Tuesday, March 31, 2015

Match Day '15: It never gets old

I keep waiting for Match Day to get old for me. For the giant clock on the wall striking noon, the medical students sprinting for their envelopes, and the emotional pendulum that follows it all to seem blah and played out. At Emory, the location hasn't changed in years. Even the faces of a lot of the faculty members who stand around with our slightly less baited than our students' breath hasn't really shifted much either. Yet every single time, year after year, it feels magical to me. And brand new.

Admittedly the “odd” years are the most meaningful to me. As a small group advisor who has students graduating from the 4-year program on those years, these are the ones I've watched since their first day of medical school. But now that I think of it, the even years can be just as awesome. Witnessing their dreams come true on Match Day is a high that I will never stop enjoying. Ever.

Beyond that is something else though. The level of investment I have in people changed since losing my sister in 2012. It's upped the ante significantly for me. Sure. I went hard before. But now that I realize how short life is and how critical it is to be a responsible steward of my influence and time, I go even harder. I decide more carefully where to pour my energy. And once I decide? I'm all in.

I've talked about this before but it bears repeating. Out of the ashes of some of the most tragic life experiences can come unexpected beauty. I hold on tighter now. I want to water the flowers entrusted to me as dutifully as I can and then watch them grow. I yearn to roll up my sleeves beside the other gardeners who aren't afraid to get their hands dirty with me and then stand shoulder to shoulder with them as we marvel at the spectacular blooms before us. Match Day is a chance to present those flowers to the world in dazzling bouquets. Big, bold beautiful ones that we helped to prepare.

Yes.

I always take a lot of pictures on Match Day. I'm particularly mindful to snap images of those with whom I had direct involvement, especially during the clinical years and residency application process. I love going back and studying their faces. The elation so unfiltered and unlike what usual happy looks like. I guess it's just that I can see more into those pictures than others might. See, Match Day for most medical students is a day of glory. But me? I know the story.

Sigh.

This year was like always. I met their parents. I met their grandparents, too. Shook their hands and tried to beat them to the kind word punch before their lips could even part. I told them who their children have been in their absence and let them know that they done good. I described the attributes that really, truly matter to parents—the ones that I now realize are the best ones. Especially now that I have children of my own.

“Your son is kind and has a heart for people. He is patient with even the most challenging patients and can find the good in everyone.”

“Your daughter fights for what is right and stands up for those who may not be able to stand up for themselves. She expresses herself well and makes sure our patients are treated with dignity. She has a servant's heart and is an advocate for the least of these.”

I didn't really talk about how smart they were. I mean, they're about to graduate from medical school and, for goodness sake, they got in to medical school in the first place. But since I know and I think their parents and grandparents know that it isn't really just about being smart, I give them those concrete words of affirmation. And for every kind word of gratitude they offer me, I trump them with some declaration of what I've seen in their child and the gifts they will offer the world.

That is, from my perspective as their teacher and mentor. And I win.

Yeah.

This is such a privilege. Each year I try and try to put it into words but feel like I fall short every time. Instead, I will just share some of Match Day 2015 through the eyes of this clinician educator and her trusty iPhone camera. The lens may not be high tech but for you to see what I see, it doesn't have to be. I especially love the ones of them holding up their Match notification letters. I love that in these photos they were looking at me and me at them … and how much of a dialogue is held in their eyes. Or that we were together sharing in a pivotal moment. Perhaps if you look close enough, you'll see it, too. And just maybe you might feel your pulse quicken, your heart skip a tiny beat, and your eyes sting with tears while you do. And even if you don't feel any of that, don't worry … I had you covered.

Yeah.

Best. Job. Ever.

That's it. That's all. Wait—and this. A certain medical student opening her envelope back in 1996.

Almost as exciting as this year.

Almost.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.

Interpreting the new sore throat article

First, this study required the work of a large team. The main work happened in 2 places, a research microbiology laboratory and our college health clinic. They took an idea and translated it into an opportunity to collect and analyze data.

Second, the accompanying editorial (written by a friend and excellent researcher Jeffrey A. Linder, MD, MPH, FACP) raises some questions that I will work to answer. He writes that we do not have enough evidence to change practice yet. He postulates that Fusobacterium necrophorum might not actually cause pharyngitis and that linking positive polymerase chain reaction testing to the risk of supportive complications (peritonsillar abscess or the Lemierre Syndrome) lacks sufficient evidence. In this blog post I will present the evidence for our assertions.

Over the past 2 or 3 decades, some authors started calling Lemierre syndrome “the forgotten disease.” It seems that the syndrome occurred regularly in the first half of the 20th century. After the introduction of penicillin, case reports almost disappeared. With the drive to decrease antibiotic use for sore throats, and the introduction of newer antibiotics that many physicians substituted for penicillin (especially azithromycin) the syndrome seemed to increase in frequency.

Published data suggest that around 80% of the Lemierre syndrome patients have a primary infection with F. necrophorum. Danish researchers reported the best 2 epidemiologic studies of this syndrome. Their studies suggested an increasing incidence of the Lemierre syndrome over the past decade.

Recent data have shown that in the adolescent/young adult age group, F. necrophorum represents the most common bacteria in peritonsillar abscess.

Data from England and Denmark reported on the incidence of F. necrophorum in pharyngitis patients. Several studies suggested that in adolescent/young adult patients F. necrophorum caused at least as many sore throats as did group A streptococcal pharyngitis.

Our current study documents that in our college health practice we find more sore throat patients having a positive polymerase chain reaction for F. necrophorum than for group A streptococcus. We also document that their clinical signs and symptoms (using the Centor score) mirror the signs and symptoms of group A strep.

How should we act on these data? The Lemierre syndrome is devastating with an estimated 5% mortality.

Paul Sax, MD, in a current blog post, explains our position succinctly: Remember this: Patients with Lemierre's are often critically ill. They frequently require ICU care, have high spiking fevers with staggeringly high white blood cell counts, and invariably have multiple septic pulmonary emboli with potentially other metastatic sites of infection, including the brain. It's a terrifying illness. These are most commonly previously healthy high school and college-age kids, so the stakes are high. No, we don't know that treatment of severe pharyngitis “caused” by fusobacterium will prevent Lemierre's, but doesn't that make biologic sense?

As I give pharyngitis talks around the U.S., infectious disease physicians often approach me to describe their personal experiences with Lemierre syndrome patients. I believe we have a responsibility to try to prevent this syndrome. Therefore, I favor treating “sick” adolescent/young adult sore throat patients empirically with penicillin (or amoxicillin) or a cephalosporin. If they worsen, I would empirically use clindamycin.

I hope we can find a company (or more than 1) who would develop a point-of-care test for F. necrophorum. Until then we should follow Dr. Sax's advice: So let's go with the pediatricians' common-sense approach to clinical care, and make a decision about antibiotics based on that sixth sense of “is the kid really sick?” If so, go with some penicillin — especially if at the first encounter they didn't get treated, and then they come back a few days later even worse.

Or, if you prefer, listen to the guru of pharyngitis himself, Dr. Centor, and his interpretation of national guidelines:

We believe that following the American College of Physicians/Centers for Disease Control and Prevention guidelines endorsed by the American Academy of Family Physicians would decrease the risk of Lemierre syndrome in adolescents and young adults. Using these guidelines, physicians can choose to prescribe antibiotics for patients with a pharyngitis score of 3 or 4 (three or four of the following: fever, absence of cough, tender anterior cervical lymph nodes, tonsillar exudate).

