Tuesday, December 30, 2014

Are doctors good businessmen? Get a second opinion!

We've all heard or used the phrase, “leave it to the professionals.” It certainly applies to me as the only tools that I can use with competence are the scopes that I pass through either end of the digestive tunnel. Yeah, I have a ‘toolbox’ at home, but it is stocked similarly to the first aid kit that your new car is equipped with. It contains a few BandAids, adhesive tape and, hopefully, the phone number of a local doctor. My home tool box has an item that can practically fix anything – the phone number of a handyman.

It is essential to know one's limitations, regardless of one's profession.
• Politicians shouldn't speak authoritatively as if they are climatologists.
• Gastroenterologists should not prescribe chemotherapy, even though we are permitted to do so.
• Bloviating blowhards on cable news shows are likely not military experts.
• The guy who fixed your toilet might not be a top flight kitchen remodeler even though his business card includes home remodeler, along with railroad engineer, IT professional, seamstress and stand-up comic.

Some of us are good at a lot of stuff. Some of us have a narrower, but deeper range of competence. Yes, we're all good at something, as our moms and teachers taught us during our early years. Without doubt, most of us are not good at lots of stuff, and it's important to know where our comfort zone approaches the chaos zone. In my own profession, it is absolutely critical that physicians readily solicit assistance from a colleague when additional knowledge, experience or judgment is needed. Asking for help to help a patient is evidence that the physician is focused on his patient's welfare. Every doctor has witnessed circumstances when a physician is reaching too far beyond his tool box, and it's not pretty.
• Should a surgeon perform a complex operation that he only seldom performs?
• Should a local oncologist treat a patient's rare cancer or refer the patient to the expert downtown?
• How long should an internist struggle with a patient's hypertension before recruiting an expert?
• If an allergist's patient keeps losing weight, is it time to consider a cause beyond the scourge of gluten?

Last year, our practice needed some restructuring. We met with our accountants for advice on streamlining and managing our practice. I was impressed how quickly these pros looked over our financial statements and readily understood the state of our practice. Of course, these guys see the world through Excel spread sheets, just like we GI physicians do through our colonoscopes. To us physician clods, these reams of number filled pages containing every permutation of various financial reports were encrypted codes that would require NSA cryptographers to decipher. Most physicians are not good businessmen, although many feel otherwise. Luckily, my partner and I know the truth about ourselves. We didn't ask the accountants for a “second opinion.” We came to them first, and we're glad we did. I presume that when they need a colonoscopy, they won't try it themselves.

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, December 29, 2014

The big dichotomies in improving hospital experience for our patients

A large number of physicians and administrators involved in health care right now are working hard on improving the hospital experience and giving our patients a more pleasant time in hospital. As I've written about previously, I don't believe the solutions are necessarily complex or particularly difficult. They rest with basic common sense and humanity. Like being able to spend more time with patients, spending less time with computer screens, and making hospitals into more healing environments. All this in association with practicing good and thorough medicine.

But there are also some other very significant dichotomies that lie at the heart of what we are doing in hospitals right now. And that's the simple clash between administrative requirements and giving our patients the best possible experience. Here are 3 examples:

1. The aggressive need to reduce length of stay

We all agree that reducing length of stay is in patients' best interests. The less time patients spend in hospital, the less chance they have of picking up an infection or developing another complication caused by their hospitalization. However, at the same time we have to be very careful about giving our patients the impression that our only goal is to “push them out of the door” as soon as they enter our hospital seeking help. Everyday example: an administrator or case manager rushing into the patient room or calling an anxious relative (even before the doctor has had a chance to speak with them about the diagnosis) talking to them about when they may be leaving the hospital.

2. Observation versus inpatient status

This issue is rightly now getting more media attention as it has huge implications for any patients who come into hospital. Without getting into the politics or the theories behind this distinction, what I will say is that on a personal level, I wish this distinction didn't even exist. If people are sick enough to need hospital level care, what difference does it make if they stay in 1 day or 5 days? If our health care system gives the impression of nickel and diming patients, that obviously doesn't promote much good will.

3. Health care information technology

The widespread adoption of IT in hospitals over the last several years is because of Meaningful Use requirements and the rush to comply in order to receive much needed federal incentives. But the technology that is available is suboptimal and often makes life more inefficient for nurses and doctors, who are forced to spend huge chunks of their day glued to their computer screens instead of engaging in direct patient care. A study published last year in the Journal of General Internal Medicine shockingly found that medical interns now spend only 12% of their day in direct patient care and 40% with computers. Anyone surprised if this causes a problem when one of the top complaints from patients is that they don't have enough time with their doctors and nurses?

I don't doubt that a lot of the policies that are being pushed in health care have some very good intentions, but as with a lot of such “push from the top” situations, the full effect on the frontlines is not taken into account. Everyone involved in hospitals, and particularly administrators, need to be aware of how many of the administrative requirements clash on a daily basis with giving our patients a better hospital experience.

If we are serious about this worthy goal, we must seek to recognize and then reconcile the diverging paths. Examples include being as tactful as possible when talking to patients and families about issues such as when they are going to be discharged and their admission status (another example is a printed pamphlet explaining the process and that it's not always the hospital or the physician's decision). On the information technology front, investing in doing everything possible to make IT work for nurses and doctors and getting feedback on what's wrong with the current systems such as poor user interfaces or too many “clicks” to do something.

I'm afraid that no “patient experience officer” or “director of patient experience” is going to solve this. Only some real frontline perspective from doctors, nurses and patients can remedy what our hospitals really need in this area.

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.
Tuesday, December 23, 2014

Want health? Try the truth

At a recent health conference in Boston, I was privileged to share the podium with a physician colleague who serves as senior health editor at The Atlantic, writing articles on topics in health and medicine that routinely reverberate far and wide. To protect the innocent, probably best that I not mention Dr. Hamblin by name.

On this particular occasion, my physician colleague was addressing an audience of health and nutrition experts on the topic of best-selling nonsense. His task was to explain, from the perspective of a media insider, why we have new fad diet books every week if not every day, and why the media and public alike tend to devour them.

My unnamed, high-profile, media-savvy colleague invoked the same toxic formula for success that I have oft lamented on these and other pages. The recipe is as follows:

1) Cite only those studies that support the position you held before you examined the evidence.

2) Invoke a scapegoat, silver bullet, or both.

3) Offer the moon and stars, by means of pixie dust.

4) Insinuate (or say) that everyone who addressed this topic before is a moron.

5) Proclaim absolute certainty.

If you want to write a best-seller on health, weight loss, or diet, there's your formula. It has worked for thousands before, why not you?

I hope you don't take that bait. Yes, it works for the author. But it is a calamity for the reader. Here's why:

1) Citing evidence selectively is an easy, old, and rotten trick. By citing studies at all, you can make yourself seem, to any reader less versed in the subject than you, rather erudite. Readers are unlikely to conduct a systematic review of the peer-reviewed literature to learn that for every study you cited, there are a hundred saying the opposite. As a would-be, best-selling author of dietary nonsense, you must, and alas, can, count on that.

