Friday, November 28, 2014

Replacing the term patient satisfaction with something more meaningful

As the patient satisfaction movement races full steam ahead, the time is perfect to regroup and define what this whole thing is really all about. Anyone involved in health care, and particularly hospital care, knows that the term “patient satisfaction” has become a buzz phrase recently. Sadly, too, it’s also evolved into a bit of a bumper sticker in hospital administration circles—more about answers to lengthy questionnaires and some rather tacky gimmicks than about getting the real fundamentals of health care right.

Personally I’m not a particularly big fan of the term either. Hospitals and health care are inherently very different from hotels and restaurants which practice the mantra to its extreme—relying on the fact that the “customer is always right”. But unlike these customer service arenas, the goal in health care isn’t really to “satisfy” our customers. To draw an example (not necessarily an exact equivalent) the goal of an educational institute isn’t to satisfy students. The goal of a sports coach isn’t to satisfy the athlete. The goal of your attorney isn’t to satisfy you. It is to get the best results. To an extent, the 2 can go hand in hand, but results and satisfaction are not always synonymous in health care.

The real mission of health care is to get our patients better by offering high quality clinical care in the best possible environment. This environment should be one where patients get to spend maximum time with doctors and nurses, patients feel fully empowered and informed in the decision making process, and are treated with the utmost respect and dignity the whole time.

Being sick is a miserable time. Our interactions with patients in the hospital will often be at the absolute lowest point in their lives. Illness and hospitals are scary and intimidating. Easy to forget when you work in the hospital every day. No amount of TV channels, gourmet food or glossy painted walls can change that. What we can do however is strive to make things less horrible. We can make people comfortable and less scared. We can reassure and give our patients all the compassion we can offer.

I once talked to an information technology entrepreneur who was getting involved in health care. During our discussion he told me that his company’s goal was “ultimate patient satisfaction.” The gentleman seemed sincere enough and thought that I would be impressed with his company when he said this. Aside from the fact that information technology will never be the main reason that people remember a good clinical interaction, I found it interesting that the term is now being used by other sectors as a way to gain traction within health care.

This obsession with “patient satisfaction” should be ditched for one that instead focuses exclusively on improving the health care experience and raising the quality of clinical care. For all the research, focus groups and administrative wrangling, the solutions are really not rocket science. Once we get the fundamentals right, namely practice good and thorough medicine in a compassionate and healing environment, the rest will take care of itself. Health care will not even need any satisfaction surveys once we achieve this.

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.
Wednesday, November 26, 2014

Over-reactors do not help health conversations

One morning, driving to work, I listened to Mike and Mike (a radio sports talk show). Mike Greenberg made a wonderful point about his job. He described what they do as “professional over-reactors”. They take every game and extrapolate, sometimes irrationally, about the implications of that game.

Does this remind you of health reporting? A study appears in a serious medical journal, and the press “blows it up” as the next great advance. But scientific knowledge grows slowly, with fits and starts. Too often initial research reports are not confirmed with later studies.

While this is a major problem, perhaps a bigger problem occurs when a new disease or epidemic occurs. Many opine dramatically and profess to have the answers. Many use the retrospectoscope to criticize public health, or individual physicians or other health care workers. Often the critiques of the situation take a serious health issue and use it to highlight an issue that they want to espouse.

Likely, I am guilty of this tendency. I wrote recently about the emergency department missing the first Ebola patient’s diagnosis to highlight my concern about diagnostic accuracy. Others have used this unfortunate story to highlight concerns about electronic health records. We use anecdotes to highlight our concerns. Perhaps we overreact.

But our concerns pale compared to political candidates. We now have the Republicans blaming the Democrats and vice versa for the Ebola epidemic. Balderdash! Neither side makes a convincing case, and they have each stooped to using a public health crisis to make political hay.

As we work to understand the Ebola epidemic, we have a responsibility to not over-react. We must let the public health professionals and the infectious disease experts carefully examine the data. Our over-reacting just leads to hysteria.

Of course the press will continue to over-react and politicians will over-react, and bloggers will over-react. That is what we do. But are we helping anyone? Are we just fueling hysteria? What do you think?

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.
Tuesday, November 25, 2014

Is hepatitis C treatment cost-effective?

One catch phrase in health care reform is cost-effectiveness. To paraphrase, this label means that a medical treatment is worth the price. For example, influenza vaccine, or “flu shot,” is effective in reducing the risk of influenza infection. If the price of each vaccine were $1,000, it would still be medically effective, but it would no longer be cost-effective considering that over 100 million Americans need the vaccine. Society could not bear this cost as it would drain too many resources from other worthy health endeavors. Economists argue as to which price point determines cost-effectiveness for specific medical treatments. As you might expect, insurance companies and pharmaceutical companies might reach different conclusions when the each perform a cost-benefit analysis.

Remember, it's not just cost we're focusing on here, but also effectiveness. If a medicine is dirt cheap, but it doesn't work, it's not cost-effective. Get it?

Pharmaceutical companies who are launching extremely expensive medicines often boast about the medical benefits while they ignore the cost factor entirely. We see this phenomenon regularly when the pharm reps come to our office or we are listening to a paid speaker.

Understandably, when expensive medical care is being paid for by a third party, patients and their families are not considering cost-effectiveness. They are focused on their own health and welfare. If the doctor advises that our mom needs chemo, we're not wondering if the cost would be a fair allocation of societal resources.

A new hepatitis C (HCV) drug, Sovaldi, has recently been launched. The 12 week course of treatment costs $84,000, or $1,000 a pill. This bargain doesn't include the costs of other drugs that are taken with Sovaldi as part of the treatment program. The cost of curing HCV, a worthy objective, approaches $200,000 including the costs of medicines, physician services and laboratory and radiology testing. Assuming that there are over 3 million Americans who are infected with HCV, the costs for curing them all approaches $300 billion. That's billion with a “B.”

Consider these facts before deciding if hepatitis C treatment is cost-effective.
• Most patients with HCV feel well.
• Most patients with HCV are not aware that they are infected.
• The majority of patients with HCV will not develop cirrhosis or other serious complications of the disease.
• Many HCV patients who are cured of the virus would never have developed any health issues. They were silently infected.

Here's what's needed.
• Identifying HCV patients who are destined to develop severe complications.
• Proof that treating these patients changes the course of their disease.
• HCV treatment that is cost-effective.

TV or print ads about HCV treatment suggest that you ‘talk with your doctor to see if the drug is right for you’, When you do so, ask for the evidence that the treatment will allow you to live longer or live better. Clearing your body of HCV sounds like a triumph and is marketed as such, but this might not change your life at all.

Information is power. I wish there was some way this post could go viral.

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.
Monday, November 24, 2014

Moxifloxacin for MRSA: Why is this not standard of care?

Moxifloxacin and MRSA. Why is this interesting?


The drug company Bayer applied for a patent on yet another drug in the flouroquinolone category of antibiotics in 1989 and received approval by the Food and Drug Administration in 1999 for Avelox, the brand name they gave to moxifloxacin. A Japanese company had discovered in the 1970s that adding a flourine to relatively ineffective antibiotics in the quinolone family, such as nalidixic acid, made them dramatically more active, thus creating flouroquinolones. That discovery led to the development of norfloxacin, then ciprofloxacin and levofloxacin which have become mainstays of antibiotic therapy.

Ciprofloxacin is extremely useful for treating urinary infections and a variety of other serious infections including anthrax and traveler's diarrhea. Levofloxacin has become one of our drugs of choice for treating pneumonia and is especially useful because it achieves the same levels when given by mouth as it does by intravenous injection. Moxifloxacin hasn't really caught on to the same extent, even though it also is absorbed extremely well when taken orally and achieves particularly high levels in the lungs. It is also more effective for treating infections caused by gram positive organisms than ciprofloxacin or levofloxacin, including resistant Streptococcus pneumoniaeand Staphylococcus aureus. It is approved for treating skin, lung and abdominal infections caused by susceptible organisms and in some hospitals (like the VA, I hear) it is the least expensive flouroquinolone option due to deals with the manufacturer, so it is used more often. It just became available in a generic form in the U.S. in 2014.


