Friday, January 30, 2015

Bedside ultrasound in the developing world: What is it good for?

In the last year and a half I've been able to go to Africa 4 times and Haiti once, for which I give thanks that the world still produces abundant fossil fuels. That much airplane travel does make me feel a bit guilty, even though I'm not actually vacationing.

Going to faraway places to practice medicine has always been something I hankered after, and it turns out that knowing how to do and teach ultrasound is a good way to get invited to exotic places. I think if I could do cleft palate surgery or eye surgery or had a traveling dentistry practice I could also be useful in foreign lands, but as an internist it is more difficult to find something that I can do well in a hit-and-run fashion which actually benefits people. Bedside ultrasound, particularly teaching it, fits the bill.

Forgive me for repeating myself if you've already heard the story, but when I quit my regular primary care practice, I learned to do bedside ultrasound. I fell quickly in love with the ability to see inside people, sharing with patients their living anatomy, quickly making appropriate diagnoses and designing appropriate management, following patients' response to therapy. I learned how to ultrasound the heart, lungs, liver, gallbladder, kidneys, bladder, spleen, intestines, great vessels, and also how to teach other people. It's been exciting and time consuming and tons of fun, and has become an integral part of my practice as an internist and hospitalist. I've written many blogs about how ultrasound has changed my practice, but I still get the question, “What's it good for?”

What it's good for varies according to the setting. A bedside ultrasound is usually done with a machine that is small enough to carry in one hand. Mine, a General Electric Vscan, is about a pound and has a screen that is just a few inches across. It gives surprisingly good pictures, but they are nowhere as good as the big ultrasound machine in the radiology suite. If that big machine was pocket-sized, I'd be like the doctor on Star Trek. Because the bedside machines are smaller and less expensive than the full size ones, their resolution is a little bit worse, so they are best for asking relatively simple questions. Also bedside ultrasound is performed by doctors who also do things other than imaging and haven't spent the extensive amount of time radiologists have in learning subtleties of reading radiological images.

At my hospital in the U.S. I can answer questions with my small ultrasound machine like, “Is there fluid in the peritoneum?” or “Are there gallstones?” or “Is the heart squeezing OK?” or “Are the kidneys/ureters blocked?” I can feel confident about whether the bladder is over-full or whether there is fluid or infection in the bases of the lungs. I can see pulmonary edema and amounts of pleural fluid that are too small to be seen on X-ray. I can follow the course of intestinal distress such as gastroenteritis or obstruction. Sometimes I can't see enough to say anything, most often if the patient is hugely fat or is plastered with bandages or stickers that I can't remove. If I need to really know what is going on inside a patient who I cannot image with a bedside ultrasound, I can order a radiological study and usually get my answer in a reasonable time period. When I can look myself, though, my treatment decisions are more fluid and timely.

In the developing world there are fewer X-rays and CT scans available, less official ultrasounds, and having the ability to do bedside ultrasound is pretty magical. There are many ultrasound machines in these out of the way places, and what is mostly needed is training. There could be more machines, of course, and when it becomes more clear how useful the technology can be, more resources may be focused in that direction. I have ultrasounded in Tanzania and South Sudan and the island of La Gonave, off the coast of Haiti, and the procedure, quick, painless and free, was profoundly influential. Last month while I was in South Sudan there was a war on nearby, and there were freshly and not so freshly wounded soldiers, which was a new thing for me. Here are a few cases of exactly what ultrasound has been good for in the developing world:
1. Young man with a gunshot wound to the leg. Is it broken? Is there a pus collection? Ultrasound is really good for ruling out long bone fractures and finding subcutaneous fluid collections. The wound was only in the muscle and a little cleaning and bandaging did the trick. No need to transfer this one to a higher level of care.
2. Different young man was injured in the face with shrapnel. He is unable to see out of one eye. Is the retina damaged (a bad sign)? Ultrasound is quick and efficient as a tool for looking at the eye, especially if the patient is unable to open it for an exam. This guy did have a thickened and abnormal retina with evidence of blood in the posterior chamber and a metallic foreign body. He is not likely to get his sight back in that eye.
3. Little boy shot in the chest and short of breath. Is it a punctured lung? A burst blood vessel bleeding into the chest? Is the heart damaged? For this boy it was none of these things, but a contusion of the lung, which looks a bit like pneumonia on ultrasound. A chest tube would have further compromised that lung and the boy avoided this procedure. Where is the bullet? It would have been great to have an X-ray to find that out!
4. A young woman with vaginal bleeding after 3 months of thinking she was pregnant. Is she having a threatened miscarriage or is this just an irregular period? Ultrasound is wonderful for seeing a uterus and whether there is a baby hiding inside. We saw many of these cases. Sometimes there was a baby, sometimes not. The treatment, bed rest vs. normal activity, was very different and knowing which was indicated could profoundly impact the whole family.
5. A little baby with an enlarging lumpy area on the lip. I could just imagine all of the creepy things it could be. The ultrasound showed it to be made up of blood vessels, so it is a cavernous hemangioma, which is a common benign tumor in infancy and usually goes away or shrinks by itself, and sometimes requires medications to help it go away.
6. A young man has been getting weaker, with swollen legs and a barrel chest. Is it heart disease? Perhaps something he was born with? These might be treatable with medications. Unfortunately it was not. There was a huge tumor obstructing blood flow to the heart and lungs. Good to know, though heart wrenching.
7. An old man, failing to thrive. He has back pain. Ultrasound shows he has a large bladder tumor which is blocking his kidney. Caught this late, and in a war zone, this is not treatable. Knowing helps his family to make plans.
8. An uncharacteristically pudgy woman with recurrent abdominal pain. Is it an ulcer? Actually no, her gallbladder is full of stones and is tender to push on. Surgery will help, and this lady lived in a place where that was safe and available.
9. A young woman with pelvic pain. Is it a tubal infection? A bladder infection? It is not hard to visualize the abdomen and pelvis with ultrasound, and this person had a ruptured ectopic pregnancy with blood loss into the abdomen. She will die without surgery and she will likely do fine with it. She was rushed, appropriately, to surgery.
10. A woman with a full term pregnancy: she hasn't been feeling the baby move. Is it in trouble? Ultrasound is absolutely wonderful for looking at babies, since they float around in a big balloon of water. This woman's baby looked healthy. Good news.
11. A woman acutely short of breath, with some chest pain: is it asthma (common) or her heart? Strangely enough her heart wasn't squeezing very well and her lungs looked wet. She responded well to medications for pulmonary edema and was fine the next day. I have no idea what that was about, and can't find out further because I'm home and she is probably lost to follow-up.
12. Pyomyositis: people get collections of pus in their legs and sometimes arms for no obvious reason. Then they get very sick and if the pus is not drained, they die. When a leg is swollen up it's pretty hard to know where to cut to release the pus unless something like an ultrasound tells you where it is. We doctors love draining pus. The young man in question, a retired child soldier, had relief of his condition and will get well.
13. A soldier, clearly sick after being shot in the belly: Has be bullet injured a blood vessel or vascular organ? Is there a significant amount of free air to suggest a major intestinal perforation? The FAST scan (focused assessment with sonography in trauma) looks for fluid, usually blood, in the belly and can determine whether a patient needs emergency surgery, if available, to avoid bleeding to death. Lots of free air looks like air anywhere, with air artifact and multiple parallel horizontal lines. This young man had peritonitis, with thickened bowel walls, fluid filled bowel loops and small amounts of fluid between the intestinal loops. He was transferred to a higher level of care after receiving antibiotics and fluids.

Also … babies with loud heart murmurs, young men with testicular swelling, the worried well … ultrasound in the developing world is great!

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.

If you spend more than 80% of your day on the computer, you are no longer a doctor or nurse

The use of health care information technology has increased exponentially over the last five years, and as a frontline physician I have seen this change at close quarters. In most of the hospitals I've worked in up and down the East Coast, it's been interesting to observe this transformation. The process has usually started with nurses and then moved on to encompass doctors. It's overall a good thing, as I wrote about a couple of weeks ago, because despite the drawbacks, information technology is undoubtedly the way of the future.