2) No one thing is wrong with our diets or lifestyle, and no one thing will fix it all, any more than some cockamamie, get-rich-quick scheme will make you rich overnight. But people favor hope over experience in this area, and there is (lots) of money to be made exploiting that willful suspension of common sense.

3) Worthwhile things always take time, effort, and patience. Think about education, work, love, money. But somehow, health doesn't make the cut. Please make mine a magical short cut with a side of pixie dust! Fad diet and health authors do just that, and presumably laugh about us buying it, all the way to the bank.

4) To get full respect as a renegade genius, you have to point out that nobody but you ever really “got it.” You have to do that even if you are stating something entirely self-evident for decades, such as: eating too much sugar isn't a great idea. You want to look smart and sell a lot of books? Call a whole lot of perfectly reasonable, intelligent people morons and climb over them. (Case in point: how many times can someone tell us that nobody but them has ever told us that too much added sugar is bad for us, before we remember that we have, in fact, heard that somewhere before ...)

5) Bertrand Russell famously said this: “The whole problem with the world is that fools and fanatics are always so certain of themselves, and wiser people so full of doubts.” You will note that the authors of fad diet and health books speak with absolute conviction at all times. That may invite you to question the wisdom of reaching for your credit card.

Since this is what prevails in our culture, it is at the level of our culture that it all must be addressed. I have a plan.

The plan is to establish a True Health Coalition: a global group of leading experts and organizations in health, nutrition, fitness, and medicine from diverse disciplines to come together, and rally around the core truths about disease prevention, health promotion, and lifestyle as medicine. The idea is for this group to speak loudly, and often, with one voice, reaffirming that we should, indeed: not smoke; be active; eat food, not too much, mostly plants; sleep enough; manage stress; and nurture our social connections. With the relentless cadence of the percussion section, this group will tell us all, again and again and again, the truth about getting to health, until the noise and the nonsense, the static and the salesmanship, the hype and hooey, are drowned out. Until the truth prevails.

The True Health Coalition, in turn, is part of a larger plan, to propagate access to the power of lifestyle as medicine. But it does begin with the relentless propagation of the truth, the whole truth, and nothing but the truth. For the truth is what can set us free, and we are incarcerated in an endless cycle of false promises, procrastination, and missed opportunity.

Had enough hooey, profitable for its peddler, costly for the rest of us? Had enough quick-fix nonsense? Ready for a bracing dose of truth, and the freedom that comes with it?

Then join us. Put your name and preferred contact information in the comments here, or send them to me privately at davkatz7@gmail.com. When I have a tally of our strength, I will report back.

We are imprisoned by cultural inanities that favor sales over sense, profits over the promise of adding years to life, and life to years. But we can free ourselves, with the simple, solid, reliable fundamentals that make up ... the truth.
Monday, December 22, 2014

Physician satisfaction in health systems

Recently I wrote this tweet:

Never have a received as many retweets. And this occurred on a Sunday evening.

I was merely channeling this article, “From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider.” My tweet was actually an homage to that article. Too often I hear about health systems restructure, often using “consultants,” in a way that frustrates the physician workforce. In 2014, rather than privately owned small practices, most physicians have become employed. This movement while not necessarily bad, does create some risks. Some health systems have seeming disregard for physician working conditions. Physicians respond to unrealistic or inconsiderate practice structures with burnout and anger. Frustrated, distraught physicians provide lower quality care, so patients suffer.

So here is our message. When you are examining scheduling, number of available rooms, work hours, etc., consider how any change will impact your physician and other health care workforce. If you do not monitor physician satisfaction, then you will have an inadequate workforce and spend considerable moneys trying to replace disaffected physicians who leave for greener pastures. And unfortunately patient care will suffer.

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, December 19, 2014

Do hospitalists miss opportunities to talk about healthy habits and preventive medicine?

As hospital doctors, we are extremely busy people. Our days whiz by, often without a moment to rest or take a deep breath. We are in “the zone” and rightly completely focused on getting our patients better and in a position when they can hopefully leave the hospital. We have chosen a specialty which is all about secondary level care, one where we know that we are not going to be seeing our patients in the office afterwards. Our encounters and relationships with them may thus seem very brief and to the point. Most of us probably believe in primary prevention too, but feel that it is outside the scope of hospital medicine.

For example, apart from the brief spiel our diabetic and heart failure patients may get about the importance of dietary compliance, how much time do we really spend talking about wellness and preventive medicine with our patients? As a physician with an interest in this area, here I believe is a massive missed opportunity. As you form close relationships with patients and their families over their several day stay, don't underestimate your power as the attending physician to exert influence over what they do when they leave the hospital. Even a passing question such as “Do you eat a lot of vegetables?” Or “Ever thought about getting more exercise?” can really register with a lot of patients, and could help bring about positive changes in their lifestyle habits after you see them. Many patients and families can really open up to you when you bring this up.

Simply thinking that we can “leave it to the primary care physician” to address, is not the right way. With the epidemic of lifestyle related conditions in society, it is the least we can do as doctors. I'm not talking about spending excessive amounts of time emphasizing wellness and preventive medicine during your hectic day, but just give it a bit of thought next time you're seeing patients. I've often been pleasantly surprised by people that I bump into again after their hospital stay who tell me with smiles on their faces that they are eating more fruits or taking longer walks after I suggested it to them (lifestyle changes that, I may add, will probably have higher morbidity percentage benefits than many medications I may have prescribed them). You may be surprised too with where your good common sense doctor advice may lead for your patients.

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, December 18, 2014

Conflict of interest and managing scandal

I have had the privilege of chairing the Industry Relations Conflict of Interest Committee at the Indiana University School of Medicine, the medical school where I work, over the past year. I have learned a lot about interactions of academic physicians with industry, and have certainly heard differing opinions on the topic. Our policies were recently approved (unanimously, I might add!) by all of the pertinent committees, and already, many faculty have had comments and questions about specifics of the policy.

One common theme that we have also heard is that "regulatory agencies and administrative bodies" have hurt the field of medicine. I certainly understand the additional burdens of what it takes to practice medicine, and how those burdens can actually damage the patient-physician relationship. However, when one looks at why conflict of interest policies are put in place, one needn't look very far to see why it is necessary.

Here is a prime example. The Journal of Patient Safety had to deal with this recent example with its own editor. Dr. Charles Denham, the [now] former editor of the journal, failed to disclose his own financial conflicts of interest with organizations which paid him. This impacted recommendations he made with respect to clinical guidelines that center around optimizing patient safety.

What is interesting to me is that sometimes, how one handles a scandal can be as important as the scandal itself. Covering it up, hiding it, or trying to sweep it under the rug are all examples of ways that don't work. It is amazing that it is this same sense of "doing the right thing" that parents try to teach their children. What impressed me in this example is how the journal chose to address this. The journal has opted to tighten its own policies and processes around conflict of interest, for authors, editors and others who make decisions about articles within the journal. They even published an article describing what they plan to do.

For anyone wondering how to handle a scandal, THIS is how to handle a scandal. Admit the wrongdoing, describe what steps need to be taken for the better, and, simply, apologize. As written in this NPR piece, "airing the dirty laundry," while painful, is a necessary step.

