Thursday, April 30, 2015

Managing the 1-star review on physician ranking sites

A newly graduated hospitalist recounted how someone posted to every online physician ranking service—there are dozens—and gave her a 1-star ranking on each. There were no comments to which she could reply or explain, just that low ranking from what she presumed was a displeased patient.

The hospitalist asked 2 experts how she could manage the situation as part of a talk on how physician ranking websites are impacting medical practice, “Ethics and being graded by patients: Help, I'm on Yelp!” at Internal Medicine Meeting 2015.

The 2 session leaders, James A. Colbert, MD, ACP Member, and Bradley H. Crotty, MD, MPH, FACP, encouraged the hospitalist to put the issue into perspective. Dr. Crotty said, “It doesn't feel good,” to have that happen, but also asked whether it mattered to her practice as a hospitalist.

Dr. Colbert added that the audience member may be doubly safe as a hospitalist, since patients are assigned to her and only likely to uncover a negative ranking after they leave her service, unlike an office-based physician, who is more likely to encounter patients who use physician ranking sites to pick and choose where they seek care.

“Just go about your business and don't let it bother you,” Dr. Colbert advised the hospitalist.

In the world of online patient rankings, extreme viewpoints good or bad are more likely to come out, and there are usually only 1 or a few rankings posted to any one website. The issue highlighted much of the typical experience that physicians are having with online doctor ranking services, Drs. Crotty and Colbert explained.

Physicians can follow a spectrum of behavior to monitor their online reputations, Drs. Crotty and Colbert explained. One end of the spectrum, Do Nothing, is not the way to go. Other options include Googling oneself and combing the online results for reviews. This might lead a physician to encourage other patients to conduct reviews.

Some doctors have gone as far as to create their own positive reviews, sometimes with unintended results when it became obvious that they were marketing materials instead of genuine patient viewpoints, Dr. Colbert said. This also tests ethical boundaries.

Some doctors have asked patients to sign nondisclosure agreements that would restrict them from commenting on physician review websites, which Drs. Crotty and Colbert discouraged. “It promotes antagonism,” Dr. Crotty said.
Monday, April 27, 2015

Medicare payment formula finally changed--win or loss?

Congress passed a law in 1977 linking Medicare payments for physician services to growth in the economy. Because it failed to take into account inflation and other factors, Congress has had to act 17 times to prevent cuts to physician pay under the sustainable growth rate (SGR) formula. This year physicians were set to get a 21% pay cut this year. This created a lot of stress and uncertainty for physicians, and caused some physicians to stop accepting Medicare patients.

The Senate recently voted to repeal this formula, 92 to 8. The bill was already approved by the House, and now President Obama has signed the bill.

That sounds like a great triumph for physicians. Although this may prompt some to pull out their imaginary violins in mock sympathy, I'm not so sure it will turn out to be such a great deal for physicians, which actually only consumes 12% of the Medicare budget.

The bill freezes the current rates, then increases them 0.5% a year from 2016 to 2019. For 2020 through 2025 there is no increase, and from 2026 onwards it increases by 0.75% per year. That is far below the current rate of inflation, and there is no provision if inflation gets worse than the currently low rate. That effectively means a real loss every year into the indefinite future.

There is a provision to transition payments to reward physicians for quality, rather than quantity. That is good in theory, but we'll have to see how that works out in practice. Quality health care is very difficult to measure, and there is a risk that quality will be defined based on what's easy to measure, and that will lead to physicians and other health care providers to concentrate on what they are rewarded to do, and not what may be in patients' best interest. I hope I'm wrong.

Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington. This post originally appeared on his blog, World's Best Site.

Why do we still use oral furosemide?

Most physicians do not understand pharmacology and pharmacokinetics. We use Lasix (furosemide) because we have always used furosemide. As an academic hospitalist, I often have patients admitted with heart failure (either right-sided or left-sided) who have gained significant fluid weight despite taking significant oral doses of furosemide. When they get admitted we start with IV furosemide and amazingly they pee like racehorses.

How many of us remember that oral furosemide is variably absorbed, with a general range of 20%-80%? You may not remember that, or you might just be in the habit of using Lasix. Lasix has a great name. It was generic when I was a medical student (‘71-’75). It is a magic drug. But should it be our first line oral loop diuretic.

We have two other good generic choices, bumetanide (Bumex) and toresamide (Demadex). Both drugs have consistent absorption in the range of 95%. Some data suggest that torsemide use improves outcomes, perhaps even all-cause mortality. Torsemide has some anti-aldosterone properties in addition to blocking the NaK-2Cl channel.

Recently, we had another patient taking 80 mg of Lasix twice daily and he had gained 50 pounds. IV furosemide worked beautifully. We tried Bumex 2 mg (the rough conversion between furosemide and bumetanide is 40 to 1) and he continued diuresing.

So why do we start with furosemide? And I am guilty also. Can anyone explain it or disagree?

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

Safety first? Not with my patients!

“Safety first” is a mantra of today's hovering parents. It's the default explanation that a parent invokes when an edict has been issued that cannot be challenged or reversed.

“Mommy, can I pleeeeeeze have a water pistol?”

“I'm sorry, honey. You know how Daddy and I feel about guns. This is a safety issue. Now go and practice your violin and afterwards help yourself to some kale chips.”