Yet at the same time there's so much further to go in designing more optimal systems that are less clunky and cumbersome to use. The problem with having suboptimal IT is that it does not stop at the computer screen or just make life more inefficient for hardworking doctors and nurses. It ultimately affects our patients by taking time away from them and thus has a huge impact on the whole hospital experience. Much was made of a study last year that showed medical interns now spend only approximately 10% of their time in direct patient care. From my own observation of how frontline doctors and nurses are spending their time, this comes as no surprise to me. Sadly for doctors it's the real frontline specialties—such as hospital medicine, emergency medicine and family practice—where our patient interactions matter most, that are most acutely affected by slow health care IT and over-burdensome data entry requirements. As for nurses, glance down any modern day hospital floor and you will see these hard working professionals, who are the very heart of direct patient care, glued to their computer carts, typing and clicking away.

I've learned the golden rule that identifying a problem is the easy part. How do we go about solving it and what realistic solutions can be brought to the table? How can we really improve this situation?

The first most obvious answer lies with the health care IT itself. People who work in information technology who are non-clinical will have no idea how systems impact frontline clinical workflow and take time away from our patients. We need to provide direct feedback, not just to IT departments, but the IT vendors themselves. The best health care IT of the future will be systems that are quick and user-friendly, “seen and not heard”.

The second avenue is to make sure feedback is given to hospital administration and CMIOs directly (chief medical information officers). I personally know many CMIOs, fortunately the better ones. Unfortunately though, some of the others in this field have chosen that route as a way of getting away from clinical medicine. In other words, former physicians who don't practice at the frontlines any more. These are the ones who need the most feedback regarding how current systems can be better optimized.

The third area is to look at mobile IT solutions, such as tablets, that can easily be used “on the go” as you are seeing patients. I would say widespread use of “voice recognition” too, but the current ones I've seen (no company names mentioned) are actually much slower than typing and good old-fashioned transcription services.

There was an interesting article published on the popular online physician social media site KevinMD.com about using medical scribes as a solution to “click overload”. Another article on the same site described how scribes can put humanity back into the practice of medicine. This would be the ultimate solution I suppose, but part of me thinks using them universally would be like admitting defeat on the part of health care IT that better systems cannot be designed. Systems that frontline staff can work with.

Finally, awareness must be raised among physicians and nurses about how their typical workdays are being spent, and how too much of the time involves the computers rather than their patients. I have a great awareness of this myself, and try my absolute best to minimize it so that I spend more time with my patients (doing things such as batching tasks and avoiding sitting down when I need to use the computer quickly).

The simple truth of the matter is that if you spend more than 80% or more of your day staring at a computer screen—typing and clicking away—sorry to be so blunt, but you are absolutely no longer a doctor or nurse. You have become a Data-Entry Bot.

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, January 29, 2015

What's the cause of chronic abdominal pain?

I see patients with abdominal pain every day. Over my career, I've sat across the desk facing thousands of folks with every variety of stomach ache imaginable. I've listened to them, palpated them, scanned them, scoped them and at times referred them elsewhere for another opinion. With this level of experience, one would suspect that I have become a virtual sleuth at determining the obvious and stealth causes of abdominal distress.

I wish it were the case.

The majority of cases of chronic abdominal pain that I and every gastroenterologist see will not be explained by a concrete diagnosis. Sure, I've seen my share of sick gall bladders, stomach ulcers, diverticulitis, bowel obstructions, appendicitis and abdominal infections, but these represent a minority of my afflicted patients.

Patients with acute abdominal pain are more likely to receive a specific diagnosis, such as those listed above. However, patients who have abdominal distress for years, which constitute most of my stomach pain patients, usually will not have a specific, explanatory diagnosis even though these patients often feel otherwise.

Many of these patients come to the office advising me that “their diverticulitis is acting up” or that “their ulcer is back again.” Usually, this is not the case and they may never have had diverticulitis or an ulcer in the first place.

Physicians often assign these patients a diagnosis of irritable bowel disease or functional bowel disease, which is a rather amorphous entity that cannot be detected on available diagnostic testing. The labs and scans and scopes are all normal in these folks. I believe that the condition is real, but it is a frustrating condition that is difficult to define. It often coexists with other chronic painful conditions, such as fibromyalgia, chronic pelvic pain and migraine headaches.

This is tough for patients and a medical profession that strive to label every symptom numerically and quantitatively. The body does not work this way.

Of course, I may be missing true diagnoses in some of my chronic pain patients. Medical science isn't perfect and neither am I. How many celiac disease patients have I overlooked? Should I test every individual who has a cramp now and then for celiac disease so I don't miss a single case? If every physician adopted this approach for celiac disease and a hundred other conditions, we would elevate our current practice of overdiagnosis and overtreatment beyond the stratosphere.

So, how much testing should a patient with chronic nausea or abdominal pain receive? Patients and physicians don't always agree here. How much cost and care are patients, physicians and society willing to expend to approach 100% chance of not missing a diagnosis? Is your answer the same if you or a loved one is the patient?

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.

Did President Obama receive high-value care for his sore throat?

President Obama had a direct laryngoscopy and then a CT scan for a persistent sore throat. As a physician who has studied acute pharyngitis for 35 years, I had to carefully think about his complaint and the decisions that his physicians made.

First, his “sore throat” was not acute pharyngitis. Guidelines and expert recommendations on acute pharyngitis diagnosis and management only apply to patients who have a brief (5 day or less) acute illness characterized primarily by a sore throat. Thus, we should not expect that the standard approach to pharyngitis would apply.

Second, we only have a label: “sore throat”. Without taking a careful history, we cannot really criticize his physicians. The term sore throat could mean several different presentations. Did he have neck soreness or throat soreness? Was it continuous? What made it worse? What other symptoms did he have? Did the pain radiate?

We are told that he had posterior pharyngitis. Posterior pharyngitis is the classic finding that patients develop with chronic GERD. Once his physician found posterior pharyngitis, then one could make an argument that he should have a trial of a PPI, and then see if his symptoms resolve.

Did he have red flags that led the physician to order a CT scan? We do not know. Some have argued that his smoking history made laryngeal cancer a possibility.

I really want to be critical – this is a ranting blog. But I do not know, primarily because I did not take the history and examine the patient! The CT scan did not seem like usual care. One wonders whether, like many famous people, he received too much investigation. But none of us really know.

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.
Wednesday, January 28, 2015

Cancer and Random Genes: Fortune Favors the Prepared

A recent study in Science purportedly demonstrated that cancer is more random than previously thought. This, predictably, has led to high-profile publications in mainstream media suggesting that cancer results more from “bad luck” than factors over which we exercise some control.

If that epiphany bothered you, I am glad to provide a prompt remedy: It is not true.

The researchers studied the rate of potentially cancer-causing genetic mutations in different tissues, with extrapolations based on a computer model derived from the number and frequency of cell divisions. The research showed that many ominous mutations happen spontaneously, meaning they are not passed down from one generation to the next; and such mutations happen more often in tissues that divide often.

At this point, you should be scratching your head and asking: Didn't they study cancer occurrence in actual people? The answer is no. Didn't they show that lifestyle factors don't influence the rate of mutation? Again, the answer is no.

Perhaps most importantly, the work in isolated tissues was only about mutations, not about clinically-relevant cancers in actual bodies. Gene mutation does not equal cancer.

Cancers are at most only initiated by genetic mutation. For a clinically-relevant cancer to ensue, two additional stages are necessary: promotion and expression. Whether or not a cancer is promoted, progresses, and ultimately expresses itself as a clinical problem is substantially influenced by the environment in which that mutated gene finds itself.

The evidence is entirely overwhelming that how we live influences the likelihood of cancer overall, and that of many specific cancers. Studies show that the very same people, with the very same genes, are subject to higher rates of cancer, along with other chronic diseases, when they leave a healthy, native lifestyle behind, and adopt a more dubious one.

