Friday, February 27, 2015

Vaccinations, measles outbreak and reasonable and civil discourse

Lately there has been an outbreak of measles, a vaccine preventable disease, along with an outbreak of people yelling at each other. There have been angry exchanges between people who would like all children vaccinated according to the recommended guidelines and people who support the rights of parents to choose which vaccines to give their children, if any, and when to give them. There has been much focus on the assertion, particularly, that the Measles/Mumps/Rubella vaccination (MMR) might cause autism. There is no believable evidence to support that assertion, but the questions of whether vaccination is safe and whether it should be required are much more interesting.

Yay vaccines!

I am a big fan of vaccination as a means of fighting disease. It is an ingenious concept. The recipient of a vaccination gets an injection or oral dose of a weakened virus or bacterium or an inactive part of one, which causes the body's own immune system to produce cells that will recognize and kill the real virus or bacterium if it enters the body at some future date. Vaccinations are so much more elegant than antibiotics, which are chemicals that are broadly active against a whole bunch of different agents and only last until the body inactivates or excretes them. Vaccines stimulate the body's own very complex and amazingly effective systems for fighting infection in much the same way that natural infections or exposures would. These systems are then available to prevent disease whenever the need arises.

Herd immunity, that's how vaccines eradicate diseases

Vaccines are ingenious at the individual level, but they are even more ingenious on the level of populations. A vaccine raises an individual's resistance to a disease, but each individual is still somewhat vulnerable to that disease because the body's defenses are not absolute. Some vaccines are more effective than others, and some people have a more robust response than others. Infectious diseases persist in our communities because they move from one person to another. If the vast majority of people in the community are immune to a disease, as can be achieved with vaccination, the disease cannot be transmitted and will die out. The few people in the population who are not immune are protected by the many who are since the likelihood of coming into contact with someone with an active infection in such a community is very low. This effect is known as “herd immunity“ and is one of the primary reasons that we should care about whether other people get vaccinated.

Curing smallpox

The word “vaccination” comes from the word root for cow, since the first vaccine in common use was derived from cows to fight smallpox. It had been observed that dairy maids who were infected with cowpox, a pustular disease, from touching the udders of infected cows did not get smallpox. In 1796 the physician Edward Jenner created a vaccine from that virus which became widely used. In 1979, smallpox, which killed as many as 500 million people in the 20th century alone, was declared eradicated. The vaccine was mandatory for school children, and I'm pretty sure I got it when I was a kid. It usually left a little scar on the upper arm but otherwise only rarely had side effects. Once in a while, when a child had something that predisposed him or her to more serious infections, the vaccination would cause an overall body pustular rash which was very nasty. The vaccine is no longer in common use, but still exists, especially for preventing the tropical disease monkeypox, which is similar to smallpox but milder.

Goodbye, polio

Other vaccine successes include polio, which was a virus that primarily infected children via the fecal-oral route, and caused paralysis, which was often fatal or disabling for life. The first vaccine was produced by Dr. Jonas Salk and was an injectable dead virus, and the second, close on its heels, was an oral vaccine that was a live attenuated virus (meaning it resembled the active virus but didn't cause polio.) Polio has been wiped out in most developed countries now due to vaccination, though it still breaks out in countries where vaccination is less common.

Measles, mumps and rubella

The measles vaccine was first licensed in 1962 and improved in 1968. It was combined with vaccines against mumps and rubella to create the MMR in 1971. It is estimated that the vaccine, in its first 20 years, prevented 52 million cases of measles, 17,400 cases of mental retardation due to measles effects on the brain, and 5,200 deaths.

Measles causes fever, runny eyes and nose, a cough, a typical spotty rash and sometimes sore throat and spots in the mouth. I saw a case in Africa in a very miserable infant who probably had measles related pneumonia and had a reasonable chance of dying of the disease.

Globally, measles vaccination has had a staggering impact. In the year 2000 it is estimated that over 700,000 people died of measles, primarily children, making it the 5th leading cause of death in kids. With a UNICEF backed measles immunization strategy, measles infections and deaths were reduced by 74% by the year 2010. Africa and India are major measles hot spots. There is no specific treatment for measles, so the only thing physicians can do is support the patient with fluids or oxygen if necessary and try to make sure the disease doesn't spread to others who might be vulnerable. Measles is very contagious. The vaccine, however, is very effective in preventing the disease. Rubella is another spots and fever disease, and can cause serious birth defects if a pregnant mother is infected with it. I had that one when I was a wee child and it didn't seem too bad, but I hope I didn't infect any pregnant people. There was no commonly available vaccine at that time. Mumps is a virus that causes swelling of the lymph nodes and can infect a young man's testicles, sometimes resulting in infertility. The vaccine is quite effective in preventing it, but not nearly as good for mumps as it is for measles.

Autism connection? Nope.

MMR is the vaccine at the center of the present controversy. In 1998 Andrew Wakefield, a gastroenterologist in England, reported 8 cases of children who developed autistic symptoms and gastrointestinal symptoms within 1 month of receiving the MMR vaccine. He proposed that the vaccine was causative, despite the fact that there was no obvious reason why it should be and there was no increase in cases of autism in the period after the MMR vaccine was introduced in England. His data was later questioned and thought to be fraudulent and the paper was retracted. Many studies have been done since then and have not shown any believable evidence that MMR causes autism, yet there are many people who still believe the vaccine/autism connection. Autism does present in early life and vaccines are given in early life, so a reasonable parent with a child who develops autism might suspect that the vaccine caused the autism, even though it did not.

But wait … not necessarily all good

Although it seems pretty clear that MMR doesn't cause autism, vaccines are not all benign and there are many diverse vaccines in common use. In the first 18 months of life the Centers for Disease Control recommends that a child receive about 24 immunizations, if I am reading this chart correctly. If successful, the vaccinations might prevent pneumonia, hepatitis, meningitis, chickenpox and the shingles that can follow in later years, tetanus, which can be fatal, whooping cough, most ear infections and rotavirus gastroenteritis. Also, of course, measles, mumps and rubella.

But this is a lot of shots. Each one might cause muscle aches, listlessness and injection site redness and swelling. Children also often cry really hard and want never to go back to the doctor's office. The shot that prevents whooping cough can occasionally cause high fever and seizures and sometimes, though rarely, results in a temporary floppy unresponsive state that can't be a good thing. The reformulated version of this, which has been available for decades now, is less likely to cause these side effects, but the reactions still occur. The rubella part of the MMR can cause chronic arthritis in adults who are rubella immune if they receive MMR to boost their measles immunity.

Other vaccine greats

There are also immunizations for older children and adults which are just as miraculous and just as much of a concern with regard to side effects. These are recommended for various subgroups and situations, but not required for school aged children. This is a list of all of the vaccines available in the U.S. One of my favorites on this list is the chickenpox vaccination. I must have been an odd and solitary child because I never got chickenpox. My twin got it when she was in her 20s and was really sick. She still has scars from it. Chickenpox is usually an annoying skin rash, with lots of small blisters that scab after a few days, but those little blisters can occur in the mouth and esophagus which makes eating and swallowing very difficult, and the virus can cause severe pneumonia.

When I was in my 30s they released the chickenpox vaccine and I got one. Since that time I have been exposed to chickenpox, which is incredibly contagious, many times without getting the disease. This means that I, and the generation of children that have gotten that vaccine will never get shingles, which is a reactivation of chickenpox which causes pain and skin lesions, sometimes with lifelong pain and scarring. Despite the fact that the flu shot is sometimes disappointingly ineffective, I happily submit to it yearly because the flu is such a nasty disease and vaccination lowers my risk of getting it or makes it less severe if I do.

The human papillomavirus (HPV) vaccination is also a winner. It is indicated in girls and boys to prevent genital warts that can cause cervical and penile cancer. It is still expensive and hasn't been embraced universally yet, partly because genital warts can also be prevented by having only one sexual partner for life and making sure that he or she has never had sexual contact with anyone else. Some parents forego the vaccine for their children because they believe that this will be achievable. Cervical cancer kills 4,000 women yearly and results in fertility threatening surgery and treatments in many more. The HPV vaccine could prevent these outcomes and potentially also make the dreaded pap smear obsolete.