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.
Monday, March 30, 2015

Marginal exercise advice from a newbie

I have lots of patients who are incredibly fit. I have patients who have run marathons. I have a patient who rides in rodeos. I have patients who have completed Ironman Triathlons. And I have lots of patients for whom exercise has always been a part of their routine, a lifelong habit. Though I hope they still enjoy it, this post isn't written for them.

This post is for people who don't exercise, for people who either hate exercise or have never done it with any regularity. This post is for people who haven't made the leap from exercising 0 times a week to exercising a couple of times a week. In short, this post is for people just like me until about a decade ago.

I'm going to try to get you off your couch.

If you're anything like me you don't care your biceps or abs look like. You don't particularly pay attention to your body, and you assume that your body will return the favor. You make a living with your brain, which means that you drive a desk or a laptop all day. As a kid you never fell in love with sports and you were never much of an athlete.

Now, if you have some chronic medical problems, like diabetes, or high blood pressure, or high cholesterol, then your doctor has already harangued you about exercising to get your sugar, blood pressure and cholesterol down. But let's assume you have the luxury of good health (for now).

I believe that what will get you exercising regularly are the mental benefits of physical activity. If you're a pointy-headed geek like me you need to know that exercise will help you concentrate better and think more clearly. It will improve your sleep and your energy. If you do cognitive work for a living, the improved efficiency will more than compensate for the time spent exercising.

If you have psychological illnesses, you should know that exercise will lower your anxiety and stabilize your mood. That doesn't mean it's a substitute for medications, but it means that it can help the medications work. I've had countless patients tell me that they rely on exercise to help lift their depression, blunt their mania, and calm their anxiety. I know myself that there's no better way to silence pointless ruminations about an unpleasant event than to climb a hill on my bike.

The only challenge is getting started and persevering until exercise becomes a pleasant habit. I promise you that it will happen. To that end, I have 2 bits of advice. But remember, I'm not a coach or a personal trainer. Most of my posts are full of links to double blind studies and reviews of data. This post is just the musings of a middle-aged guy who grew up not exercising and now actually likes it.

My first bit of advice is to find the cardiovascular exercise you hate least. Walking is a terrific choice. You can do it almost anywhere, and Los Angeles has gorgeous hikes and walks within short drives from almost anywhere. I love biking and swimming because I can do them alone or with friends. I don't enjoy running (yet) but some patients and colleagues persuaded me to give running a try. I love the efficiency of it; you can put your shoes on, leave your front door, and have a very hard work out in 30 minutes.

My second bit of advice is to do some kind of exercise almost every day. Doctors will tell you to exercise 3 times a week to get the cardiovascular benefit. But it's hard to have a 3-times-a-week habit. We don't do things 3 times a week. It's much easier psychologically to do something every day, or at least every weekday. Then, it's just like brushing your teeth or getting dressed or going to the office. It's routine.

I know you don't think you have time. I know when you have a stressful week you'll be very tempted to skip exercise. But I also know that after a month you'll look forward to it, you'll feel better after you do it, and you'll realize that the rest of your day is calmer, more focused and more organized because you force yourself to elevate your heart rate for 30 minutes daily.

Last weekend I ran my first race, a 10K. My time was abysmal, but my goal was only to run the whole thing without walking, and by that measure I succeeded. This is not bragging. Any serious runner has a much faster time on a 10K race than mine. It's the opposite of bragging. It's insisting that if I can do it, you can too.

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, March 27, 2015

COPD exacerbations and respiratory syncitial virus--maybe a huge problem?

We're having a curtailed winter and early spring here in the inland Northwest, or so it seems. We could still get a snowstorm or 2, but the crocuses are blooming and the redwing blackbirds are singing by the unfrozen ponds. Despite the mild temperatures and sunny skies we are still having an influenza epidemic and many of our patients with chronic lung disease are becoming sick with wheezing and low oxygen levels. We have rapid tests for influenza and for another lung infection, respiratory syncitial virus (RSV) and I am presently seeing less flu and more RSV.

I have never routinely checked my patients with asthma and COPD exacerbations for respiratory syncitial virus. I thought that it was one of those tests that would take so long to come back from the lab that the patient would be well before I ever found out the result. It is possible, though, to get a result back from a rapid antigen detection test (much like a home pregnancy test) using a sample of mucus from the back of the nose, in 30 minutes.

Last week 2 patients with severe wheezing and uncontrollable cough who were in the hospital with worsening of their COPD tested positive for RSV. Yesterday another 1 did. It is RSV season. In fact, it is even more RSV season than it is flu season. We are smack dab in the middle of RSV season, which stretches from January to April. RSV is best known as the virus that causes acute lung disease in infants and children. In the U.S. alone, over 80,000 children are hospitalized each year due to this virus and worldwide it kills more children under the age of 1 than any other infectious agent with the exception of malaria. More high risk adults, such as those with lung disease or immune suppressing diseases, contract RSV than they do the flu.

RSV is, for most of us, just a cold. It causes a stuffy runny nose and a cough, sometimes a fever. In small children or people with lung disease it can cause respiratory failure. It is very contagious. It is most often contracted by directly touching an infected person or objects with infectious secretions, even when they are dry. It is very important to avoid transmitting it in the hospital, and since we don't routinely test adults for it, we are probably very efficiently spreading it from infected to uninfected patients. The time from exposure to symptoms is 2 to 5 days. There is no vaccine, and people who get RSV can get it again, even during the same season, though perhaps more mildly. In very susceptible babies, a monoclonal antibody, Palivizumab, can be given monthly to prevent disease, but it is terribly expensive. For a baby it might run $1,000 to $3,000 per dose, but since it is dosed by weight, it would probably cost around $30,000 per dose for the average size adult. Not an option.

Prevention involves good hygiene, avoiding exposure to infected people, hand washing, and avoiding cigarette smoke which can make a person more susceptible. There is an antiviral medication, ribavirin, which is active against RSV and sometimes used, primarily for immune suppressed patients like those with bone marrow transplants. Ribavirin costs about $30 a pill, would be dosed twice daily, has a black box warning for causing hemolytic anemia. It is not known if its use improves symptoms.

I think that it is likely that many of the winter adult lung disease admissions that I see are related to RSV. It is much more common than I believed. Since there are no really useful pharmaceuticals to treat it, none of the economic forces that lead to mass education are at work to raise awareness of its importance in the aging and chronically ill population that we internists see in the office or hospital. There is talk of vaccine development, but if natural infection does not give long term protection, it is unlikely that a vaccine will. It would certainly be nice if we knew whether ribavirin helped improve symptoms. Old-fashioned and low-tech prevention is probably the key to reducing its impact. I certainly need to be checking for it more often and thinking about taking precautions to avoid spreading it in the hospital or waiting room!

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.
Thursday, March 26, 2015

Eulogy

Howard died on Friday.

Howard was the general surgeon I preferred sending my patients to because he took good care of them. He listened to what they said, he joked around with them, and he took them seriously. He also was famous for wearing tie-died scrubs. This type of care is unfortunately difficult to find from consultants.

Howard was also a friend. No, we didn't spend a whole lot of time outside of the office together, but he was one of the few consultants who had my cell number and who gave me his cell number. We used that number regularly to run things by each other.

We also shared trust; I was his doctor, and he was mine. Howard took out my gallbladder when it awoke me in the middle of the night. I took care of his cholesterol, blood pressure, and helped him through the grief from the death of his son.

His loss leaves a big hole. It leaves a hole in the physician community in this city, a hole in the care of my patients, and a hole in my own life. Howard, of course, would make some snide comment on my use of the word “hole” when referring to him. Maybe he just did.

To top off a well-lived life, his obituary in the paper was one of the best I've ever read.