I applaud Dr. Albert Wu, Dr. David Bates and the journal editors for demonstrating the right way to manage this situation. I think this is a great learning experience for the patient safety movement, for editors, and for all physicians who interact with industry. Conflicts of interest are complex, but it all comes back to the fact that there is a public trust that must be put front and center. If we violate that trust, then we have done a disservice to the profession, to ourselves, and, most importantly, to our patients.

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.

Help me understand how you react to uncertainty

Uncertainty is a common experience in health care. For an upcoming book and ongoing research project, I want to be in contact with patients, families, and caregivers to learn their strategies for approaching, dealing with, and understanding such uncertainty.

For example, Ms. A. has back pain unaccompanied by underlying serious disease. She has no way of knowing whether it will go away in weeks, months, or not at all. She wants an MRI, which accepted evidence indicates will neither aid in treating her pain nor reassure her.

On the one hand, both she and the health care provider would like to do “something” as a sign of care; on the other hand, we want to harm neither Ms. A (with tests/procedures that won't work), nor society (afflicted by a health care system which costs too much, delivers poor care in comparison to other systems, and treats people unequally).

There are many scenarios in which treatment is pursued despite evidence showing it does not work more than placebo. For example, hormone treatment in the patient with local (not metastatic) prostate cancer; repeated CT scans for thyroid nodules without symptoms; treatment of ductal carcinoma in situ (DCIS), mammograms in a patient without significant family history more often than every 2 years.

How do you as a patient, family member, or caregiver seek the best care in such a situation, where things are uncertain and more tests/procedures might not work? What strategies do you use? What should health care providers do? Please be in touch with me to help guide this work. zberger1 at jhmi dot edu

See the presentation below for another depiction of the problem.
How Do You Deal With Uncertainty In Healthcare? from Zackary Berger

Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.
Wednesday, December 17, 2014

Patient safety, Swiss cheese and the Secret Service

I was listening to the news on my way to work last week, and heard a story about the review conducted after the well-publicized security breach at the White House. Like many people, I was shocked when the story of the fence-jumper first broke. How was it possible that some guy with a knife managed to get over the fence, cross the lawn, enter the White House and get deep into the building before he was stopped? The answer, according to NPR's reporting of the Department of Homeland Security investigation is that a whole sequence of events made it possible:

It turns out that the top part of the fence that he climbed over was broken, and it didn't have that kind of ornamental spike that might have slowed him down. Gonzalez then set off alarms when he got over the fence, and an officer assigned to the alarm board announced over the Secret Service radio there was a jumper. But they didn't know the radio couldn't override other normal radio traffic. Other officers said they didn't see Gonzalez because of a construction project along the fence line itself. And in one of the most perhaps striking breaches, a K-9 officer was in his Secret Service van on the White House driveway. But he was talking on his personal cell phone when this happened. He didn't have his radio earpiece in his ear. His backup radio was in his locker. Officers did pursue Gonzalez, but they didn't fire because they didn't think he was armed. He did have a knife. He went through some bushes that officers thought were impenetrable, but he was able to get through them and to the front door. And then an alarm that would've alerted an officer inside the front door was muted, and she was overpowered by Gonzales when he burst through the door. So just a string of miscues.

The explanation rang true. Of course it was no “1 thing” that went wrong; it was a series of events, no 1 of which in isolation was sufficient to cause a problem but, when strung together, led to a catastrophic system failure. The explanation also sounded familiar. It is a perfect example of the “Swiss cheese” conceptual model of patient safety.

First articulated by Jim Reason, the Swiss cheese model holds that serious adverse events that occur in the context of complex systems are generally the consequence of multiple failures, not the fault of a single individual. In the case of a serious patient harm event (e.g., operating on the wrong body part), thoughtful analysis inevitably finds that many things have to go wrong for the surgery to occur. Indeed, just as the Secret Service has multiple layers of barriers around the White House to prevent an intruder from reaching the President, patient safety experts speak of “layers of defense” within medical systems that are designed to assure that small errors caused by human frailty don't allow harm to “reach” the patient.

The “Swiss cheese” description derives from the visual shorthand of imaging a series of slices of Swiss cheese, each of which represents a system defense. In the case of the White House, the perimeter fence, the guard dog and the building alarm are each like separate pieces of cheese. The holes represent imperfections or failures of each slice. For the intruder to get through them all, the holes in the cheese have to line up in a particular way. If the holes don't line up, the fence fails, but the dogs respond, then the system works.

For a wrong side surgery to occur, it may take a similar string of failures: maybe the surgical drape covered the surgeon's pre-op marking and the patient had bilateral disease, and the surgeon working in an unfamiliar OR, and so on.

Addressing patient (and Presidential) safety is almost never about finding the single person who failed at his or her task, or about an easy fix. It is about understanding how complex systems work and creating a culture of safety to continuously improve them. I hope the Secret Service takes that approach, instead of just fixing the fence and firing the guy who was on his cell phone.

What do you think?

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.
Tuesday, December 16, 2014

Public health as political prisoner

If a foreign government took the U.S. Surgeon General hostage, I'm confident we'd be pretty upset. I think we would be working on reprisals, and maybe even prepping a SEAL team.

I don't know if it's better or worse that we need no help from a foreign power to take our surgeon general hostage. Our own political system manages all on its own.

Admittedly, it's not quite the surgeon general who is hostage to our political system; it is the president's nominee, Dr. Vivek Murthy. Dr. Murthy's nomination is in limbo, because Congress won't take up his confirmation. We'll get to why in just a moment.

Before that, however, it's worth noting that everybody who is anybody in public health and medicine supports Dr. Murthy as a highly-qualified candidate. I am pleased to be counted among them, and from a uniquely personal vantage point. Dr. Murthy was a medical student of mine at Yale quite some years ago, and I got to know him well during those formative years. We have remained close, and collaborated, ever since.

He is both an excellent candidate for the job, and a really good person.

But, as noted, his candidacy is, in essence, a prisoner of our political system, or at least, of political discord.

Why? In some reports, Dr. Murthy is cited as having spoken in favor of various gun control measures long before he was a candidate for surgeon general. Naturally, we are talking about truly radical stuff here, like, for instance: background checks so we don't routinely arm deranged sociopaths. Or, perhaps, not everyone being entitled to semi-automatic weapons with high-capacity magazines. Truly outrageous assaults on the second amendment, clearly.

But we needn't go nearly that far. The official reason for opposition to Dr. Murthy is a tweet dated 10/16/12 that states: “Guns are a health care issue.”

If we reasonably take the full expanse of “health care” to encompass both patient care, and public health, I think the only possible reaction to this statement is a yawn, and: Duh!

What can possibly be controversial about this statement? For gun control advocates, there is clearly no cause for dissent. Those contending that guns foment murders and massacres certainly agree that a public health issue is in play.

But there can be no cause for dissent from the most ardent gun enthusiasts either. After all, the rationale for guns-for-all is so that we can defend ourselves, presumably against the harms to which we might succumb if unarmed. Self-defense against harm is, pretty self-evidently, an issue of both public justice, and public health.