Yellow fever: not without its problems

The yellow fever vaccine is both wonderful and terrible. In the 1600s yellow fever came from Africa to the Americas and eventually to Europe with captured African slaves. Yellow fever is so named because it causes liver failure with jaundice. It also causes nausea, vomiting, kidney failure and diffuse bleeding. It killed more soldiers in the Spanish American war than battle injuries. It slowed work on the Panama Canal and infected people in Boston and other U.S. port cities.

In the early 1900s it was found to be caused by the bite of the Aedis aegyptimosquito and mosquito control led to significantly better control of the disease. It was still a considerable problem in places where mosquitoes could not be controlled so a vaccine was created in 1930 which has been very effective in reducing disease. Travelers to parts of South America and Africa are still at risk, as are residents. Unfortunately the vaccine can rarely cause a version of yellow fever in some people and can cause a fatal inflammation of the brain. The newer version of the vaccine is less likely to cause these side effects, but they can still occur. Despite the known side effects, travelers to many countries need to provide proof of vaccination in order to enter if they are arriving from an area with known risk of yellow fever.

The Swine Flu debacle

In 1976 there was an outbreak of swine flu (H1N1 influenza) in Fort Dix, N.J. One army recruit died, and there was fear that this virus, which was similar to the one that caused the influenza pandemic in 1918, would spread across the country. In fact, the only infections were at Fort Dix and 40 million Americans were vaccinated against it, resulting in quite a number of cases of Guillain-Barre syndrome, an immune mediated paralysis that can result from both infections and vaccinations. On the bright side, apparently immunity from that vaccine did last until the most recent pandemic in 2009, so the folks who got that vaccine were less likely to come down with our most recent H1N1.

Where do we stand, legally?

The laws about vaccinating children differ by state. All states require some vaccinations in order to attend school, but some states offer exemptions, not just on the basis of medical issues such as immune system diseases, but on the basis of parents' religious or philosophical beliefs or values. With the recent measles outbreak, children who did not receive measles vaccination are being kept out of school, and some schools in California have reported up to 65% of students not being fully vaccinated due to their parent's objections. Some suggest more stringent requirements for vaccination, eliminating exemptions on the basis of religious or philosophical beliefs. West Virginia has already taken this step and several other states have only medical and religious exemptions.

Stupid people? Not so fast …

So are “anti-vaxxers” stupid and selfish? I don't think so. At least not necessarily more so than anyone else. Some of their concerns are not really valid, like worrying about the presence of tiny amounts of mercury as a preservative in some vaccines (hardly any now) and the possibility that multiple vaccines given at the same time will overwhelm the immune system (it's actually built for that: picture what happens when a child eats a handful of dirt.) There are some reasonable arguments against vaccinating ones children, even though I may not agree with them. Since vaccination protects the population and because it can be a big money maker for clinics, pharmacies and drug companies, it would not be surprising if we didn't hear much about occasional side effects. So suspicion is not entirely unwarranted.

As a loving parent it is hard to be a party to 24 immunizations before the age of 18 months, especially since most of them involve sticking a needle into tender baby flesh. When a disease, like measles, seems to be vanishingly rare, how wise is it to expose one's children to an immunization which definitely has associated side effects (though not autism)? Some of the parents who reasoned in this way now have children with measles and many more have children who aren't able to attend school because they are not vaccinated. Are they selfish? They probably didn't think they were, but the vaccine isn't 100% effective and it isn't given until after a child's first birthday, so infection with measles does put other children, especially babies, at risk of measles and its complications.

Civil discourse—perhaps we should give it a try

How do we, as a society, want to deal with this issue? Americans are fiercely individualistic compared to many other countries, and we usually tell the government that they have no jurisdiction when it comes to our personal decisions. We draw the line (but it's a very wiggly one) at personal decisions that put our children or other people at risk. That's how our rules about vaccination came about in the first place. We, as physicians and nurses, now tell people about side effects of vaccines at the time they are administered, but we don't, in fact, allow them to refuse them for their children unless they also want to opt out of public school, except in the case of religious or philosophical beliefs. Do we want to close those loopholes as well?

What we really ought to do is have civil and respectful conversations. We should carefully weigh both the value of controlling vaccine preventable and otherwise untreatable diseases against the actual observed side effects of vaccines. We want to support scrutiny by organizations that have as little vested interest as possible, such as the CDC. We want both sides, vaxxers and anti-vaxxers to avoid black and white thinking.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

The very palpable doctor shortage and how to help solve it

The nationwide shortage of physicians is a very real crisis across all 50 states, causing a huge strain at all levels of health care. Hospitals and clinics are struggling to hire, current physicians are overworked, and ultimately patients are having to wait longer. There are number of reasons why this has happened, but one thing's for sure: with the ageing population, the problem is only going to get worse.

One estimate from the Association of American Medical Colleges predicts that the shortfall could be as high as 90,000 doctors by 2020. The problem is most acutely felt in primary care, but many hospital-based specialties are also in short supply in certain geographic areas. A number of alternative solutions have been proposed, including increased use of other professionals, including Nurse Practitioners and Physician Assistants, and allowing patients to see primary care doctors through non-traditional routes such as standalone “retail clinics”.

Before we discuss any further, let's focus here on why there is such a shortage to begin with. After all, it may seem bizarre at first glance when you consider that so many people apply to medical school to become doctors and that the number of medical graduates is at an all-time high. So why the shortage? One of the main reasons is that over the last couple of decades, American medical students have understandably been drawn to much more lucrative niche specialties, including radiology, anesthesia and dermatology. As well as the lower pay, primary care is also widely perceived to be a significantly more stressful career choice compared to these other specialties, with mountains of paperwork and bureaucracy to navigate, and never mind an increasing need to see more patients in less time.

The other very real problem is that the number of residency slots for newly graduated physicians to train in internal and family medicine, has not budged over the last 20 years. This at the same time the U.S. population has increased by almost 50 million. It doesn't take a mathematician to work out how this quickly becomes a problem. In fact, the number of residency positions has remained the same since the Balanced Budget Act of 1997 (when Bill Clinton was still President), which set a broad limit on training positions according to what Medicare would fund.

At the current time, there are actually hundreds of physicians out there who are qualified to enter residency, but have not been able to find internal medicine or family medicine residency slots. That's a travesty at a time of such a shortage. Many of these would undoubtedly make fine practicing doctors who would serve their patients well. Another congressional bill is desperately needed on the U.S. Capitol.

So here is a summary of the 3 things we can specifically do for primary care:
1. Make primary care a much more attractive career option for medical students.
Incentives should include generous loan repayment packages and sign-on bonuses to serve for a set amount of time. Fortunately this has already been happening to some extent in many places (I've encountered many more medical students telling me about these opportunities), but still, more is needed.

2. Drastically expand the number of internal medicine and family medicine residency slots, especially in universities affiliated with underserved and rural areas.
Medical school intake probably still needs to be expanded further as well (this shouldn't be a problem since the number of medical school applicants greatly exceeds the number of slots available). While we are at it, how about taking a serious look at the problem of medical school debt, which can easily exceed $250,000? Aside from the debt burden, this has serious downstream consequences including specialty career choice and ultimately driving up health care costs.

3. Substantially reduce the bureaucracy involved in the practice of primary care.
This push needs to start right at the very top if the government really wants a strong primary care sector. One example over the last decade of where things haven't gone according to plan is with the introduction of electronic health records, incentivized by the federal Meaningful Use program. Unfortunately, the technology hasn't yet lived up to its promise and has made life more inefficient and cumbersome for frontline physicians. We need to realize that less bureaucracy for doctors and more time to be productive and see patients is a win-win scenario. Concierge medicine, which is starting to take off, is one such way that physicians have found to eliminate the middle man, but hopefully this isn't the sole answer.