Methicillin-resistant Staphylococcus aureus (MRSA) has grabbed headlines as it has become more common, both as a bug acquired in the hospital and now in the community, that is to say outside of hospitals. In some places resistant staph infections are now more common than the ones that are sensitive to the antibiotics we use most often. S. aureus is usually quite a virulent bug, spreading aggressively in infected tissue and often seeding the bloodstream and even establishing itself on heart valves. It can cause particularly severe pneumonia, especially in already ill hospitalized patients and patients from nursing homes. It has become an especially big problem among intravenous drug abusers who are some of our sickest patients anyway, with coexisting issues like HIV infection and lack of adequate medical care. We have struggled to find antibiotics which work for MRSA and have turned to older and sometimes less effective antibiotics as well as newer and absurdly expensive ones.

A few weeks ago, while treating a patient with a MRSA infected wound, a colleague who is a wound care doctor suggested using moxifloxacin to treat her infection. I thought he was maybe just a little stupid, not to know that MRSA is usually resistant to flouroquinolones. I told him as much, except the stupid part and he told me that I was wrong, that he had just heard a talk at a wound care meeting and that moxifloxacin was good for MRSA.

I checked the microbiology sensitivity sheet for my patient's MRSA to see what antibiotics it was sensitive to, and it was, indeed, resistant to levofloxacin and ciprofloxacin and our lab did not even test for moxifloxacin. I started poking around in the literature to find out what supported his claim that moxifloxacin was good for MRSA. There wasn't much, but there was an article that showed that, using MRSA from 12 patients who acquired it in the community or the hospital, moxifloxacin was more effective in killing the staph than trimethoprim sulfamethoxazole, linezolid or clindamycin. Another article showed that moxifloxacin was more effective than vancomycin, a standard treatment for MRSA, in treating MRSA in experimental biofilms, like the bacterial mats that characterize infected wounds. A third one looked at the effectiveness of vancomycin, ciprofloxacin and moxifloxacin at curing experimental heart infections (endocarditis) in rats and found that moxifloxacin was more effective than vancomycin and that ciprofloxacin didn't work at all. There were no human studies comparing moxifloxacin, head to head, with other standard antibiotics such as vancomycin for MRSA. So I guess he was right and I was wrong.

Standard of Care

The Journal of the American Medical Association featured an article entitled Clinical Management of S. aureus Bacteremia, A Review, by Thomas L. Holland MD et al. The article concluded that vancomycin and daptomycin (a moderately toxic and very expensive new antibiotic for MRSA) are the first line antibiotic choices for MRSA bacteremia , that is infection found in the blood. This was based on 81 studies, none of which looked at moxifloxacin. The antibiotics studied were pretty much all the newer, recently released, very expensive and usually intravenous antibiotics. Studies involving humans are very expensive to perform, and funding is usually from pharmaceutical companies attempting to show that their drug works, which will make back the money they spend in research if all goes as planned. To give the article credit, the final conclusion was that well-designed studies to address the management of S. aureus bacteremia are needed.

Sepsis and Pneumonia

The standard of care in the hospitals where I have practiced is to use vancomycin (along with other broad spectrum antibiotic coverage) for patient who are seriously ill, in whom MRSA is suspected. Vancomycin is a difficult antibiotic to use, requiring measurement of levels to assure it is effective but not reaching toxic levels. It can cause kidney failure and hearing loss and if it is given quickly can cause “red man syndrome” which is what it sounds like, and quite disconcerting, though not deadly. Vancomycin must be given slowly which is a bit of an issue when a person is dying of rapidly progressive infection. But that's not actually the whole problem. We tend to use vancomycin when we suspect that there may be resistant staph in the lungs, but vancomycin actually has poor lung penetration and, even at standard doses, falls to what are probably ineffective levels during treatment.

It is often difficult to exclude pneumonia as a cause of serious infection in a patient who presents with sepsis, and the usual approach is to clobber them with broad spectrum antibiotics to cover whatever they might have. We try to get the antibiotics in to the patient as soon as humanly possible, ideally within an hour of arrival. Sometimes, however, it is difficult to get an intravenous line started and so a central venous catheter is placed, which must wait for a physician to do it, usually. Then there is a chest X-ray done to make sure that the line is in the right place and there is no lung collapse complicating the procedure. Then come the antibiotics. It can be agonizingly slow to get that first dose of life-saving antibiotics into a patient. Moxifloxacin can be given orally. “Here, take this.” Bloop. Done. Or it can be given intravenously, if gut function is questionable, but quickly. Moxifloxacin covers most gram negative and gram positive organisms as well as atypical lung pathogens that cause serious infection including MRSA. Moxifloxacin dose is 400mg once daily and need not be adjusted for kidney or liver function.

So what is the catch?

What is wrong with moxifloxacin and why are we not using it more commonly? Moxifloxacin does not reach adequate levels in the urinary tract to treat urinary tract infections, which can be the cause of sepsis. But we can evaluate the urine quite quickly, in minutes actually, and adequately rule out urinary tract infection. Moxifloxacin can cause liver failure and serious skin rashes, but liver failure is extremely rare and all antibiotics cause skin reactions in some patients. It can cause tendons to rupture, similar to other fluoroquinolones, though that is also pretty rare. Moxifloxacin isn't cheap, somewhere between $5 and $20 a pill. But that is compared to $8 a day plus administration costs for vancomycin and about $300 for daptomycin, plus administration costs. And moxifloxacin is now generic and produced by over 30 companies worldwide so its cost will likely become negligible. The biggest issue is that it hasn't been adequately studied in the setting of serious infection and isn't likely to be studied because it will make nobody money to do the expensive research.

If, by some chance, it were to be studied and found to be superior to our present goofy standard of care, it would make some pretty profound changes in the way we do things. If moxifloxacin could be used to treat S. aureus bacteremia then patients would not have to remain in the hospital or have outpatient intravenous antibiotics for 2 weeks, or 4-6 weeks in the case of complicated infections. It is incredibly inconvenient and dangerous to have patients on intravenous antibiotics for a prolonged amount of time. Intravenous drug abusers cannot be allowed to go home with an intravenous catheter in place because they will use it to inject drugs and the catheter will become infected. Those patients end up becoming fixtures in our hospital wards, often bored and disruptive, as they finish their prolonged treatments. When they leave against medical advice without completing their course of treatment a significant number will return, gravely ill, with a recurrence of their infection. The intravenous lines themselves, in addition to being very expensive, can cause infections and blood clots. Moxifloxacin achieves nearly identical levels when given orally as it does when given intravenously, so there would be no need for IV lines for 2-6 weeks.

In light of this information, what now?

I am not prepared to go against the standard of care at this point and use oral moxifloxacin for S. aureus bacteremia, except in patients for whom intravenous therapy is impossible or likely to cause harm. I am, however, likely to use it for sepsis, when the urinary tract is not the source, in place of vancomycin plus other empiric gram negative and atypical organism coverage. I am also likely to choose it for treatment of wounds in which S. aureus and gram negative organisms are identified or suspected. It is more than about time that adequate research was done to determine how we should use this drug for staph, especially MRSA bacteremia.

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.
Friday, November 21, 2014

Unscrambling our eggs

I recently saw a patient in my clinic who made me think about the many other patients like him I’ve treated over the years. He had a rather dramatic family history of heart disease, and had himself undergone coronary bypass surgery before his 40th birthday. He had, of course, seen many doctors before me, including all those directly involved in his surgery. But nonetheless, he traveled a considerable distance to see me and get my advice.

We may reasonably leave out the particulars of pharmacotherapy, and merely state the obvious. Since he was very overweight, he needed to lose weight. Since he didn’t exercise, he needed to start. Since he didn’t eat especially well, he needed to eat far better. In other words: well, duh.