And, of course, anything with the potential to involve emergency surgery and blood transfusions is pretty much, by definition, a health care issue.

And then there is the, forgive the pun, real smoking gun of the “guns are a health care issue” issue: suicide. I don't think anyone wants to refute the notion that suicide attempts are a health care issue. After all, we health care professionals are the first responders to them. This one, too, should be among those truths we hold to be self-evident.

So here's the thing: Guns are used far more often for suicide than for either homicide or self-defense. We don't have all the research we would like on the topic, mostly because the NRA spends pretty lavishly to ensure it won't get done, but what we have is rather compelling. A peer-reviewed paper from 1998 suggests that the ratio of gun use for suicide to use for self-defense is 11 to 1. CDC data from 2010 indicate that 60% of firearm deaths are suicides, and more than half of all suicides are by gunshot.

That second statistic is more compelling than it may seem. After all, most people who contemplate, and then attempt suicide, don't have guns. So what it means that more than half of all suicides are gun related is this: Most people who attempt suicide do NOT use guns, but those who use guns succeed much more often.

Guns don't kill, people kill, even themselves. But guns make them a whole lot better at it.

And that's tragic, because suicide may result from uncompensated depression, or a moment of despondency that could be assuaged. A suicide attempt is an opportunity to identify the source of such anguish, and restore the chance to live. A completed suicide is: game over. Guns are strongly associated with the latter.

The simple, if sad, fact is that we are indeed all subject to the slings and arrows of outrageous fortune. Maybe at one time or another most of us think at least fleetingly about taking arms against that sea of troubles, and by opposing, ending them. For most of us, it is just a fleeting thought. For some, it evolves into a plan, a gesture, or an attempt. For those with a gun handy, it results far more often in the need for a hearse rather than an ambulance. This is not ideology; it's just epidemiologic fact.

Suicide is a health care issue. If guns figure in it, as they irrefutably do, then guns are a health care issue, too. QED.

The surgeon general, whatever his or her views on gun control, has no political authority, and will do absolutely nothing about gun control in office. Even if the position did allow for that, why would that unsettle anybody? Even the president of the United States, openly in support of gun control legislation also supported by a decisive majority of us Americans, can't get much of anything done about it. Is the NRA really all that concerned about the profound ramifications of a public health physician's personal opinion? I'm impressed if so, because it must mean I have all kinds of power to which I am oblivious.

Far more likely, nobody actually is all that concerned about Dr. Murthy's totally predictable, completely uncontroversial position on this topic. It is all just political theater.

But it is bad theater. A public health physician stated, before ever he was under consideration for surgeon general, that guns are a public health issue. We may ignore the fact that he was exercising his first amendment rights at the time, and posed then, as he poses now, no threat to the second amendment rights of anyone else.

More importantly, he was speaking a truth, universally recognized as such. There should be no political agenda directed against universally recognized truths.

Cheer or lament it, public health is no threat to gun rights. But threats to public health that result from ideology over epidemiology, and resistance to statements of fact, are potentially ominous for us all.

However we may differ over guns, I suspect all of us like to live in a society where stating a fact does not bring reprisals. On that basis alone, please tell your members of Congress you would like Dr. Murthy freed from his political prison, and confirmed as U.S. Surgeon General. Ideally, no SEALS will get involved.

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, December 15, 2014

Lessons learned from 35 years of ward attending

My first time was January 1980. I remember where and remember 1 patient. Like many new attendings I overestimated my skills. Over the years I have learned much about ward attending success. Now I plan a series of posts that share some thoughts.

The overriding principle of ward attending seems obvious, but apparently evades many who become ward attendings. We have several responsibilities. First, we must try to have the team deliver the best possible care for our patients. Second, we must help all of our learners grow into excellent physicians.

These responsibilities have changed from the 70s and early 80s. Then the attending did a bit of teaching, but the resident had the patient care responsibility and ran rounds. My resident rounding experience helped frame my current ward attending style.

When academic practices started billing for attending services, the attending role changed focus. Unfortunately, some attending physicians undervalue the teaching role.

So compared to 1980 when I started, the role has more complexity. We have to balance work hour requirements, billing requirements, learners' needs and patients' needs.

Yet the job is doable, and in many ways more enjoyable now than when I started.

We should prioritize several factors in developing our attending style. First, the interns and residents have work to do each day. We must respect their time constraints. No matter how brilliant we are as attending physicians, rounds that last too long are disrespectful and therefore substandard. Second, the learners should have the opportunity to present their plans and we should evaluate those plans. If we strongly disagree, we must explain why we should go in a different direction. Our disagreement should stimulate a learning situation. We should have good justification for changing the plan, but we do have a responsibility to the patient to develop the best plan. If one can justify more than one way to address a current issue, let the learners proceed with their plan. Finally, we are role models. We must demonstrate excellent bedside manner, respect for patients, and physical exam findings. Our learners need us to show them physician excellence. We must discuss patient interactions and patient education.

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, December 12, 2014

Health care information technology: new rules

Information technology clearly has a long way to go before it delivers on the immense promise of technology to truly improve health care. Most of the current solutions—quickly rolled out in response to Meaningful Use requirements—are slow, inefficient and cumbersome. Physicians (and nurses) spend far too much time staring at their screen and navigating the system, often to the detriment of patient care time.

A study published last year in the Journal of General Internal Medicine shockingly found that medical interns now spend only 12% of their day in direct patient care and 40% with computers. Statistics like that are a great shame for the practice of medicine. The problem is not so much the idea of increased use of information technology in health care, but that what's available right now is suboptimal and actually takes longer to use than it should. So until those dream systems of the future are released, here are 5 new rules for our interactions with health care IT:

1. Do not let the computer cost you your patient relationship

During any patient encounter, refuse to spend more time looking at a computer screen rather than them. Even if it takes a bit longer and you need to use the computer again later, sit down and spend time engaging in direct conversation. This applies especially to office care, where the worst thing a doctor can do is keep turning their back on the patient every few seconds to start typing away and being a data entry robot

2. Do what's necessary

If free data entry takes too long on your IT system, try to enter the minimum needed in order to be succinct and to the point. Avoid typing long descriptive paragraphs if they are not needed, which can take a lot of time above and beyond what's required

3. Learn the intrinsic quirks of your system

Every IT system has its own quirks and way of getting things done. There will likely be more than one way of placing a certain order or entering data. By getting to know your system well, you can often find a quicker and more efficient way of doing something

4. How you interact with your computer

Many tasks, such as ordering a medication, can be done “on the go”. If you get into the habit of sitting down every time you are in front of the computer, a task that could take 10 seconds can easily turn into 2 or 3 minutes. Whenever you can, stand up and do whatever you need to, and get right back to where you should be—with your patient

5. Give feedback and organize

My experience is that hospital IT departments are usually very responsive to feedback from frontline doctors and do whatever is in their power to make the system work better. It could be changing a menu option, altering a screen appearance or reducing the amount of clicks it takes to perform a given task. If you see something that can be done to improve workflow, pick up the phone or send an email. And on a national level, how about making this problem a bigger issue?