AUGUSTA, Ga.-Once upon a time there lived a wise and wonderful man named Howard. He spent his days healing the sick, loving his family, and teaching those around him. He slayed dragons of disease, protected his castle well, and rescued thousands of people in distress. At 58, after repeatedly punching cancer in the face, he became very tired and released his soul to gallivant around the galaxy. He leaves behind his beautiful queen, and three princesses. In his galactic exploration we hope that he finds Prince Daniel so that they may travel together always, only stopping to help those in need. A celebration of an Earthly life well lived will be held at his home on Monday March 2nd from 5pm to 9pm. A colorful dress code is requested as black was not his color. In lieu of flowers, please consider donating to the charity of your choosing. Life Lessons from Dr. Howard: 1) Never be afraid to cover yourself head-to-toe in tie-dyed clothes. 2) Always laugh at people's jokes. 3) You can never say “I love you” too much. 4) Travel, Travel, Travel. 5) When packing for vacation, all you NEED to pack is underwear and a toothbrush. 6) Medicine is about more than treating a disease; it's about healing a human. 7) Always do your best. Show up! ON TIME!! 8) All education is valuable. 9) Crossword puzzles should always be done in pen. 10) If you act like you know what you're doing, people will believe that you do. 11) Don't spend a lot of money on a fancy hotel room. You shouldn't be spending too much time there, you should be out seeing the world! 12) I'm never late; nothing ever starts until I get there. 13) Always turn off the light when you leave the room.

I hope my eulogy is half as good.

I don't have any tie-died clothes, but I do have a pseudo-Hawaiian shirt:

This shirt's for you, Howard.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.
Wednesday, March 25, 2015

Isaac Newton's nutrient supplements

An article just out in The Atlantic is entitled, provocatively, “Vitamin B.S.“ This seems to share journalistic DNA with “Enough is Enough: Stop Wasting Money on Vitamin and Mineral Supplements“ from the Annals of Internal Medicine, and “Skip the Supplements“ from the New York Times.

This new piece in The Atlantic is a Q&A format with Catherine Price, a journalist and author of a book entitled Vitamania: Our Obsessive Quest for Nutritional Perfection. I have not read the book; in fact, this was the first I've heard of it. At least one review calls it measured, and it may well be. If so, it could be a very worthwhile read.

But the transcribed conversation in The Atlantic, starting with that headline, is rather the opposite of measured, taking the measure of prevailing sentiment, and apparently concluding that prevailing faith in nutrient supplements warranted some additional throttling. If enthusiasm for supplements is the action of concern here, this piece has opted to highlight the opposing reaction.

There are 2 potential problems with this. First, those most prone to have blind faith in the magical healing powers of nutrient supplements, a penchant I agree exists and I agree is a problem, are least likely to read an assault on that faith in The Atlantic, for rather the same reasons that evangelical Christians are unlikely to read even the most erudite treatise on the virtues of atheism. This begs the question: for whom, exactly, does the alarm bell in this piece toll?

It needn't toll at all for those who read, and believed, prior indictments of nutrient supplements. I suppose they might read this, too, if only to enjoy revisiting the opinion they already own.

We may surmise, then, that an article like this is mostly for someone other than the unshakably opposed or the unflappably faithful. If so, it suggests the readership is in the middle, those who may have certain convictions about supplements, but they are not fixed. The audience for such argument is an audience willing to hear argument, presumably.

That leads to the second problem here. That group seeking truth through an openness to new arguments—a large group, I hope—is unlikely ever to get there from here if every direction along the way is of the “abandon everything you thought you knew and start again“ variety.

That is the prevailing approach in our culture to the translation of research, expert opinion, or journalistic investigation into headlines, and it is a pernicious malady, propagating confusion and distrust at best, abject disgust at worst. This problem bedevils all discussion of diet, where we seem incapable of moving past the unending contestants in a beauty pageant to the beautiful truth of invisible consensus. It encumbers the dialogue about supplements, too, where the reality is more nuanced than panacea vs. B.S.

I have written at length about nutrient supplements before, and won't do so again here; those prior columns are at your disposal. Suffice to say that the evidence by no means rules out benefits of multivitamins, to say nothing of more targeted nutrient supplementation. In some cases, nutrients once thrown under the bus have been proven in time to have therapeutic effects as great or greater than the proprietary drugs that drove the bus. The exclusivities of a patented drug allow for profits vastly greater than those likely with any supplement, and that monetary divide propagates a divide in related research evidence. We are well advised to recall that absence of evidence does not equate to evidence of absence.

Magical thinking about nutrient supplements certainly exists, and needs to be discouraged. But it is rather discouraging if the only way we know to clear out such dirty bathwater is to let the baby go down the drain. The evidence in support of various nutrient supplements in various contexts is quite decisive. A one-answer-for-all approach does not work here, and hyperbolic headlines to not pave the way to understanding, or truth.

We may be thankful to Sir Isaac Newton for his brilliant insights about action and opposing reaction, the cosmic ping and pong of inertia, the native intemperance of physics. But we cannot possibly know what, if any, supplements Sir Isaac might himself take were he among us today. We do know that Newton's laws make a poor source of inspiration for headlines of science in the service of neither active fervor, nor reactive furor, but more temperate truths.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
Tuesday, March 24, 2015

The story behind the new sore throat article

Today, our latest sore throat article appears in the Annals of Internal Medicine. The story behind the article starts with this blog!

This post documents the story as of 2009 when I wrote about Expanding the Pharyngitis Paradigm

To recap, I first posted an article about the Lemierre Syndrome in 2002. Because of my long standing interest in adult sore throats, I immediately wondered if the rise in the Lemierre Syndrome should influence pharyngitis management.

Since my thought experiment publication in 2009, working with some great colleagues, we developed a polymerase chain reaction (PCR) for Fusobacterium necrophorum. We did some pilot work and proved to ourselves that the European data that showed a very low rate of F. necrophorum in preadolescents were consistent in the U.S.

Therefore we partnered with the wonderful staff at our college health clinic to prospectively collect throat swabs and clinical data. The European data did not include clinical information, but did suggest that in the 15-30 age group, F. necrophorum pharyngitis occurs at least as often as strep pharyngitis.

We found a wonderful collaborator at Michigan State University who did the PCR testing for group A and group C/G strep. Thus, we had the most complete data on the incidence of 3 bacteria (we also tested for Mycoplasma pneumoniae, but found it very uncommon in our patients) and their clinical presentations.

We hypothesized that F. pharyngitis would resemble strep pharyngitis. We based this hypothesis on our understanding of the Centor score. The score likely works because it captures 3 clues to bacterial pharyngitis (as opposed to viral pharyngitis). Bacterial infections more commonly induce an inflammatory response (exudates and adenopathy), cause fever, and do not cause upper respiratory viral symptoms (lack of cough). Logically we thought that these predictors were non-specific to any bacterial infection.

Our paper supports this hypothesis. The results explain why patients with scores of 3 or 4 do not have strep. Likely many of these patients have a different bacteria, group C/G strep or F. necrophorum. Perhaps there are other bacteria causing the pharyngitis in many of these patients.

We hope that this paper makes us all think about our approach to adolescent and young adult pharyngitis. More on that later.

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.
Monday, March 23, 2015

"It's their dying; not yours."

Ever heard of a doula?

Doula is an ancient Greek word that translates as “woman who serves.” Specifically, it's come to mean someone who serves as a birth attendant, a person trained in childbirth who acts in support of a birthing mother. A doula provides knowledge, comfort, and an extra pair of hands, whether it's to provide nourishment or massage, or help a mother find a comfortable position.