Studies show that some populations around the world get much less cancer, as well as other chronic diseases, not because of genetic advantage, but because of lifestyle advantage, mediated by culture. And perhaps most relevant for those of us not yet living in a blue zone, intervention studies show, over and over and over, that a constellation of healthful lifestyle practices translates into less cancer along with other chronic diseases, just as it translates into more years in life, more life in years.

Potentially cancerous mutations will occur more often in tissues with a higher rate of cell division; that's no great surprise. Some such mutations will occur randomly no matter the care we take of ourselves. And many potentially cancer-causing mutations are spontaneous, not endowed to us by our ancestry. That's what the new study shows.

It establishes nothing at all to refute the substantial preventability of clinically-relevant cancer by lifestyle means. It reports nothing to contradict the large body of evidence already established showing the power of our behavior to influence the behavior of our genes.

Yes, there is a random element in cancer-related mutation. Call it luck or fortune if so inclined, but prepare your defense just the same. Lifestyle choices provide a robust defense against bad outcomes resulting from episodically bad cells. In the life cycle of clinically relevant cancer, as in life generally, fortune favors the prepared.

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.
Tuesday, January 27, 2015

Whatever got you into this specialty, anyway, doc?

Whenever I am asked this question, I can't help but think of the punch line to a joke that was once supposed to be funny but would now be considered beyond the pale in all respects, so I won't repeat it. The punch line is: “Just lucky, I guess.” That's the short answer to why we gastroenterologists work in our field. Despite the distasteful aspect of human waste and the perverse nature of inserting rubber tubes where the Good Lord never intended, there are many reasons my colleagues and I work in a specialty where our slogan might be “Your business is my business”. And speaking of medical specialists, for the information of the jokesters among my 2 or 3 readers, we gastroenterologists are not referred to as proctologists. That's a branch of surgery.

I myself find it surprising that anyone would wonder why I chose my specialty when most people themselves have such a keen interest in such matters. As a rule, people I encounter, upon learning what I do for a living, have questions. Even complete strangers in public places have on occasion immediately shared their digestive problems in embarrassing detail. (One time when the GI professional convention was in town, a ticket-taker at the movies spotted my badge and inquired about his flatulence while my wife and the rest of the queue were kept waiting.) I once thought to try to fend off potential requests for medical advice at cocktail parties by misrepresenting my specialty: if asked what I did for a living, I would reply in a somewhat ominous tone, “I'm in waste management.” I soon gave up that dodge when I discovered that the few people I fooled into thinking I operated a garbage hauling business were even more interested in that business's—undeserved, of course—reputation as mobsters than they were in doctors.

Now, for a few answers …

Above all, I love to eat. Remember that the upper GI tract is half my bailiwick. There is something inherently fascinating about even the fact that we creatures are capable of ingesting and digesting food substances, not to mention what becomes of them. The whole process is nothing short of miraculous! Spinning flax into gold is the stuff of fairy tales, but turning a perfectly good meal into, well, you know what, is something only we living beings can do.

Moreover, eating is a particular interest for my fellow gastroenterologists in general, as best I can tell from our meetings. I would submit to you that our specialty has more and better quality dinner meetings than any other. The whole digestive process is so fascinating that I recently devoured with relish a book about the GI tract aimed at lay people, ”Gulp,” by Mary Roach, and enjoyed every page, even though I knew most of the stories therein. I highly commend it; the digressions and the droll reportage are worth the trip.

As for the distasteful material I have to work with, remember that there are other specialties whose stock in trade I regard as far less delicate. Pulmonology, for example: I would rather deal with a bucket full of stool than a bucket full of phlegm any day. Granted, the urine that my friends the kidney specialists work with is fairly sterile, but so is nephrology as a specialty, in my opinion. And while pathologists nowadays spend the bulk of their time looking at slides with lots of pretty colors, they still have to slice up dead bodies or cut up smelly organs in buckets of formaldehyde. And anyway, for the most part, by the time I come to routinely examine your colon, it is essentially as clean as the inside of your mouth.

But I don't mean to be flip. I will next offer some serious answers to what is a legitimate question, “Why do you enjoy practicing gastroenterology?”

Firstly, most of the people who come for me for help can truly be helped. While cure is only an occasional outcome in medicine, relief of symptoms is a common and attainable goal, and reassurance is almost always possible. (I am paraphrasing a mission statement that was proposed centuries ago by a great physician.) As I see it, of all the medical specialties, with the exception of infectious diseases, ours offers the greatest chance to achieve positive results and even cures. In my own professional lifetime, I have seen stomach ulcers practically vanishing from among the diseases we regularly encounter. We are on the path to wipe out colon cancer. And there is even reason to hope that we will someday find the cause and cure for the most common, least serious, but extremely distressing ailment among GI diagnoses, irritable bowel syndrome!

Second, the converse of the previous claim is the following one: only in minority of cases do we have to deal with the weighty matters of life and death. Of course, it is painful to inform a patient that she has colon cancer or pancreatic cancer. But that task is fortunately infrequent, and when it must be done, it can at least be done in the most supportive possible manner. I am happy I don't have the daily task of the trauma surgeon that comes after an exhausting marathon of trying to patch together a human being: presenting the prognosis to one or more distraught loved ones. Nor do I relish the life of the obstetrician, whose practice usually leads to the joy of a healthy human being arriving in the world, but occasionally, tragically does not.

And third, speaking of OB-GYN and surgery, my hours are definitely more predictable than in those specialties I just mentioned. Of course the hours are long, but these days the number of patients in need of emergency procedures is diminishing. Gastrointestinal hemorrhages are rarely in need of middle-of-the-night endoscopy at my small community hospital. The biggest threat to my sleep is actually the seemingly innocuous piece of steak or sausage that becomes lodged in some poor soul's esophagus, usually during dinner. That's the call from the emergency room that I welcome least, because there is no putting off what we refer to as a “foreign body” stuck in the esophagus.

Fourth, we gastroenterologists get to treat the greatest number of different organs in the human body, although the endocrinologists come in a close second. Of course, oncologists and infectious disease specialists might argue that their disciplines treat every organ in the body, since none are immune to malignancies or infection. But with all due respect, their acquaintance is only passing and superficial. After all, what does the oncologist really know about the life of the stomach that she has cured of cancer? No more than the firefighter knows of the life of the citizen carried from a burning building. In any case, we do manage to avoid boredom in our specialty by treating everything along the pipe that runs from mouth to anus as well as a few side branches such as the liver, gallbladder and pancreas. My first patient of an afternoon in the office might be complaining of trouble swallowing and the next one of difficulty defecating. I pity the poor pulmonologist or cardiologist, with only one organ to claim for their own.

Next comes the matter of how we gastroenterologists spend our workdays. We get to know our patients. I love meeting people and getting to know them as people in the course of diagnosing and treating them. As a gastro doc, I have learned things about people I would never have in any other profession. Of course, the price I pay is having to hear on a regular basis certain intimate descriptions of things that I would just as soon not discuss over dinner. Even in that, there can be some humor. But overall, the role of the gastroenterologist is as close to that of a psychiatrist as any other specialty. Addressing the ”psychosocial” aspects of illness (as they are referred to) can be at times depressing but at times rewarding. I have learned to put people at ease in a wide range of ages, social classes, nationalities and personalities, and they, in turn, have welcomed me into their worlds. (I will concede, though, that there is another specialty that demands an intimate relationship between doctor and patient, namely, oncology, and I suspect this accounts for some of the motivation that keeps my esteemed colleagues doing what they do.)

But sometimes I get weary of hearing about the woes of the world, the worries of the well and the suffering of the ill. That's when it's time to walk down the hall to a place where I don't have to listen to people endlessly bemoan their problems, or act as though they can expect miracle cures, or return and inform me they have failed to do anything I have asked of them. It's called the “endoscopy suite”. There, I can confine even the most tedious of such conversations to the few minutes before we sedate the patient and after they wake up when I brief them before they leave. Tough conversations can be postponed until the biopsy comes back, and even the neediest characters understand when I tell them that I have to see to my next patient who is already “on the table”. And while each patient is “under,” I get to play my favorite music and listen to the gossip of the nurses and assistants while I do what is, thankfully, a routine set of tasks. Lest you worry that as a patient, your doctor is distracted, it is quite the opposite. Sometimes it is routine enough to be “mindless” in the Zen sort of way that driving in Manhattan traffic is for me; I can become so focused on the task that I forget all else. At other times, it is challenge to decide what best to do and how best to do it. Either way, it's a welcome change from the office.