As electronic medical records evolve, the likelihood is that we won't be having this conversation in a few years. The ideal systems of the future will make life better for both doctors and patients—seamless, user-friendly and efficient. They will also be the ones that are “seen and not heard,” allowing direct patient care and maintaining the human relationships in medicine. Until that day comes, let's get to work.

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, December 11, 2014

Randomized controlled trials, social media and "intention to tweet"

I have to hand it to cardiologists. For years they have created the most innovative and fun names for trials that are conducted. As a generalist, I still remember the DIG trial from way back when, or the RALES trial, sometimes referencing names of trials when discussed medications for common conditions such as heart failure. As therapy evolves, we get a PARADIGM-HF shift, some might say!

Today, I was sent a tweet about a fascinating trial, the “Intention to Tweet“ trial (hats off again to our cardiology colleagues: TNOTY (Trial Name of the Year). This trial was a randomized trial of social media to see the impact of social media on views of articles within 1 journal, Circulation. In the intervention group, they tweeted out links to half of the articles, and a link to the Facebook page. In the control group, no tweets were sent. Kudos to Lee Aase for a wonderful review of what was done in the study, and what it might mean for the future.

Essentially, what the authors found was that there was no difference in clicks between the articles which had tweets sent/Facebook page links, and those which did not. Some might refer to this as a “negative trial.” I think that, in medicine, we need to see results of “negative trials” that show something was ineffective or not better than “usual care”, just like we need to see results that demonstrate a positive effect of an intervention.

But here is the clincher for this: I have seen several tweets from physicians and other scientists who are meaningful users of social media who are questioning the results or the design of the trial. Some might interpret this as a “defeat” for social media.

Looking on the Altmetrics page for this particular article, however, paints a different picture. Recall that this article was announced and sent out the same day as an early release article. The Altmetrics description for this article puts it at the 92nd percentile of all articles within this Circulation journal. It is in the 94th percentile for all articles of a similar age. 94th percentile! That is pretty awesome! Compared with other articles of a similar age in this journal Circulation, it ranks 2nd, in the 85th percentile. Again, this article came out the same day.

So here is the kicker. This article on social media, based on these Altmetrics data, has “gone viral” on social media (at least compared with other articles from this same journal), and is ranked quite favorably in one metric used to gauge social media impact (that metric being “Altmetrics”). I think that suggests exactly the opposite of what the conclusion did (meaning that dissemination of this article via social media made it quite a favorable article), which could be interpreted as “social media does have an impact on readership of journal articles. See this screenshot from Altmetrics from 10:30 pm EST on 11/19/14.

I applaud the authors for developing such a trial and Circulation for having social media editors in the first place. Those of us who “believe” in the power of social media to teach, to learn and to advocate appreciate the scientific principles which went into creating this trial. I do agree with 1 sentence in the conclusion that “further research is necessary to understand and quantify the ways in which social media can increase the impact of research”.

This article is a wonderful first step towards understanding these concepts, and provides a meaningful way to understand how to consider the impact. As a social media editor for a journal myself (Journal of Continuing Education in the Health Professions), I plan to reference this article and use it in descriptions of how social media can impact journals, and ultimately, patient health and outcomes.

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.

High drama in an ambulatory surgery center

A patient had a complication in my office. I have discussed on this blog the distinction between a complication, which is a blameless event, and a negligent act. In my experience, most lawsuits are initiated against complications or adverse medical outcomes, neither of which are the result of medical negligence. This is the basis for my strong belief that the current medical malpractice system is unfair. It ensnares the innocent much more often that it targets the negligent.

I performed a scope examination through 1 of the 2 orifices that gastroenterologists routinely probe. In this instance, the scope was destined to travel inside a patient's esophagus on route to her stomach and into the first portion of the small intestine. Sedation was expertly administered by our nurse anesthetist (CRNA). The procedure was quickly and successfully performed. The patient's breathing became very impaired and her oxygen level decreased markedly, a known and uncommon complication of sedation medications. We took the appropriate measures, but her low oxygen level did not respond.

At that point, our experienced and calm CRNA decided to intubate the patient by passing a breathing tube into her lungs, in the same manner as is routinely performed prior to surgery. The RN on the case, an ICU veteran, showed how quickly and superbly her medical skills and judgment could be recalled. In decades of medical practice, I had never had a patient whose scoping test and sedation led to a breathing tube insertion. Moreover, this procedure was performed in our outpatient ambulatory surgery center, not in the hospital, so drama like this is exceedingly rare.

The patient's oxygen level immediately returned to normal and she was transferred to the hospital in stable condition. She was appropriately treated and discharged after a few days.

I was so grateful to have a team in place that had the skills to rescue a patient who was in a dire situation. I told this to them directly and they seemed to regard the matter in a more routine manner than I did. They saved her life. Nothing routine about this, as I see it.

For nearly all of the patients we see in the office, our staff is overqualified. But, once or twice a year, we need these folks on site, locked and loaded.

Physicians and the rest of us need back up. Do you have a contingency plan in your job if a crisis befalls you? Will you wait for a catastrophe before implementing one? We've all heard vignettes about cities who were warned about a dangerous intersection, but failed to ask until a tragedy occurred.

Finally, if someone helps you out of the abyss, give the credit to whom it is deserved. Conversely, if something goes wrong and it's your fault, do the right thing.

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, December 10, 2014

In-hospital versus out-of-hospital heart attacks: Wow, things sure cost a lot of money!

An article from the Journal of the American Medical Association has been gnawing at my consciousness for the last couple of weeks. Dr. Prashant Kaul and colleagues out of the University of North Carolina reviewed records from hospitals in the state of California from 2008 through 2011, looking for patients who had been hospitalized with heart attacks. Specifically, they were looking for patients with ST elevation myocardial infarction (STEMI), which are generally the most damaging and deadly of the events generally known as heart attacks, due to the amount of damage they do to the heart muscle.

The authors compared patients who were already in the hospital for another reason when they had their heart attack, versus ones who were admitted specifically for heart attacks. They found that the patients who were admitted specifically for the heart attacks were generally younger and healthier, more often male, and were much more likely to survive than the ones who were hospitalized with other illnesses at the time of their STEMI. This is not terribly surprising, since people who have some other problem bad enough to put them into the hospital and then develop a heart attack on top of it are clearly at a disadvantage, even though there are cardiologists with magical potions and procedures close at hand.

What was most interesting and disturbing to me was the sheer astounding magnitude of costs associated with these groups of patients. The patients admitted for STEMI stayed an average of 4.7 days and total costs were $129,000. About 9% of them died. The patients who were already in the hospital at the time stayed an average of 13.4 days, their costs were $245,000 and a third of them died in the hospital.

I don't think we should get jaded to numbers like this. This is real money, the kind of money that can buy a house in some places or at least a very hefty down payment, can support a person for years, and the co-pays on which can destroy a family financially. As a person is racking up such a bill, there are days of inadequate food and sleep, indignities of hospital gowns and waiting for someone to come with medication or to allow one to empty bladder or bowels, if it's not already too late. And death, in 9% to 30% of the people thus cared for. In a hospital.