While both you and I might understand why someone already working very hard to eat well and be active might seek out expert guidance on how to do even better, I trust you see the anomaly in this case. Why would anyone need expert guidance to start using what essentially all of us already know about lifestyle as medicine? More fundamentally, with a compelling family history of heart disease, a host of very obvious risk factors, and even an entry-level understanding of the link between those risk factors and their potentially calamitous consequences, why wait until after bypass surgery to consider doing something about it all?

This patient, as noted, made me think of other patients like him; in particular, one whose story I tell, calling him by the pseudonym “Doug,” in the first chapter of Disease Proof. But this patient, and Doug, and all the others like them, made me think of Ebola. In their cases, it was a body in danger. With Ebola, it is the body politic. In both cases, a penchant for attempting to unscramble our eggs is on display.

As noted in a column by Dr. Steven Osofsky, executive director for wildlife health and health policy at the Wildlife Conservation Society, published yesterday by CNN, we know a lot about the origins of Ebola outbreaks, just as we know a lot about the origins of heart disease. Unlike virtually all of the Ebola coverage inundating us at present, half of which is telling us not to panic and the other half telling us why we should, Dr. Osofsky looks beyond the current outbreak to its root causes. There is a proud history of that very method in preventive medicine. Root causes tell you what you can and should fix not just now, but so that the current crop of bad news isn’t replicated any time soon. That’s the benefit of getting to the roots.

The roots of the Ebola outbreak reside not with the arcane biology of exotic viruses, but the mundane behavior of hungry people on an overcrowded planet. In parts of Africa where other food sources don’t meet the need of populations swelling ever more into wildlife areas, hungry people wind up catching and killing wild animals for food. Their choices can be rather indiscriminate, and include both bats and primates. Such exposures are how Ebola first infected humans. Much the same is true of HIV.

I won’t repeat here the insightful, clear recommendations Dr. Osofsky offers for addressing this problem at its origins; I commend his column to you for that. I will note, as he implies, that failure to learn from the follies of our history may well destine us all to endless repetition of them. There are many other animal viruses we have yet to encounter. In a world of business as usual, where bush meat is the only way to fill the bellies of hungry people in rural Africa, we will inevitably find them, in the worst way possible.

So, at the moment, it is Ebola. It was once the high waters of hurricane Katrina on the low ground of New Orleans. Or the mostly undefended stretches of Jersey Shore in the face of Super Storm Sandy.

It could also be the high temperatures of global warming. Or the high threat level on our color-coded scale of terrorism. It might just as readily be the low rainfall in California, and the desiccation of aquifers.

It might also be Doug’s many risk factors for heart disease; or your own.

The common theme? The risk of crisis portended by warning signs all too often neglected. In the case of wayward biomarkers such as cholesterol, only somebody is harmed by that neglect, although that’s small comfort if the somebody is you or anyone you love.

In the case of Ebola and Katrina, it is the body politic. In all such cases, bodily harm tends to ensue from willfully mindless neglect of the obvious.

That’s what we do, bodies and the body politic alike: wait for catastrophe, then scramble.

So it is that Ebola, a preventable catastrophe like so many before it, is upon us. Even as we address it, we should be considering the root causes, and directing resources there to prevent the next outbreak, potentially, of something even worse. At the roots, ounces of prevention will do. Once the next calamity germinates, even pounds of cure may not suffice.

The best treatment of any disease is its prevention. The best response to any crisis is its aversion.

Alas, we, anybody and the body politic, alike, seem to harbor an aversion to just that approach. We are forewarned again and again, but never quite manage to be forearmed. We wait for the inevitable fall, then dash in madly to unscramble our eggs.

By all means, let’s do what we always do: call in the King’s horses and the King’s men, at the customary high cost in dollars and human potential. And why not, while we’re at it, go ahead and cross our fingers.

As for those good eggs lined up atop that wall over there, wavering in the wind, well, pay no attention to them. I’m sure they’ll be fine.

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.
Thursday, November 20, 2014


I got a call yesterday. It's not the kind of call most people get; it was a call from someone who is dying and wanted to talk with me.

“How are you doing?” I asked, not knowing exactly what to ask.

“Pretty lousy. They say my cancer is spreading and the oncologist told me there wasn't much more to do at this point.”

There were a few seconds of silence, and I was about to say something when the patient said, with voice cracking, “I just want to thank you for all you've done for me over the years. You've been a good doctor, someone I can talk to when I needed. Thank you for all you've done.”

“Thank you for letting me take care of you,” I answered, “It really is an honor when people trust me with their care.”

Another pause.

“Just let me know if I can help in any way” I said, again not knowing what to say. ”I assume they've set you up with hospice. You are facing that time that we all will face some day. It's just got to be weird when it's actually happening to you.”

“Yeah, doc,” the patient said. ”It's not something normal, that's for sure.”

I thought about that conversation for the rest of the day. Someone had felt strongly enough to call me and thank be before they died. I was a person on their list that they wanted to contact before death. That's amazing. It may not be the first time this has happened, but it was the first time I was acutely aware of its significance.

We talked for a while after the things I chronicled above, talking about family, plans for wrapping things up, about whether quitting smoking had brought on the cancer (I didn't debate the point), and about our shared experiences in my office. It was hard to say goodbye, as it could easily be my last conversation with the person.

This all got me thinking about a conversation I heard on sports radio about the definition of the word “heroic.” One of the hosts was complaining about the use of the word “hero” in conjunction with the amazing efforts of Madison Bumgarner in the World Series. Yes, it was amazing how he pitched 5 scoreless innings on 2 days of rest, but would you truly call his efforts heroic? ”Shouldn't we reserve the term for people who are true heroes,” the host asked, “like soldiers, firefighters, and doctors? This guy pitched in a game; he didn't save anyone's life or find a cure for cancer. It just bugs me when people call this heroic

The reference that caught me was his assumption that doctors were heroes. This is something that has been said to me before, after I discovered heart disease, found cancer early, or helped a person gain control of their difficult disease. I can't deny it: I have saved many people's lives, but I resist any suggestion that what I do is heroic.

It is my job to find cancer early, diagnose heart disease, and put people on the path to health. I am supposed to save people's lives. I would consider myself a poor doctor if I didn't do these things, just as a firefighter or soldier would deflect the title of “hero” for their doing their job as they should. Are there truly nobler jobs than others? If so, does having a noble job confer its nobility to the people who do it? I must say, I've known many doctors where the terms “hero” and “noble” would be far down on the list. Yet these people also save lives and help the helpless for a living.

I think there is something in us that makes us want to make heroes. This is part of the attraction of sport and other entertainment. We want to see people doing things that are amazing, superhuman, and heroic. As a child, I imagined me hitting the home run in the bottom of the 9th inning, or hitting the basket with no time left on the clock. I imagined the adulation and praise of my skill from the adoring masses. I dreamed of being a hero.

But then, is the fact that Bumgarner plays a game and doesn't save lives make his superhuman effort less heroic? I tend to think this is an unnecessary distinction. It is the effort that is heroic, not the outcome. It is the person being in the place that matters, when nobody else is able to do the task. It is when we are truly ourselves when we are the only people who can make a difference.

So, in some ways, the fact that this person wanted to call me before they died, that fact makes me feel heroic. This is not the heroism that attracts outside praise from the masses (I say ironically as I publish this on my blog). Really, I am not writing this to garner praise, but to say that we all can and should be heroes. Being heroic is to be who we are in the position we've been given. It isn't sexy, loud, or earth-shaking.

Being truly heroic is something solid, which comes from ourselves, not from the opinions of others. In a strange way, this patient, by calling me and letting me know how much I've done, did something heroic for me.

Thank you for being my hero.

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.

Defeating the purpose

The Affordable Care Act. Obamacare.

No matter what you call it, the law has 2 main goals: Insure more (all?) Americans, and in doing so, lower the aggregate costs of health care in the U.S.