These are just 3 options for rejuvenating primary care. It is undoubtedly the backbone of any solid health care system. Other hospital-based medical specialties that suffer with shortages, such as hospital medicine and emergency medicine, will also need similar policies over the long-term.

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, February 26, 2015

Guns, steel, grit, and grief

Michael Davidson, the cardiothoracic surgeon shot and killed in Brigham and Women's Hospital last week by the distraught son of a woman on whom he had operated some time ago and who died in November, was a medical student of mine at Yale back in the early 1990s.

Some few of my former students, including our newly minted surgeon general, Vivek Murthy, became friends of mine, and we stayed close over the years. I didn't know Dr. Davidson that well, but seeing his photo in the Boston Globe, I certainly remember his face. It's a good face.

I can't speak to Dr. Davidson's character corresponding to that good face, but others can, and have. According to colleagues, he was one of the greats, the kind of doctor every medical student wants to be, and the kind of doctor every patient wants to have. By all accounts, including those of patients, he was deeply caring. He was thoughtful, expressive, and clear. Peers credit him with the grit to wield the steel of scalpels in situations where other surgeons would balk, great surgical skill, the brilliance of innovation, and an extraordinary work ethic.

In addition, Dr. Davidson had a life outside the hospital. That life, according to the Boston Globe, included a wife, also a physician, and three children, with another on the way. That baby, of course, will now never meet his/her father.

The story line of this tragedy is almost unbearably heart rending.

And there's more. The shooter, who also took his own life, left behind a complicated legacy of love, anguish and disbelief. He had four grown children, and siblings, who say he was nothing but a good guy who was devastated by the death of his mother, with whom he was very close. Rightly or wrongly, he blamed his mother's death on an adverse reaction to medication, and rightly or wrongly, he apparently implicated Dr. Davidson in the use of that medication.

From the information available thus far, it could be that the medication had nothing to do with the patient's death, and that Dr. Davidson had nothing to do with prescribing the medication. Either way, there is nothing in the record to suggest any misstep in the treatment; just a bad outcome. Unfortunately, sick people die sometimes despite all that modern medicine can offer, and even when everything is done right.

Of course, sometimes patients die because something is done wrong, too.

But accuracy about who did what, when, and whether or not it was appropriate is not a priority in a moment of anguished passion. Passion clouds the mind, and tenses the muscles, including those of the finger, on the trigger.

Admittedly, Mr. Pasceri might have hurt, or even killed Dr. Davidson without a gun. And he might have killed himself without one, too. But both scenarios are a whole lot less likely. Try to remember the last time you heard about a murder/suicide involving, for instance, a knife.

I myself was stabbed long ago, on a train while traveling in Europe. I fought back with no weapon, and lived to tell the tale. If my assailant had used a gun instead, I suspect it would have been the end of the line for me.

There is a bitter irony underlying this dreadful story that has torn holes in two families at least. The shooting took place in the hospital where our new surgeon general worked, prior to his confirmation. That confirmation was held up for months and months because Dr. Murthy had stated publicly that guns were a public health issue. So here we are, in the immediate aftermath of that long forestalled confirmation, and a current colleague and former classmate of the surgeon general was shot dead with a gun also used to kill its owner, in a health care setting.

The irony is too thick to cut with a knife; you would have to shoot through it. Of course guns are a public health issue, if suicide is; if bleeding is; if emergency surgery is.

The public discussion about who has guns when, where, and for what obviously includes rights related to the use of such arms. But it cannot exclude the right to life, liberty, and the pursuit of happiness, all taken from Dr. Davidson. It cannot exclude the need to do what is right.

A finger on a trigger in a moment of acute grief is very unlikely to result in the right thing being done. In a moment of aggrieved passion, beastly and beatific look the same; it's a particularly bad time to pull a trigger.

That makes it a bad time to be holding a gun. That's where my sad ruminations on this tale take me. Guns and acute grief make for a very bad combination.

Whatever my own beliefs and preferences, I am not currently challenging any contentions about the right to bear arms, or the value of guns in self-defense. I am merely asserting this: if liberal gun policies mean more guns carried by more people more of the time, the likelihood of a gun in the hands of any given transiently, passionately aggrieved person goes up. This is a statement of statistical fact. Guns and such grief are a volatile mix.

Killing any other way requires real intimacy, and that's hard. Guns don't kill, people do, we are told. But guns allow those people an antiseptic, insulating distance. They make killing easier, and more efficient. One's hands need not even get dirty.

And in that way, they can convert the kind of emotional devastation we have all felt at one time or another into an irrevocable tragedy such as played out in Boston last week.

Guns and grief are a bad combination. Our judgment is clouded and undone in moments of aggrieved passion; we are least suited at such times to take on the roles of both jury and judge, leaving aside the illegality of such vigilantism. We may, in the throes of passion, misconstrue causes and misdirect blame. But we may hope to live through such moments, and see in a calmer, clarifying light.

First, though, we need to live through such moments at all. Guns in aggrieved hands make that tragically less likely.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
Wednesday, February 25, 2015

Resident burnout--not fixed

An article in Academic Medicine has this conclusion: “Job burnout and self-reported sleepiness in IM resident physicians were unchanged after the 2011 DHRs at 3 academic institutions. Further investigation into the determinants of burnout can inform effective interventions.

This conclusion shows that the authors of the regulations and of this study do not understand the determinants of burnout. Burnout generally follows a lack of control. Changing work hour rules, if anything, worsens lack of control.

To decrease burnout we need a more fundamental residency reform. We need to convince hospitals that trainees are not slave labor. We need to convince attending physicians that micromanagement does not help residents grow.

The ACGME rules are not helping residents. They are not improving patient safety. They are likely impacting education.

They hamper continuity. They make attending physicians unhappy, and therefore because everything flows downhill, resident-attending relations often suffer.

We need to look at programs that are successfully addressing burnout before we speculate on ways to decrease burnout. We need to treat residents with proper respect. We need to remember what being a resident was like.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.
Tuesday, February 24, 2015

Measles vaccination: a response from Dr. Bob Sears

In my last post, I called for the licenses of anti-vaccination doctors. In response to my request, I received an e-mail from Dr. Bob Sears. I was asked to post it only in its entirety. However, in the long-standing internet tradition of “fisking” I will comment on it extensively. It begins: “I didn't read the story, but I can certainly speak to the question posed in the title. Although I am a pro-vaccine doctor, I don't think anti-vaccine doctors should lose their licenses.”

Whether or not Dr. Bob is “anti-vaccine” could be said to be a matter of opinion, but an examination of the facts based on his statements and writing leads me to conclude otherwise. I suppose it depends on what you choose to define as “anti-vaccine.” For my purposes, an anti-vaccine doctor is one who consistently recommends against following the science-based guidelines on vaccination for people who should otherwise follow it. In my opinion, Dr. Sears is most certainly anti-vaccine: “There are very few anti-vaccine doctors anyway. However, in America, as in most free countries, everyone is entitled to their own opinions, and doctors can choose to practice the type of medicine they wish.”

This is a non-sequitur. It doesn't matter so much how many doctors are anti-vaccine, but what effect these doctors have. A radiologist who is anti-vaccine is much less relevant than a well-known pediatrician. And certainly anyone is entitled to their own opinions, but not their own standard of practice. If I decided that amputation was the cure for all toe-nail fungus, I would and should lose my license, not because of an opinion but because of a dangerous and incorrect practice: “For example, most doctors of Chinese medicine don't offer vaccines. Neither do chiropractors, homeopaths, naturopathic physicians, and many other integrative and complementary practitioners. To say that such practitioners shouldn't be allowed to practice the form of medicine they wish to is prejudice against forms of medicine that are widely accepted in many parts of the world. Of course, we should also “do no harm,” and there are policies and practices put into place which prevent practitioners from providing harmful treatments.”