This money is not buying comfort and luxury. What costs so much? I'm not entirely sure. The interventions done on people with heart attacks include bypass operations, which are costly, but happen to very few of these people. There are the “percutaneous interventions” meaning high-tech catheters passed through arteries to place stents in clogged blood vessels in the heart, which are also terribly costly, sometimes as much as $40,000 for placing a tiny metal finger trap in a partially blocked artery. More stents are placed than need to be, per many studies, but an STEMI is definitely a good reason to place a stent and doing so is often lifesaving.

But why? Why so much money? There is nothing absolutely expensive about any of this. A little expensive, yes, but not hundreds of thousands of dollars. But the costs add up. The equipment is getting incrementally slightly better and is priced somewhere in the ozone. But it's not about raw materials or time or any of the resources that are truly set in stone. The costs just rise to the level that we agree to pay. The many places where money hemorrhages from the system feed our vibrant healthcare economy. We pay huge amounts of money to insurance companies who disburse it to the entities that charge this much. If there were limits on costs, or even goals for cost cutting, I'm confident we could slim down our spending. But there aren't and we don't.

Heart attacks and their treatment are just a tiny piece of the picture. There are still a few good values (a needle and syringe still costs less than $1), but generally everything that has to do with health care is overpriced. I learned a new computerized medical record keeping system last week and talked at length to the trainer who had been instrumental in adopting it. I complained because it was clearly clunky and lacking in the subtleties that would have made it really useful. I asked about another program I had heard about which was looked at as the best. According to her, the “best” cost about half a million dollars per hospital bed to implement. A medium sized hospital might be 200 beds. So $100 million. Apparently hospitals, hoping for efficiencies, have gone bankrupt after adopting this Mercedes Benz of medical records. And the other systems aren't much cheaper. How is that even possible? There are almost no fixed costs in computer software. They charge this much entirely because they can.

There are no obvious solutions to this, while we remain attached to a non-centralized third party payment system. Payment structures are changing, but slowly, and the powerful interests who make money off of this system seem to escape ideas made to dampen profits. As individuals, though, it's important to continue to notice that things cost too much, they don't have to, and it's not OK.

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.

RIP Don Steiner, who discovered proinsulin

Don Steiner died. You probably haven't heard of him, unless you're steeped in the lore of the University of Chicago or involved in the world of diabetes research.

Steiner is being remembered for discovering proinsulin, the hormonal precursor to insulin. As part of his work, he made the realization that proinsulin was made in the beta cells of the pancreas as 2 molecules bound together by a short molecule which came to be known as “c-peptide.” It's not a stretch to say that his work was key in transitioning the mass manufacture of insulin away from grinding up the pancreases of cows and pigs to being able to manufacture pharmaceutical-grade insulin using modern technology.

Steiner was a throwback to a more innocent time in the world of biomedical research. As his Times obit states:

Some of [Steiner's] research could have been patented, but Dr. Steiner never considered doing that, said Dr. Arthur Rubenstein, a professor of medicine at and a former dean of the medical school at the University of Pennsylvania, who studied under Dr. Steiner and collaborated with him.

“There it was, one of the really, really great discoveries, and there was no patent,” Dr. Rubenstein said.

That decision was part of a pattern. “He shared everything with everybody,” Dr. Rubenstein said. Dr. Steiner, he said, gave his students ideas and time, made them first authors on scientific publications that would advance their careers, and even shared materials and data with competitors who did not always credit his contributions.

This would never happen today. Universities have become more sophisticated about intellectual property, entrepreneurialism, and—let's be honest—profits.

The story about Steiner's openness reminded me of his contemporary, Professor Gene Goldwasser. Goldwasser, also of the University of Chicago, spent 2 decades unraveling the secrets of the hormone EPO (erythropoietin). He, too, could have patented his discoveries, but he thought it too important to share his work to move the science forward. Some say had he patented his molecular discovery he (and the university he worked for) would have made hundreds of millions of dollars.

I was lucky enough to spend time with Goldwasser near the end of his life. He introduced me to Professor Steiner on a couple of occasions. They were great friends. The 2 of them were part of a golden age in bioscience at the University of Chicago, the place where in 1942 the first sustained atomic chain reaction took place under Enrico Fermi.

I know that Goldwasser felt that since taxpayers (i.e. the federal government) had supported his research career, there was no doubt his discoveries “belonged to all of us.” I've no doubt that Steiner felt the same way.

The 2 of them shared not only a love for science, but were “fiends for culture,” supporting the arts—they were lovers of music, drama, and studio art.

Their deaths not only are a huge loss in Chicago, but for the whole world.

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

Best diet? Look beyond the beauty pageant

Can we say what diet is best? Well, not on the Today show.

A study published this week in Circulation: Cardiovascular Quality and Outcomes purportedly compared an array of “popular” diets and found that, despite a whole lot of marketing claims and clamor, none was demonstrably better than another, and none was particularly good.

The study, predictably, has been generating a lot of media attention. This is common to almost all high-profile diet studies and almost always comes to my attention, given the professional lens through which I view the world. This case was different, however. I wrote the editorial that accompanied this article, so I have known about the study in all of its particulars since long before the media embargo lifted. Presumably for that reason, I was asked to opine on the Today show.

As I said on TV, this study does indeed suggest that almost all of the “my diet can beat your diet” claims are a product of salesmanship, not science. Consider the huge number of diet books that have been popular over the yeas, every one of which telling you why it is the best. Obviously, that can't be true about all of them. It isn't even true of any of them.

And if the 576,228 (or so) fad diet books we've had so far have failed to provide the Holy Grail of dietary salvation, what, really, is the likelihood the 576,229th will do so? Let's just go with: not much.

As I noted in my editorial, the new study actually provided only a very narrow window to the never-ending dietary beauty pageant. The researchers compared 3 variations on what they themselves called “carbohydrate restricted” diets: Atkins, South Beach, and the Zone. The fourth contestant was Weight Watchers, which is now more about improving food choices overall, but historically has been about using points as a surrogate for calories.

My assessment of the study, it's strengths, limitations, and implications, is fully developed in the editorial, which the journal has generously made openly accessible here, so I won't revisit all of that. Suffice to say the findings of the research indicated that data and diatribe diverged widely. The data did not really back up the claims and clamor underlying any given diet.

Would this still be true if the window were much wider, examining the full expanse of diets competing for our attention, and our cash?

Yes, it would. I know, because I have been obligated to look through those larger windows. I did so while writing the 3 editions of my nutrition textbook, examining for the newly released third edition, and with the help of my co-authors, nearly 10,000 scientific publications. Yes, it was just as painful as it sounds! But it sure did provide the bird's eye view.

I was obligated to do much the same on a smaller scale to write an invited, peer-reviewed paper entitled, “Can we say what diet is best for health?”

So, can we say what diet is best for health and weight control?

Let's start with a bracing dose of honesty, then come back to that question. If you are reading this, you must be literate. If you are literate, you should be able, despite the crap you learned in high school, to read the writing on the wall. The wall says: Grow up!