Which brings me to a related attraction of doing GI, which I share to a great extent with surgeons: I get to work with my hands. There is something just plain satisfying about seeing the work of our hands. Even since I was a child, I enjoyed playing with tinker toys, then erector sets, then balsa wood airplanes and then ham radio equipment. Even recently, one of my greatest pastimes has been going to my workshop and putting together a tube guitar amplifier. As you can imagine, it is no small source of pride having cauterized a hemorrhaging ulcer or having removed without hemorrhage a large potentially cancer-causing polyp. And these are just a few of the procedures we general gastroenterologists do. Nowadays, the hotshots in my specialty are actually doing surgery in the abdomen by deliberately making a hole in the stomach with the scope and operating through it and then closing the hole! And all of this work we do is performed by working the controls of a scope and watching a video screen. It's not as much fun as playing a video game, because you can't just reset and start over if you “die,” but you get used to the high stakes involved early in your training, so it's still a rewarding way to spend a morning.

And finally, the intellectual aspect of diagnosing and treating GI problems is an enduring challenge that will not depart from me even if colonoscopy becomes an obsolete test or my hands become too weak to hold an endoscope. The challenge of solving a puzzle, and one that has direct meaning for the person sitting in front of me, remains one of the things that brings me back to work each day. Other doctors do the same thing in their own branch of medicine, but I like to think that I am using my brain so that others can make the most satisfying use of some of their most treasured bodily functions, or at least, some of my favorites. I believe it was Mark Twain who said that of the human needs, one of the most overrated is sex, and one of the most underrated is … well, you know.

So now that you know how I chose my specialty, I plan to share with you in a future discussion, the not-so-secret ways in which I have been able to avoid thus far a doctor's biggest professional hazard: “physician burn-out.” Stay tuned.

David M. Sack, MD, is a Fellow of the American College of Physicians. He attended Harvard and Johns Hopkins Medical School. He completed his residency at Lenox Hill Hospital in New York City and a gastroenterology fellowship at Beth Israel-Deaconess, which he completed in 1983. Since then he has practiced general gastroenterology at a small community hospital in Connecticut. This post originally appeared at his blog, Prescriptions, a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Health care prediction checkup

A while back I made a list of predictions about the world of health care as we entered the Obamacare era.

Let's see where we stand:
1. “Obamacare will move forward” in spite of staunch opposition. Check.
2. Big Data #1. You'll be nudged by your doctor or medical home with reminders for preventive care items like flu shots or colonoscopies. Check minus. This was already happening (e.g. letters reminding women of annual mammogram screenings), but not yet to the extent I foresaw.
3. Big data #2. Targeted medical marketing along the lines of Netflix or Amazon, using your prior purchases/preferences. Nope. I still see this coming. We are at the precipice of a slippery slope.
4. “Patients will be a step closer to becoming true consumers.” What I meant here is that we will see increasing efforts launched to provide price transparency and comparability for health care services, so that patients will actually be able to value shop. Big proto-check. Big because of a few key efforts—see Elisabeth Rosenthal's amazing series called “Paying Till it Hurts” in the New York Times, which inspired its own Facebook group and grassroots effort to rein in health costs and bring greater transparency to the ‘market,’ and Steve Brill's TIME magazine wholly devoted to the mysteries of the “chargemaster”—we are moving quickly in this direction. But only a proto-check because we are nowhere near where we need to be.
5. “More people will get insurance. The 47 million uninsured will be cut in half within four years …” Check. We are well on the way. See #6.
6. “By 2020, all states will have expanded their Medicaid pools, providing more coverage to the poorest of the poor.” Nope. But 27 states and the District of Columbia potentially have us near a tipping point. I gave myself some leeway here, and I'm confident we'll get there.
7. “The number of nurse practitioners and physician assistants will grow dramatically. Nurse practitioners will continue to gain more independence in practice. A new category of health worker will flourish: the community health worker, a lay combination of social worker and medical provider. In particular, community health workers will help with the 5% of people who account for half the health care spending in the U.S.” You betcha.
8. “We will see the rise of the first nationwide health plans. Archaic rules that keep health care local will be modified to eventually allow for consolidation. Like hotel chains, you'll be able to get health care at the same organization in different cities. The sponsors may be hospitals, say the Cleveland Clinic, or big health insurers, like Aetna. As with hotels and airlines, you'll have frequent visitor programs, and you'll be able to amass points toward discounts and perks.” Not yet. Just you wait. Industry consolidation (i.e. mergers and acquisitions) will continue and drive this.
9. “The traditional doctor-patient relationship in which a single doctor gets to know you over years will become a luxury.” Check. Just take a look here. Or here.

Generously scoring, that's 6 out of 9 right so far. Sixty-seven percent is no Nate Silver, but there's plenty of time still on the clock for the long-range bets..

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.
Monday, January 26, 2015

Mumps checks the National Hockey League

If you're old enough, you remember kids sent home from school, cheeks swollen like chipmunks. Mumps is a very contagious disease, and one that most people younger than me have never seen. This is a good thing, since mumps in children can sometimes lead to deafness. In adults, it can swell the testicles, breasts, and the brain. Painfully. Thankfully, mumps was nearly eradicated, dropping to just 248 cases in 2004. And then Wakefield happened.

Certainly Andrew Wakefield cannot be held solely responsible for the rise in cases of measles and mumps in the U.S. and UK, but in my opinion he certainly bears some responsibility. In 1998 Wakefield published a paper in the Lancet claiming that the MMR (measles, mumps, rubella) vaccine was linked to autism. His paper was eventually retracted, and Wakefield struck off the rolls of doctors in the UK. The British Medical Journal published a series of pieces by journalist Brian Deer convincingly laying out the case for fraud in Wakefield's part. The study was not only junk science, but probably not even based on real evidence.

Despite this, MMR vaccination dropped in the UK and the U.S. There have been a number of mumps outbreaks over the last several years, some associated with unvaccinated Americans who travelled abroad and brought the disease back to their under-vaccinated community.

The most recent outbreak though is a new one, and potentially quite serious. Players in the National Hockey League have been hit by an outbreak which seems to have started in Anaheim. Mumps doesn't always cause the classic swelling and often looks like a cold, making prevention by isolation difficult. And when it hits adults, it can be devastating, with the testicular inflammation and possibility of brain swelling. Given the travel habits of professional athletes, there is reason to think more cases are on the way. Some cases of mumps are no doubt due to failure of the vaccine to prevent the disease. This is why universal vaccination is even more important. The more of us who are immune, the less likely the disease is to spread to those who aren't protected. There is no good reason, after nearly wiping out the disease, that we should put up with the rise in mumps outbreaks.

We need to reexamine our vaccination practices, both to make sure vaccination is as near to universal as possible and to research into preventing vaccine failure (e.g. booster shots). The Andrew Wakefields and Jenny McCarthys of the world cannot be blamed for every outbreak, but they play a role, as does every parent who decides not to vaccinate their child on time and completely. They are the problem. (Meanwhile, as you watch your favorite NHL team, try not to think about what it be like to play the rough game with swollen huevos.)

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog at Forbes. His blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.

A global force for good

A few years ago, the United States Navy launched a new recruiting and marketing campaign using the slogan: “America's Navy – a global force for good.” The line was apparently a flop, and the Navy threw it overboard for “protecting America the world over,” but I liked it. I thought it captured a deep truth about the Navy, which is that it is undoubtedly a “global force” and that the force exists for a good purpose, but I guess most people thought that it made the Navy sound too much like a bunch of social workers.