As you may imagine, the modern “doula movement” started as a reaction to over-medicalization of the birth process in the U.S. Too much hospital, too many medical interventions, too much “invasiveness” of what should be a joyous and miraculous time in a family's life. The movement began in the early 1970s. The interesting thing about doulas is that they have achieved widespread acceptance from the skeptical medical profession. There's strong science showing that labor attended by doulas results in better outcomes, such as less use of epidural anesthesia, fewer C-sections, and improved infant mother bonding through successful initiation of breastfeeding.

One of my mentors in medical school, Dr. John Kennell, was instrumental in doing the research that showed how doulas make a positive impact.

My wife and I were lucky to have the births of both of our children attended by doulas, one near Boston and one in Chicago. Both doulas even came to our home after birth to check in on us and see what we needed.

Recently I was surprised to see the term doula used in conjunction with the other end of life—death. A recent piece in the New York Times business section, in the “Shortcuts” column, discussed the emergence of doulas helping those that are dying ease the process.

It's quite logical, really. Most of us are afraid of death. The article chronicles a few for whom there was little in the way of family or friend support. A person experienced in listening, attending, and just being present is a wonderful gift to anyone, but especially someone who knows they will die soon.

Some of the doulas mentioned in the piece come from the hospice world, others from the birthing side of life who wish to use their skills elsewhere. The article gives details on the financial considerations if one were to hire a doula (it's in the Business section, after all), but trust me, no one is profiteering in this type of work. These are folks in it for the meaning.

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.
Friday, March 20, 2015

Residency (GME) positions: addressing the nation's health care needs

I'll start this post with full disclosure: I am a medical educator, and have spent a good portion of my professional life educating trainees (residents) to prepare for independent practice. My specialty is combined internal medicine-pediatrics, or “Med-Peds” for short, and my personal clinical practice is primary care for the underserved.

I have been very interested in what the future health care environment will look like, and thus follow updates from agencies that comment on the future of health care, as well as the supply of physicians and other health care providers.

There are some facts about which very few disagree, and there are others where interpretations are very different. We do know that many new medical schools have opened up within the past few years, and also that many existing medical schools have increased matriculation.

From this, it would seem as if the supply of physicians to care for future generations is being addressed. But remember that, to be a physician practicing independently, one must graduate medical school, and also complete residency training. It is this part, the percentage of residency training positions, which has NOT increased as much as the medical school matriculation. The actual number of positions has increased, but not at the same rate as medical school graduates (see Figure 1). In short, the “bottleneck” for U.S. students to become practicing physicians is indeed U.S. residency positions, known as GME, or graduate medical education. The National Residency Match Program (NRMP) does state that there are enough GME positions for all U.S. graduates, but there are other graduates (from international medical schools) applying for these same positions.

This was a busy week for such projections. The American Association of Medical Colleges came our with a roadmap describing plans for how to address this situation. The Commonwealth Fund, however, delivered another interpretation of the situation, stating that the current healthcare situation can handle the influx of new patients as a result of the Affordable Care Act. This follows on the heels of the Institues of Medicine's report last year addressing the GME issue and recommending no additional funding for new residency positions, among other things.

So who is correct? I admit my biases on this topic, in that a) I am an educator, and attend the AAMC meetings, and b) I practice in a state where even the Commonwealth Fund writes that there are fewer primary care docs. For the record, our med-peds residency program is the largest one in the country, and has been for at least 20 years. About 40-45% of our graduates choose primary care as their ultimate specialty, higher than either hospital medicine or further fellowship subspecialty training. This percentage of graduates choosing primary care was higher in the 1990s.

I'm curious what readers of this blog think about the situation. Is there a doctor shortage, and is there a shortage of primary care physicians? Will patients be able to get access to health care given the influx of new patients into the health care system? What else should be done besides the roadmap outlined by the AAMC?

Thanks for reading; I'm curious to hear differing opinions.

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

Why counting only resistant bacteria ultimately harms our patients

You've seen the numbers. The Centers for Disease Control and Prevention (CDC) estimates that 23,000 deaths are caused by antibiotic resistant pathogens annually and as many as 14,000 of these deaths are linked to Clostridium difficile. Every time I look at those numbers, they make me incredibly sad.

First, they include all C. difficile deaths and not just those attributed to fluoroquinolone-resistant C. difficile, for example. This tends to incorrectly overweight the importance of C. difficile relative to other pathogens. Second, and you've heard me rant about this before, they only count deaths caused by the small proportion of bacterial pathogens that happen to be resistant, as narrowly-defined. This would tend to diminish the importance of bacterial pathogens compared to other causes of death (e.g. accidents). But I'm getting ahead of myself.

The numbers I'm about to throw at you are very rough estimates. I'm using these estimates to illustrate a point, and hope that others will eventually provide more accurate estimates. If you think I need to correct a specific number, let me know in the comments, and I'll do my best to make the change, but I'm not promising.

Let's take Staphylococcus aureus as an example. The CDC estimates that 80,000 infections and 11,000 deaths are attributed to methicillin-resistant S. aureus each year. In 2005, they also estimated that MRSA was associated with 18,650 deaths, but I'll be conservative and stick with 11,000. Per this 2013 National Health care Safety Network report, the proportion of S. aureus that were MRSA ranged from 43.8% for a surgical site infection to 58.7% for a catheter-associated urinary tract infection. I'll use the lower proportion (44%) since this allows for some mortality secondary to more community (less MRSA) infections. However, I suspect most patients that die from S. aureus infection will ultimately be hospitalized. For simplicity, I will also assume that MRSA is twice as lethal as a methicillin-susceptible S. aureus (MSSA) infection (also known as penicillin-resistant S. aureus).

Taking the above numbers, if there were 80,000 MRSA infections, we would expect 102,648 MSSA infections. If the mortality rate for MRSA was 13.75% (11,000/80,000) then MSSA's mortality rate would be half of that or 6.875%. So there would be 7,057 deaths from MSSA. If you add that to the 11,000 you get 18,057 deaths due to S. aureus. We can quibble about numbers, but I suspect that 7,000 deaths caused by MSSA, passes the so-called giggle test.

Thus, if we used the CDC rankings to fund research and prevention activities, we would rank C. difficile at the top of the report. However, if we used my ranking system, S. aureus (MSSA+MRSA) ranks ahead of CDI. Since most interventions to prevent MRSA deaths would also work against MSSA (vaccines, new antibiotics) shouldn't both types be included in burden of disease estimates? The imbalance gets worse when you look at Gram-negative infections. Do we really only care if grandma dies of the 2-12% of Erichia coli or Klebsiella that are resistant to carbapenems? Do we really only count the 610 deaths from carbapenem-resistant Enterobacteriaceae (CRE) and 1,700 from extended spectrum beta-lactamase producing organisms (ESBL)? Clearly it would be better if we counted all deaths from E. coli and Klebsiella and projected a future where almost all strains would be ESBL or CRE. This would allow us to make better decisions regarding current and future research priorities and prevention efforts.

I suspect if the S. aureus mortality estimate jumps from 11,000 to 18,000 when counting MSSA, it's not a stretch to imagine that deaths from bacterial infections would approach 100,000 in the U.S. If we count attributable mortality appropriately, deaths from bacterial infections would be a top 10 cause of death in the US. Top 10 means more money for research and prevention. Let's get these numbers right; grandma is counting on us.

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.
Thursday, March 19, 2015

What can't be afforded

“I've been getting winded lately.”

He's a middle-aged man with diabetes. This kind of thing is a “red flag” on certain patients. He's one of those patients.