This is, in my opinion, either willful ignorance or stupidity, and I doubt Dr. Sears is stupid. I don't give a cricket's cloaca what various sorts of “alternative healers” do. It's not a matter of “prejudice” but “postjudice.” None of these “alternative” healing arts has anything to do with the scientific practice of medicine that keeps us alive and well. I'm sure a homeopath doesn't prescribe beta-blockers for heart failure either, but that doesn't make it right. We're not talking about chiropractors or auto mechanics here. If someone is a licensed physician and cannot follow basic standards of care, they need a new job: “But, in my opinion, failing to provide vaccines in a practice is not the same as “do no harm.” It's simply a more narrow scope of practice. I practice what is called allopathic medicine, which is the standard type of medicine that American doctors are trained to practice. I provide vaccines in my office every day. But I'm not so arrogant as to claim that my way is the only way, and I certainly acknowledge that these other forms of medicine are valid and have their place in our country and around the world, as does the American Academy of Pediatrics (which has a section on Complementary and Alternative Medicine).”

Hey, I'm a so-called “allopathic” doctor, too. I treat heart disease every day. My patients with heart disease take aspirin because it's the standard of care. I can't simply say, “Yeah, I treat heart disease but aspirin is outside my scope of practice.” That would be something else, like malpractice, say. It is most certainly not OK to hang out a shingle as a “homeopath” and claim to prevent influenza with vitamins and tinctures, but not offer flu vaccines. This argument is idiotic. I'm also curious what percentage of Sears' patients receive all their recommended vaccinations on time: “

Now, I would add that if your article is speaking more to those American-trained doctors who receive standard medical training, but then decide to be anti-vaccine (there are very few such doctors), I would still hold that they should not lose their license, and that they have the right to practice a scope of medicine that does not include vaccines.

—Dr. Bob Sears”

Dr. Sears and I obviously disagree as to what a doctor is. I certainly need to be free to choose treatments based on my patients' individual circumstances within the standard of care. If my patient has had a bad reaction to flu vaccines, I would advise against it. If they simply decline a flu shot, so be it. But if I were to advise them that flu shots “aren't for everyone” and are “often harmful” and then spout some unscientific nonsense as many do, I'd be a lousy doctor.

No doctor should ever be forced to offer services which they do not feel comfortable with. I don't do surgery, which is a very good thing. But if I have a patient who needs an operation, such as a gall bladder removal or an abortion, I refer them to someone who can help them. If an anti-vaccine doctor were to say (somewhat ridiculously) that vaccination is outside his scope of practice but he knows a guy who will take care of you, that seems relatively ethical, if somewhat bizarre.

If Dr. Sears and those like him really believe what they say about vaccination, where's the data? Why aren't they working on testing their hypotheses? In my opinion, it's because you cannot reason someone out of a position they never reasoned themselves into in the first place.

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.

When health care workers strike

In a relatively unusual development, mental health professionals who work for Kaiser Permanente in California went on strike.

At issue is the demand for mental health services, and the perception by the employees that they are understaffed, overworked, and not meeting their ethical obligation to see Kaiser patients in a timely fashion.

Job actions in the health care world are pretty uncommon, because of the direct impact they can have on day-to-day patient care. It's a fine line between taking a negotiating position and potentially harming the people that we've signed on to help.

In health care, perhaps the most prominent unionized workers are the nurses and/or service employees (food service workers, custodial employees, etc.), who generally belong to local chapters of national unions like National Nurses United (NNU), the National Federation of Nurses, and the Service Employees International Union (SEIU), just to name a few.

KQED radio health reporter April Dembosky covered the Kaiser story, and was featured on NPR's All Things Considered. She pointed out a couple of interesting reasons for the appointment backlog:
1. The Affordable Care Act has provided coverage to more than a million Californians who were previously uninsured, so demand has risen.
2. A state initiative has worked to reduce stigma associated with mental illness, which has also driven up demand, especially in the University of California system, site of another backlog.

I was lucky enough to interview Dembosky for Studio Tulsa on Health, our local public radio show, in which we explored this issue in more depth. If you're interested, you can hear it here.

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is Interim President of the University of Oklahoma-Tulsa. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.
Monday, February 23, 2015

Medicine is an art and science

Medicine is an art, not a science. We've all heard that maxim before, but what does it actually mean for living, breathing patients?

Physicians rely upon knowledge and experience when we advise patients. We try to stay current on relevant medical studies to guide us, knowing that the latest medical breakthrough may be debunked in a few years. Seasoned physicians resist the temptation to abruptly change their medical advice based on a single study, even if published in a prestigious journal.

Knowledge and experience are important, but judgment trumps them both, in my view. The best clinicians are those who consistently exercise excellent medical judgment.

A knowledgeable physician may be able to recite a dozen explanations for your high calcium level.

An experienced doctor can expertly perform a colonoscopy having mastered the technique.

A physician with a high level of medical judgment knows that surgery is wrong for a particular patient, even though medical textbooks and journals recommend an operation.

Keep in mind that medical judgments are not right or wrong. Physicians on the same case may have differing judgments and recommendations. This is a typical scenario in the medical universe which can be vexing to patients and their family.

Consider a few typical patient vignettes which call for medical judgment.

A cardiologist recommends Coumadin, a blood thinner, to start today to treat a patient's heart condition. The gastroenterologist wants to delay this for a few weeks as the patient has a duodenal ulcer that could start bleeding once the blood thinner begins. When should the Coumadin be started?

A man undergoes a CAT scan of the chest which shows a 1 cm nodule in the lung. The nodule is slightly larger than it was 6 months ago. The patient is a smoker. The location of the nodule is at high risk for a serious complication if a biopsy is done. Should the biopsy be done to determine if a cancer is present? Considering the risk of the biopsy, should the lesion be watched with a repeat CAT scan done in 3 months to see if it is enlarging or remaining stable?

A patient is seen by a surgeon after a severe attack of abdominal pain, which resolved. The patient was immobilized during the pain and was seen in an emergency room where he was found to have a gallbladder full of gallstones. The surgeon is not certain that the gallstones were responsible for the pain. The patient is very frightened that if nothing is done, that the pain might return. Should the surgeon remove the gallbladder, which might have nothing to do with the pain, or advise watchful waiting?

Medicine is art and science. If I'm sick, I'll skip the scientist. Give me the artist.

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.

So what else is new?

Steven Brill made a name for himself with an article in Time magazine back in 2013 entitled “Bitter Pill,” in which he harshly criticized how health care providers (especially hospitals) inflate the costs of their services. The piece created a lot of buzz, and some backlash from hospital groups and others. Now it seems that Mr. Brill has had a bit of a “sick-bed conversion.”

He has a new piece in the Jan. 19 issue of Time called “What I learned from my $190,000 open-heart surgery: the surprising solution for fixing our health care system.” Since Time won't let you read the article without subscribing or paying, I will save you the trouble. It seems that what he learned is that health care providers, the same ones he vilified in 2013, were pretty great when they were taking care of his heart in 2015. In fact, he now believes that the way to “fix” health care is to “let the foxes run the henhouse” by allowing large integrated health systems become insurance companies and compete on price and “brand” and regulate their profits to assure that they are acting in the public interest. Yeah, well, no kidding.

The surprising thing about this article is that it is both unsophisticated and un-original, yet presented as nothing short of brilliant and novel.

First of all, the whole idea of systems of care competing on the basis of “brand” is dangerously simplistic. While Mr. Brill does make a brief nod to the need for “data transparency” around “quality ratings,” he completely misses the boat. This isn't about marketing the brand, it is about improving the outcomes. Patients shouldn't go to the Cleveland Clinic because of their brand; they should only go if the Cleveland Clinic can prove that their clinical outcomes are as good as or better than other providers.

Even more disturbing, there is nothing new about the basic idea of providers competing on the basis of price and quality. As I wrote back in December 2013, Michael Porter and others have been writing for years about shifting reimbursement from volume-based to value-based, and payors and providers are actively engaged in that transition right now. Thanks for the “suggestion” that health systems should consider becoming insurance companies. North Shore-LIJ started its insurance company, Care Connect, in 2013.

I guess I should be pleased that Mr. Brill has a better appreciation of health care providers and now believes that we should be taking on the role of insuring the health of a population. I just think it is a shame that it took heart surgery for him to see what has been clear for a long time.