After year 1 of the Act’s main rollout, there is no doubt about the first goal—millions more Americans now have health insurance. Many have purchased it on the “exchanges,” whether they are state run (best example might be Kentucky) or run by the federal government (think “”). Millions more are now covered by Medicaid, the 1960s-era federal program (which also uses state matching funds) to insure the poor.

The jury is still out on whether the law will lower costs. In principle, insuring more people lessens costs by bringing more healthy people under the insurers’ umbrella, thereby spreading risk more effectively and using more (but smaller individual) premium payments to provide care to more individuals in a group market setting. More buying power, and more market efficiencies (see automation and digitalization of health care, as well as streamlining of processes) in theory lower the aggregate costs.

Another way in which insuring more people while costing less occurs is by providing insurance that people don’t use. When we don’t use our health plans, the overall spending in the system goes down. Obstacles to using health insurance include co-pays (the out-of-pocket portion of health costs that insurance doesn’t cover) and deductibles (an annual out-of-pocket amount that you must spend before your insurance kicks in).

In a solid analysis of this situation, the New York Times ran a front-page article demonstrating how the new plans use tiered deductibles, which have the net effect of dissuading people from using their insurance.

Remember that everyone has the right (in fact the responsibility, i.e. the mandate) under the law to purchase an affordable plan, tiered as platinum, gold, silver, or bronze. [This does not apply if you a) have insurance through your employer or b) you qualify for Medicaid.]

The platinum plans cost the most up front, but have the least in terms of deductibles and co-pays. Just the opposite for the bronze plans, the most “affordable,”—i.e. the ones with the lowest annual premiums. The problem with these is that it turns out the deductibles can be so high as to impede people’s use of the insurance. It’s in effect an insurmountable hurdle to using newly-gained health insurance.

Here’s an excerpt from the article to give you the idea: Mark Yuschak, 57, of Jackson, N.J., said he had a silver plan with an annual deductible of $3,000. He discovered its limits in March.

“My wife had an incident, a digestive disorder, and we had to go to the emergency room of a hospital in Freehold, N.J.,” Mr. Yuschak said. “We presented our insurance card and filled out all the forms. They told us, ‘You don’t have a co-payment, you’re free to go.’ “

Later, though, they received a bill “that could choke a horse,” Mr. Yuschak said—for more than $1,000. “Our insurance wouldn’t cover any of it because we had not met our deductible.”

How can we make this system work better?

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.
Wednesday, November 19, 2014

Health insurance companies sometimes put money over care

From the New York Times article, “U.S. Finds Many Failures in Medicare Health Plans: In more than half of all audits, “beneficiaries and providers did not receive an adequate or accurate rationale for the denial” of coverage when insurers refused to provide or pay for care.
When making decisions, insurers often failed to consider clinical information provided by doctors and failed to inform patients of their appeal rights.
In 61% of audits, insurers “inappropriately rejected claims” for prescription drugs. Insurers enforced “unapproved quantity limits” and required patients to get permission before filling prescriptions when such “prior authorization” was not allowed.
Medicare plans frequently missed deadlines for making decisions about coverage of medical care, drugs and devices requested by doctors and patients.

Unfortunately this story does not surprise physicians and many patients. This report focuses on Medicare, but we would all believe that private insurance plans would have the same “track record”.

The profit motive is at work here. While I love capitalism, sometimes it has a dirty underside. In health care insurance, 1 way to improve profits is through rationing care. We would hope that the rationing has logic, but indeed it appears to not have logic.

One could easily make the case that these companies are committing malpractice. Their denials constitute a practice of medicine. When you practice medicine and deny need prescription drugs or testing that the physician has recommended, how can that process be anything but the practice of medicine.

This story is very important. It confirms the belief of almost every physician with whom I talk. This story is an outrage.

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.
Tuesday, November 18, 2014

Why I won't refill your prescription

Giving prescription refills is not quite as fun as it used to be. Years ago, we doctors would whip out our prescription pads, often sooner than we should have, and we'd scribble some coded language that pharmacists were trained to decipher. I'm surprised there were not more errors owing to doctors' horrendous penmanship. On occasion, the Food and Drug Administration (FDA) would require a pharmaceutical company to change the name of a drug so it wouldn't be confused with another medicine with a similar name. The name of the heartburn drug Losec was too similar to congestive heart failure drug Lasix, so the former drug name was changed to the familiar Prilosec.

Nowadays, we physicians refill medicines with point and click techniques within our electronic medical record (EMR) system. When this works, it's a breeze. Three clicks and the refill has been transmitted to the patient's pharmacy. Alerts notify the physician of any potential drug interactions with a patient's other medicines. A record of all prescriptions and refills becomes a part of the EMR system for all time.

Often, the drug interaction alerts are too sensitive. More than once, an alert has appeared warning me that if I hit the ‘prescribe’ button, that my patient will suffer the same fate as did the Wicked Witch of the West when Dorothy doused her with water. When I can't verify this doomsday scenario using old fashioned techniques, I call the pharmacist directly who may reassure me that the drug is safe to use. So, I prescribe the drug knowing that my EMR system will document that I have been duly warned and have chosen to cavalierly override the admonition. Guess which profession likes this EMR function?

Patients contact us nearly every day for prescription refills. Of course, we beg them to do so when they are in the office, but life doesn't work this way and I understand this. Here are some instances when I will not refill the requested medicine.
• One of my partner's patients calls after hours for a refill on narcotics
• A patient wants a refill beyond my expertise. I won't be refilling your cardiac medicines as this should be done by the prescribing physician for several self-evident reasons.
• I haven't seen the patient recently.

It is a common scenario for a patient whom I have not seen for a year or two to request a refill on their GERD or heartburn medicine. When this occurs, I politely request that the patient see me in the office first. The patient may not grasp any urgency as he is feeling well and only wants another year's worth of acid-busting pills. However, the moment I refill it, I am in effect accepting responsibility for this action and any resultant consequences. Here are some pitfalls with refilling a patient's heartburn medicine who has been AWOL.
• Does this specific drug still make sense?
• Can the dosage be lowered?
• Have any new symptoms developed that might require diagnostic investigation? Suppose the patient has been losing weight, for example? What if the ‘hearturn’ has worsened and a new disease is responsible?
• Is the patient experiencing side-effects from the medicine that he or his primary care physician might not appreciate?
• Could the heartburn medicine interfere with new drugs that the patient is now taking?
• Is the patient up to date on other issues within a gastroenterologist's responsibility such as colon cancer screening?

Refilling routine medicines may not be routine and should be done with care and caution. The patient from 2 years back who has GERD might think he needs Nexium for his ‘heartburn’. What if his symptom is actually angina? Get my point?

So, when we ask you to stop in for a brief visit, it's not because we delight in hassling you or are hungry for your copay. We're trying to protect you and to keep you well. Doesn't this seem like the right prescription?

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

The week after Kidney Week

Kidney Week ended on Sunday, but these pearls about protecting the kidneys should still be valid for quite a while:

To avoid the risk of acute kidney injury (AKI) associated with fibrates, start at a low dose, and get serum creatinine levels to monitor any effects the drugs are having on the kidneys, said Amit Garg, MD, PhD.

On the same subject, it's reasonable to halt RAAS blockers before surgery in an effort to protect the kidneys (although there's some evidence that the drugs can lessen the severity of AKI if it happens), but don't forget to restart them later, said Rabi Yacoub, MD.

Finally, I'll quote Chi-yuan Hsu, MD, directly, because this was a great way to put it. "We should not be nihilistic about treating hypertension in dialysis patients," he said. Dr. Hsu noted that nephrologists often only measure their dialysis patients' blood pressures during dialysis visits, so it may fall to internists to accurately assess and adequately control the patients' hypertension.

The good, the bad and the ugly

I had a recent conversation with an old friend about her elderly father that encapsulates a lot of what is both great and terribly wrong with health care in America today.