Anyone with half a wit knows that a get-rich-quick scheme is almost certain to be a scam. But in our culture, that same, generally sensible person reaches for his or her credit card every time a get-thin-quick scheme comes along.

If that includes you, then: Grow up! There is no magical pixie dust for getting to health, any more than for getting to wealth. Treat the two the same, and acknowledge that time, effort, and commitment are required in both cases. What worthwhile thing in your life happens with no allocation of time or effort? Why should health or weight control be different?

They aren't. Grow up about it.

Now, back to the question: Can we, in fact, say what diet is best, for health, and weight control?

Yes, by looking beyond the beauty pageant. Look, for instance, to the Blue Zones. These populations around the world live longer and better than the rest of us, because of what they have in common. They eat diets of food, not too much, mostly plants; they exercise routinely; they don't smoke; they sleep enough; they are not ridiculously stressed out; and their social connections are strong. Feet, forks, fingers, sleep, stress, and love are the 6 cylinders in the engine of lifestyle as medicine, and they are firing on them all. As a result, they often live to be 100, then go to sleep one night, and just don't wake up. Folks, that's how it's done!

But the Blue Zones are also noteworthy for their diversity. In Loma Linda, Calif., they are vegans. In Costa Rica, their diet includes eggs, dairy, and meat. In Ikaria, Greece and Sardinia, Italy they practice variations on the theme of Mediterranean diets. In Okinawa, Japan, a traditional plant-based, rice-centric diet produces the same outstanding results.

In all cases, the theme is the same: real food, not too much, mostly plants. Or put even more generically: wholesome foods, in sensible combinations. Unlike us here in the U.S., if it glows in the dark by some contrivance other than bioluminescence, they don't eat it!

Why choose low-fat or low-carb, when there are good and bad sources of fat, good and bad sources of carbohydrate? Why choose between low-glycemic and low-salt, when a diet of wholesome foods results reliably in both? Why choose between the quantity of calories and the quality, when the best way to control the former without perennial hunger is to improve the latter? Why choose any dietary dogma at all?

No, looking at the never-ending parade of quick-fix contestants, we cannot say which diet is best, because none is. But looking beyond the beauty pageant, to a vast expanse of evidence and the compelling, real-world examples of the Blue Zones, we certainly can say what theme of eating is best for both health and weight control. Wholesome foods in sensible combinations. No highly processed, willfully addictive, glow-in-the-dark junk. Food, not too much, mostly plants.

I guess for a culture eager for the winner of the swimsuit competition, that theme just isn't sexy enough. But folks, it's the real deal. And there is beauty in it, because a theme leaves wiggle room. A theme means you can choose the variation on the theme that you, and your family, like best. A theme means you can choose your preferred way to love food that loves you back.

Can we say what diet is best? Yes, in fact, we can. But only if we grow up, get real, and look beyond the beauty pageant.

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.

Why can't we easily clean our stethoscopes?

I just finished two weeks on the inpatient internal medicine service. When we round on the service every morning, I insist on 100% hand hygiene and 100% stethoscope hygiene but one of these targets is far easier to achieve than the other.

As my colleague Mike Edmond, MD, FACP, mentioned last year, almost 50% of stethoscopes are contaminated with pathogens including Staphylococcus aureus and methicillin-resistant S. aureus. Despite this level of contamination, hospitals have done almost nothing to make cleaning them quick and easy.

Like many (? all) hospitals, we have hand rub dispensers every few feet but nothing easily available to clean our stethoscopes. I usually end up “bothering” nurses to give us a few alcohol prep pads, but this uses up their daily supply and generally seems like an unnecessary barrier. Why can't we have wipes next to the hand rub dispensers outside of every room? That way we can actually achieve 100% stethoscope hygiene. If we don't develop good systems, we can't expect good results. How do you practice stethoscope hygiene at your hospital?

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.
Monday, December 8, 2014

Show your work--what my algebra teacher taught me

The most valuable lesson about teaching that I ever learned occurred in high school. I took my first algebra test. The questions were easy, and I wrote down the answers. All my answers were correct, but I got a B. After each answer, she wrote “show your work.” She explained that while algebra questions start out easy, they become more complex over time. Only through careful understanding of ones thought process could we make progress through the more difficult concepts. We had to have a very solid foundation on which to build our algebra house.

In my journey as a clinician educator, implicitly I understood that lesson. The thought process of medicine always intrigued me. At the Medical College of Virginia where I went to medical school and internal medicine residency, we had some wonderful clinical education role models who took us through the thought process. As I have developed my personal attending style, these role models had a great influence.

Our research on ward attending rounds revealed explicitly what was instinctive. Learners are more interested in how we approach a diagnostic or therapeutic decision than they are in a list of facts. This research helped me understand the difference between true micro-managers and excellent managers.

Micro-managers tell us what to do, but do not explain why. Managers have us discover what to do through an explication of the reasons. Here is my classic example:

Micro-managers look at your IV fluid orders, and either tell you to change the amount of potassium in the fluids, or even worse write the order themselves.

Managers ask you to state the goal of giving potassium. They then teach you how fast you can give potassium. They discuss the patient's potassium deficit and then help you work through the needed replacement.

The patient gets the same dose of potassium in each case, but in the first case the learner is aggravated and the second the learner has enlightenment.

And it all comes down to showing your work. A belated thank you to my teacher from over 50 years ago (I wish I could remember her name).

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.

We need an Ebola test with perfect negative predictive value at time zero

The tragic death of Dr. Martin Salia has triggered a spate of news articles about the limitations of Ebola diagnostic testing. According to news reports, Dr. Salia tested negative twice early in his symptomatic period, and was already quite ill by the time he tested positive.

The fact that the most sensitive Ebola virus diagnostic test (PCR applied to a blood sample) may not be positive until 3 days after symptom onset is well known, however. The reason for this has to do with the pathogenesis of Ebola virus infection. The point of entry and initial replication for Ebola is the “dendritic” cell. Present in large numbers in the skin, mucosa and intestinal lining, dendritic cells are sentinels, guarding the interface between the human immune system and a hostile environment. They encounter invaders, engulf them, and present their antigens to cells of the adaptive immune system. Dendritic cells carry the virus to lymph nodes and other organs of the “reticuloendothelial system” (liver, spleen). So before the virus reaches detectable levels in the blood, there may be hours-to-days of replication in these cells and organs, along with symptoms of fever and fatigue. A test, even a very sensitive test, that is applied to blood will not detect the virus until it appears in the bloodstream in larger numbers.

This lack of a rapid and accurate diagnostic test early in the Ebola disease course is a major problem, not only for early initiation of therapy for those infected, but also for the management of “persons under investigation” (who may require Ebola-level isolation precautions for several days while awaiting a negative test that has been taken at least 3 days after symptom onset).

But this problem plagues infectious diseases diagnostics generally. As this recent Lancet ID article points out, the lack of early and sensitive diagnostic testing is one reason why so many patients in our hospitals receive days of unnecessary antimicrobials. More on this study later, perhaps from my colleague Eli Perencevich, MD, one of the authors!