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, February 20, 2015

Health and Human Services announces push to end fee-for-service payments for Medicare

On Jan. 26, 2015, the department of Health and Human Services (HHS) reported plans for a sustained effort to end “fee for service” in medical care. Fee for service is a model of payment we are all familiar with and it works really well when we get our car fixed or our dog groomed or our baby babysat. In these situations we want to pay for what we get, and if we aren't satisfied, we don't come back. If the dog's hair looks terrible a week later, we won't just go back to the same groomer and if any of the other people who do us service perform it in a way that makes us need ever more service we will go to someone else who gets the job done better.

Doctors and other medical service providers are primarily paid “fee for service,” but most patients don't pay them directly and they don't have a good grasp of whether the job of doctoring is being done right, and they don't usually blame it on the doctor if he or she tells them that they need to keep coming back and keep getting things done in order to be healthier. The result is that doctors make more money by providing a service that keeps patients coming back for yet more treatment. A dermatologist is not financially rewarded for diagnosing and removing a potential skin cancer in one visit and calling us on the phone with the results, despite the fact that most of us would prefer that. He will make much more money by diagnosing the spot one day, having us return for a biopsy, then return to have the stitches out and to discuss the results, then again for the excision and then to review the pathology report. If I, as a primary care provider, treat a condition and in so doing make you sicker or more insecure, resulting in more visits, I will be monetarily rewarded. The economics of fee for service make medical care more expensive and more time consuming and don't encourage good health.

Payers, especially Medicare, have worked hard to reduce this tendency to make more money by doing more things, rather than by giving better care. Years ago they began bundling payments for hospital stays, paying by the diagnosis rather than the intensity of the treatment provided. Doctors' fees, though, have been relatively spared, as have costs of individual surgical or diagnostic procedures. With the introduction of the Affordable Care Act, Medicare has been phasing in the practice of not paying for preventable readmissions, which provides a strong incentive for hospitals to keep patients for long enough to ensure they are well enough to go home and stay at home. Some patients are too unstable, either socially or medically, to stay out of hospital long, which makes this strategy far less than perfect.

What HHS would really like, though, is for the health care system to provide appropriate and efficient service without significant oversight. This would cost them less and allow them to focus their attentions on something more interesting, like human services, whatever that entails.

In their Jan. 26 announcement, HHS has characterized the evolution of Medicare payment as a series of 4 steps, or categories. The first is fee for service, which we are transitioning away from, at least sort of. The second category is linking fee for service to quality. We will still be paid according to the volume of work we do, but we will be paid better if patients are made healthier with better efficiency in how we use resources. The practice of not paying for preventable readmissions and not paying for the treatment of preventable complications is an example of this.

Category 3 is paying us a little differently than fee for service while maintaining some of our present structures. The most talked about model is the Accountable Care Organization (ACO) which brings doctors and other service providers together to care for patients in a coordinated manner which will presumably save money, some of which will be given back to the providers as a bonus for doing such a good job.

The other model, which works for smaller organizations, like clinics, is the patient-centered medical home (PCMH). This pays physicians at a higher scale when they keep track of patients better, including having care coordinators for complex or high risk patients and making sure preventive health care is actually done. Both the ACO and the PCMH are total bears to set up, expensive, and require computer systems that function at a really high level and practitioners who know how to use them. The up-front costs are amazingly high and the administrative support required is huge. Because of the massive amount of detailed data gathering and manipulation required to make these things fly, they burn doctors out and make us spend even more time looking at computer screens and less time talking to patients.

Category 4 is good, though. Category 4 is population based payment, and is the system that would reduce the need for HHS oversight. Clinicians or organizations would be paid to provide care to people for, say, a year. The incentive, then, is to make patients as healthy as possible with as little intervention as possible so that we can reduce the intensity of the medical care they need. Providing good, high quality care would mean patients are less likely to need expensive hospital stays or procedures. This system provides an incentive for the dermatologist to take care of the little skin cancer in one visit and encourages me, as a primary care provider, to give you just the care that makes you healthy and confident.

Some people actually like going to lots of doctors appointments and getting lots of tests, and they may not be pleased with population based payment. Care that makes patients a little happier for a lot more money tends to thrive under our present fee for service system, especially with insurance paying the bills. This kind of care would happen less frequently. When better treatments do arise, there will be strong incentives to find ways to make them less expensive. Population based payment's natural tendency to improve value would definitely bring down healthcare costs. There will also be a tendency to stifle astronomically expensive innovation, which has been far more common than low cost innovation in our profit driven system.

HHS says that they hope to have 30% of Medicare patients in category 3 or 4 by 2016 and 50% by 2018.

Changing the way things are paid can be really difficult, however. This category 3, with the ACO and PCMH requirements, is so complex as to be almost impossible and maybe not even a good idea. Paying for population health sounds to physicians a lot like managed care, which we tried years ago and sometimes made us feel like jailers, denying patients care that was expensive but right for them. If patients have adequate input into what is valuable to them (it looks like the medical establishment is moving in that direction) some of those problems may be allayed. But one of the biggest hurdles is that if private insurance continues to pay fee for service, we will continue to have systems set up that push for us to do more rather than better. If we get good at taking care of a patient's needs in one visit rather than several, we may feel penalized if insurance companies other than Medicare now pay us less. HHS has decided to set up Learning and Action Networks to interface with private insurance and other payers to encourage them to adopt population based payments, which would save them money as well.

Population based payment is where I would like to see health care move, but it will be a painful transition, if it works. A huge amount of the money that goes into health care (I've heard figures as high as 50%) is spent on billing and all of the record keeping relating to that. If doctors and hospitals are paid by the number of patients for whom they provide care, we will not be billing insurers for what we do. As lovely as it is to think of a system without billing, those people, doing that work, will lose their jobs. At least most of them will.

As we reduce overdiagnosis and overtreatment, which would be a natural consequence of population based payment, hospitals will lose revenue and some of them will close, unless they can re-tool to help healthy people stay healthy. Radiology technicians and lab technicians will also lose their jobs, because much of what we do in medicine is based on an exaggerated idea of what is needed, shaped partly by generations of being paid fee for service.

It will be particularly awkward to move from the very high administrative burden of category 3 to the simpler and more focused category 4 of population health and population based payment. Bureaucracies like to be large and tend to grow. At some point in this evolution they will need to shrink. Something like 17% of our gross domestic product goes into health care, which is a sizable chunk of our economy. The money we expect to save on more efficient health care is huge and may have a very large positive effect on something. Transitioning health care jobs to ones that are life sustaining rather than ones that react to disease and dysfunction could be beautiful, but it is not at all clear what it will look like on the way to that goal.

Thanks HHS for keeping us focused on a payment system that provides an incentive to keep people healthy, but do take it slowly and please prepare for the consequences.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

The great things about patient-centered care in America

As part of the increasing push for health care quality improvement, a lot of energy is being focused on improving our communication with patients and making sure that patient-centered care is more than just a buzz phrase. Gone are the days when the doctor-patient interaction was a wholly paternalistic one, where the doctor's word was taken as final and absolute, and patients weren't encouraged to ask questions or raise concerns. Although we've moved on a long way from those times, it's still important that we are always trying to raise standards and correct areas where we are deficient (and there are certainly still plenty of those). But we also start from a point which is way ahead of most other health care systems and countries. Speaking as someone who has seen health care in several other places, both first and third world nations, I really believe that the United States can teach the rest of the world an awful lot. Here are 3 such areas:
1. Getting to see your attending physician every day
This may sound very basic to most people, but the first cornerstone of doctor-patient care in hospital is getting to see your doctor! In lots of countries (and I'm talking Western health care systems) the senior doctor, i.e. the attending physician, doesn't always see their patient every day. In many cases on general medical floors, more junior staff are the ones who are tasked with rounding on hospitalized patients, with the attending seeing them perhaps only 2 or 3 times a week very briefly. Patients can therefore linger with very little progress compared to the more aggressive approach of U.S. physicians in wanting to see daily advancement. Patients here will always have the chance to interact with their doctor regularly, having someone visible who is accountable for their care.
2. Patient empowerment to choose
Every hospitalized patient has the right to ask for a certain doctor or a second opinion at any time during their hospitalization, even those who don't have health care insurance. The same goes for requesting certain tests such as CT scans or other inpatient investigations, which are frequently heeded. The counter argument is that it's exactly things like this that push up costs, but I know what I would want if I was a patient. Try to ask for these things in a more paternalistic health care system, and you may well be laughed at.
3. Putting energy into customer satisfaction and good service in hospitals
There is simply no concept of this in most other countries, where the role of the doctor and the hospital is simply seen as being ”to cure the patient” and not viewed in customer service terms. No formal training is given on basic communication, empathy, or what constitutes appropriate ways to interact with patients and their families. In the United States, there isn't a hospital out there that doesn't take this seriously. If a patient makes a formal complaint to senior administration, it's thoroughly investigated at a number of levels. Such avenues simply don't exist for most patients around the world.