Here are the basic facts: the man is in his mid-80s, retired from teaching school, and is active and vigorous, living in the community; he is cognitively intact. He has a history of coronary disease and had an intracoronary stent placed some years back. He is asymptomatic on a typical “cocktail” of meds including aspirin, a statin, and an ACE inhibitor. Over the summer, he had a routine follow-up visit with his cardiologist, who detected a carotid bruit. After a duplex sonogram and a CT angio, a high-grade unilateral internal carotid stenosis was identified, and carotid endarterectomy surgery was recommended. My friend called me to see if I could recommend a surgeon in the city where she and her father both live.

It will come as no surprise to those who know me (or read this blog regularly) that I asked about the specific advice that her father had been given and the process by which he apparently decided to go ahead with the surgery. Both the cardiologist and the vascular surgeon to whom he was referred pitched surgery as pretty much a no-brainer. Although his daughter had questions and reservations, the patient did not really see this as a “decision” to be made. His doctors had recommended a course of action and he was going to do as they said. When I pressed for details about what had been presented as risks and benefits, here is what I learned they told him. Surgery would require a 1 to 2 day hospital stay; risk of major complication was about 1%; risk of stroke without surgery was 15% over five years. Seemed like they were implying that his chances were 15 times better with surgery than without. Who wouldn’t go for that?

OK, so here’s what I think is good about this. Assuming that he had appropriate indications for his prior stent (big “if”), then this man has clearly benefited from modern cardiovascular care. He is asymptomatic, and his medical therapy has likely added years of event-free survival. He is, in many ways, a counter-example to the prolonged disability anticipated by Zeke Emanuel, which I wrote about recently. I certainly would not want to “check out” at 75 if I could be active, cognitively intact and symptom-free at 85.

So what’s so bad?

First, there was no attempt made to engage the patient in shared decision-making. Even if the evidence strongly favors a particular course of action, it is a truism that the outcomes of interest to the patient are not necessarily the outcomes that interest the physician, and neither set necessarily includes the outcomes for which reliable evidence exists. For example, if a patient is thinking “avoidance of disability” while the doctor is thinking “survival” and the evidence is unreliable with regards to either, then the conversation can’t possibly go well. Put another way, to say that 1 treatment is “better” than another without agreeing what better means to the patient is to head irretrievably down the wrong path.

Second, there is the citation of evidence that, on the face of it, can’t possibly be accurate. Even if the surgeon were accurately quoting his own track record for this type of surgery, it is not credible that he has sufficient experience in 85 year old men with coronary artery disease (and whatever particular set of other co-morbidities my friend’s father has) to formulate an accurate assessment of risk for this patient. Likewise, the quoted risk of stroke in the absence of surgery is likely an extrapolation from a mix of observational and interventional studies in populations that probably included few if any 85 year olds. Of course, physicians must make recommendations in the absence of perfect data all the time. The point is not that this uncertainty is avoidable; it is that the uncertainty should be appreciated by physicians and disclosed to patients.

The third problem is one that I have also written about: the “innumeracy” that is common among patients and physicians. Even if the numbers quoted were “right” (that is, they were the best point estimates of the risk and benefit for a population of similar patients facing a similar decision), the framing makes a big difference. Would he have agreed to surgery if the same data had been presented in a different way? What if he had been told that he had an 85% chance of making it to 90 years old without a stroke? Or if he were told that the risk of stroke was 3% per year? How about if he were told that he had a >80% chance of making it to the end of his predicted life-span 91 for a man his age without surgery or a stroke?

Finally, the ugly. I can’t help but wonder how much of this whole cascade, from the “routine” and likely unnecessary follow up visit with the cardiologist, to the multi-modality imaging, to the inevitable recommendation for invasive intervention, was driven by the unholy alignment of fee-for-service reimbursement with the well cultivated (and totally wrong) belief among our patients that more “care” is always better, and facilitated by Medicare shielding the patient from the cost of care.

The good, the bad and the ugly of American medicine. What do you think?
Monday, November 17, 2014

I'm confused and fuming about why drugs cost so much

Drug prices are a difficult issue to write about because real data about the workings of pharmaceutical companies is very difficult to uncover. Still, last week I came face to face with something that seemed extremely not right and so I feel I should at least make some comment. It started when I prescribed a patient sumatriptan for her recently more frequent migraines. Her cost exceeded my wildest expectations.

Sumatriptan is a nearly magical medicine which was FDA approved in 1991 for treatment of acute migraines. “Nearly magical “ is a bit of an overstatement. It does work pretty well compared to other pain relievers, but only about a third of patients taking it have relief of their headache in an hour, and only 1 in 5 is headache-free 24 hours later.

Sumatriptan is similar to the neurotransmitter serotonin and reduces inflammation of arteries in the brain which is associated with migraine headaches. It does other things as well, and may have a much more complex mechanism of action. Although it has some side effects, it works well for most people, can be given as an injection, pill or nasal spray and doesn't cause drowsiness, constipation or nausea like many other pain medications can. When sumatriptan was first released, under the brand name Imitrex, it was astoundingly expensive. I can't remember what it cost, but it was a bundle. People were willing to pay because it often saved them a trip to the emergency room or many hours of misery. Global sales of this drug top $1 billion yearly. It has been approved as a generic since 2008.

Back to the patient. I prescribed thirty 50 mg pills of sumatriptan, generic, via a national pharmacy chain, hoping that she would be able to treat her migraine at home, have leftover medications for future migraines and avoid a trip to the emergency department. The pharmacy told her it didn't take her insurance and that the prescription would cost her $550. She didn't have $550. I called the pharmacy, told them that I meant generic, not brand name, and they told me that they understood that and that the cost was $550. I called an independent pharmacist who I know well and asked if this drug was still ridiculously expensive or if there might have been some mistake. She said that her cost for 9 pills (they come in 9 packs for no particular reason) was $6.50. At her pharmacy she would charge an uninsured patient cost plus a dispensing fee. That would be about $30 for 30 pills.

I went online to see how Canada charges for this drug, and “Canada Drugs,” which sells medications at Canadian-ish prices to people in the U.S., charges about $40 for 9 50 mg pills. A physician blogger, Leslie Ramirez, MD, who is particularly interested in pharmaceutical costs, reported that Costco, an American wholesale warehouse club, had drug prices that were at pharmacy cost plus 14% dispensing fee. Costco's price for nine 50 mg sumatriptan pills was about $14. Although Costco requires a membership for most of their merchandise, anyone with a prescription can buy medications there. (Dr. Ramirez's website on cost comparison of drugs in the Chicago area disappeared around 2011 after this article was written about it in Forbes.)

So this person, my patient, with a raging headache, left her pharmacy empty handed because she was unable to afford a medication which had been marked up over $500 above cost, a medication which has been available as a generic for over half a decade.

I asked my pharmacist friend what this was all about, and she said that it had to do with “Average Wholesale Price,” which is a number created by pharmaceutical people and distributors, originally intended to represent the actual cost of medications, allowing the price paid by insurance companies to be standardized. Since large pharmacies base their prices on AWP, that $550 for 30 sumatriptan tablets was probably pretty well set among retail pharmacies. Hiking up the AWP has various benefits to the many players in the pharmaceutical industry. Pharmacies can benefit because their costs are usually much lower than the published price (on average 14% lower, but clearly much, much lower in some cases) meaning they make a handsome profit on some generic medications, wholesalers benefit since pharmacies want to buy drugs that they can sell at a substantial profit and pharmaceutical companies that produce brand name products benefit if generic drugs are kept artificially more expensive, since patients will often spring for the brand name original or be willing to pay high prices for new nearly identical brand name drugs.