I was reminded of the phrase, and of an experience I had while serving in the Navy Medical Corps, when I read a recent article in the Annals of Internal Medicine. A Navy physician retold the story of a mission he was on to a remote village in Honduras. He and his team were flown into small villages, where they would “see dozens of patients each day and dispense an assortment of symptomatic medications” and where “the most practical health benefit that we provided villagers consisted of hundreds of tooth extractions.” He further noted that “although advertised as humanitarian missions, these exercises provided U.S. military personnel with experience working with military and civil authorities from host nations.”

It was in that context that he was confronted with a desperately ill little girl, who had been brought to the makeshift medical facility with peritonitis from a ruptured appendix. His initial request to have the girl medevac'd to a regional facility was denied, and only later authorized when he framed the request as necessary to prevent her from dying in front of the American military personnel who were there.

My own experience was less dramatic, but in some ways similar. I was serving on a training/humanitarian mission in 2010 in Indonesia aboard one of the Navy's 2 dedicated hospital ships, the USNS Mercy. We also provided care in remote villages to underserved populations who had no regular access to care. We too saw dozens of patients and were only able to provide simple treatments for most – antibiotics, analgesics and the like. Some were brought on board the ship for surgical interventions, but the complexity of procedures was limited by our sailing schedule (we couldn't offer an operation that required a week's recovery if we were leaving in 3 days). The most frequently performed operations were cataract extractions and repair of cleft lips and palates, both of which delivered a huge positive impact.

One day, one of our “on shore” teams radioed the ship to seek permission to bring a child aboard for a diagnostic evaluation. This was not standard procedure, but the boy was sickly and cyanotic, and it was clear to all that he would die in his village if we did nothing.

With the help of our entire team, we found that he had transposition of the great vessels, and were able to make arrangements with a local charitable foundation to get him to a major center for definitive evaluation and possible surgical correction.

While there was much we could not do for many people we saw, we decided that day that we could not do nothing for one child. I still like “a global force for good.”

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.
Friday, January 23, 2015

8 states seek to speed cross-state licensing

Eight states, Iowa, Minnesota, Nebraska, South Dakota, Texas, Utah, Vermont, and Wyoming, have introduced legislation that could speed the process of issuing licenses for physicians who want to practice in multiple states.

The Interstate Medical Licensure Compact would modernize and streamline interstate licensing while maintaining oversight, accountability and patient protections, according to the creator of the model legislation, the Federation of State Medical Boards (FSMB). The new interstate compact system would help physicians improve access to care for patients in multiple jurisdictions and help underserved populations receive the healthcare they need.

“The Interstate Medical Licensure Compact, which is now being considered in state legislatures across the country, offers an effective solution to the question of how best to balance patient safety and quality care with the needs of a growing and changing health care market,” said Humayun J. Chaudhry, DO, MACP, president and CEO of FSMB. “We're pleased to have supported the state medical board community as it developed this groundbreaking model legislation and look forward to working with states that wish to implement this innovative approach to licensure.”

The final model Interstate Medical Licensure Compact legislation was released in September 2014. Since then, more than 25 medical and osteopathic boards have publicly expressed support for the Compact.

“The growing number of introductions in state legislatures represents the desire for a dynamic system of expedited licensure that simultaneously respects the inherent role of state regulatory agencies in protecting the public,” added Dr. Chaudhry. “At a time when some within the telemedicine industry seek to implement licensing frameworks that undermine and circumvent state licensing rules and practice requirements, the Compact is a key element to ensuring state sovereignty while providing the license portability necessary to enhance the delivery of health care.”

The Federation of State Medical Boards (FSMB) has launched a new webpage and interactive map to track the progress of the Compact in state legislatures, as well as answer compact-related questions where individuals can see if their state has introduced legislation supporting the Compact.

3 highly effective ways to reduce readmissions

The enormous push continues to reduce readmissions, due in no small part to stiff financial penalties from CMS for the worst performing hospitals. The most commonly cited statistic is that about 1 in 5, or 20 percent, of Medicare patients are readmitted within 30 days. A staggeringly high number when you think about it. Having discharged thousands of patients and seen the characteristics of those patients that are frequently readmitted (who are unfortunately called “frequent flyers” in hospital circles), here are my 3 ways to help solve the problem:

1. Focused targeting

When we talk about readmissions, the first step is to identify those patients who are at the highest risk of coming straight back into the hospital. It's a mix of socioeconomic status, demographics, social support, education, and most importantly baseline co-morbidities and functional status. If your readmission program targets “everyone”, it will expend too much energy on the vast majority of people who don't get readmitted. Employing Pareto's principle (see my previous article); remember that 80% or more readmissions will come from 20% or less of the same patients.

2. Discharge process

Discharging a patient in the typical rushed environment of a hospital is too often haphazard and disjointed. This is the one chance to make sure that all the paperwork and instructions are as thorough and comprehensive as possible. Exhaustively educate the patient and family. It should be the physician that leads this process. Much is made of a discharge taking at least 30 minutes—but perhaps even an hour would be a better time.

The problem with this? It's not as simple as it sounds. In the real word of economic pressures for both doctors and hospitals, spending an hour with every patient you discharge isn't really possible (that's not just a problem for U.S. medicine, because socialized countries in fact usually see more patients in even less time).

3. Intense primary care

Studies may show differing results, but I can tell you with certainty that patients with strong primary care follow-up and outpatient monitoring are definitely less likely to be readmitted. Make sure those high-risk patients have close follow-up ideally within a day or two of exiting the hospital.

The drive to reduce readmissions is a noble one. But we have to be realistic too. With an ageing population, this issue is going to remain at the forefront. The nature of illness is that it's a fragile time for our patients, and particularly for those with chronic underlying illnesses such as COPD or congestive heart failure. It doesn't take much to push things over the edge and for people to be sick enough to require a hospital bed. Battling nature can be hard. The question is: how can we best minimize the likelihood of the next setback and continue to keep more and more people out of hospital and in the comforts of their own home?

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, January 22, 2015

An update on flu season

This year's flu season has started earlier than expected and has already reached high numbers of flu cases in 36 states. California is not one of them, but that likely means we're a couple of weeks behind the East Coast, not that we'll be spared. In fact, this week I saw my first patient of the season who had a positive test for the flu, and Google Flu Trends suggests that the numbers of cases in Los Angeles just started to increase.

It's too early to know whether this season will be worse than previous years. That largely depends on how soon the disease peaks and then declines. But this season has already caused more hospitalizations than usual and a large number of deaths. As of December 20, 18 children have died of the flu.

Part of the reason for this season's intensity is that the predominant virus strain circulating is H3N2, a strain that usually causes more hospitalization and deaths. To make matters worse, though this year's vaccine includes the H3N2 strain, the virus has changed since the vaccine was made, making the vaccine an imperfect match for the circulating virus. Still, an imperfect match is better than none, and health officials still urge everyone over 6 months of age to get vaccinated. Remember, if you're young and healthy getting the shot isn't primarily about protecting yourself. It's about making it less likely that you'll transmit flu to a more vulnerable person that you come into contact with.

Please take a moment to review the Centers for Disease Control and Prevention's (CDC) advice about what to do if you get the flu. It has a helpful summary of flu symptoms and treatment, as well as warning signs of severe illness. If you have a mild illness, please stay home. If you have severe illness or are at high risk of developing complications contact your doctor immediately. Antiviral medication works best if taken in the first 48 hours after the onset of symptoms. Let's also all do our best to cover coughs and wash our hands frequently.

I wish you a happy and healthy year. Let's hope this flu season peaks soon and that your first achievement of 2015 isn't getting sick.

Learn more:

Severe Flu Cases on the Rise in U.S. (Wall Street Journal)

This season's flu activity has reached the epidemic threshold, the CDC says (The Washington Post)

Teen's death shows horror of flu epidemic (CNN)

Google Flu Trends for Los Angeles

The Flu: What to do if you get sick (CDC)

Weekly US Influenza Surveillance Report (CDC)

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

Does quality of colonoscopy depend on time of day?