I was recently overseas (in a country that shall remain nameless), but certainly one that boasts high first-world standards. While I was visiting a hospital, it reinforced to me how far ahead America is in providing the best possible hospital experience for patients and keeping them and their families at the center of their own care. Aside from the high medical standards seen here (a homeless American will get higher quality acute care for a myocardial infarction or sepsis than a rich person almost anywhere else), this country also leads the world in effective communication and striving for good service. So while we are all aware that health care here has its fair share of problems and inequalities, it's worth pausing to think about all the good as well. It's well known and respected abroad that America taught the world about customer service in commerce and industry. She also leads the way in the health care sector too. Other countries should be looking here for how to do it better.

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, February 19, 2015

Measles in the Magic Kingdom? It's a small world, after all

One would think our recent experience with Ebola, the rapid and predictable, albeit, rare transmission of the disease out from its site of origin to far-flung places around the globe, including here, and the attendant hysteria, would have taught us already that when it comes to infectious diseases, it's a small world after all. With a human population well in excess of 7 billion filling global nooks and crannies, and modern technology to get our stories from here to there all but instantaneously, and ourselves only a bit slower than that, it's a small world after all. It's a small, small world.

But on the chance we did not indelibly get that memo from the still simmering Ebola calamity in West Africa, perhaps we will get it now that measles is propagating rapidly outward from an index case at Disneyland.

The story, as we know it thus far, is that measles was transmitted at Disneyland and Disney's California Adventure Park, by 1 or more infected visitors around mid-December. Measles is a highly infectious viral disease, and has thus predictably spread to 5 states and 2 countries from the inception of the outbreak in California. News outlets are reporting 59 confirmed cases thus far, although the news, fast as it is, is unlikely to keep up with the spread of this disease, and there are apt to be others who already have it but are as yet undiagnosed.

We don't know the status of all outbreak victims thus far, but of the 34 cases in California, 28 were unvaccinated.

That is of profound importance for 2 reasons.

The first, and obvious 1, is that immunization against measles is highly effective, so predictably in any outbreak the victims are disproportionately the unvaccinated. They chose to play Russian roulette, with their own health and/or that of their children, and lost.

The second, though, may be just a bit less blatant. Since thus far 6 of the 34 infected in California were fully or partially immunized, this outbreak tells us that the best defense against an infectious disease is not just immunity against it, but rather the combination of immunity against, and the unlikelihood of encountering it at all, because everyone else is immune, too.

No matter how effective a vaccine is, the strength of the immune response can wane with time. Routine booster vaccines can compensate for this, but obviously won't do so if they are forgotten. If viruses mutate slightly over time, that might also help them overcome a vintage vaccine.

The implication, I think, is obvious. If you choose to avoid standard, recommended vaccines such as measles, you are not merely putting your own health at risk, you are choosing to do the same for all the rest of us. Sorry, folks, but that's the harsh reality. There is an obligation at times to think beyond our own skin. However much we admire the brave health professionals who treat Ebola in West Africa, we want to be certain they honor all of the safety protocols and quarantine, to protect us. That, too, is part of their mission: precautions to prevent spreading the disease to innocent bystanders.

What's good for the goose is good for the gander. The unimmunized who not only acquired measles, but spread it, are quite analogous to someone dodging their Ebola quarantine, and taking chances with the health of all around him or her. Except, of course, the measles scenario is in a way far worse, since the folks acquiring measles did not do so as a byproduct of heroic altruism.

So, yes, there is a public obligation being trampled here. With power, comes responsibility, and since we have long had the power to prevent measles, we have the responsibility to use it judiciously.

I know, of course, that many who opt out of vaccines think they are being judicious, invoking everything from vaccine ineffectiveness, to vaccine risks, to the nefarious shadow-world of evil science run amok, to government conspiracies extending all the way to genocide. Most of this is absolute nonsense, and all of it is wrong.

No vaccine is perfectly effective, and all vaccines carry some, small risk. But there is, of course, some tiny risk attached to the use of baby car seats, and seat belts, too. There is some highly unlikely scenario, a one-in-10-million kind of crash, where being loose would work out better than being strapped in. Unfortunately, without a crystal ball, we can't predict such scenarios.

But whatever the actual numbers, we know quite reliably that car seats and seat belts save lives, a lot of lives. The reason to use them is not because they are 100-percent effective (they are not), nor because they are completely devoid of any possible or actual risk (nothing is), but because the net benefit to us all, and the probability of benefit to each of us, is astronomically in their favor. It's no contest.

The same is true of the vaccines long-since codified into our standard protocols, on which list the measles vaccine is an archetype. Immunization against measles is extremely safe. The vaccine is monumentally effective, as indicated by the near banishment of measles from the U.S. until the anti-vaccine movement invited it back.

This matters more than you realize, because we learn to forget to fear diseases we haven't had to deal with for a while. Roughly 30% of those infected with measles develop complications, some of which are life threatening. As recently as 2013, measles killed almost 150,000 children around the globe, in places where the vaccine is not readily available. In 1980, before the vaccine was in wide use, measles killed over 2.5 million people every year. If you think measles is a minor menace, it's only because you and I are privileged to live in an era that makes it so; an era of routine immunization.

I am, of course, aware of the anti-vaccine sentiment and arguments that are probably the root cause of the current outbreak, and potentially far worse to come. I can even appreciate the wince factor associated with getting an injection and taking a chance, while feeling fine. But the simple reality is that the conspiracy theories and paranoia are just noisy nonsense, and the notion that Nature taking its course is our best defense is a delusional load of New-Age revisionism. I have addressed the particulars before, and refer you there rather than reiterating them all here.

I know: I should tell you what I really think.

But honestly, we have enough troubles with infections we aren't yet able to prevent or treat. We have enough troubles with bacteria increasingly resistant to our antibiotics. We have enough troubles with a growing, global burden of chronic diseases. I do not want my grandchildren to grow up in a world where all such perils are compounded by the threat of dangerous infections we are fully capable of eradicating, but choose to invite back instead.

Measles is serious; we have forgotten because, and only because, the effectiveness of the vaccine has allowed us to forget. When measles was killing more than 2 million people a year, no one had the opportunity to forget what a bad actor it is.

Measles is preventable to an extent that offers us the promise of eradicating it altogether. But only by, quite literally, rolling up our sleeves, and getting it done. Immunization is one of the great achievements in medical history, eradicating smallpox, and banishing polio from much of the globe. Immunizations are neglected at our peril.

We have an unnecessary epidemic radiating out from its origins in the Magic Kingdom. It tells us that what happens anywhere is relevant everywhere, because it is a small world, after all. And it tells us there is no magic, in any kingdom, to substitute for what modern medicine can do.

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.

$1.2 billion requested for antibiotic resistance!