It sounds like drugs are more expensive than they should be because there is collusion to overcharge for them. But it is not all based on Average Wholesale Price rigging. The cost of generic drugs to pharmacies has also gone up drastically. This article in the online version of the Wall Street Journal reports on rising costs of generic drugs, sometimes as much as 8,000% (in the case of the antibiotic doxycycline), at least some of which was associated with rising costs to pharmacies. I wasn't able to find the actual data, but apparently lawmakers are “probing staggering price hikes” and sending letters of inquiry to the drug manufacturers asking why prices were raised, how much money they are making off of the affected drugs, who is responsible for price hikes and how costs for these medications compare overseas. The letter I linked was sent earlier this month and I don't see any information yet about a response.

Price hikes would seem to negatively affect patients, of course, but also insurance companies which pay at least some of these costs. In my review of the Affordable Care Act I haven't come across any provision that controls how much drug companies charge for their products. Old laws against price fixing do seem to apply to this sort of thing, but there is nothing new that says that Mylan, for instance, can't make a drug that cost $11 a bottle one month increase in cost to $400 a bottle a few months later. The insurance industry, though, is powerful enough that I would think they would balk at these price hikes. Medicare itself is not allowed to negotiate prices with drug companies but private insurance companies can. I'm not quite seeing what dynamic is at work here to keep them from refusing to pay for overpriced drugs.

Another thing I don't quite understand is why, when Costco charges cost plus 14% for medications consumers and insurance companies don't avail themselves of this option. I do love my corner drugstore, and realize that they survive partly by selling inexpensive drugs to insured patients for inflated prices, but I wonder why this continues to happen. It is truly valuable to have an independent pharmacist dispense medications and maintain a relationship with physician prescribers and patients, as happens in locally owned pharmacies, but we should find some way of paying for this service that is not arbitrary and subject to whimsical fluctuations.

The explanation that makes the most sense regarding drug prices is that the producers and purveyors of pharmaceuticals will charge as much for their wares as anyone will pay. Doctors cannot help because they are not aware, at the time of a patient encounter, what of their many drug options for a given condition is the best value. Unless lawmakers have the stomach to regulate the profits of big pharmaceutical companies, their most powerful lobbying entity, or enact legislation to allow market forces to reduce drug costs, prices of medications will continue to be subject to staggering increases.

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.
Friday, November 14, 2014

Health care, the unforgiving online world versus real life

It’s funny to think that the internet and the online world, so entrenched in our modern day lives, is still a relatively new phenomenon. When I first started medical school (not really that long ago) we hardly used the internet and the concept of a web search barely existed. It only became widely available on home computers shortly after that.

The invention of social media is newer still. If any of us had been told 10 years ago that we would be carrying around phones and mobile devices that would instantly be able to pull up any information and communicate with the rest of the world through so many different channels, we probably would have found it quite incredulous. Fast forward to today and a lot of what we learn, opinions that grab our attention, and issues that become important to us—we hear about through this new online world.

For those of us in health care, this means that we are getting a large percentage of our daily information through a combination of news articles, opinion pieces, and social blogs. A scroll through the comments section of any of these will quickly reveal how high passions are running. Sadly, the picture can often be painted extremely negative (which actually holds true for most things that are debated online—be it politics, celebrity or other news events).

Major media outlets like the New York Times have been leading the charge recently—running stories about problems such as health care transparency and inappropriate billing practices. All, I may say, very valid issues that need to be raised. Other online blogs such as the popular have regular physician-written articles that vent their widespread daily frustrations. Anyone reading these could naturally feel quite dejected about the state of medicine. Doctors seem to have a laundry list of complaints about the profession. Patients are derogatory and condemn doctors and hospitals about their bad experiences. The general public posting comments often don’t have a good thing to say either.

But while it’s true that health care does indeed have a lot of challenges to overcome, I’m also convinced about the fact that the positives significantly outweigh the negatives—a fact that cannot be garnered from just reading the internet. And herein lies the problem with the online world versus the real world as it pertains to health care and the practice of medicine. My own experience is that health care is an overwhelmingly accommodating, compassionate and kind environment, where nothing short of heroes work each and every day.

Despite what I read online, I find the vast majority of patients to be courteous, highly respectful, trusting and ultimately very grateful. Likewise I think the vast majority of physicians are the same way, among the most dedicated professionals you could ever meet. I think that most doctors when pressed will have more good things to say about their profession than bad, and I know that most patients will do likewise for their interactions with doctors.

Who would have guessed this after reading all those news articles and blogs? This is a problem for many reasons, but the most consequential is the fact that the younger generation now get most of their initial information and impressions online. The future would-be doctors and nurses are saturated with negativity. Antagonism that doesn’t entirely hold true for the realities of frontline medicine. There is no job or system in the world which is 100% perfect, but the health care world is nowhere near as bad as the internet makes out. I would reassure the next generation that the online arena can be a very gloomy place. I would tell them to spend some time in hospitals, with real everyday doctors, nurses and patients, before forming their opinions. I would also encourage those involved in medical online publishing to just occasionally focus on the massive amount of good that’s out there as well.

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, November 13, 2014

For doctors who blog, a 5-letter mnemonic and a top 10 list about professionalism

Physicians who blog spoke about their experiences at Kidney Week in Philadelphia, so it feels very “meta” to blog about the bloggers: Bryan S. Vartabedian (AKA Doctor_V), MD; Margaret S. Chisolm, MD; and Joel Topf, MD, (AKA Kidney_Boy). Each touched on professionalism in the age of social media.

(The American Society of Nephrology has adopted social media, specifically, Twitter, Dr. Topf explained, using the Twitter hashtag #Kidneywk14. Signs throughout the conference center encouraged attendees to participate. The panel also included a patient blogger, Sarah E. Kucharski, who separately discussed how doctors can use social media to communicate with patients.)

The 3 doctors each emphasized aspects of professionalism that are worth reviewing for those who are already extending their reputations online. And, Dr. Vartabedian said, physicians' professional reputations are already on the Internet. Patients expect to find information about their physicians online, and may be put off if they can't.

Dr. Vartabedian told the audience that physicians can maintain their reputations first by creating content, and then joining the conversation about that content.

Dr. Chisolm encouraged professionalism from physicians who use social media. Any mistake quickly becomes public, cannot be erased or truly kept private, and can quickly become amplified as it is reposted.

Dr. Topf recalled a case of a physician who thought that he could anonymously post everyday grumblings about patients on Twitter. But, during a malpractice case, the opposing lawyer asked him about a specific tweet, and asked point blank if that “anonymous” doctor was behind it. The physician had to settle the next day.

Before blogging, Dr. Chisolm encouraged physicians to THINK. Specifically, is the post:


If you're posting about a patient, it's OK. She compared it to a case study. But, she encouraged the physician to get the patient's permission, preferably in writing. An audience member recounted his own experiences asking patients for permission. First, he said he writes the post. Then he shows it to the patient and asks permission to post it. “I'm always terrified before I ask, and they are always flattered,” he recounted.

10 rules for professionalism, as related by Dr. Chisolm:
1) Manage your online image proactively,
2) Your personal and professional identities can't always be separated,
3) Engage with the public, but be careful about giving advice,
4) Respect the privacy of all patients,
5) Show your human side (talk about sports, hobbies and the like) but maintain professional boundries,
6) Contribute expertise, insights and experiences, which are for physicians, the meat of the social media experience,
7) Treat others with respect
8) Remember that others may be watching you,
9) Support colleagues, and intervene when necessary, particularly for learners, and
10) Test out new ideas, learn from mistakes, and have fun.

Softer care for harder cases, of Ebola and everything else

The evolving Ebola outbreak is very disconcerting, to say the least. The situation in West Africa is, obviously, truly dire, with projections of the toll escalating from terrible to calamitous day by day. A dreadful, transmissible disease in a part of the world where access to clean water can be elusive is a very bad and volatile mix.

But the situation in countries putatively far more capable of confronting this kind of problem effectively has provided little comfort to date. Transmission in Spain apparently owed something to the ravaging of public health resources in an austerity economy. Here in the U.S., we are navigating through an embarrassing sequence of public health blunders. We, too, have routinely raided the never copious public health coffers whenever economic challenge came calling. Even so, we should certainly be able to do better than this.