Over the past decade, there has been renewed effort to increase the quality of colonoscopy. New data has demonstrated that colonoscopy quality is less than gastroenterologists had previously thought. Interestingly, colonoscopy is less effective in preventing colon cancers in the right side of the colon compared to the left side. Explanations include that some pre-cancerous polyps in the right side of the colon are more subtle to recognize and that the right side of the colon has many hidden areas that are difficult to visualize. New examination techniques and equipment are addressing these issues.

The goal of colonoscopy is not to detect cancer; it is to remove benign polyps before they have an opportunity to become malignant. A new measure of medical quality is to record how often gastroenterologists (GIs) remove polyps from their patients. For example, if a GI only detects polyps in 5% of patients, which is under the quality threshold, then someone will conclude that this physician is not diligent. So, now GIs may be scouring the colons to remove every pimple in order to reach threshold. While this may result in higher “quality” colonoscopies, will patients actually benefit? We don't know. Pay-for-performance and other quality initiative create opportunities and incentives to game the systems. Is our mission to help patients or to play the game?

An interesting issue regarding colonoscopy quality has been published in medical journals. GIs who are doing colonoscopies all day long lose their edge as the day progresses. It may be that that physician fatigue is a factor, or that afternoon patients are not as thoroughly cleaned out as morning patients are. This issue has been covered in the press and patients have asked me about it. I am not aware that my procedural quality is time dependent, but I haven't looked at my own data. I wonder what my optimal colonoscopy time slot is. Perhaps, I should run my data and then charge fees in accordance with my polyp detection rate. In other words, if a patient is seeking a bargain colonoscopy, then he gets the last slot of the day. However, if a patient wants concierge medical quality, and is willing to put some cash on the line, then he'll get scheduled accordingly.

I wonder if other medical specialties, including primary care, experience quality decay over the course of the day. I am interested if any physician readers are aware of published data on this issue or can share relevant personal experiences.

The lessons gleaned from the lower portion of the alimentary canal may apply beyond the medical arena. Do other professions perform better in the morning than they do in the afternoon?

Here are some studies I propose, which can be funded in our government's usual manner: borrow.

Profession vs. Quality Measurement per Shift Hour
Policeman vs. Arrest Record
Thief vs. Successful Robberies
Financial Advisor vs. Profitable Advice
Politician vs. Promises Kept
Stage Actor vs. Lines forgotten
Judge vs. Decisions Reversed

Since pay-for-performance is the panacea that will cure the medical profession, why shouldn't we share it with the rest of you?

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, January 21, 2015

Infectious diseases and the terrible, horrible, no good, very bad match

Here we go again. Another internal medicine subspecialty “match day” and another record (bad) day for infectious disease as a subspecialty. How bad? The previous record (set last year) for unfilled ID programs was 54. This year 70 programs went unfilled, meaning that for the first time ever there were more programs that didn't fill than that did. Almost 100 funded ID training positions unfilled in a single year!

We've blogged about this trend before, here and here, and discussed some of the reasons that ID is in decline as a specialty (along with some suggestions for how to turn this around). I don't have any new insight, except to make the point that this is now beyond a crisis situation for our specialty. It's a dumpster fire.

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.
Tuesday, January 20, 2015

The world will end in 2050 because of resistance

UK Prime Minister David Cameron requested a review of the health and economic burden of antimicrobial resistance in July. Quicker than you can say supercalifragilisticexpialidocious, economist Jim O’Neill has delivered his report and the results are surprising (at least for those who don't follow this blog).

Utilizing commissioned studies from KPMG and Rand Europe, the Review estimates that the economic losses attributable to antimicrobial resistance will total $100 trillion and 10 million excess deaths will occur annually by 2050. In fact deaths due to resistance will surpass other major causes of death even the 8.2 million due to cancer. Of course, cancer deaths might rise due to the fact that we can no longer safely give chemotherapy without effective antibiotics. The report covers these issues in a sobering section titled: ”The secondary health effects of AMR: a return to the dark age of medicine?”

Good times.

The independent review will outline recommendations for an international response by 2016. Just for reference, $100.2 trillion is 6 times the size of the U.S. Gross Domestic Product for 2013. Perhaps this will wake up the world to antimicrobial resistance?

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, January 19, 2015

Shared accountability

There are plenty of good reasons why thoughtful physicians are often unhappy with the current approach to measuring the quality of care they provide. Some, of course, object to the whole notion of quality measurement, but I believe they are in a shrinking minority clinging to an anachronistic mental model in which each physician defines for himself what constitutes high quality care. I have addressed this previously. But even those, who like me, believe it is essential (and possible) to measure quality, can point to legitimate shortcomings in the way it is done.

Among these shortcomings is the imperfect process by which individual physicians' “results” are “adjusted” to account for differences in the patients they care for. In the simplest case, when the quality of care is judged by looking at patient outcomes, this risk-adjustment is meant to reflect the fact that clinical outcomes reflect both the baseline characteristics of the patients being treated and the treatment they get. For example, if one were to use in-hospital mortality rates to assess the quality of care for acute myocardial infarction, it would be essential to know “how sick” the patients, on average, were on presentation. A 50-year-old man with a small inferior wall MI is likely to live even in the absence of good care (or any care for that matter), whereas a 90-year-old woman with cardiogenic shock from an anterior wall MI is likely to die even with state-of-the art care. Any attempt to assess the quality of care for a population of MI patients must take this into consideration.

There is a more subtle way in which patient characteristics play into quality measurement schemes, even when the measurements are about processes of care instead of patient outcomes. In this construct, providers are assessed by how often patients eligible for some service or intervention actually get it. Did the patients with diabetes get fundoscopic exams? Did the women in their 50s get mammograms? Are the patients with coronary heart disease all on aspirin? Here it is easy to prospectively define exclusion criteria, which are meant to mimic reasonable clinical decision-making, and shield the provider from a “grade” that really reflects unmeasured differences in patient populations. For example, it would not be reasonable (or be indicative of high quality care!) to give aspirin to a patient with an aspirin allergy, so patients with aspirin allergy are excluded from the denominator, and the provider is not judged harshly for a “failure” to prescribe it. So far, so good. This gets a whole lot trickier, however, when trying to figure out how to handle instances where care is recommended, but not done. What happens if the patient is advised that she should have that mammogram, but doesn't get it?

Assuming for a moment that it is possible to accurately distinguish between a failure (on the part of the physician) to recommend and a failure (on the part of the patient) to adhere to the physician's recommendation, who is responsible for the latter? On the one hand, it seems pretty straightforward: the “right” care was recommended, and the patient failed to take good advice, so this can't possibly be used to judge the care the doctor provided, right? Well, maybe so, but maybe the patient didn't take the recommended course of action because the doctor failed to explain it in a way the patient understood, or because the patient couldn't access the recommended service, or because the patient experienced a side-effect that the physician did not elicit. In these instances, accountability is shared by patients and their physicians.

This idea of shared accountability was recently addressed by a joint committee of the American College of Cardiology and the American Heart Association. These organizations have been collaborating for years to produce clinical practice guidelines. The guidelines, in turn, have been used as the basis for a wide range of performance measures, which have been used to assess the quality of cardiovascular care. The published “statement” is a thoughtful consideration of how to balance the interdependent responsibilities of clinicians, patients and systems of care. I urge you to read the whole thing. Once you do, let me know what 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.
Friday, January 16, 2015

Thoughts about tropical medicine in South Sudan

After returning from the Republic of South Sudan, where I spent about 3 weeks, jet lag is fading, and in time I may even stop complaining about how incomprehensibly bad the Juba airport was. Overall the experience was great, though.

My intention was to spend 2 weeks with my friend Jill Seaman, a doctor who has been working in Sudan for decades, primarily fighting tuberculosis and visceral leishmaniasis by establishing and pushing treatment protocols. Jill now helps run a community hospital in the (usually) tiny town of Old Fangak, on the Zeraf River. The hospital serves a community that usually numbers a few thousand along with anyone who can make their way there, but now Old Fangak has become a busy metropolis of over 30,000 people because of the many people who have fled their homes due to fighting. My job was to help out with patient care and teach bedside ultrasound.