“You don't tug on superman's cape
You don't spit into the wind
You don't pull the mask off the old Lone Ranger
And you don't mess around with Jim”
Jim Croce

Most days, controlling the spread of antibiotic-resistant bacteria in hospitals feels like fighting with one hand tied behind our backs, or spitting into the wind or … For example, we have very little control over whether patients are colonized or infected with antibiotic resistant bacteria on admission. It's not like we can move a hospital from the high-prevalence East Coast to the low prevalence upper Midwest. And once resistant bacteria become endemic in our region/hospitals, we have few reliable evidence-based interventions to prevent patient-to-patient transmission.

So, it's with some trepidation that I began reading the President's proposal to provide extra funds to tackle antibacterial resistance. Would there be any funds for infection prevention? When discussing past initiatives, we've remarked on how little attention is given to infection control programs and research. This time, however, things are looking better.

Here's how the $1.2 billion will be distributed under the current plan:
• $650 million to the NIH and the Biomedical Advanced Research and Development Authority to expand development of antibacterial drugs and diagnostics
• $280 million for CDC-led efforts to curb overprescribing of antibiotics and track outbreaks of drug-resistant infections
• $47 million would go to FDA to evaluate new drugs and monitor livestock antibiotics use
• $77 million to USDA to help develop alternatives to the antibiotics used in farm animals
• $75 million to DoD and $85 million to VHA to focus on reducing antibiotic-resistant infections in health care settings

This is a well thought-out list and is very close to how I would wish to distribute the resources. I would perhaps request a bit more for CDC to study health care acquired infections (HAI) prevention interventions in addition to stewardship efforts; however, this extra-funding, while long overdue, is on target. I'm also encouraged that the President is asking for increased funds and not reducing other critical research in infectious diseases like HIV, TB and malaria. Let's just hope Congress can approve this request and it's renewed annually. It will be nice to get back to work preventing HAI, this time with 2 hands and a mask to keep the spit off our faces.

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.
Wednesday, February 18, 2015

I'm astounded, too

Sen. Chuck Grassley of Iowa, as of this month the Chair of the Senate Judiciary Committee, has led a decade-long crusade to make our nation's non-profit hospitals more accountable to the public.

After all, the reasoning goes, non-profit hospitals are tax exempt because they provide community benefit. How this standard is defined has been the crux of the issue.

Hospitals always face a share of patients that are uninsured, who are therefore unable to meet the high costs of hospitalization. Depending on their location, some non-profits care for more non-insured patients than others. Of course, the Affordable Care Act (Obamacare) was designed in part to greatly lessen the number of uninsured among us—a win for those patients, and for the hospitals that struggle financially because of non-collected fees. The American Hospital Association (AHA) supported the passage of the Affordable Care Act under the premise that nearly all patients would become paying customers.

Since not all states (>20) have agreed to expand their Medicaid pools in spite of generous new federal funding, there are still millions of uninsured patients straining the finances of hospitals. Businesses (non-profit hospitals included) have a right to collect payment for services rendered. But how aggressive should non-profit hospitals be in pursuit of unpaid fees?

Propublica, a non-profit investigative journalism enterprise, has researched the billing practices of non-profit hospitals in 6 states. What they found “astounded“ Senator Grassley: aggressive collection practices including lawsuits, wage garnishing, and the placement of liens on personal property. These practices are legal, but skirt the ethical notion of helping our fellow humans. If sick people are rendered health care services but then put into collections, the results can be emotionally, financially, and even physically catastrophic. To me it certainly seems counterproductive to bully members of your community, who more than likely will continue to be customers.

Stay tuned to find out if Sen. Grassley and his committee do anything to rein in these practices. My guess is we'll see an attempt made to more clearly define the community benefit standard and put limits on what extent hospitals can go to for collecting unpaid bills. One option: taking away a hospital's non-profit status if it continues engaging in such aggressive collection practices.

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is Interim President of the University of Oklahoma-Tulsa. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.

Performance measurement has major problems

I started writing about performance measurement and associated problems for 10 years. For the first few years, we in the blogosphere seemed to be shouting in the wilderness.

When I first joined the ACP Board of Regents, the general consensus favored pay for performance. We who questioned the value of performance measures were told that “the train has left the station.”

Over the past 7 years, many leaders in medicine have seen what the blogs saw first, we have too many bad measures, and too often performance measurement has significant unintended consequences.

Now even MedPac has major concerns about the proliferation of performance measures.

Over the past few years the Commission has become increasingly concerned that Medicare's current quality measurement approach is becoming “over-built,” and is relying on too many clinical process measures that are, at best, weakly correlated with health outcomes. Depending on a large number of process measures reinforces undesirable payment incentives in fee-for-service Medicare to increase the volume of services and is overly burdensome on providers to report, while yielding limited information to support clinical improvement or beneficiary choice. Instead the Commission has urged more focused attention on a small number of population-level outcome measures, such as potentially avoidable hospital admissions, emergency department visits, and readmissions.

When MedPac complains to CMS we must have reached a “tipping point.” The current approach to performance measures is actually harmful. The ACP Performance Measurement Committee is endorsing approximately 20% of proposed measures. Most measures have inadequate data supporting them. Too many proposed measures read like expert opinions.

Bravo to MedPac for making this letter public. Now we can only hope that CMS will listen.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.
Tuesday, February 17, 2015

Money back guarantee on medical care?

How many times each week do we hear the phrase, “If you're not completely satisfied, we'll refund the purchase price, no questions asked.”

This is more often a marketing ploy than a true money-back guarantee. I have a sense that trying to obtain a promised refund on an item that dissatisfied us is about as easy and carefree as changing an airline ticket reservation or reaching a live human when our home internet service is down. So, when the weight loss pills don't really melt the pounds off, don't be shocked if the check isn't in the mail when you mail back the placebo pills to a post office box several states away. And, of course, you won't recover the shipping and handling costs.

This is my opportunity to ask for help from my erudite readership. What exactly is shipping and handling? Doesn't postage already cover the shipping? $8.95 seems pricey for a “handling” charge for anti-wrinkle cream or a set of steak knives endorsed by make-believe chefs. I don't really want strangers handling my stuff anyway. Are they wearing gloves, I hope?

I hear a commercial often for a zinc product that promises a full refund if the product does not shorten the course of the common cold. I do have some medical training, as readers know. Readers who are smart enough to understand “shipping and handling” are asked now to explain how an individual can assert that the zinc product was not effective.

The Complaint

“Please give me a full refund. My cold lasted 6 days. Usually, I feel better by the fifth day. Your zinc stinks.”

The Response

“Thank you so much for your input. All of us at Zinc Jinx, Inc. welcome customer feedback. Please send urine samples for days 4, 5 and 6 packed in dry ice at your own expense so we can verify that you were taking the product as directed. Include all packaging including the shrink wrap around the bottle that you should have retained had you consulted our customer service website prior to opening. Expect a response in 6 weeks. Even if your urine drug content is deemed to be sufficient, our onsite cold and flu experts may conclude after impartial study that your cold would have lasted 9 days without our product.”

I'm not offering an opinion on zinc's effectiveness in fighting the common cold. I'm suggesting that it is not possible for a zinc swallower to really know if zinc expedited his recovery. Belief is not evidence. If we recover on day 6, perhaps, zinc was an innocent bystander receiving credit for a favorable outcome that it did not contribute to.

Sometimes, we physicians are lucky in the same way. Our patients get better, as they usually do, and we get the credit. As we know, the converse is sometimes true. We get blamed when we don't deserve it.

Should doctors offer a money back guarantee if our patients are not fully satisfied? The zinc scenario illustrates how difficult it can be in medicine to assign credit or the blame for the outcome. The only secure guarantee in medicine is that there are no guarantees.

If any reader is not fully satisfied with this post, the full purchase price will be promptly refunded, no questions asked.

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, February 16, 2015

Retrievable stents offer improved outcomes for stroke patients

There are few illnesses as disabling as a stroke. A stroke is the cessation of blood flow to part of the brain. It can cause sudden difficulty speaking, difficulty moving a limb, facial drooping, or the loss of vision in a fragment of the field of view. In many stroke patients the loss of function never improves and the patients remain permanently disabled.

