need to learn how to do it.

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.
Wednesday, October 29, 2014

Let's talk Ebola

Ebola is all the rage so it is time for EverythingHealth to “talk Ebola”. Unless you have been in a coma, you are aware that Ebola is sweeping through West Africa and there have been several identified cases in the United States. This is a big news story so anxiety and fear are being felt by anyone who picks up a paper, goes on the internet or watches TV. What does EverythingHealth say? First, calm down, everyone!

Here are some Ebola facts:
• There are actually 5 different Ebola viruses that cause hemorrhagic (bleeding) fever;
• Ebola is not very contagious because it is not airborne;
• Initial symptoms are fever, body ache, diarrhea, stomach pain and vomiting; and
• The incubation period is up to 21 days.

The average American is not going to be at risk for Ebola. Direct contact with body fluid is needed so standing in a room or an airplane with an Ebola victim will not cause infection. Gunshots kill more than 30,000 Americans a year. Now there is a risk for you to worry about!

Health care professionals, trash collectors and airline cleanup crews are the most at risk of exposure to Ebola virus. Those workers should keep abreast of current events and take precautions. Until the infection can be controlled in Africa, there is always the chance that a traveler will have silent disease. The best way the World can protect itself is to help Africa contain the infection. This does not mean closing airports. That would simply prevent needed help and cause the virus to spread across borders to other countries in Africa.

What can you do? First, get a flu shot. As winter approaches, influenza will be here and it causes some of the same early symptoms as Ebola. I worry about our Emergency Departments being crushed by people with flu symptoms who think they may have Ebola. Please make it easy on all of us and get a flu shot!

Second, send some money to your favorite relief organization. I recommend Partners in Health and International Medical Corp. I have personally worked with both of these organizations and they do wonderful relief work around the world.

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

All Ashkenazi Jewish women should be tested for BRCA

Mutations in two genes called BRCA1 and BRCA2 greatly increase the risk of breast and ovarian cancer. Last year I wrote about Angelina Jolie’s discovery that she carries a harmful BRCA1 mutation and her decision to have preventive double mastectomy.

In the general population mutations in these genes are quite rare, but among Ashkenazi Jews these mutations are much more prevalent. One in 40 Ashkenazi Jews carries a mutation in BRCA1 or BRCA2. In the Ashkenazi population one in 9 cases of breast cancer and 2 in 5 cases of ovarian cancer involve mutations in a BRCA gene.

Identifying women with BRCA mutations who are at high risk of breast and ovarian cancer isn’t just an exercise in predicting trouble. Preventive action can be taken. As Angelina Jolie’s story teaches us, preventive surgery that removes the breasts and ovaries greatly decreases the risk. Mastectomy, of course, is difficult physically and psychologically. For some women at very high risk, intensive screening with mammograms and breast MRI offers some level of protection without resorting to surgery.

Thus far genetic testing for these mutations has only been recommended for Ashkenazi women with a strong family history of breast or ovarian cancer. That’s because BRCA mutation carriers with a family history of breast or ovarian cancer were the only group studied and found to have increased cancer risk.

But if the BRCA mutations themselves cause breast and ovarian cancer, why should family history matter? Why not test everyone who might have these mutations? The answer is that the risk of cancer in BRCA mutation carriers without a family history of cancer has never been measured. Without knowing that, it is possible that the mutation carriers who have a family history of cancer have an increased risk because of some other shared genes that have yet to be identified or because of some shared exposure to cancer-causing agents in the environment. That is, without knowing the risk of BRCA mutation carriers who do not have a family history of cancer, we can’t be sure if the BRCA mutations are the cause of increased risk, or simply a marker for some other cause that is yet unknown.

A study carried out in Israel and published this month in the Proceedings of the National Academy of Sciences sought to answer this question in an ingenious way. The study enrolled about 8,000 Israeli Ashkenazi men without a history of cancer and tested them for BRCA mutations. 175 of them were found to carry harmful BRCA mutations. The first degree female relatives of these 175 men (their mothers, sisters and daughters) were invited to undergo BRCA testing. This identified 211 female BRCA mutation carriers, many of whom had no family history of breast cancer. By studying the medical histories of the identified female mutation carriers, their risk of ovarian and breast cancer was calculated.

The results showed that a woman with a BRCA1 mutation has an 83% risk of developing breast or ovarian cancer by age 80. BRCA2 mutation carriers have a 76% risk of breast or ovarian cancer by age 80. These numbers are very similar to those from studies that only counted women with strong family histories of cancer. That means that a family history is not necessary to identify women who benefit from screening, and suggests that all Ashkenazi Jewish women should be tested for BRCA mutations.

National groups that evaluate scientific data and make testing recommendations like the American Cancer Society and the US Preventive Services Task Force haven’t had a chance to digest the news yet. They still recommend BRCA testing only for women with strong family histories of breast and ovarian cancer.

A medical geneticist I spoke with said that BRCA testing costs about $400 and is generally not covered by insurance. If you’d like to pursue testing, the first step is asking your doctor to refer you to a medical geneticist for pre-testing counseling.

Population screening for specific genetic diseases, like Tay-Sachs, has proven in the past to make enormous reductions in the societal burden of disease. Screening all Ashkenazi Jewish women for BRCA holds out the promise of similar gains against breast and ovarian cancer.

Learn more:
Study of Jewish Women Shows Link to Cancer Without Family History(New York Times)
Israeli research team: Screen all Ashkenazi-Jewish women for BRCA mutations (The Jerusalem Post)
Population-based screening for breast and ovarian cancer risk due to BRCA1 and BRCA2 (Proceedings of the National Academy of Sciences, abstract free, full article by subscription)
Understanding Angelina (My post from 2013 explaining the BRCA testing recommendations at that time)

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.
Tuesday, October 28, 2014

Ebola question: From the mailbag

Here’s a letter from 1 of our readers:

Dear GlassHospital,

While I am a firm believer in the infallibility of doctors and modern medicine, I am desperately struggling with the Dallas handling of an Ebola patient. Sure, sometimes there’s that perfect storm of things gone wrong, opportunities missed, etc (think about the assassination story of Archduke Franz Ferdinand; seems it was destined to happen) but the spread of infectious diseases need not be history-making-world-changing-events in today’s “modern” era, should it? Is there that much of a divide between the knowledgeable and the uninformed, a gap that rivals our economic disparity? Is politics playing a role here, like [Texas Gov. Rick] Perry won’t allow any federal coordinated oversight/CDC management?