“When does it happen?” I ask.

“Just when I do things. If I rest for a few minutes, I feel better.”

Now the red flag is waving vigorously. It sounds like it could be exertional angina. In a diabetic, the symptoms of ischemia (the heart not getting enough blood) are atypical. It's the pattern of symptoms that is the most important, and to have exertional shortness of breath which goes away with rest is a pattern I don't like to hear.

What he needs is a stress test - more specifically in his case, a nuclear stress test (because his baseline EKG is abnormal). But there's a problem: he has no insurance. A nuclear stress test will cost thousands of dollars.

I can refer him to the hospital, but I know the financial situation he and his wife face. They have no money because of a chronic pain problem he has. He hasn't worked in several years, but hasn't ever been able to get disability either (“I tried, but was denied 3 times”). Without insurance he's not able to get his problem fixed, so he's disabled. But he can't get disability, so he can't get insurance to get his problem fixed and no longer be disabled.

But the problem on hand is this: He needs a test he can't afford.

There are many folks out there in this same situation. It may not just be the people with no insurance, and it may not even be people who don't have money. In fact, my own family is facing this same problem. Multiple family members (myself included) need dental work done. Some need it done badly, yet we don't yet have the money to pay for it. So we wait for the money to show up while the problems gets worse.

Many problems are being put off because of high-deductibles or under-insurance. Sure, the Affordable Care Act has helped people get insurance, but many people got the “bronze plan” and so pay out of pocket for much of their care. What ends up happening is that folks don't get their blood pressure managed, their diabetes controlled, or their shortness of breath assessed because it simply costs too much to do so.

And so my patient, who has a lot more than cavities, puts me in a difficult situation. He can't afford to wait to get this test done, but he can't afford to get the test done. We will do what we can to find ways to find the cheapest way to assess this problem and potentially fix it, but I am not sure exactly how we will accomplish that.

Until our system can figure out a way to handle this kind of thing, we will pay a big price. Waiting for problems to become emergencies is a terribly expensive practice. I'm not sure I know exactly what needs to be done for this, but it's becoming an increasingly common problem. Some say that a single-payor system will be the remedy, but they ignore the fact that a third-party payor system is what got us in this mess in the first place. Things are far too expensive because patients don't have to pay for them. That's why stress tests, which don't actually cost thousands of dollars to do, are so expensive. That's why there is $100 hemorrhoid cream. That's why medications are unreasonably expensive: someone else pays the bill.

I hope the answers are out there somewhere. I'm trying to work on ways to negotiate cheaper prices for my patients for such services, but this kind of thing will take a lot of work and will have to overcome a lot of inertia. It's going to take time.

Unfortunately, my patient with shortness of breath may not have so much time.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

Measles vaccines and the right to refuse treatment

It's been amusing to watch Rand Paul, a doctor, trying to “clarify” comments he made suggesting that vaccines for kids should be a matter of parental choice. Conversely, Rick Perry some years ago had to walk back his aggressive pro-vaccine stance, when he championed mandating HPV vaccines for young girls. This political clumsiness is not restricted to the GOP. In 2008, both Barack Obama and Hillary Clinton argued that “more research was needed on vaccines' potential side effects.” Presidential candidates, it seems, have not all been vaccinated against panderitis.

Of course, I recognize an informed individual's right to refuse treatment. An adult with appendicitis has a right to refuse appendectomy, against the advice of the surgeon.

Does a parent have a right to deny the measles vaccine for their kids? I don't think so. Here's why:
• Medical evidence provides overwhelming support for the vaccine's safety and efficacy;
• Unvaccinated children pose a health risk to other school children;
• The claim that any vaccine causes autism has been vigorously refuted; and
• Adults do not have an absolute right to deny children medical care.

I doubt that a 15-month-old child can make an informed choice about the measles vaccine. Would those infants who have been denied the vaccine, support this decision when they reach the age of understanding?

Parents have rights also. They have the right and the responsibility to make health decisions for their kids. This right, like all rights, is not inviolable. Parents should not be able to deny a life-saving blood transfusion or curative chemotherapy to a minor child who does not have the capacity to understand the ramifications of a denial of care. In contrast, some kids should be permitted to make their own decisions even if they have not reached the age of majority. A 17-year-old Jehovah's Witness, for example, has a more legitimate argument in turning down a blood transfusion than would a 5-year-old.

Immunizations are a towering achievement of the medical profession that has saved millions of lives. No, they are not perfect, but they work much better than nearly every medical treatment that doctors prescribe. Moreover, vaccinating kids offers a public health benefit that extends far beyond the youngster who is vaccinated.

If you are a libertarian who is suspicious of government, then go make a sign and protest. This is your right. But, vaccinate your kids. They have a right to good health. And, so do the rest of us.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Wednesday, March 18, 2015

We're fat and sick and the broccoli did it!

The ink hadn't yet dried on the report of the 2015 Dietary Guidelines Advisory Committee before the assaults began. I guess in this day and age, that's not much of a big, fat surprise.

Despite all the over-heated rhetoric I've seen about not trusting this report because the “government” can't be trusted, this report is not from the government. While we may, indeed, need to worry about what the political authorities will do with the recommendations of this advisory group, as historically cautioned by Marion Nestle, this advisory group is a multidisciplinary assembly of top-tier public health scientists. They don't work for the government. The government does convene them, but they work for us. It is, in fact, the very group Dr. Nestle herself once chaired.

In other words, the very best way to prevent government lobbyists from adulterating this report is by supporting the evidence-based consensus of the scientists themselves. The more we all bicker, pretend that know better, or malign this effort as biased, misguided or morally bankrupt, the more we play into the hands of lobbyists only too happy to say: “You certainly can't trust those guys, so listen to me … “

Predictably, most of the griping under way is by entities with obvious interests at stake. No surprise, really, that the makers of bacon-cheeseburger-muffins would rail against advice to eat more vegetables and less sugar, refined flour, and meat.

That someone with book sales at stake might inveigh against the collective judgment of the diverse members of the Dietary Guidelines Advisory Committee is also not much of a big, fat surprise. That the person in question might misconstrue her own, strong opinion for genuine expertise despite lack of relevant training is no big, fat surprise either. Our culture indulges in this routinely, having already killed off expertise, and now indulging in routine abuse of its rotting corpse. We are routinely told what research studies mean by people who not only were never trained to do research, but weren't trained to interpret it, either. Whether or not they even bother to read it is anybody's guess most of the time.

But since it's how we roll, it's no big surprise that someone untrained in research methods would tell us all what the research really means and why the scientists on this committee, all trained to do research and interpret it, are just a bunch of hacks.

But that the New York Times would allocate its imprimatur and rarefied real estate to an infomercial masquerading as an Op-Ed is, well, a genuinely big, genuinely fat, and lamentably disappointing surprise. That journalistic standards are complicit in the death of expertise is a sad surprise. Oh, well.

There is another actual surprise in the mix as well. The author in question, who has used social media before not only to tell me truths I am apparently too stupid to recognize despite my nine years of post-graduate training in relevant subjects; but also to impugn my character, my research funding, and maybe even my ancestors, engaged me recently in such an exchange to tell me: the broccoli did it!

The contention, via sequential tweets, was that advice to eat more vegetables and fruits must be wrong, because we have eaten more vegetables and fruits and only gotten fatter (and, I might add, sicker). The evidence presented was a table of per capita availability of vegetables in the U.S. between 1970 and 2005. The conclusion? We are fatter and sicker, and have more vegetables now than years ago, so: the broccoli did it! Okay, that last part is mine, but it's a close approximation of the indictment intended.