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.
Friday, December 5, 2014

Doctor, do you suffer from Glory Day Syndrome?

The practice of medicine is changing faster than anyone can keep pace with. As a hospital physician at a relatively early stage of my career, I'd say that a sizable number of physicians that I work with are towards the latter end of the spectrum. I find that these doctors, typically over the age of 50, are struggling the most to keep up with the changes occurring around them.

I have the greatest respect and admiration for these colleagues and always learn a lot from them on a daily basis. I feel their pain as they talk to me about issues such as increasing bureaucratic barriers between them and their patients, the encroachment of information technology on patient time, and the inability to thrive as small practices. But I've also noticed another trend among some of these doctors—who represent all medical and surgical specialties. And that's a tendency to exhibit symptoms of “Glory Day Syndrome”.

Let me digress for a moment and explain what I mean by this. One of my favorite new authors is a gentleman named Chris Guillebeau. For those of you who don't know him, he's an Oregon-based author and entrepreneur who has written 2 New York Times bestselling books over the last few years. He dedicates a lot of his time to public service and one of his personal goals was to visit every country in the world before his 35th birthday, which he achieved in 2013 (that's 193 countries and for those of you who are wondering; this was done on a shoestring budget).

In his first bestseller, The Art of Non-Conformity, he wrote an excellent chapter based on the phenomenon of Glory Day Syndrome. He recalled a time when he was listening to a speech in which the speaker was recounting an experience from his youth. The person was describing in vivid detail the events from decades ago, as if they had happened yesterday. The speaker was clearly proud of what he was talking about and all of his past achievements. Guillebeau then went on to write about those “Glory Days”, which all of us have to some extent. They are foundational experiences which shape us and represent a time in our life when we felt a great sense of personal growth and attainment. They could be our university days, a sporting achievement, early career success, or a time when we met someone very special.

But the statement that came next from Guillebeau was very profound: Glory Days are dangerous. They are dangerous because as soon as we get into a situation where we are thinking too much about the good old days and yearning for them again, it means that we are assuming that the best is behind us, that we cannot ever have those days again. But this should never be the case, because if those days were as good as we think, why can't we draw on what made them so wonderful, build on those lessons and make the future even better? It's not about forgetting about the good times and stopping to remember them fondly. Far from it, we couldn't forget them even if we tried. We are rightly proud of our Glory Days and what we accomplished. But neither can we get stuck on them for too long.

How does this relate to health care and what I was talking about a couple of paragraphs above? Well, I see many late career physicians who talk a lot about the “good old days of medicine”. The days when physicians enjoyed autonomy, patients felt close to their doctors, and there was much less bureaucratic control. All very valid points. These doctors are nostalgic about those Glory Days when they savored the practice of medicine a lot more than they do now. Never mind the fact that if the older generation wants to look at the current state of affairs with dismay. They only have their own generation to partly blame for “losing” those days and getting to where they are now.

Harking back too much in life can never be a good thing. As an optimist I don't believe that the glory days for doctors and the practice of medicine are necessarily behind us. Looking on the bright side, the medical world is developing amazing new treatments and cures unthinkable a generation ago, people are living longer, and the philosophy of patient-centered care is the right way forward. We are making great strides in patient safety and lowering the length of time that people spend sick in hospitals.

The not so good side: More bureaucracy, administration requirements, concern about falling reimbursements, health care information technology as it currently exists is a pain, and career burnout is increasing. However, surely these are things that together physicians can all work on to reverse and make better? The pendulum can easily be swung back (much harder things have been done before) with the right organization and vision. With all of the scientific and technological discoveries around the corner, a golden age of medicine is on our doorstep. The question is, what role will doctors play in this? Keeping a focus on patients, practicing good medicine in this time of rapid medical advancements, and keeping the doctor-patient relationship at the front and center of all healthcare. Surely the Glory Days must still lie in front of us.

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.

Causal opacity

Medicine as a science is predicated on causality. We seek to understand the causes of disease. Similarly, in the field of patient safety, we aim to determine the causes of adverse outcomes: What factors led the nurse to administer the wrong dose of heparin to Mr. Smith? What caused the surgeon to operate on the wrong knee? Using root cause analysis, we can work backwards from the adverse event to determine the underlying causes.

Now consider the case a of 24-year old man hospitalized for 3 months following multiple, life-threatening injuries following a motorcycle crash. He required 17 operative procedures, a 4-week ICU stay, and had numerous invasive devices (including central venous lines, endotracheal tube, urinary catheter, ventriculostomy catheter, arterial line, and external fixating devices). On hospital day 93, he develops a Methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection. The magic question is this: when was MRSA transmitted to this patient? And, of course, in cases such as this, we are never able to answer that question. The field of infection prevention is plagued by causal opacity. We are rarely, if ever, able to connect cause to outcome in non-epidemic health care associated infections.

In infection prevention, causal opacity is the result of 2 factors. First, the transmission event is silent since the pathogens are invisible to the eye. Second, the incubation period temporally separates cause from effect. With multidrug resistant organisms, the intermediate state of colonization, which can extend for very long periods of time, can separate transmission from onset of infection by months or even years.

Causal opacity also negatively impacts hand hygiene compliance. Imagine if you failed to wash your hands, examined a patient, and the infection in the patient manifested within seconds after touching the patient. Like an instantaneous electric shock, the immediate feedback would probably keep you from ever failing to wash your hands again. Recently, causal opacity has hampered our ability to understand why currently available personal protective equipment may be failing us in caring for patients with Ebola virus infection.

The end result is that causal opacity makes it harder to hold persons and systems accountable with regards to infection prevention. Yes, causal opacity sucks. But it's an integral part of what we signed up for. Otherwise, we'd all be cardiologists or urologists—driving better cars, but bored silly.

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.
Thursday, December 4, 2014

Knife dancing

This week, I covered for one of the chief residents. I was the attending physician for about 25 patients in the hospital during the space of a few days. On 1 of those days, I still had scheduled my regular outpatient clinic; the entire day became a way to experience the contradictions inherent in the practice of medicine, crossing the street again and again between the hospital and my clinic like a shuttle on a loom.

How many contradictions, or rather, pairings that we see as contradictions, confronted me with each patient I saw, comparing in my mind the medicine I practice every day in clinic with the kind of health care delivered in our hospitals!
• Providing each person the care that works for her uniquely, while uniformly assuring best practices for safety to hundreds of patients at a time.
• Getting the tests and treatments that are needed as fast as possible, while deliberating appropriately on the evidence base of every intervention.
• Treating pain, but acknowledging the dangers of opiate addiction.
• Enabling the patient to make decisions, while recognizing they need the support of a treatment team in an alienating and scary environment.
• Discharging as soon as medically possible, while aiding the patient in their convalescence.
• Hewing to principles of safety and organizational efficiency, while being unafraid to venture out of the box when changed situations demand it.

How can we treat patients while on the very knife-edge of these contradictions? Treating both inpatients and outpatients makes me more sensitive to the edge, but I'm not sure I can dance any better … yet.

Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.