I used to watch silly action movies (“Whitehouse Down” for example) and think, “that would never happen! there’d never be such a dumb-ass breach of security like that!” Now I question if I’m the silly dumb-ass who believed there was a working system in place.

So tell me Dr. Glass: while I retain confidence in individuals and continue to hold doctors in high esteem, should I/can I trust hospitals?


A Lost Patient

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.

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.

Our health, on fire: the #UseWhatWeKnow campaign

I was privileged to speak to hundreds of health care colleagues at a Lifestyle Medicine summit in Nashville, Tenn. I was even more privileged to give the keynote address that closed out the conference, although there are some liabilities attached to being the last thing between a restless audience and their freedom.

As the conference “closer,” I obviously spoke after all the others who populated the sessions for 2 days prior. Inevitably, I followed speakers who presented theories and epiphanies competing with the theories and epiphanies of other speakers (at this conference, and all the rest). There were authors of books that refute everything in all the other books that in turn refute everything the audience heard in the session just preceding. There were claims, counter-claims, and contentions about this food and that; this nutrient and that; this supplement and that.

Business as usual, in other words, in the world of health promotion, or what passes for it in our culture.

I won’t belabor the particulars of what I had to say; those of you who visit here often already know. I will instead simply share one fundamental point I consider the take-away from my talk, and then ask something of you.

The one point is this: we know enough.

Believe it or not, when the parsing and peddling, back-peddling and back-stabbing are all done, it’s a fact established and reaffirmed over a span of decades that we know enough! What we know about health promotion, disease prevention, sustainable weight control, and lifestyle as medicine is enough to prevent 80% of all chronic disease and premature death. We already know enough, and have known enough for literal decades, to add years to life routinely; and add life to those years.

No one refutes this; the evidence is too strong, too consistent, too often replicated. The iconoclasts don’t refute it. The renegade geniuses don’t refute it. Those with competing theories to sell don’t refute it.

They simply ignore it, and pretend that the focus should be on what we don’t know; what can be made (to seem, at least) controversial. They ignore it, and pass on to the one particular thing they want you to believe, buy, or berate.

They ignore it.

Which leads to what I am asking of you. Please don’t ignore it. Please don’t let anyone else ignore it. Please don’t look on passively at a culture fiddling while Rome burns. And please, don’t add your own fiddle to that orchestra.

This isn’t a column; it’s a campaign. I am calling it the let’s #UseWhatWeKnowcampaign. I am asking you to share, tweet, pin, and email that moniker, and help me agitate a movement.

Imagine letting a building burn to the ground while debating the best particular kind of fire hose (e.g., length; caliber; materials; etc.); the best kind of water (e.g., soft; hard; etc.); and the best way to handle and direct the spray. Imagine, far worse, that there are people in the building while the debate rages along with the fire. Imagine our collective horror at discovering that the bickering and parsing lasted until there was nothing but ash and body bags.

This, folks, is our culture. We are bickering over what may even be legitimately debatable at times, but doing so while failing to use all that we already know, and let preventable chronic diseases reduce lives to ash and cinder. It is a tragedy; it is a travesty. We could put an end to it any time we decide to #UseWhatWeKnow.

Admittedly, if we #UseWhatWeKnow, we could only save about 80% of such buildings. We could only save 8 out of every 10 people in such buildings. But right now, the hyperbolic claims compete for our attention as the flames take them all.

Let the parsing continue, for that competition is healthy if it helps us do something about the residual 20% of all chronic disease we don’t already know how to prevent. But let us not squander what we do know while working to learn what we don’t. Let us not subordinate the tried and true to the new and titillating. Let us not ignore what we know and count the cost in years lost from life, life lost from years. Let us recall that we all have skin in this game, our own, and that of the people we love. The next time one of these metaphorical buildings catches fire, one of us, or one of them, could well be in it.

Knowing more is always good. Bring on the next Nobel Prize! But we know enough to do an astonishing amount of good right now; good we would all see and feel. Good we squander every day.

Please help spread the word. Please help put out the fires. Please, let’s#UseWhatWeKnow.

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.
Monday, October 27, 2014

Ebola preparedness and the Lab

By Lab, of course, I mean my yellow lab Mindo, pictured during this morning’s walk along the Iowa River. Look carefully and you’ll note a few important things: (1) She is alert, poised, vigilant for any potential threat (including, in her case, a random squirrel or rabbit); (2) She nonetheless appears calm. She understands that loud barking, tail-chasing, and similar behaviors are wastes of energy, counterproductive, foolish; and finally, (3) She is a dog, and probably doesn’t know anything about filoviruses.

How does this inform Ebola preparedness? We similarly must remain calm as we continue improving our preparedness, and increasingly we must differentiate between appropriate readiness and counterproductive overreactions. Most efforts currently being made in US hospitals to improve preparedness, particularly those directed toward screening and triage, are absolutely necessary and on target. The nonsense we’re hearing about border closings, quarantine of asymptomatic individuals without documented exposures, closing of schools, diverting of cruise ships—it’s all the equivalent of nuisance barking and tail-chasing.

Daniel J. Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. This post originally appeared at the blog Controversies in Hospital Infection Prevention.

Avoid premature performance standards

This tweet inspired this post:

“@ACSmaggus: This history of peri-operative beta-blockade is a good case for allowing evidence to mature before changing practice”


Learning from mistakes in clinical practice guidelines: the case of perioperative beta-blockade

Unfortunately, I do not have access to the entire article, but this quote stands out.

On one level, what may be most remarkable about the rise and fall of preoperative beta-blocker guidelines is how unremarkable it seems. Preoperative beta-blockade is only one of several recent examples in which expert endorsements of promising therapies changed markedly when new evidence highlighted potential harms that had been overlooked by these endorsements.

Most experienced physicians learn not to believe the first reports of anything. When new pharmaceuticals arrive, we delay rapid acceptance. Too often the initial reports are over enthusiastic.

This phenomenon also occurs with research. My first NEJM article was a refutation of a clinical prediction rule. Inability to predict relapse in acute asthma.

My good friend Sandy Schwartz taught us this with a brilliant abstract presentation at the Society for Medical Decision Making in 1981. He had developed a decision rule, but after the abstract was accepted for presentation, he found that retesting the rule with fresh data yielded a failed rule.

Science is a process. Scientists do studies, report them, then other scientists check the results. Especially when the results do not make sense, we need further studies.

Declaring a new performance standard prematurely can have (drum roll please) UNINTENDED CONSEQUENCES. We talk often about ill-advised performance measures. This article should influence guideline writers and performance measurement developers. We must continue to question research findings and argue against premature adoption of practice standards. The emperor is not always clothed.