Does this make even a snippet of sense? Of course not.

Since 1970, per capita availability of the following have also gone up: Internet access; smartphones; Acai berries; solar panels; noise-canceling headphones; hybrid cars; DVDs; music downloads; and fitness apps. So, maybe the solar panels did it!

But let's not rush to judgment. Also up per capita are: reality TV show episodes; winners of American Idol; Geico commercials; and Uggs. Maybe the Uggs?

Oh, and by the way: over that same time frame, per capita meat consumption (not just availability) in the U.S. reportedly increased 50 percent. In, from what I believe to be the very report cited at me on Twitter, we get these statistics for the period between 1970 and 2005: total meat available per capita increased 13 percent; total cheese availability increased 106 percent; and total added fats and oils increased 63 percent. Then, of course, we have the rather famous study by Dr. Robert Lustig, pointing out the marked, global rise in per capita availability of added sugar (by whatever name), and the obesity and diabetes that follow predictably in its wake.

But damn the distractions! The broccoli did it.

True, we produce more vegetables than we did 45 years ago. But are we eating more produce?

In absolute terms, probably a bit. But as a percent of calories? Not at all.

You see, our calorie intake has gone up, and not from broccoli, but from the usual suspects: junk food, fast food, the stuff Michael Moss tells us is willfully engineered to be addictive. Some of it is meat and cheese, much of it is refined starch and added sugar (who ever came up with the idea that only one of these at a time could be a bad actor?). But it sure isn't unadorned vegetables.

Why do we eat more now than in 1970? Well, for starters because we can; tens of thousands of new, hyper-palatable, hyper-processed, and perhaps willfully addictive foods have been introduced into the food supply since 1970. Back then, the typical U.S. supermarket had about 15,000 items; they often now have 50,000 or more. If you can think of 35,000 new vegetables invented since 1970, I would love to see that list.

And, by the way, the now famous notion that we decreased our intake of dietary fat, or even saturated fat, is mostly belied by national trend data. We actually kept our total fat intake, and saturated fat intake, nearly constant, but diluted it down as a percent of total calories by eating more low-fat junk food. The idea that cutting saturated fat doesn't foster cardiovascular health is based on the antics of a population that never cut their saturated fat intake in the first place. Oops.

We got fatter because we ate more calories. But then, we also began eating more calories because we were fatter. Why does this make sense? For the same reason that a lean horse needs more daily calories to maintain its weight than a comparably lean rabbit. The bigger the animal, the more it needs to eat just to maintain its body mass, whether lean or obese. We are bigger animals than we were in the 1970s.

So, yes, perhaps we eat a little more produce, although availability of produce doesn't guarantee that. We also export some, and waste a lot. But our intake of produce as a percent of our total diet? Hasn't moved up in decades! Study, after study, after study attests to that, as they attest to the lamentable level of produce intake in the U.S. as compared to countries that tend to have less obesity and better health.

So did the broccoli do it? Not so much. The case against the solar panels and Uggs is still in court. Moving on.

The evidence is, in fact, overwhelming, from every conceivable kind of study, ranging from rigorously controlled intervention trials in Americans with heart disease, Europeans with heart disease, diabetics, cancer patients, and more; t oobservational epidemiology at the level of entire populations over decades, that the Dietary Guidelines Advisory Committee got it right.

Well, there's a big, fat surprise: a multidisciplinary panel of highly trained, public health experts commissioned to develop dietary guidance for an entire population in one of the most watched fishbowls in American public policy was more right than someone saying, in essence, “buy my book.” A real shocker.

Call me old fashioned, but I think when someone says “the data show,” they are obliged to show actual data, and ideally, more than the data they cherry-picked.

The committee did that. They followed the evidence where it lead, and clearly put epidemiology ahead of ideology, unlike those now lining up to take them down. For instance, the committee opted to put a whole section in their report on sustainability. Much as that argues for plant-based eating, they also chose to remove guidance against dietary cholesterol. This appears to be at odds with the gist of the report, but that's the beauty of it. The committee members looked at a vast array of evidence, and did the hard work of research: considering conclusions they didn't necessary hold at the start. The result is a report that reliably leans with the weight of current evidence, the very thing the committee was tasked to produce.

Folks, we are pervasively, persistently, and unnecessarily fat and sick. If we want to fix it, we may need to get sick and tired instead.

We need to get sick and tired of pseudo-expertise; of iconoclasts only showing the citations that support the position they held at the beginning, a dangerous variety of legerdemain for public health. We need to get especially sick and tired of iconoclasts who aren't even that, but rather copycats, reheating decade-old revelations of the “been there, done that” variety. We need to get sick and tired of exploring the innumerable ways there are to eat badly, so we might actually try eating well.

The broccoli didn't do it. We are fat and sick for rather obvious reasons. If we've had enough of that, it's time to act accordingly, by getting sick and tired of business as usual.

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.

Freedom of contagion

This blog tries not to be “political” (Too many trolls). But who'd have predicted that infection prevention would suddenly become a partisan political issue? Wow.

I was tempted to write a post about how misguided the anti-vaccine movement is (or how selfish, depending as it does on the responsible majority for herd immunity). But now I think I'm starting to get it. It's all about freedom! For too long the heavy hand of government has oppressed us with mandates to prevent infection. Thom Tillis (R-NC) nailed it with his devastating criticism of requirements that restaurant employees wash their hands. Let the free market do its work instead! As long as there is transparency, of course:

While we're at it, what right does the government have to restrict my ability to make a right turn on a red light? Or obey traffic signals and speed limits at all? Freedom!

I blame the social contract, that outdated theory positing that individuals should surrender some of their freedoms to achieve other benefits. Sure, life might be “solitary, poor, nasty, brutish and short” in the absence of the social contract, but at least it's free.

Daniel J. Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. This post originally appeared at the blog Controversies in Hospital Infection Prevention.
Tuesday, March 17, 2015

Snow storms and health care

No, this is not about getting a heart attack from shoveling snow (though that is a real phenomenon). It's about how the rising cost of health care is eroding the ability of state and local governments to fund investments in infrastructure. This becomes most apparent when that infrastructure is stressed, as it is, say, during a snow storm. Case in point: Boston.

As a former resident of “Beantown” I can attest to the fact that snow is a constant part of the winter landscape there. We could always count on the first snowfall to come before Thanksgiving (and could never count on being done before April. I recall 1 depressing year where it snowed in May! So I was not surprised, and was even a little nostalgic, when I witnessed Boston's second major snowstorm of the year. I was, however, surprised at how much the city struggled to cope with the snow, and in particular, how poorly the public transportation system held up under the circumstances. With another snowstorm arriving, the system failed completely. I was in town taking an executive education course at the Kennedy School of Government about health care delivery, which got me thinking about the connection between a failing transit system and health care.

Here is a slide from one of the lectures, taken from a publication by the Blue Cross Blue Shield of Massachusetts Foundation:

What it shows is that state spending on health care in Massachusetts has gone up, while everything else in the state budget, education, infrastructure, public safety, and more, has declined. As health care expenditures rise, it limits the ability of government to do everything else we want it to do, like making the trains run on time (or at all).

Here is something from Commonwealth Magazine from 2011: “The MBTA (the public transportation authority in greater Boston) is severely underfunded with regard to maintenance and upgrades of the regional bus and subway system. On the Orange Line, 120 cars built between 1979 and 1981 need to be replaced. On the Red Line, 74 cars from 1969 are well past their useful life. More than half of the MBTA's 82 commuter rail locomotives date to the 1970s, and nearly all are at or past the manufacturer's recommended lifespan of 25 years.”