So, yes, even as someone formally trained in epidemiology, I find the situation, not just in Africa, but right here at home, disconcerting. I rather wish I hadn’t recently watched Dawn of the Planet of the Apes, much as I enjoyed the movie, because a virus catching a plane and going global has life imitating art a bit too closely for comfort.

That said, I hasten to note that there are still some important differences in perspective attached to formal training in public health.

First, Ebola is bad enough as a quasi-natural occurrence, compounded by a series of unfortunate events (or actions). There is no basis for the conspiracy theory nonsense all such crises propagate.

Second, the risk of Ebola transmission to any one of us in the U.S. or Europe is, until or unless truly dramatic and very unlikely changes occur, vanishingly small. There have been 24 deaths in the U.S. from lightning strikes so far this year. National Geographic tells us that 5 people die from shark attacks every year.

OK, you are not worried about lightning hitting the shark that’s eating you. Let’s move on.

Third, while new, exotic, and seemingly scandalous threats for which we can hold someone else accountable fascinate us, we routinely dismiss, disparage, and neglect the vastly greater risks we have the means to manage. I have lamented this many times myself, but now have the excellent company of Frank Bruni, who did so masterfully in this week’s New York Times. Globally, measles kills over 100,000 people annually. Even as we eagerly await news of effective Ebola vaccines, we forgo use of those we have, invoking a toxic blend of paranoia and complacency. So measles is back.

These points have all been made before. There is, however, another consideration in all of this, a connection I have not yet seen others make. We need all of our care, clinical and public health alike, to be more holistic.

Holism may evoke butterflies and wildflowers, as the term has taken on a New-Age, touchy-feely kind of glow. Holism suggests not so much the rigorous analytics of applied epidemiology, as the soft touch of doting humanism. My argument here is that if holism is indeed “soft,” then the softest of care may best suit the hardest of cases.

Consider that the origins of the Ebola crisis relate not directly to public health, but to ecosystems, native diets, and biodiversity. We have known for a long time that bats and primates were prone to harbor viruses that could infect humans, Ebola included. A failure to think holistically, however, precluded culturally tailored approaches to modifying traditional diets, providing for ample alternatives, and sparing the world its current catastrophe. It’s not too late, however, to prevent the next one.

As for Ebola containment, holistic thinking is clearly essential. Control of an outbreak is not limited to treating the sick, but managing the social network of every index case. Hospital care becomes the workings of a village, with the comings, goings, tasks, and interactions of providers inextricably tangled up with the patient’s requirements, and the vulnerabilities of us all. The social contacts of a hands-on caregiver, both in the hospital and beyond, suddenly have clinical relevance.

The lesson here is that they always do. The nature of care and social interactions influence the propagation of heart disease, too. That some populations are so much more prone to diabetes than others isn’t about biological distinctions, but social ones. Type 2 diabetes is, fundamentally, a social disease.

We will spend a fortune on a global Ebola response. We might have spent much less, proactively, on the source of the problem, and saved both lives and money. There is nothing unique to Ebola in that. We spend billions on after-the-fact treatment of chronic disease and obesity every year, and pitifully less to address them at their origins, use what we know, and add a bounty of both years to life, and life to years as a result.

Imagine for a moment if we thought heart disease were “infectious.” In a sense it is, since families tend to share vulnerability, and it runs in social networks. But we take this to be due to behaviors and exposures we can ostensibly control, not some virus we cannot. So we are complacent about it. The result is that millions are diagnosed with heart disease every year in the U.S., and it kills some 600,000 of us prematurely. Ebola, of course, terrible as it is, is a very long way from any such toll.

We know heart disease to be preventable 80% of the time, if not more. But we just keep treating cases as if each man and woman to succumb were an island, and the carnage goes on.

The ramifications of more holistic thinking extend to medical enigmas. Patients suffering from what they are apt to call “chronic Lyme,” for instance, have a choice between clinicians who endorse the condition and treat with antibiotics often long after the last spirochete is dispatched, or those who renounce the condition altogether. What about a likely truth in the middle? Bodies exposed to a serious infection and then antibiotics may suffer long-term symptoms as a result of either or both, whether or not active infection is “chronic.” More holistic thinking about such cases expands treatment options, and obviates the need to tie symptoms warranting attention to a specific, controversial diagnosis. There is more to the patient than the name of their pathology.

Effectively addressing the Ebola crisis, now and in the future, can’t just be about infectious disease. It also needs to be about hunger and diet, poverty and culture, ecosystem management and biodiversity. Different, but related ripples spread out from every case of diabetes, and heart disease; depression and chronic fatigue.

Holism tends to bespeak the touchy-feely end of the medical spectrum. And indeed, thinking and treating holistically does tend to result in softer, gentler, more caring care. But there are ways to operationalize holistic care that involve rigorous thinking, and invoke systematic methods. That would serve us well now, as ever. For it may be that in the hardest of all medical situations confronting individual patients and populations alike, the seemingly softer aspects of care are just what the doctor ordered.

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, November 12, 2014

The pain and inflammation of documentation

I recently lamented the incredibly bad the documentation I get from a local hospital is. In truth, the documentation I get from everyone is terrible. Seldom does it tell me what I actually want to know, and if there is useful information it is buried in an avalanche of yadda yadda.

The main reason for this is that documentation is driven by our ridiculous payment system, which requires us to follow arcane rules to generate notes that justify the obscure codes we submit for money from the payors. This is the reason for much of the gibberish. These rules, combined with computers' ability to quickly and efficiently generate drivel (see also The Entire Internet) are the hot house and Miracle Gro for meaningless words. Sprinkle the rules on a computerized medical record and stand back! Useless words and codes will spew out at you like milk from the mouth of an overfed baby.

When I started my new practice, one which is outside of those rules, I was excited about the possibility of actually documenting based on patient care. I asked myself, “What would a patient record look like if the only reason for it was for patient care?” It was a compelling question; one which I undertook in earnest to answer over the past 18+ months. Much of the reason for the downturn in my blogging volume is that I've spent an incredible number of hours working on a charting system that did exactly that. It has sucked out a lot of my creative juices, leaving me only the mental energy at the end of the day to play solitaire on my iPad.

Undertaking this endeavor had taught me an important fact: documentation in itself, without the stupid rules, is still really painful. As many bells and whistles I put on my computer system (I recently put a “coffee break” button on we can press when we want to take a break), it still is difficult to generate good documentation.

Notice the coffee cup between the exit and address book icons

This is what you get when you press on that coffee cup!

Why? Imagine having to go through each day and keep track of every conversation you have with people. Imagine trying to not only have meaningful interactions with people and to make good decisions about important things, but to make sure all of the facts were accurately documented in a form that will be useful in the future. Imagine too that you had to do this with all of your emails, phone calls, and text messages you have with people. This is a real pain in the gluteus maximus!

Add to that the joy of patient confidentiality (and our dear friend HIPAA) along with the gobbledygook we get from other practices and hospital documents, and things get really tough. Not only do I have to find a place for each of the pieces of “documentation” I get from hospitals, consultants, and old records, but I also need to go through them and pull out the bits of useful information and put them in as “structured data.”

What, you may ask, is structured data?

Structured data is information that is sorted so the important stuff can be gotten to easily. Some structured data are numbers (like a blood pressure or blood glucose), some are words (like mammogram reports, heart exam findings, and pathology reports), some are dates (date of last colonoscopy, flu shot, or office visit for diabetes), and some are images/documents (like a picture of that rash you had in July, or the video of accident you had with the golf cart that got posted to YouTube). Not all data should be structured (it gets way more confusing that way), just the stuff you might need later on.

You see? Gluteus maximus acquires trauma and inflammation. It is really hard to document things well, and human nature means that by the end of the day you've spent your time doing things and not documenting it all. It's really hard to be diligent about this stuff and not require a double espresso Adderall latte with a valium mojito chaser.