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, October 24, 2014

What I learned from Ebola

I’m sitting at my dining room table trying to reflect on and process the events of what, without a doubt, will go down in the annals of infection prevention as a pivotal point in time. Hospitals across the country furiously raced to prepare for Ebola, propelled by the unfortunate news of transmission of the virus to 2 nurses at Texas Presbyterian Hospital in Dallas. I’ll share with you what I think are the lessons of this incredibly interesting week:

Texas Presbyterian Hospital isn’t the exception, it’s the rule. It’s easy to be the Monday morning quarterback and criticize the emergency medicine providers for initially missing the diagnosis of Ebola, but given that this was the first case to ever present to an emergency department in the U.S., it should not be surprising. In the process of diagnosis physicians are trained to use probability in their reasoning. And Ebola simply wasn’t on their radar screens.

It’s also important to keep in mind that even today given everything we know, fever in a returning traveler from Liberia is most likely not caused by Ebola virus disease. Malaria remains a much more common diagnosis. For this reason, our Ebola plan reminds physicians to consider infectious diseases consultation in the setting of a person under investigation for Ebola, so as to avoid having a patient die of falciparum malaria while Ebola is being ruled out.

In addition, there may have been, and likely were, systems issues at play. There are many distractions in the hectic environment of an emergency department that may have had impact as the physician worked through Thomas Duncan’s case. Nosocomial transmission to healthcare workers would have also likely happened at almost any hospital with the exception of the four hospitals that have a biocontainment unit. While American hospitals have made great strides in reducing health care associated infections over the last decade, the challenges posed by Ebola virus in terms of the prevention of transmission are unparalleled.

The efficacy and effectiveness of personal protective equipment (PPE) need to be considered. By efficacy we mean how well PPE works in the ideal setting to protect the healthcare worker. Effectiveness is how well it works in the real world. For most pathogens, this difference is likely quite small. Not so for Ebola. Removing PPE in the Ebola setting without contaminating yourself is a Herculean effort, and we are dealing with what Dick Wenzel calls “an unforgiving virus.“ Before Ebola, the implications of minor errors in doffing were trivial. Now they’re life-threatening. An article in today’s New York Times sums it up beautifully:

Debra Sharpe, a Birmingham, Ala., biosafety expert, has overseen safety at a nonprofit laboratory that researches emerging diseases and bioweapons, and has run a company that trained workers to handle biological agents ... “It’s totally shocking ... It would take me anywhere from 4 to 6 weeks to train an employee to work in a high containment lab in a safe manner. It’s ludicrous to expect doctors and nurses to figure that out with a day’s worth of training.

To her comments I would add that the challenging setting of an ICU with an Ebola patient having 10 liters of vomiting and diarrhea per day is nothing like the controlled environment of a specialized laboratory dealing with contained aliquots of the virus. How well PPE works in the lab approximates efficacy. How well it works in the ICU is a measure of effectiveness.

The most advanced ICU in the best U.S. hospital is not a biocontainment unit. It’s absurd to think that the standards of a biocontainment unit can be met outside of that special setting. These units have special physical layouts with lab facilities, specimen dip tanks, employee showers, and autoclaves. They were created and supported with federal funding, and their providers have had ongoing training over years. So we need to realistically attempt to match the facility with the expected function: all hospitals should be proficient at rapidly identifying a potential Ebola patient, quickly isolating them and providing initial care, but once the diagnosis is confirmed, these patients should be transferred to a specialized biocontainment unit if a bed is available.

We need to think about exposures differently. In infection prevention, we tend to classify exposures to infectious agents on the basis of whether the exposure was protected: Did the nurse have on an N95 mask when she treated the patient with tuberculosis? Did the young man wear a condom when he had sex last night with an HIV-infected man? Typically, unprotected exposures pose greater risk of infection than protected exposures. In Dallas, the same paradigm was applied: the unprotected healthcare workers in the ER who evaluated Mr. Duncan before he was suspected to have Ebola were thought to be at higher risk than those who cared for him in the ICU will full PPE. This turned out to be wrong. Early in the course of Ebola the infectivity is low, as demonstrated by the fact that none of Mr. Duncan’s unprotected household contacts became infected. Late in disease, infectivity is very high and two nurses in gowns, gloves and face protection became infected.

Equipment and supplies for state-of-the-art care are inadequate. Several of us tried to find a stethoscope without ear tubes so that auscultation could be performed without bringing a device close to your face. We had no success. Much has been made of the fact that the Dallas nurses used PPE that didn’t cover their necks. This was even noted in an editorial in the New York Times. However, almost all (if not all) products that provide neck coverage, including bunny suits, are difficult to doff, making self contamination likely. Fortunately, our hospital has an in-house seamstress who rose to the occasion and rapidly began designing an item to cover the neck that is easy to remove. In addition, the supply chain for PPE is tenuous. Already, many items are on allocation and the national supply for some is not robust. Just-in-time manufacturing processes are not advantageous in the current situation.

Investment in infection prevention infrastructure and research is necessary. The health care system in the U.S. has talked a good game regarding the importance of infection prevention, but if budgets are statements of what we value, infection prevention has been a stepchild. Ebola should be our wake up call. Funding is needed to answer basic questions of infection control and to train hospital epidemiologists. Mandates for all hospitals to have infectious disease trained hospital epidemiologists should be considered. New models for compensation of infectious diseases physicians must be developed to encourage young physicians to pursue training in our field.

It was a truly challenging week. But from an infection prevention standpoint, it was challenging in a really good way. It allowed us to collaborate with experts across the health system and think creatively with them, while providing us an opportunity to demonstrate the value we add. I am very lucky to work with an amazing group of epidemiologists and a strong leadership team at the University of Iowa. And the Society for Healthcare Epidemiology of America (SHEA) staff did an outstanding job of promoting what we do in the mainstream media.

Lastly, we must keep all of this in perspective. Every issue I have talked about in this post is a first world problem. The tragedy of what is happening in West Africa remains incomprehensible.

Michael B. Edmond, MD, FACP, is the Chief Quality Officer at the University of Iowa Hospitals and Clinics. This post originally appeared at the blog Controversies in Hospital Infection Prevention.

The 'nocebo effect,' statins, and Dr. Ben Goldacre

I just recently became aware of a study that came out in March of this year which concluded that statins, drugs like Lipitor (atorvastatin) and Zocor (simvastatin), which people take, increasingly, to lower their cholesterol and their risk of heart disease, have NO SIDE EFFECTS. Here is a paper which explains the study. It is not possible to link to the actual study in the European Journal of Preventive Cardiology because they want me to pay for it.