This is neither good nor sustainable. I think it is one more piece of incontrovertible evidence that we need to lower health care costs.

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.
Monday, March 16, 2015

Expediting the physician credentialing process

It's 2015 and there are many areas of health care that seem to lag way behind the rest of the world. One such area is in the realm of physician credentialing, which can take several months or longer in most hospitals (the ones I've worked in have all averaged 3 to 4 months at the minimum, and that's been in 3 different states).

For anybody reading this who is not aware of what this process is all about, in a nutshell it goes something like this: A physician applies for a position, is interviewed, agrees on a contract, and then needs to complete a mountain of paperwork in order to get “hospital privileges” before working. This last part of getting privileges to work in any particular hospital is what is known by physicians as getting credentialed. It is rightly a very robust “checklist” that needs to be completed to verify the physician's qualifications, perform a thorough background check, and check personal references. The completed application is then brought before the hospital “credentialing committee” for approval. Only when this is done can the physician start working in the hospital.

It's reassuring for the world of health care and also the general public that physicians are vetted to this degree. Nothing less than a thorough process would be acceptable. Nevertheless, in this day and age the whole process is much longer than it should be and at a time when doctors (and for that matter nurses) are desperately needed in so many hospitals. It represents an often unnecessary delay for physicians to start their work. Even when all of the paperwork has been gathered and completed by the physician and sent to the hospital credentialing department, we are still looking typically at a couple of months before their hospital privileges are approved. The delay has become so much part of the norm that physicians now know that they have to apply months in advance for any job to take this into account!

Of course, every hospital and health care facility is different and has its own rules and regulations. The individual bottlenecks are unique for each facility. Some may take a long time to perform background checks via third party companies, and others may need more administrative staffing power to review the paper applications (note: they are still paper in most places). It would be in the broader interests of not only hospitals, but health care in general, to make it a priority to address these bottlenecks and make it quicker for much-needed physicians to join their staff. Being thorough doesn't need to take several months in 2015!

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.

Expensive placebos work better than cheap ones

The power of placebos has long been known. People who believe that they are taking an effective drug frequently feel better. In fact, prior to the discovery of penicillin, it is likely that the placebo effect accounted for much of the benefit of medical care.

A study published in the journal Neurology makes an interesting connection between the magnitude of the placebo effect and the medication's perceived price.

The study enrolled 12 patients with moderate to severe Parkinson's disease. They were told that they were going to be given 2 new injectable medications for Parkinson's that increase dopamine levels. They were told that the medications were believed to work equally well, but because of differences in how they are manufactured 1 medicine costs $100 per dose while the other costs $1,500 per dose.

The patients were randomized as to which medication they received first, the cheap or the expensive one. The patients received objective measurements of their ability to move and other Parkinson's symptoms before and after the medication dose. The measurements were made by people who didn't know which medication the patient received. About 4 hours after the first medication they received the other medication, again with symptom measurement before and after.

What the patients didn't know is that both injections were just saline, salt water without any active ingredient.

Not surprisingly, the patients improved after both injections. What was surprising was that the “expensive” placebo was much more effective than the “cheap” one. In terms of magnitude of effect, the expensive placebo was about halfway between the cheap placebo and the effect of levodopa, a Parkinson's medication that actually increases dopamine levels in the brain.

The result would have been less surprising if the patients were told that the more expensive medicine was more effective, but they were told that they were thought to be equally effective and the difference in price was attributed to a difference in manufacturing. Still, apparently, we can't help but fool ourselves into making “you get what you pay for” into a self-fulfilling prophecy. The patients expected a greater effect from the more expensive medicine and actually had more improvement in their motor function.

This may help explain why we spend so much on things we should know won't help. It may explain the continued success of the vitamin and supplement industry and the preference of some patients for brand-name rather than generic medications. (Many of my patients boggle when I tell them that my family and I use generic medicines whenever possible.)

Students and fans of behavioral economics likely would have predicted the outcome of this study. Wines with more expensive price tags are known to taste better than the same wine with a cheaper price tag. In fact the whole art of wine tasting seems to evaporate when experts are blinded about what they are tasting. So we should definitely buy cheap wine (and then fool ourselves by putting big price tags on the bottles).

The clinical applications of this study are not obvious. It's not ethical to deceive patients, so we can't just start lying and telling them that their medicines are more effective or more expensive than they really are. But we are reminded again of the power of patient expectations. If we can honestly shape expectations, for example by educating patients about the proven benefits of a medicine, perhaps we can ethically allow our patients to benefit from the placebo effect.

And I'm now surer than ever that I'll be able to cure more of you as soon as I double my fees.

Learn more:
‘Expensive’ placebos work better than ‘cheap’ ones, study finds (Los Angeles Times)
An ‘expensive’ placebo is more effective than a ‘cheap’ one, study shows (Washington Post)
Expensive Drugs Work Better Than Cheap Ones (Well, New York Times health blog)
Placebo effect of medication cost in Parkinson disease (Neurology article, abstract available without subscription)
Do More Expensive Wines Taste Better? (Freakonomics Radio)

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, March 13, 2015

COPD exacerbations and respiratory syncitial virus--maybe a huge problem?

We're having a curtailed winter and early spring here in the inland Northwest, or so it seems. We could still get a snowstorm or 2, but the crocuses are blooming and the redwing blackbirds are singing by the unfrozen ponds. Despite the mild temperatures and sunny skies we are still having an influenza epidemic and many of our patients with chronic lung disease are becoming sick with wheezing and low oxygen levels. We have rapid tests for influenza and for another lung infection, respiratory syncitial virus (RSV) and I am presently seeing less flu and more RSV.

I have never routinely checked my patients with asthma and COPD exacerbations for respiratory syncitial virus. I thought that it was one of those tests that would take so long to come back from the lab that the patient would be well before I ever found out the result. It is possible, though, to get a result back from a rapid antigen detection test (much like a home pregnancy test) using a sample of mucus from the back of the nose, in 30 minutes.

Last week 2 patients with severe wheezing and uncontrollable cough who were in the hospital with worsening of their COPD tested positive for RSV. Yesterday another 1 did. It is RSV season. In fact, it is even more RSV season than it is flu season. We are smack dab in the middle of RSV season, which stretches from January to April. RSV is best known as the virus that causes acute lung disease in infants and children. In the U.S. alone, over 80,000 children are hospitalized each year due to this virus and worldwide it kills more children under the age of 1 than any other infectious agent with the exception of malaria. More high risk adults, such as those with lung disease or immune suppressing diseases, contract RSV than they do the flu.

RSV is, for most of us, just a cold. It causes a stuffy runny nose and a cough, sometimes a fever. In small children or people with lung disease it can cause respiratory failure. It is very contagious. It is most often contracted by directly touching an infected person or objects with infectious secretions, even when they are dry. It is very important to avoid transmitting it in the hospital, and since we don't routinely test adults for it, we are probably very efficiently spreading it from infected to uninfected patients. The time from exposure to symptoms is 2 to 5 days. There is no vaccine, and people who get RSV can get it again, even during the same season, though perhaps more mildly. In very susceptible babies, a monoclonal antibody, Palivizumab, can be given monthly to prevent disease, but it is terribly expensive. For a baby it might run $1,000 to $3,000 per dose, but since it is dosed by weight, it would probably cost around $30,000 per dose for the average size adult. Not an option.

Prevention involves good hygiene, avoiding exposure to infected people, hand washing, and avoiding cigarette smoke which can make a person more susceptible. There is an antiviral medication, ribavirin, which is active against RSV and sometimes used, primarily for immune suppressed patients like those with bone marrow transplants. Ribavirin costs about $30 a pill, would be dosed twice daily, has a black box warning for causing hemolytic anemia. It is not known if its use improves symptoms.