Before the 1980s there was no effective treatment for this devastating illness. Stroke patients were simply observed and given physical therapy. Some improved, and many didn't. In the 1980s a blood clot dissolving medication called tissue plasminogen activator (tPA) began to be used for stroke patients with encouraging results.

tPA is given intravenously and has to be given within 4 hours of symptom onset. In patients with small clots who present to the emergency department in time, it can make a dramatic improvement in outcome. In the 1990s a large study proved that treating stroke patients with tPA is better than not. The main limitation of tPA was the narrow time window and its lack of effectiveness against large clots in large arteries.

By the late 1990s many large stroke centers were trying to improve on tPA. At UCLA, where I trained, stroke patients were treated by inserting a catheter in the clotted artery and delivering clot-dissolving medications directly to the clot. That became the standard of care at many centers, though there were never large studies to show that this was better than intravenous tPA.

More recently, various devices have been designed to remove blood clots from brain arteries. But again, there has never been evidence that these are more effective than intravenous tPA, until now.

A study performed in the Netherlands and published online this week in the New England Journal of Medicine (NEJM) attempted to determine the best treatment for stroke patients who have large clots in large arteries. These are the patients at greatest risk of serious permanent disability. The study randomized about 500 such patients into 2 groups. Patients in 1 group received usual care, which for the vast majority meant intravenous tPA. Patients in the second group received intravenous tPA and an attempt to remove the clot from the artery. In most of the patients this was done with a retrievable stent, a wire cage that is pushed through an artery, envelops the blood clot, and allows the stent and clot to be pulled out of the artery. This treatment can be performed as late as 6 hours after the onset of symptoms.

Ninety days later 33% of the patients in the group randomized to clot retrieval were functionally independent, compared to 19% of the patients in the group that only received tPA. That means for every 7 patients that receives clot retrieval in addition to tPA one additional person is functionally independent 3 months later.

Note that even though the patients in the clot retrieval group did better, even in that group two-thirds of the patients were not functionally independent at 90 days. That means they needed assistance for their activities of daily living. That is a sobering reminder of the poor outcomes that await most patients with large clots in large arteries.

There was no difference in mortality or severe bleeding between groups. The group receiving clot retrieval did have an increased risk of another stroke within 90 days, but this risk was numerically smaller than the improved functional independence. This NEJM Quick Take Video summarizes the findings of the study.

So stroke is more treatable now than ever. But the time from the onset of symptoms to the initiation of therapy is still critical for a good outcome. So if you ever suddenly develop difficulty speaking, or can't move a limb, or lose vision in a fragment of your field of view, call 911. Getting to an emergency room promptly can make the difference between getting 1970s care for your stroke and getting 2014 care.
Learn more:
For First Time, Treatment Helps Patients With Worst Kind of Stroke, Study Says (New York Times)
Stents Boost Stroke Recovery, Study Finds (Wall Street Journal)
Clot-grabbing devices offer better outcomes for stroke patients, study finds (Washington Post)
Video: MR CLEAN (NEJM Quick Take)
A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke(NEJM, subscription required)
Interventional Thrombectomy for Major Stroke—A Step in the Right Direction (NEJM editorial, subscription required)
The Stroke – Billy Squire (YouTube)

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.
Friday, February 13, 2015

Does oseltamivir work and does it have side effects?

The flu season has really gotten into gear now with 46 of our 50 states reporting widespread influenza activity. Influenza is a virus that infects the respiratory tract, causing sore throat, runny nose, fever and cough. Rarely people with the flu will have nausea, vomiting and diarrhea, but this is not “stomach flu,” which is a term some of us use to describe any one of a number of viruses that give us intestinal symptoms. Influenza is the one where you hurt all over, you have a high fever and cold symptoms, then you start coughing and you can barely get out of bed for days. Sometimes it's milder than that, but it can also be more severe, affecting brain function and sometimes requiring oxygen or life support with a ventilator. It also kills people, on the order of about a half a million worldwide every year, either directly by the destructive effects of the virus or by setting the stage for a devastating bacterial pneumonia.

Flu is very contagious. A person with the flu can spread it to others for 1-2 weeks, and it frequently runs through whole schools, resulting in as many as 1 in 3 children being absent from classes. The very best way to reduce the spread of flu is to have people with the flu stay away from people without the flu. Hand washing is also good. Epidemic flu usually lasts for about 13 weeks each year, tapering off toward the end of the season, and usually it's pretty much gone by March. This year we are starting with influenza A, which is usually the most severe type, and the genetic signature is not one that is well covered by the present flu vaccine.

The Centers for Disease Control (CDC) posted an article detailing the present flu situation. They estimate that the vaccine is 23% effective, but that is based on an odds ratio calculated by comparing a group of sick people who did or did not have the flu when tested and looking at whether or not they were vaccinated. What they mean is that if you are sick enough to be tested for the flu, you are 23% less likely to actually have the influenza virus if you got the vaccination. But the vaccine is still recommended because there will be influenza B coming around later, as well as the non-seasonal flu, H1N1, which should be covered by the vaccine. There is also a chance that the influenza A you are exposed to could be one that has not genetically drifted, which might mean the vaccine would make you more immune to it.

This year's flu is a pretty nasty one, with many people getting sick enough to need hospitalization. It is not the most terrible we have seen, and is similar in how sick it makes people to the 2012-2013 season, 2 years ago. Because the vaccine is less effective this year, though, the CDC is recommending that physicians be very generous about prescribing 1 of the 2 influenza antiviral medications. These are oseltamivir (Tamiflu) and zanamivir (Relenza). Oseltamivir (which is not available as a generic) is a capsule or liquid which is dosed twice daily and costs a bit over $100 for a 5 day course. Zanamivir (also still on patent) costs a little less and is inhaled, twice daily, and is contraindicated in asthmatics since it can make them wheeze. The Cochrane Collaboration, an organization which reviews scientific data in an unbiased fashion, says that neither drug does much for healthy people infected with the influenza virus, and there is no really good data to determine if it helps people who aren't otherwise healthy or who are desperately ill with it. They both tend to make the symptoms a little less severe and shorten the duration of illness by half a day to 1 day. I have been prescribing them generously for years to my patients with the flu, since I know how nasty it is and have always figured that they could use all the help they could get.

A few days ago a friend asked me if I had heard anything about mental effects of Tamiflu. She said that an acquaintance of hers had a son who had committed suicide after being started on it. His girlfriend had just left him, but he was a very psychologically stable person, and this wasn't like him. She said that she had heard that the drug could make people mentally unstable. I thought that it sounded like hogwash, so I checked my handy dandy iPhone Epocrates app and found that behavioral effects and self-injury were quite high on the list of serious side effects. Today, I looked further into it and found that in Japan, where Tamiflu is used more commonly than in the U.S., they reported quite a few cases of psychological side effects, including delirium, primarily in children and adolescents within the first 48 hours that they took the drug, with something like 70 deaths. The Food and Drug Administration reviewed side effects, especially during the 2009 pandemic when Tamiflu was widely used, and found that there were some psychological side effects reported, but pretty rarely. There were also some severe skin reactions, even resulting in death. There were more case reports, including a girl who had manic depressive symptoms that resolved only after a few months, out of South Korea. Tamiflu also makes about 1 in 9 patients vomit.

In general oseltamivir (Tamiflu) is safe and the influenza vaccine is safe. They are also both somewhat, though not gloriously, effective. Both are lucrative for the companies that make them. The flu is a huge public health issue, causing death and disability and work and school loss, and it repeats itself yearly, with varying intensity. Because control of the flu, even shortening illness by a day or decreasing transmission just a bit, is so very important on a population level it is likely that the down side to an individual will tend to be minimized. As an individual and as a member of a human herd, I will continue to get yearly flu vaccines and nudge my dear ones to do the same. If I wake up feeling like I got hit by a truck and then nanobots have attacked my mucus membranes with sandpaper I will probably take one of the anti-flu drugs (but maybe zanamivir, since it is cheaper and probably won't make me jump off a balcony.) These are decisions, though, that individual patients should make after being fully informed of both effectiveness and potential side effects.

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.