The paper says that, when comparing patients who took statins to ones who took an inactive pill, the side effects of both were about the same. That is called the “nocebo effect.” Many people have heard about the “placebo effect” in which a sham treatment or sugar pill has a beneficial effect due, we think, to the fact that the subjects who receive it think it will work. Placebo, in Latin, means “I will please” and nocebo means “I will harm.” So the researchers who wrote the paper about statins, after reviewing the data, found that patients who believed they would have side effects on statins did have side effects, whether or not they took the real drug. This is the nocebo effect. It implies that statins have no more side effects than sugar pills.

Now this would be really interesting if it were true. But it’s not, so it’s just really annoying. Patients who have received these drugs and physicians who prescribe them have noticed such a marked incidence of side effects, especially muscle weakness and pain, which resolve when the medicine is stopped, that any study questioning that finding is extremely suspect. When I heard about the article, I looked a bit further to see who had written it and what data they had looked at. I suspected that the study had been funded by pharmaceutical company lackeys using faulty data. It turns out I was only half right.

One of the major authors on the paper is a British physician named Ben Goldacre who is absolutely passionate about revealing the truth in scientific research and medicine, particularly in research done by unscrupulous pharmaceutical companies. He has founded a group, AllTrials, to promote honesty in reporting the results of clinical trials of medications. He actively publishes articles aimed at lay audiences about ways in which drug companies use skewed data to mislead the public about the safety and effectiveness of their drugs. He has written a book, Bad Pharma, about how the pharmaceutical industry distorts the truth to get patients to use their products. He is passionate about it and appears to be an excellent human being.

So what happened? Why did this guy who seems to be such a voice for truth write this paper? He explains it all quite entertainingly and in much more detail than I will here in his column “Bad Science.” What happened is that he used very incomplete data about side effects from studies that were mostly performed and designed with drug company support to show that statins were safe and effective. They didn’t even ask about many of the side effects that patients frequently complain about and they didn’t evaluate for muscle weakness in patients unless their muscle enzymes were 10 times normal or more, which is extremely rare. Dr. Goldacre attempted to write a disclaimer to the effect that he believed his data was inadequate, but the paper had gone to press. Oops. The news that statins have no side effects was on front pages of newspapers. There must have been champagne opened in the spacious offices of the companies that produce these medications.

So we still need good unbiased data on the true side effects of statins, and that will be pretty difficult to get at this date. Statins are so commonly used that finding a cohort of patients who have never used them to participate in a double blind study to evaluate their short and long term side effects will be tough. There are several statins on the market, with different incidence of side effects based on their chemistry, and each would need to be tested. Different categories of patients have different side effects, and the side effects vary based on dosage. Most patients who are willing to take statins are already on them, since physicians love to prescribe them. Patients who don’t want to take them probably also don’t want to take them in a double blind fashion for a long period of time. We will probably have to settle for a re-examination of data which was collected but not released, if anyone has the time or energy to find and scrutinize that.

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.
Thursday, October 23, 2014

Ebola: The questions keep coming

The progression of the Ebola epidemic, particularly the recent episodes of transmission to health care workers who wore appropriate personal protective equipment, raises interesting questions. Certainly we need to continue to work on learning everything we can about the best approach to personal protective equipment and minimizing the risk of transmission during the process of care. But it’s also time to rethink some of the rituals surrounding care that have persisted in hospitals for decades.

Academic medical centers by their very nature increase the number of interactions with patients. Trainees at all levels need to interview and examine patients, and participate in their care to acquire necessary skills. While the benefits to the trainee are obvious, in some cases the patients benefit as well, via the therapeutic effects of another empathetic ear or the uncovering of a critical clue by the careful history of a novice interviewer. However, with a disease like Ebola, which can be transmitted in the health care setting, has no post-exposure prophylaxis, no effective treatment, and a high mortality rate, a strict approach to limiting the number of individuals in the physical proximity of the infected patient is appropriate as recommended by CDC.

Limiting contact typically means that in addition to students, other trainees such as residents and fellows also do not enter the room. But perhaps this needs to be taken a step further. Perhaps there should be one “examining” physician whose documented exam is used by consultants in their evaluations so as to limit room entry. In many cases, an additional exam probably doesn’t add much value, and is often performed because it’s expected or to maximize billing. Even before Ebola, as hospital epidemiologists we’ve asked ourselves the simple question: does every person on the care team need to examine every patient every day? Every encounter adds some level of risk for transmitting pathogens in the health care setting, but with Ebola the implications of transmission are taken to a whole new level. Fortunately, given technologies such as Skype, the ability to interview patients should not be impacted.

Ebola also pushes us to reconsider therapies that have a reasonably high probability of futility but increase risk to health care workers. In the case of the Dallas patient, who underwent endotracheal intubation and hemodialysis, we are left to question whether these procedures played some role in infection of the critical care nurse. Should CPR, which would seem to involve a very high degree of risk to bedside providers, not be performed? The ethical issues associated with withholding these procedures typically associated with “routine” critical care need to be explored since the risk-benefit calculus is markedly shifted by the level of risk to health care workers.

Lastly, should health care workers be compelled to work with Ebola infected patients? Do they have the right to opt out? Should those who volunteer receive hazard duty pay? Should there be a compensation fund for families in the event a health care worker contracts Ebola disease occupationally and dies? How do we handle the issue of pregnant health care workers? In the long run, how do we design the hospital of the future to maximize safety of the patient and provider?

These initial questions demonstrate that the Ebola crisis is challenging us in many ways and will likely continue to do so for quite some time. But perhaps we’ll emerge from this with a more thoughtful approach to patient care that improves safety without sacrificing quality.

Michael B. Edmond, MD, FACP, is the Chief Quality Officer at the University of Iowa Hospitals and Clinics. This post originally appeared at the blog Controversies in Hospital Infection Prevention.

Which medical specialty should medical students choose?

A medical student recently asked my advice on her decision to pursue a career in dermatology. It was about 25 years ago when my own parents encouraged me to pursue this specialty. What was their deal? Perhaps, they anticipated future developments in the field and were hoping for free Botox treatments? As readers know, I rejected the rarefied world of pustules and itchy skin rashes for the glamor of hemorrhoids, diarrhea and vomit.

My parents were making a lifestyle recommendation. Dermatologists are doctors who sleep through the night. Spying one in a hospital is a rarer sighting than spotting a liberal Democrat at a Michelle Bachmann rally (unless a planted heckler). Nocturnal acne medical emergencies are uncommon. And anyone who has had cosmetic work done understands painfully that this is a cash business.