The other week of my 3-week trip is how long it takes to get to and from Old Fangak. I only got 10 days there, as it turned out, since the government has become more strict about flights to and from that area because it is a hot spot in their civil war. South Sudan is a new country, having gained its independence from Sudan in 2011. There was relative peace until last December, when violence broke out in the capital between supporters of the ousted vice president and the president over policy disagreements. Since the vice president was from the second largest tribe, the Nuer, and the president was from the largest tribe, the Dinka, the disagreement became a tribal conflict in outlying regions, and has been bloody and destructive. South Sudan has had lots of civil war, and this situation is more the norm than peace, which was sort of present for 2 years after independence.

My last visit to South Sudan was a year ago, right before the new civil war broke out, and my timing in leaving was close to perfect, since the whole place became hellish a week after I departed. This time the war was pretty close to Old Fangak, but its isolation, with no passable roads and only access by river, made travel there pretty safe. Still, much of the medicine this trip had to do with wounded soldiers. There was also the usual constant stream of the medically ill and occupationally injured, with their tropical ulcers, parasitic diseases, diarrhea and fevers. Complications of starvation will set in more substantially due to disruption of farmers and cattle herders, but presently food aid from organizations such as the World Food Program is keeping this partially at bay.

When I got back, the Christmas holidays were quickly approaching. Family from far away were going to descend on our house, and I had piles of journals and notes and bills and certificates on important horizontal surfaces. While taking care of these, I found the notes I took from a brief DVD course in tropical medicine, released by the Mayo Clinic, that I took last year. I don't actually have a place to put hard copy notes where I will see them again and learn from them, other than coffee tables which would look way better without stuff all over them. So I am going to combine what I learned in South Sudan in Old Fangak with my notes as a way of remembering stuff. Here goes!

Poor nutrition, homelessness, poor sanitation and stresses underlie most of the conditions we saw. The vast majority of illness and injury we saw were preventable by clean and adequate water supplies, food and shelter security, good prenatal care, waste disposal and non-violent problem solving. There were almost no uncomplicated conditions.

We saw patients in several situations. There were the inpatients, who had beds or pads on the floor of the hospital buildings and were given mosquito nets. They were usually the sickest patients, with problems that were life threatening and sometimes without easy solutions. There were patients with wounds, who were living either somewhere in the compound or in the surrounding village and would come in for dressings and sometimes minor surgical procedures. There were clinic patients who came to the morning, afternoon and evening clinics, staffed by local clinicians (nurses, clinical officers and community health workers) and sometimes by a doctor. Patient visits in clinic numbered around 200 per day. Some of these became inpatients. There were patients with conditions that required less intensive observation but which required long treatment courses, such as tuberculosis, nephrotic syndrome, Kala Azar and Brucellosis. These are exotic and rare in the U.S. and common as dirt in Old Fangak.

Malaria is the most likely cause of high fever. It is the treatable cause which needs to be ruled out first. The test we use is a “paracheck,” which is a rapid diagnostic test based on presence of malaria antigens. A drop of blood from a fingerstick is placed on a plastic stick with absorbent paper inside, a drop of fluid is added and lines appear in a few minutes indicating a diagnosis of malaria. This is similar to a urine pregnancy test and can be done in the clinic or at the bedside while the patient waits.

The commonest form of malaria by far in Old Fangak is Plasmodium falciparum, the most severe and acute variety. It can present with metabolic acidosis, shock, coma, renal failure, even ARDS. In Old Fangak it can have all kinds of associated symptoms especially nausea and vomiting with diarrhea. Most cases can be treated with oral Artemisin combination therapy, though cerebral malaria and other severe presentations are treated with intravenous medications. Somewhat less severe versions of malaria are caused by Plasmodium vivax, ovale, malariae and knowlesi (usually in southeast Asia) and these have different fever patterns. The Anopheles mosquito transmits malaria and is controllable with elimination of standing water (mostly impossible) and use of insecticides. Since these mosquitoes primarily bite as evening falls, use of mosquito bed nets, especially for children, drastically reduces malarial disease. Pregnant women are treated monthly during their first trimester with Fansidar (Sulfadoxine/Pyramethamine) because they are more susceptible to the disease and because it can cause miscarriage.

Visceral Leishmaniasis, also known as Kala Azar, commonly presents with prolonged fever, enlarged spleen and liver, sometimes with diffusely enlarged lymph nodes, and bone marrow involvement which can lead to anemia and low platelet and white cell counts. It often coexists with HIV infection, though not so much in Old Fangak where HIV is still relatively rare. It can be diagnosed with a rapid diagnostic test which detects rK-39 antibodies and is about 80% sensitive. If this is negative, a DAT (direct agglutination test) is performed which should detect 95% of cases. A lymph node aspirate can detect the actual organism, which is helpful when the immune response is not vigorous, like with HIV coinfection. It is about 60% sensitive, and can be used for detection of recurrence, unlike antibody and agglutination tests. Spleen aspirates, also useful in recurrence, have sensitivities as high as 95%.

The lab staff is capable and confident in performing lymph node aspirates, which in the U.S. would be a great big deal, and splenic aspirates are performed at the bedside in patients without significant bleeding risks, quickly and nearly painlessly, with vanishingly rare complications. The specimen is smeared on a slide, giemsa stained and examined for the tiny protozoans which look like an eyeball with a dot and are about the size of a platelet. The disease is usually treated with sodium stibogluconate (SSG) and paromomycin injections for about 3 weeks, which often cause nausea and vomiting and can also cause fatal heart arrhythmias and kidney problems. A less toxic but much more expensive option is liposomal amphotericin B which is given intravenously on an intermittent schedule, usually over 21 days. This is used for resistant or recurrent cases and in patients who don't tolerate the SSG/paromomycin regimen.

Back pain and tenderness, prolonged fever with weight loss, chronic arthritic joints in children, unexplained chronically enlarged lymph nodes, especially with fluid collections inside and cough with fluid around the heart or lungs is usually tuberculosis and requires prolonged residence at or near the hospital compound for directly observed treatment. Treatment of TB is effective and lifesaving and most patients comply with medication therapy which is impressive. Worries about contributing to multi-drug resistant tuberculosis slowed the development of programs to treat the disease, but at Old Fangak people are getting appropriate therapy along with nutritional support, blankets, mosquito nets and sometimes shelter and are being cured of their TB.

Nausea, vomiting and diarrhea could be anything, but is often Giardia. In many areas of Africa good sanitation has made this uncommon, but it is pretty rampant at Old Fangak. Despite aggressive latrine construction, babies and children, especially those with diarrhea, leave Giardia parasites everywhere, and though both Sudanese and Americans are clean and tidy in their own homes, the hospital compound seems to be covered with a thin layer of filth. Most floors are dirt. The floors that aren't dirt are mopped daily, but walls are not and small islands of cleanliness do not make a huge overall difference in infection control. Giardia is treated with tinidazole which tastes horrible and is slightly nauseating. It seems that, improbably, most children actually take it when it is prescribed.

Schistosomiasis is probably nearly universal, since most people swim and bathe in the river, which carries the parasite to the skin of the human host, which it penetrates to cause infection. Schistosomes are blood flukes which can affect most body systems, but schistosomiasis is usually either assymptomatic or associated with symptoms that are hard to notice, such as discomfort with urination or fatigue from chronic iron deficiency. The 2 types present in Africa are mansoni and haematobium. Mansoni is famous for causing portal hypertension with symptoms of liver failure, but more commonly causes chronic intestinal distress and intestinal blood loss. Haematobium is known for causing scarring and sometimes cancer in the bladder. The eggs can be identified in urine or stool, but in Old Fangak it is most often treated when patients present with classic symptoms, since most people are likely chronically infected. Reinfection is nearly impossible to prevent, though in some countries routine and repeated blanket treatment has been tried. Praziquantel, as a single dose, is usually effective in clearing the disease, and is sometimes used prophylactically for children at high risk.