I think that it is likely that many of the winter adult lung disease admissions that I see are related to RSV. It is much more common than I believed. Since there are no really useful pharmaceuticals to treat it, none of the economic forces that lead to mass education are at work to raise awareness of its importance in the aging and chronically ill population that we internists see in the office or hospital. There is talk of vaccine development, but if natural infection does not give long term protection, it is unlikely that a vaccine will. It would certainly be nice if we knew whether ribavirin helped improve symptoms. Old-fashioned and low-tech prevention is probably the key to reducing its impact. I certainly need to be checking for it more often and thinking about taking precautions to avoid spreading it in the hospital or waiting room!

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.

Getting religion about vaccines

As the current measles epidemic continues unabated, many are looking for explanations. One obvious target are the religious and personal belief exemptions that have allowed for increasing pediatric undervaccination. Yet the fact that many states and other entities allow religious exemptions might suggest that most religions object to vaccines. Miriam Krule writing in Slate explodes the myth of religious exemptions and describes how despite few true exemptions, it is very easy to claim one.

Her conclusions: “The only 2 religions that have any possible negative stance (though it's not even clear that they do) on vaccination are Christian Scientists and the Dutch Reformed Church.”

“In order to apply for a religious exemption, you don't even need to be religious. If you live in Connecticut, for example, all you have to do is fill out this incredibly simple form … In Florida, all that is needed is the child's name, date of birth, and social security number—no proof of religion, or even name of a religion, is needed.”

Irrespective of the lack of formal religious exemptions, when we speak with parents as physicians or public health officials, we need to be aware that 3 existing vaccines (hepatitis A, rubella, chicken pox) were developed from cell lines derived from aborted fetuses. For this reason, some Catholic and other parents might refuse to vaccinate their children. However, this issue has been well studied by the National Catholic Bioethics Center and the Pontifical Academy for Life, who “have determined that it is morally licit, and even morally responsible, for Catholics to use even those vaccines developed from aborted fetus cells.”

Dr. Paul Cieslak in the Catholic EWTN news states, ”While the new measles cases are cause for concern, the outbreak isn't nearly as bad as it could be, and that is thanks to vaccinations. The fact that it doesn't spread to everybody is a testimony to the fact that most of them [who were exposed] are immune, and most of them got that way through vaccinations. And when we have seen transmission of multiple cases, it has been largely among unvaccinated people. As a Catholic, I would argue that it [vaccination] is a socially conscious thing to do. It's not only good for you, it's good for your fellow man.”

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.
Thursday, March 12, 2015

How to avoid being a dumb-ass doctor

It's been two years since I first started my new practice. I have successfully avoided driving my business into the ground because I am a dumb-ass doctor. Don't get me wrong: I am not a dumb-ass when it comes to being a doctor. I am pretty comfortable on that, but the future will hold many opportunities to change that verdict. No, I am talking about being a dumb-ass running the business because I am a doctor.

We doctors are generally really bad at running businesses, and I am no exception. In my previous practice, I successfully delegated any authority I had as the senior partner so that I didn't know what was going on in most of the practice. The culmination of this was when I was greeted by a “Dear Rob” letter from my partners who wanted a divorce from me. It wasn't a total shock that this happened, but it wasn't fun. My mistake in this was to back off and try to “just be a doctor while others ran the business.” It's my business, and I should have known what was happening. I didn't, and it is now no longer my business.

This new business was built on the premise that I am a dumb-ass doctor when it comes to business. I consciously avoided making things too complicated. I wanted no copays for visits (and hence no need to collect money each visit). I wanted no long-term contracts (and hence no need to refund money if I or the patient was hit by a meteor or attacked by a yeti). The goal was to keep things as easy as possible, and this is a very good business policy.

Despite this, I've increasingly had to educate my gluteal muscles over the past two years. I am not allowed to abdicate my responsibility as a business owner any more. It's hard, as I have never been one who likes to attend to the numbers after the decimal point or the fine print in the contracts. My ADD screams when these things come into my visual fields, hitting me with the uncontrollable urge to play “Candy Crush Saga” or watch “American Idol.” I want to turn my mind off whenever confronted with minutia. It's taken a while to decondition this Pavlovian response. I am getting better at it.

The good news is that I actually want to get more organized and on top of the business. I am starting to enjoy spreadsheets, budgets, and even task managers. No, I'm not ready for my membership card for Pinheads International. I'm still not able to look at fine print without high doses of caffeine and antiemetics. But things are moving in the right direction.

So how does one avoid being a dumb-ass doctor? Here are my tips for doctors wishing to retrain their buttocks:
1. Don't ever forget that it is your business. No matter how much employees are invested in the business (and mine are as good as they get), nobody cares like you do and nobody pays the price you will pay if things fail.
2. Don't try to change overnight. I've learned these lessons over the past two years; they weren't there in the beginning. I've had to go through the process of change, which has come out of my desire to do best for my patients and still make a reasonable income.
3. Speaking of income, if you start a business like I did, don't forget to pay yourself. It's cool to get new gadgets or fancy task management programs (heh), but they don't pay your mortgage or your kid's tuition. There are plenty of ways that I want to grow the business, but that must wait until the cash-flow lets me do it.
4. On the other hand, don't skimp on things that will let you grow the business or improve service (which means you keep your patients). It's OK to borrow money if it helps bring in new patients and/or retain your present patients.
5. Hire staff that believe in your mission. I can't stress this enough for this kind of practice; my nurses are very dedicated to my practice and bend over backwards for my patients because they relish the chance to take care of people.

All this being said, here are some dumb-ass things that I avoided:
1. I kept it simple. The business of medicine is a morass of rules, codes, and disclaimers. It's way too much for docs to deal with. I don't charge copays. I don't expect people to pay more than 1 month at a time. I don't file insurance. I don't nickel and dime people for charges if I don't need to.
2. I didn't plan too much. I got all bent out of shape in the first few months we were open, as I wasn't doing everything I imagined doing. I realized (after being politely called a dumb-ass by a friend) that it would take time to figure out how to do all of the stuff I hoped to do. We've prioritized what is most important to our patients: access, and have been working to improve the process and quality since then.
3. We didn't grow too fast. This partly comes out of the fact that I was a dumb-ass, deciding to build my own EMR system, and was hence too busy doing that junk to focus on growth. To be fair, the system is the central way we are working to improve our care quality, so it's not all bad. But growing too fast will decrease the quality of care patients are getting.
4. I didn't pay a whole lot in advance for a consultant to give me a business plan I'd just abandon. This business is so new, it would've taken a person with a crystal ball to view into the future and anticipate what would happen. I am very glad I didn't waste the money.
5. I've enjoyed the chance to do what I want. We have fun in our office. We laugh at ourselves and each other. Despite all of the stress of starting a business, it all seems worth it when I think about what I left behind.
6. I accepted and embraced the reality of my dumb-assness. Doing so has lowered my expectations and made me more open to learning and listening to others. Those aren't easy things for us docs to do (I often wonder if “MD” stands for “Major Dumb-Ass”).

That last one is probably the most important one to learn. I have to learn how to learn and that I need to learn.

Ironically, I am grateful for my old mistakes that drove me from my old practice. Without those mistakes I'd still be on the hamster wheel of codes and data, making my patients angry and giving them lousy care. I am now nearly up to 600 patients, have 2 nurses, and am proud of what we do. I am also excited about our future, which is something most docs (and patients) cannot say.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.