Here’s where some readers or dermophiles will accuse me of skin envy. Not true. Some dermatologists may be a tad thin-skinned over this assertion, but facts are facts. These docs have a soft lifestyle and earn much more money than most physicians do. Sure, these guys and gals see some serious stuff, but the nature of their specialty is less intense and frenetic than that of other colleagues.

Many professions push back when it is suggested that they are afforded unique and soft perks that most of us don’t have. Teachers, for example, never state out loud that having every federal holiday off, enjoying school vacations every few months and having 10 weeks off in the summer are unbelievable soft padding that no one else has. We know you work hard under difficult circumstances and we respect you and your profession. But just admit that you have some unbelievable professional cushions. This won’t diminish your self-worth or contributions to society.

Many medical interns and residents don’t consider lifestyle when they are making their career choice, and they should. Obstetrics is thrilling when you are 30 years old. Fifteen years later when you are overworked, tired and have your own kids, it may be slightly less thrilling to bring new life into this peaceful world in the middle of the night on a regular basis.

For me, leaving my own bed at an ungodly hour to haul out to the hospital is an unwelcome activity. I do not relish being awakened with phone calls or having to attend to an individual in the emergency room when the rest of Cleveland is soundly snoring. While gastroenterology is a more taxing specialty than the skin gig, it is still uncommon for me to have leave for the hospital during the black of night. Since we are in the era of medical hospitalists who are on staff around the clock, there is only a rare need for me to make a personal appearance. On most nights, my scope rests securely in its holster.

Do I think that medical students should consider lifestyle as they are contemplating their future? Absolutely. Indeed, the emerging culture of the medical profession has morphed from the prior culture when doctors worked 24/7 and interns were proudly on-call every other night. Medical doctors today are increasingly employed by institutions, work shifts and delegate the hassles of hospital life to hospitalists. Doctors are self-prescribing R & R.

Leisure, relaxation, avocations and personal time for reflection are not evil pursuits. They are the fuel that cultivates and sustains our humanity. Who wouldn’t welcome a little more humanity in the medical profession?

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.
Wednesday, October 22, 2014

Medicare follies, or, the Annual Wellness Visit

Over the last few years, Medicare, the government insurance program for the elderly, has added a few benefits, one of them being a yearly doctor visit. This “Annual Wellness Visit“ is a great source of confusion around the office. Patients come in for a yearly wellness visit thinking that they are here for a “full physical.” They are not. The Annual Wellness Visit is something much more complicated and much less useful.

No one seems to agree on exactly how to run an AWV, but the basics are this: the patient fills out a questionnaire on their health; the doctor notes the patient’s basic data: age, blood pressure, body-mass index, etc. The patient is then assessed for their risk of falling, depression, and alcoholism, and their ability to take care of their basic needs. Their medications and other doctors are reviewed. After the visit they are supposed to receive a written plan detailing any prevention recommendations, such as mammograms, weight loss, etc.

Importantly, the AWV does not include a physical exam. I am not supposed to listen to your heart, feel your belly, or talk about your newly-diagnosed cancer. You have to make another appointment for that.

This sort of foolishness could only have been dreamed up by someone who doesn’t see patients. The AWV might as well be done at a self-serve computer station.

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.
Tuesday, October 21, 2014

Clinical practice guidelines, autism, and ordering of tests

I gave a presentation to the Institute of Medicine (IOM) on the topic of emerging technology in medical education (more specifically, on graduate and continuing education in the health professions). The overall theme of the IOM Roundtable discussion was to examine practical approaches to improving genetics education in these groups. I am a primary care physician, and by no means an expert in genetics or genomics. My involvement in the meeting centered around using emerging technology within education of health care professionals.

It was a fantastic one-day conference, and I had the opportunity to meet some very wonderful people; not only fellow educators but also true experts in the field of genetics and genomics education. The discussions included how genetic providers can best partner with primary care physicians on ordering of tests that will help patients. We also talked about primary care physicians referring appropriate patients to geneticists for further evaluation. One of my take home points was that I should be considering genetic conditions more often than I am. Consider that objective achieved, IOM!

So I recently received this advertisement card in the mail, by Quest Diagnostics. On one side “Their future is in your hands.” On the other, a pitch to use the ClariSure brand of chromosomal microarray analysis.

I have never ordered one of these tests. I probably need to refer more patients to a genetics clinic, for sure, and not just for patients in whom I am entertaining a diagnosis of autism.

But this phrase right on the pretty glossy paper caught my attention: “Chromosomal Microarray Analysis is recommended as a first tier test for autism spectrum disorders and developmental delay by ACMG” (the American College of Medical Genetics). Wow, I thought! That could be considered a pretty bold statement. Remember, this was sent to me, a primary care doctor, who sees patients with autism, screens pediatric patients at well child visits for it, and refers where appropriate. The statement above does NOT say “for diagnosis”, “when/if referring to genetics”, or anything like that. It says “recommended as a first tier test for autism ….” How should a pediatrician reading this pamphlet sent directly to them interpret that?

I pulled the ACMG guidelines, entitled “Clinical genetics evaluation in identifying the etiology of autism spectrum disorders: 2013 guideline revisions“. In that guideline, Table 4 is titled the following: “Template for the clinical genetic diagnostic evaluation of autism spectrum disorder”. Indeed, chromosomal microarray is listed as a first-tier test. But let’s go back to the title of Table 4 and read it more carefully: “… for the clinical genetic diagnostic evaluation of autism spectrum disorder”. It does NOT say “for pediatricians and primary care providers” anywhere in this table. I don’t really know too many primary care pediatricians who are ordering this test, but maybe I am insulated. I am not a clinical geneticist. So why is this pamphlet being sent to me, a pediatrician?

When I am not sure about something, I like to “go to the literature”. So I looked for guidelines or a policy by the group with which I affiliate as a pediatrician: the American Academy of Pediatrics (AAP). I do not recall the AAP recommending chromosomal microarray testing the last time I looked. The AAP does indeed recommend Screening for Autism, in a guideline from 2007: “Identification and evaluation of children with autism spectrum disorders”, with a simplified algorithm found here, on page 2). Basically, routine screening in every patient at 18 months for autism spectrum disorders is what pediatricians should be doing. There is even a code for screening (It’s 96110, for anyone interested!) I know this algorithm well.

We are actively working to improve screening for autism in the state of Indiana, and colleagues at my institution have some preliminary data that demonstrate a lowering of the mean age of diagnosis of autism in certain communities by quite a bit (the lower the age, the earlier the patient can be referred to an autism specialist). Maybe in the future, ordering of a chromosomal microarray analysis will be part of a general pediatrician’s armamentarium, but I’m not sure it is right now.