Tapeworms and roundworms are surprisingly rare in our little community, but with the influx of internally displaced people that equation may be changing. These are pretty easily treated with a single dose of a pleasant tasting tablet, albendazole. They can cause intestinal distress and malnutrition and are associated with poorer school performance. I did see one case of an overwhelming infection with Strongyloides stercoralis, a roundworm, in a young woman who was chronically ill with kidney failure and vomiting who had tiny worms in her urine. Despite appropriate treatment, she died. Once this infection becomes so widespread it is hard to eradicate and usually implies an associated immune dysfunction. Malnutrition and kidney failure might have been what made her vulnerable.

Brucellosis is a disease carried by cows and dogs and transmitted to humans primarily through contact with their urine and feces. The cows, which are a common form of wealth and currency in South Sudan, are heavily infected. A vaccination program could be very effective in reducing cow morbidity (primarily abortion and infertility) as well as human disease but hasn't been tried. Ongoing civil disruption due to war gets in the way of all sorts of good ideas.

Brucella causes recurrent fevers with nausea and vomiting and overall feeling miserable and can persist for years, causing chronic arthritis of the large joints and the back. Most infection is assymptomatic. It can affect the skin, with rashes, the eyes, causing inflammation and blindness, bladder, testicles and ovaries, lungs and brain. It is diagnosed in the lab with a serum agglutination test and treated with 6 weeks of doxycycline along with 2-3 weeks of gentamicin, which is usually given as a rather painful intramuscular shot. It frequently recurs.

Chronic kidney disease with nephrotic syndrome is surprisingly common and probably related to ongoing immune system activation by repeated infections of various kinds. This is treated with a slow taper of prednisone, which sometimes works. Patients usually present with facial and leg swelling along with frequent urination and fatigue. There is a fingerstick monitor of the creatinine level, something I haven't seen in the U.S., which is the only available way to document the status of a patient's kidney function. High blood pressure is treated appropriately which helps in recovery or at least to slow the progression of disease. Endstage kidney disease is right now a terminal diagnosis since there is no available dialysis or kidney transplant available to these people.

Late stage cancer is surprisingly common. There was a 17-year-old boy with a tumor in the chest that had displaced his heart to the right chest cavity and obstructed blood flow into the heart. It was likely a mediastinal germ cell tumor, since this is not terribly uncommon in young men. It is quite sensitive to chemotherapy, even curable, but this person presented at such a late stage that he would have been lost even in the U.S. He had been in bed close to a year, had deep bedsores and legs which no longer would straighten. He had devoted parents and a winning personality. He died after a week in the hospital.

There was a man who came in unable to swallow. This had progressed over a year, but his esophageal cancer (visible on bedside ultrasound) had now completely obstructed his swallowing and, though he would receive some intravenous hydration, there was nothing we could do for him. In the U.S. he would likely have died, but would have had palliation with radiation therapy and a feeding tube. Esophageal cancer is common in East Africa. A woman returned to clinic after having received radiation and chemotherapy for a tonsillar cancer that turned out to be a lymphoma. With advice from doctors who were friends of Jill's, she received appropriate therapy and was free of disease when she returned.

A beautiful young man had a deep and fungating wound of the right groin that was foul-smelling and liked to bleed. It appeared to be a squamous cell carcinoma, but we did biopsy it and results are pending from Nairobi. He could get radiation therapy for palliation if transport could be arranged and if he is able to survive that long.

Tropical ulcers are very painful and appear usually on the lower legs after minor trauma. They are inhabited and probably caused by a collection of bacteria and can cause bone infections and even cancer if untreated. These are very common, and are treated with dressing changes, debridement and antibiotics. Presently we are using gentian violet topically which seems to speed healing. War wounds often cause extensive tissue damage and are treated with dressing changes and sometimes delayed primary closure once they are clean and healing. They can be disfiguring and painful. I tried a combination of guar gum (a component of many high tech wound dressings) with powdered antibiotics for some of the more weepy wounds. This was popular with the patients but I wasn't there for long enough to see if it improved healing. It did appear to reduce evidence of infection.

Pneumonia, especially in kids, and diarrhea with dehydration in babies accounted for a reasonable amount of sickness. Most pneumonia is treated, successfully, with amoxicillin, some with ceftriaxone, and diarrhea was treated with oral and sometimes intravenous rehydration, with treatment for the specific cause if that became at all clear, often with antimalarials or antibiotics. Runny nose with runny eyes, especially in the presence of rash was measles and often quite a severe disease in small children. Most medical missions take vaccination of children quite seriously, but most remain unprotected.

In the U.S. I normally see complications of heart failure and vascular disease, primarily related to smoking and obesity, diabetes and its sequelae, chronic lung disease, again related to smoking and infections that are often complications of IV drug abuse. I also see the devastations of extreme old age with dementia worsened by urinary tract infections or pneumonia. None of this is common in South Sudan. In the hospital at Old Fangak the common conditions are about as diverse as I see at home, but the options for diagnosing and treating them are much more limited. For me there was quite a steep learning curve.

Staff from the community who have little or no formal medical training do a tremendous amount of the work, including diagnosing and treating very significant and, for me, exotic diseases. This is made possible by protocols developed by generations of doctors, including ones working with Doctors Without Borders and especially Jill Seaman who has been doing this kind of thing for a really long time. When no Americans are present, Kala Azar, tuberculosis, brucella and many other diseases are treated effectively and followed appropriately by South Sudanese health workers. They could certainly use more training, but I am in awe of their skills. I saw one of them put an IV in a dehydrated baby with no difficulty which I doubt could have been done with such skill in a U.S. hospital. With access to medical and nursing school, which they do not have, their potential would be tremendous.

Working in Old Fangak is something that doctors dream about. It is expensive to travel there and disruptive to my work schedule, and there are all kinds of diseases that are easy to pick up. There are grouchy people with AK47's wandering around looking twitchy. The medical care requires flexibility and is often incredibly frustrating when lack of resources makes it impossible to solve a problem that is so very soluble if only the situation were different. Still, the company was excellent and the patients were great and the attitudes and skills of people working there were inspiring. It was deeply fulfilling, I learned a ton and have a bunch of great stories. Also … hooray, I didn't die!

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.

How information technology has made health care (just a little bit) better

Health care information technology really has a long way to go before it lives up to its promise of truly improving healthcare. Having written a lot about the pitfalls (which I will continue to do, because it's important we address them) including reduced efficiency, less thoughtful medicine, and worst of all decreased human contact with our patients—I thought I would write about where IT has actually made things a little better.

I had a conversation at a hospital medicine meeting recently with a former colleague, a wonderful Chief of Hospital medicine who served as my mentor when I first became an Attending physician. I was telling her my thoughts on the suboptimal state of health care IT, and while she agreed, she then started telling me about how she thought the changes over the last several years may have actually improved hospital medicine in several ways as well. We discussed this in detail, and yes, it made me reflect on the fact that there are many good things along with the bad. Here are some of them:

1. No more paper charts

Who can ever forget those days of trawling through dozens of paper charts to get that elusive information we needed? Computers save so much time when you're searching for certain documented notes and test results. Furthermore, paper charts are also hard to locate on hospital floors, and doctors would often need to circle the unit several times to find it! Nowadays—just go right to any computer to access the chart. Not to mention it's much better for the environment as well to not to be using so much paper.

2. No more hand written forms

In the past, admitting a patient to hospital would mean that the doctor or nurse had to manually fill out reams of paper forms. Not anymore.

3. Remote access

Paper charts meant that the doctor would have to physically go to the specific unit to look at the information they required. Now this can be done from any computer in the hospital and even from your own home if doctors are called late in the evening.

4. No more doctors' handwriting issues

Enough said, we all have a story here to tell. The days of unit secretaries asking everyone on the floor: “What does this medicine look like to you?—are over.

5. Clearer doctors' orders via computerized entry

Fewer ambiguous orders that may not reflect best practice standards or correct medication dosages.

The above 5 points are worth reflecting on every time physicians and nurses (understandably) feel frustrated by some of the current crop of unwieldy and inefficient systems. If we can just make these better, magnifying the obvious good and minimizing the very apparent bad—while keeping human contact at the heart of health care—we will be on the right track.

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.