Still the process I've been trying to build has several strategies to make this better:
1. Focus on office workflows to make sure important things get done. When I order a lab test, I need to make sure that it gets done, we get the report, the report is sent to the patient along with a plan, and then a follow-up interval is determined. This needs to be baked into any record system a doctor uses. There are lots and lots of these kinds of workflows that need to be automated.
2. Make the record a collaborative record. There is one person with far more at stake than the folks in the medical office: the patient about whom the record is about. I have yet to implement, but my plan is to give people the ability to see and edit their own records in a way that maximizes accuracy. When a person goes to a consultant, why not have them enter it into their record? When they get results back from another doctor or hospital, why not let them at least notify me in the record that this happened? Accurate records are far more important to patients than anyone else, so why do we keep them out of them (and why the hell do we charge people for their own records??)?
3. Embed communication tools into the record itself. Why have an email or voice message transcribed into a record system? Why not just have the email message go right to their record? Customer relations management programs already do that, keeping track of all communications with each customer. Why doesn't an EMR do that?
4. Use other common tools, like timelines, task management, and tag clouds, to make data easier to understand and compile. There are lots of things done in other information systems that are painfully absent from medical records. Why, for example, don't we have a medication timeline for each patient that has start and stop times overlapping with things like symptoms, lab tests, etc.

I am not saying that documentation will become any more fun than cleaning a cat's litter box, but if we gain enough from the tool, we will use it better. Right now medical records are caught up in the vortex of codes, ACOs and meaningful use. Getting out of that vortex is only step 1 in the process. I've been busting my butt (more gluteal inflammation, sadly) to get something that does even a small part of this. I'm getting closer, but of course I have to build that new record while also seeing patients each day and properly documenting each encounter.

I'll go into more detail as things develop, but I think I need to stand up for a bit.

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.

Quality starts with diagnosis

The recent Ebola death in Dallas highlights the point that many have made recently. The Society to Improve Diagnosis in Medicine seeks to place diagnostic error and accuracy at the forefront of medical quality. Bob Wachter’s wonderful editorial in USA Today,What Ebola error in Dallas shows,” highlights the problem and some causes of diagnostic error.

We have politicians and administrators championing incentives to improve quality, but they are missing a key point. We can measure performance that experts define, but we cannot measure quality, because we cannot have quality with first having the proper diagnosis. All performance measures depend on knowing the diagnosis.

But here is the key problem. Defining diagnostic accuracy is extremely difficult. We often do know that we make diagnostic errors. We often do not have gold standards or reference standards for diagnosis.

Herein lies our conundrum. We want to reward quality, and thus we use proxy measures that do not actually measure quality.

We must embrace the concept of diagnostic accuracy. It is our lynchpin in all medical fields. The surgeon must make the correct diagnosis prior to cutting. The internist, the family physician, the pediatrician, the gynecologist, the ophthalmologist, the otolaryngologist, etc. all function on the basis of a diagnosis or several diagnoses. Yet current quality definitions do not take diagnostic accuracy into consideration.

Until we can better assess diagnosis, we can never assess quality. Unfortunately, diagnostic errors like what Thomas Eric Duncan suffered can lead to bad outcomes.

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.
Tuesday, November 11, 2014

Ebola hysteria in Ohio

The Ebola hysteria continues. True, we might have a greater chance of being struck twice by lightning, but the press would have us think we need to purchase Hazmat suits for our families just to be prepared. I'm surprised that an entrepreneur hasn't at least constructed prototypes for Hazmat suites for newborns, popular dog breeds, pet rodents and heirloom tomatoes.


Yes, tomatoes. I have not heard any authoritative official from either the NIH, the CDC the WHO or Medicins Sans Frontieres (Doctors Without Borders) who have stated unequivocally that you cannot contract Ebola from an heirloom tomato. To me, the hypothesis is entirely plausible as the sneaky virus can hide in the heirloom's surface crevices just waiting and hoping to gain access into an unsuspecting mucous membrane.

As of this writing, there are 159 contacts in Ohio who have had contact with an Ebola infected nurse who for reasons known but to God was cleared by the CDC to board a commercial airplane with a fever after she had treated an Ebola patient in Texas. Each day, the number of Ohio contacts grows, so by the time these words are posted on Sunday, I expect that there will be more contacts.

The definition of what constitutes contact with an Ebola patient is evolving. As of today, the new and improved definition of contact is being an enclosed space with the patient for any length of time. Hmm, if I am watching the Cleveland Cavaliers in our downtown stadium from the last row, and an Ebola patient is in the first row on the opposite side, am I now considered a contact? Would all 10,000 fans be forced to enter into a 21 day period of quarantine?

Does it matter that medical experts have consistently explained that you cannot catch this virus unless the infected individual is symptomatic and you are within reach of that individual's bodily secretions?

An Ohio school was closed as a staff member was on the Frontier airplane that the nurse had traveled on although on a different flight. Two hospitals in Cleveland sent nurses home with pay and admitted publicly that this was for PR protection, not for patient protection. What hope is there when our medical institutions are lubricating our hysteria instead of battling it?

This past Monday, I noticed a new procedure had been implemented in our office. On the advice of local and state medical authorities, we were asking every patient who enters our office, if they have in to West Africa or had contact with an individual who has been there. This nonsensical policy would protect no one. There are zero known Ebola patients in Ohio at present. This is a difficult disease to contract as contracting this virus requires that one is in direct contact with bodily fluids of an infected person. Querying every patient about recent travels from West Africa only feeds the hysteria, while it burns up our staff's time. Asking Granny who comes to see us from her assisted living facility if she's been to Sierra Leone recently, doesn't seem to be sound preventive medical policy.

I think that our moratorium on heirloom tomato ingestion makes more sense than the Ebolaphobia policy. Can this post go viral?

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.

Over and out

I highly recommend a provocative essay by Ezekial Emanuel that appears in the October 2014 issue of the Atlantic. Dr. Emanuel is a prominent academic who has also held important positions in government, including as a Special Advisor on Health Policy to the Director of the Office of Management and Budget and National Economic Council. He is also the eldest of the three impressive “Emanuel Brothers” that also includes Rahm (former White House chief of staff and now mayor of Chicago) and Ari (a prominent Hollywood agent). His piece is entitled “Why I Hope to Die at 75.”

OK, so the title is a bit over the top and meant to shock, and it is not even entirely accurate. But the message is really worth thinking about. Emanuel sets out why he wants to avoid the typical American approach to aging and progressive infirmity; he does not want to join the ranks of what he refers to as “American immortals.” Instead, he says that when he hits the admittedly arbitrary age of 75, he will no longer actively seek to prolong his life. No more doctor visits, no more “preventive” measures, no more diagnostic tests, no more interventions. Done. Whatever happens after that, well, so be it.

He is quick and careful to point out that this is not a public policy recommendation (though the on-line comments that accompany the article indicate that a lot of readers are not buying that), but rather his own personal decision. He wants to avoid the decline in physical and mental capacity that comes with aging, and figures his best contributions will be well behind him by then. He specifically rejects the notion that the longer life spans we now “enjoy” come with “compression of morbidity” at the end and instead cites evidence that longer life nearly always comes with a longer period of infirmity or reduction.

On one level, his position resonated with me. I see plenty of behavior that can only be explained by some irrational belief in immortality coupled with Medicare fee-for-service reimbursement unencumbered by any need to demonstrate evidence of efficacy. How else can you explain things like removing basal cell skin cancers in a 90 year old, or doing mammograms in women in their 80s, or worrying about your cholesterol at that age?

On the other hand, he seems way too sure of himself. As Daniel Gilbert pointed out in his book Stumbling on Happiness we humans are pretty awful at predicting our future emotional state. Things we are convinced would devastate us, don’t. Things we know would make us happy, also don’t. So I am not convinced that the good doctor won’t wake up at age 75 and say, “This isn’t so bad, and I would really like to stick around for a while.” I think the article would have been much more compelling if he were 75 already, and was entitled, “I’m done.”

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.