Is it just me, or should I be bothered by this pamphlet which I received from Quest Diagnostics? Again, the wording on the pamphlet sent to me, a primary care doctor, at my home address, recommends “chromosomal microarray analysis is recommended as a first-tier test ….” I struggle with the wording, which omits “by clinical genetics.” I am not saying that geneticists should not order this test; they probably should. I am saying that sending this pamphlet to pediatricians, who see scores of patients who may have positive screening tests for autism, seems a bit bold.

Pediatricians should refer patients they are concerned may have autism spectrum disorders to a specialist. Their concern may arise from a gestalt, or from a formal screening test, such as the M-CHAT-Revised. If this screening test (which costs only time to complete) is positive, a referral to a specialist and a community early intervention service resource is indicated. One such specialist is a clinical geneticist; another might be a behavioral/developmental pediatrician or a child neurologist. In addition, each state has its own individual process for early intervention service referral.

People wonder why the costs of health care are so ridiculously high. I agree with this sentiment: costs are too high! I do believe that we should be referring patients and interacting more with our genetics colleagues about patients with whom we might be considering certain diagnoses, such as autism spectrum disorders. But I wonder if general pediatricians are the right audience for such an advertisement for a specific diagnostic test. I certainly can see this pamphlet sent to the offices of clinical geneticists.

I think the point of the IOM meeting recently was to improve the education of primary care physicians. IOM: consider your goal achieved, with this primary care doc (me), at least. I wonder how many of my primary care colleagues are now ordering this chromosomal microarray test in patients who have a positive (abnormal) screening test, versus just referring. Something tells me that chromosomal microarray analysis is not a cheap test either. But that’s a discussion for a future blog.

Alexander M. Djuricich, MD, FACP, is Associate Dean for Continuing Medical Education and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis. This post originally appeared at Mired in MedEd, where he blogs about medical education.
Monday, October 20, 2014

We physicians need a Ganesh attitude

Over the years, I have had the great fortune to learn about different cultures and religions. I have many colleagues and residents who are Hindu. They have taught me about Ganesh. For those of you who do not know about Ganesh, this paragraph gives a summary:

In general terms, Ganesha is a much beloved and frequently invoked divinity, since he is the Lord of Good Fortune who provides prosperity and fortune and also the Destroyer of Obstacles of a material or spiritual order. It is for this reason that his grace is invoked before the undertaking of any task (e.g. traveling, taking an examination, conducting a business affair, a job interview, performing a ceremony,) with such incantations as Aum Shri Ganeshaya Namah (hail the name of Ganesha), or similar. It is also for this reason that, traditionally, all sessions of bhajan (devotional chanting) begin with an invocation of Ganesha, Lord of the “good beginnings” of chants. Throughout India and the Hindu culture, Lord Ganesha is the first idol placed into any new home or abode.

He represents intellect and wisdom. But the most important characteristic is Destroyer of Obstacles. Too many in medicine seem resigned to that train that has left the station. They sit around and lament what “they” are doing to “us.” They no longer consider fighting for changes.

Yet I see hope. I will admit to being an incorrigible optimist, but to me the signs are positive.

Performance measurement is changing. Bad performance measures are being changed and withdrawn. Many more “mainstream” thought leaders are advising a significant reconsideration of performance measure.

The enthusiasm of EHRs has waned. We now see an appropriate backlash. ACP published an important letter in JAMA Internal Medicine about the impact of EHRs on outpatient practice, “Use of Internist’s Free Time by Ambulatory Care Electronic Medical Record Systems.”

We all have a responsibility to not give up. We must speak out against administrative burdens that harm patient care. We should channel Ganesh and work to destroy obstacles to outstanding patient care. That is our responsibility. No excuses, no crying, no despair.

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.

Donning and doffing

Many have spent the last month or so preparing for possible patients with Ebola (PPE). I had the opportunity to review the tremendous amount of work that the UIHC infection preventionists have completed towards our preparation. During this process, I watched these videos prepared by the Biocontainment Unit at the Nebraska Medical Center that demonstrate the proper use of Biological Level C PPE. My thoughts when viewing these are that without significant practice, it would be very difficult to prevent contaminating or breaking protocol when removing this level of PPE and that donning and doffing take almost 14 minutes. That’s a bit more time than hand hygiene, so no more complaints about that! And thanks to Nebraska for sharing these well-prepared videos.


Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands). This post originally appeared at the blog Controversies in Hospital Infection Prevention.
Friday, October 17, 2014

How can we make hand-offs a good thing?

Health care is actually a 24-hour-a-day, 7-day-a-week job. People get sick even when we physicians are supposed to be sleeping or eating dinner or showering or brushing our teeth. Having care available all the time often saves lives and usually reduces suffering. In the U.S., we have that pretty well worked out. Everyone with a doctor has an after-hours number to call and if that fails or the problem is too big, there is always an emergency room or at least an ambulance or fire truck to whisk one away to where help is waiting.

One of the problems with our after-hours options is that a person is rarely seen by a doctor who knows them and is familiar with their medical history. It would be ideal for all of us to have rapid access to the doctor (or nurse practitioner or physician’s assistant) who has been with us for years and who knows what works, what doesn’t and who we can relate to and trust. Unfortunately that person has to sleep and eat dinner and sometimes even go on vacations. Most people run into the reality of seeing different doctors depending on who is available.

In my present profession, hospital medicine, I work for several days in a row taking care of a collection of patients who are in the hospital at that time. Most of them I don’t know. When I have days off, I tell another hospitalist about the patients I’ve been seeing and write a rather complete note. We discuss how I envisioned managing the patients’ medical problems, as I understand them and then I go, and Doctor Next takes the helm.

I always feel bad, at least a little bit, deserting my patients and leaving my physician partners with a job half finished, even though that is the nature of the job. But when I think about it, sometimes it is a really positive thing, and if I approach it that way it can be even more positive.

Not all hospitalist programs have “face to face sign-outs.” It is ideal to sit with the doctor who is assuming care of my patients and explain what is going on. That becomes impractical if there are too many patients and when I am not physically working at the same time as the physician assuming my patient’s care, like in places where there is a night shift physician. Telephone sign-outs are not bad, but are also impractical in a big hospitalist group where my 18 or 20 patients may go to several different doctors when I leave. A good sign-out, in person, from a good doctor is key to not being completely helpless on the first day of a set of shifts. Nevertheless, much can be gleaned from reading progress notes and reviewing labs and sometimes that’s all there is, since two minutes sign-out times 20 patients on a service equals 40 minutes, which is way too much time and still not enough detail to really be helpful.

In short, transitions of care are difficult, no matter how you slice it, and the more intensity that is put into the communication, from departing to starting doc, the better it is. But there is a silver lining to this dark cloud. Sometimes when we treat patients we go off down a wrong path. We concentrate on one aspect of a history or a data point and head off enthusiastically, missing what is really going on. If the doctor who takes over when we go is attentive and not excessively busy, the patient gets another chance for us to get the right answer. If done right, every transition can be a second opinion.

In some of the hospitals where I did my residency training, they had these wild and woolly doctor free-for-alls called morbidity and mortality conferences. They were a chance to dissect all of the decisions and actions that contributed to a patient becoming sicker or dying under our care. They were not quite blood baths, but doctors did cry regularly as they were grilled on their reasoning by more senior physicians, resting in the certainty of 20-20 hindsight. Besides being confrontational and unpleasant, these were incredibly informative and it was hard to forget the lessons learned in that context. We rarely see these anymore, but I miss them. Instead, I try to keep track of situations where what my colleagues have done or have thought was going on turned out to be wrong, and to discuss it with them later. This can be tricky and needs to be done in a trusting relationship, with the understanding that they will do the same for me.

We have been discussing lately doing a small morbidity and mortality type meeting with the emergency physicians, who by necessity only see the beginning of a patient’s evaluation and frequently do not have the benefit of all of the data, and the hospitalists, like me, who receive and take care of the patients from the emergency room and eventually hear the end of the story. I suspect this will be really interesting and will not only improve our medical thinking but also help us work together better. It will be a little bit tricky finding a time when even a quorum could be present together because of our very different work schedules, but I’m looking forward giving it a try.

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.

The very real-world limits of patient satisfaction

Everyone involved in health care, and particularly hospital care, has witnessed a sea change over the last decade. Things that were never even thought about, let alone formally taught to frontline doctors and nurses, have now come to the forefront. Chief among these is the drive towards improving patient satisfaction and delivering a more optimal hospital experience.

True, a large part of this is due to federal incentives and tying reimbursements to patient satisfaction scores. Whatever the motivation, a lot of this focus was in fact long overdue. As one of my own personal areas of interest, I really believe that health care must always strive to be more customer service oriented with a focus on keeping our patients as comfortable, informed and satisfied as possible. Being sick is horrible enough for anyone without feeling like you’re being treated badly or with disrespect.

I’ve written a lot about the things we can do to improve care, like spending more time with our patients, being clear on wait times, allowing them to get a good night’s sleep, and even giving them more palatable food to eat. Yet sometimes I fear that the patient satisfaction movement is going a bit too far and not realizing where to draw the line. Interestingly studies are now also showing that patient satisfaction isn’t necessarily correlated with good care, including a recent study published in JAMA.

My own experience is that the vast majority of patients are pleasant, motivated, listen to the doctors’ advice, while also asking very reasonable questions or expressing legitimate concerns. But let’s look at a few everyday real-world hospital scenarios where keeping patients happy and granting their wishes definitely isn’t the best thing:
• The patient who has a narcotic dependence who is demanding additional pain medications (often when already over-sedated)
• A patient who is insisting on a treatment or discharge plan that you know goes against your better judgment and is not safe
• A patient who has a misunderstanding of a clinical situation and is drawing the wrong conclusions, or seems unreasonable in their complaints

These are just 3 examples that will be familiar to all those practicing at the front lines. It’s important that the new generation of doctors and nurses doesn’t have “patient satisfaction at all costs” drummed into them so much that they are reduced to yes-men professionals. As much as we strive to improve communication skills or the comfort of hospitals in a patient-centered environment, it simply isn’t always the case that the doctor and patient are completely equal partners. Just as the job of a teacher isn’t to please their students, the job of a doctor isn’t to always please their patients. Ironically I’ve found that patients tend to appreciate and respect an educated, authoritative well-intentioned “no” over an insincere “yes,” especially over the long-term.

In hospitals we are already in a work environment that is among the most compassionate and understanding. All doctors and nurses will also be familiar with the angry relative who storms into the hospital demanding immediately to speak with the physician. Just think what would happen if someone ever aggressively walked into a bank and demanded immediately to speak with the bank manager in a raised voice? Security would probably promptly escort them out. But health care is an emotional arena, and we make allowances and are always accommodating (as we should be).

In the new patient-centered health care of the future, the worst-case scenario would be for doctors to be fearful of a patient being able to pull up his or her iPhone and threaten them with a bad online review if their wishes are not immediately granted, or scared to tell a patient that they need to lose weight because it might offend them. That shouldn’t be the health care satisfaction of the future. Doctors must never be afraid to stand by their principles and clinical judgment. Patients are ultimately the ones who will lose out if that happens.

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.
Thursday, October 16, 2014

Medical complications torture doctors too

If you are a physician like me who performs procedures, then rarely you will cause a medical complication. This is a reality of medical life. If perforation of the colon with colonoscopy occurs at a rate of 1 in 1,500, and you do 3,000 colonoscopies each year, then you can do the math.

Remember that a complication is a blameless event, in contrast to a negligent act when the physician is culpable. These days, for many reasons, an actual complication is confused or misconstrued as an error.

Some complications are more difficult on physicians than others. For example, if I prescribe a medication and the patient develops a severe rash, I do not feel personally responsible. It’s the drug’s fault. However, when I perforate someone’s colon as a medical complication, I feel responsible even if this act was a blameless event which will occur at a very low but finite rate. (Of course, there are perforations of the colon which result from medical negligence, but I am leaving these aside to make my point here.)

I feel responsible because my hand was on the instrument that caused harm. I can’t as easily blame the scope, as I blamed the rash-causing drug. I’m sure that surgeons feel the same painful emotions when they perform a routine operation and serious bleeding results that requires additional surgery and complicates what should have been an uneventful recovery.

When your hand is on the colonoscope or the scalpel, and the unexpected happens, it’s an awful experience for the doctor even if we have performed according to proper medical standards.

Of course, serious medical complications are much more difficult for the patients and families involved than they are for us. But, we physicians suffer greatly when a patient is harmed from a procedure that we recommend and perform. You can imagine how we torture ourselves with second-guessing when these events occur.

Complications are inevitable. The only gastroenterologist who hasn’t had a perforation of the colon is one who is brand new. So, if you are drawn to a gastroenterologist because he has a 0% perforation rate, caveat emptor! Paradoxically, the most experienced colonoscopists have accumulated many more complications over their career because of a much higher volume of cases or that they are referred very challenging cases by virtue of their skill and experience.

A medical complication is an especially difficult event when it occurs in what was expected to be a routine outpatient examination. Patients who come to our office for a screening colonoscopy understandably expect to be home 2 hours later. So do we. On those rare occasions, when this recovery path is altered, we must have a very serious, sober and unexpected conversation with the patient and the family. Our plan is always to tell the truth and reassure all involved that we will do all that we can to make it right.

Medicine is not a simple or predictable endeavor. Sometimes, it can be rather complicated.

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.

Engaging patients

Patient satisfaction is hot. Major payers, including the federal government have linked hospital payment to institutional performance on patient surveys of their experience with care, and are poised to do the same with physician payments. There is a proliferation of commercial websites for patients to offer up their reviews of physicians and to check out the ratings already there. An entire industry of consultants has appeared to help institutions improve how patients experience the care they provide. Hospitals and health systems, including our own, have hired Chief Experience Officers.

I think that this is generally a good thing. We have traditionally paid too little attention to how patients actually experience the care we provide, and it is pretty hard to make that experience better without actually asking patients and their families. I would be more enthusiastic about these efforts if we spoke less about “patient satisfaction” and more about “patient engagement.”

As I have written previously, I think that “satisfaction” is a pretty low bar. Patient engagement, however, is a much higher goal of establishing a therapeutic partnership with patients. It is not just about making sure that they were, as the patient satisfaction surveys would have us assess, spoken with in a way they could understand, or treated with courtesy and respect. It is about making sure that we have made it possible for them to be active and effective in their own care. A really eloquent statement of what that ought to look like is available here. It is written as an open letter from a patient to a “new doctor” and we would all do well to follow her advice. I recommend you read the whole thing, but her main points of advice to us are:
• Seek first to understand, then to be understood;
• Join a system or create a practice that prioritizes coordinated care;
• Recognize that being a patient and being part of the health care environment is not my job; and
• Learn from me.

I know it is not easy to organize our systems of care to achieve these goals, but it really seems to me we ought to try. 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.
Wednesday, October 15, 2014

Seeking the sweet spot, from mouth to microbiome

A study out last week in the top-tier journal Nature told us that non-caloric artificial sweeteners (NAS) may contribute to glucose intolerance by mucking up our microbiomes. That’s a serious indictment, since these products are intended to help defend against glucose intolerance, and other ills related to diabetes risk and weight gain. After all, they are replacements for sugars that have already been comparably indicted.

The study, which received considerable media attention and may already have caught yours, was both elegant, and complicated. It was actually one paper, but a series of studies in both mice and people. Most of the work was in mice, where the introduction of NAS, specifically saccharin, aspartame, or sucralose, induced glucose intolerance. The underlying cause of this metabolic effect was traced to a marked change in the bacterial populations colonizing the GI tracts of the mice. The adverse effect was reversible with antibiotics that killed off the newly favored bacterial colonies.

Studies in humans suggested much the same, but these were less controlled, and conducted in very few people, with less consistent results. The translation of these findings from mice to people was generally supported.

While the human research was far from decisive, the takeaway from the constellation of studies was clear enough. Replacing sugar with artificial sweeteners may fail to facilitate the intended benefits. By compromising the ecology of the microbiome, of both mouse and man, the effect may be just the opposite.

The epidemiology is, for the most part, rather consistent with such unintended consequences. Diet soda has been linked to obesity, although questions are routinely raised about the direction of causality (i.e., maybe drinking diet soda makes people fat; maybe overweight people turn to diet soda to help control their weight). Associations have been established with serious chronic diseases as well, although again, both specific proof of causality and mechanism are lacking.

From my perspective, this new research, provocative though it may be, merely puts the icing on a well-baked cake. I think we had good reason to avoid artificial sweeteners before now.

In brief, we are right when in the vernacular we refer to a “sweet” tooth, rather than a “sugar” tooth. The taste preference we are referencing is, indeed, generic to all substances that trigger the recognition of “sweet” in the brain.

What we mean, of course, when we say “sweet tooth” is a preference for all things sweet. When the issue of food addiction is debated, the sensation that tops the list of likely candidates is sweet. If any response to food hardwired into our nervous systems rises to the level of addiction, it would be the response to sweet.

This means several things. First, a sweet tooth may be exploited to propagate our eating and profit from it. Put sweeteners into foods, even foods not customarily thought of as sweet, and the amount of eating we are apt to do before stopping increases. This is done, and the results are as predicted, entirely by profitable and exploitative design.

It also means that the more we get, the more we want, and need, to feel satisfied. In addiction, this is called tolerance. In the case of a sweet tooth, it means graduation to a sweet fang that pretty much takes over your kitchen, and your life.

There is every reason, residing in sense as well as science, to suspect that NAS contribute just as readily to this phenomenon as caloric sugars. The commonly used artificial sweeteners are intensely sweet, all much more so than sugar. The net result, then, is that while NAS might remove sugars and the associated calories at any given time, they would cultivate the sweet tooth that would favor their readmission at some other time. That’s easily done, since there are popular brands of bread, crackers, chips, pretzels, salad dressings and pasta sauces with added sugar. One might favor such products due to a sweet tooth, and never even be aware of it.

What, then, is the answer? Neither the current excess of sugars, nor the sugar substitutes that foster a sweet tooth and disrupt the microbiome. There may be better options in the pipeline, namely non-caloric sweeteners that don’t exert unintended harms. Both stevia and monk fruit extract look promising at this point, but we need more data.

In my opinion, the best answer is a method I call “taste-bud rehab,” that allows for titrating down one’s standard daily exposure to sweeteners quite painlessly, then acclimating to that ever lower level. Taste-bud rehab is one example of skillpower, willpower’s oft-neglected cousin. Titrate down exposure to total sweeteners, come to prefer foods less sweet, and then use actual sugar, but much less of it.

The nutritional sweet spot will never be reached courtesy of the prevailing excess of added sugars, whatever their formulations. We now have more cause than ever to think that it will not be facilitated by substituting non-caloric artificial sweeteners, either.

Science and sense have long suggested that the way to go was reducing the total amount of “sweet” in our diets, and rehabilitating our taste buds in the process. The result is not only a diet much lower in sugars and free of NAS, but a diet that you genuinely prefer that way. Add the relevant skillpower to science and sense, and you can get to the much-less-sweet sweet spot from here. When you do, you will find yourself loving food that loves you back, from your mouth, to your microbiome.

And, I suppose, to your mice, too, if you happen to have any of those.

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.