The safety concept has crept into the medical arena. In many cases, safety concerns about our patients are justified. I see many of our elderly hospitalized patients approaching hospital discharge who face safety concerns at home with respect to falls, understanding complex and new medication lists and monitoring active medical issues. Hospitals today have a staff of capable and compassionate professionals who do excellent work protecting patients poised for discharge. This effort saves patients suffering and saves the system cash—a medical win/win.

It's no victory for a cardiologist to rescue a patient from congestive heart failure if the patient goes home and doesn't take her medicines or veers widely off the recommended diet.

But sometimes safety should not be first. How safe would you want to be if your quality of life would suffer? To those who argue that safety is paramount, would you support the following proposals?
• outlawing motorcycles
• decreasing the speed limit by 10 mph on every road
• prohibit high school and college competitive athletics
• no swimming, anywhere
• avoid gluten, the silent killer

Don't take the above too seriously, since I don't. But, here's my point. I am often asked to place feeding tubes in elderly individual after they are tested and told that it is not safe for them to take food or drink by mouth. These patients are found to have imperfect swallowing function. The fear by those who make these recommendations is that the patient will choke while eating with some food dropping into the lungs causing a pneumonia.

These concerns are real, but we need some context. First, if all 80-year-old folks were subjected to the conventional swallowing test, many would be found to have swallowing dysfunction, and yet they are eating and drinking without significant difficulty. So, we have to be cautious about placing a feeding tube just because a swallowing test is abnormal. Secondly, many elderly patients have few pleasures remaining in their lives. Are we comfortable convincing them or their guardians to take food away when this may be a singular pleasure for them? Even if oral feeding has risks, for many of these folks I suggest that it may be the better choice. I think that we talk many of them and their families into the tube, which has its own medical risks in addition to its effect on human dignity and quality of life.

Do feeding tubes make sense for some patients? Definitely. But, it shouldn't be for everyone, We can devise a series of rules to live by that would make us much safer than we are now. Would you want to live like that?

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.
Thursday, April 23, 2015

Dietitians, food and truth: winds of change?

In what became a notorious move before ever the ink had time to dry on the hermetic plastic wrappers, the Academy of Nutrition and Dietetics, until recently, the American Dietetic Association, conferred its “Kids Eat Right“ seal of approval on Kraft American Cheese Singles. Blessed, indeed, are the cheese makers! But even they aren't entirely sure this stuff qualifies entirely as cheese, its somewhat dubious pedigree having been parsed for public consideration before now.

I can leave the specific merits and demerits of cheese and cheesy derivatives of it, and for that matter the particular uses and abuses of the “Kids Eat Right” seal to others, as the ink involved here has migrated from the Kraft wrappers to many columns and blogs. I am thus unburdened of that to focus on dietitians, food, and truth.

In principle, the Academy of Nutrition and Dietetics represents the interests of its roughly 75,000 dietitian members. But like all institutions, this one has developed a preferential interest in itself, which leads inevitably to an interest in money. Money tends to flow most readily to an organization advising the public on food choice from the entities most interested in the public choosing their foods. This makes for somewhat unsavory liaisons, and the history of the Academy has been sullied by just such trysts.

While the Academy will need to officiate, or prevaricate, its own way out of this mess of its own devising, the dietitian members are not so constrained. Members though they may be, they speak for themselves, and all the good ones, on behalf of truly good nutrition and public health. So they have done what needed to be done: they have mutinied.

The mutiny here takes the form of a petition, labeled “Repeal The Seal,” and which had 7,336 signatures when I arrived, and 7,337 when I left. That's less than 10% of the Academy membership thus far, but the petition was just launched, and it is nearly 10% of the entire membership. I suspect it has the Academy's attention, and Kraft's, along with every other would-be suitor for that seal.

So, first and foremost, I applaud my many dietitian friends and colleagues who have made the public's right to true food, and the unadulterated truth about food, their rallying cry. I encourage the many thousands more on the sidelines to get in this game, stand up, and be counted.

But then we need to look past this incident to the greater problem underlying it. We do not allow Toyota, or Ford, to determine who wins “car of the year.” Such designations are courtesy of those famously independent third parties, such as Motor Trend in this case. We do not permit appliance makers to manufacture their own metric for energy efficiency; they are all scored on the same, government-sanctioned scale. And while vacuum makers may all choose to accentuate the particular way their product sucks, the savvy shopper is generally more interested in the judgment of Consumer Reports, which doesn't sell a vacuum.

In nutrition, though, we have long allowed foxes to guard the hen house. The easy access of Kraft to an apparent endorsement by the Academy of Nutrition and Dietetics is only the latest example, and by no means the worst. Remember “Smart Choices“? Confronted by various efforts, including one I directed, to provide reliable, at-a-glance guidance to better nutrition, Big Food developed its own, and for a while, it seemed as if everyone would be okay with that.

The program, which declared Froot Loops a “smart choice” didn't last long, because it garnered the well-deserved ire of some state attorneys general, notably ours here in Connecticut; and some members of Congress, notably our own, much-loved Rosa DeLauro. But until all that, there was no reflexive, public outrage that the makers and marketers of multicolored marshmallows as part of a complete breakfast would be the ones to tell us what constituted a “smart” choice.

Why not? Would anyone take it seriously if the toothpaste-of-the-year award were conferred upon Crest, by Crest?

This has to stop. Food is right at the top of a short list of factors that most potently determine nothing less than our medical destinies, factors that account for roughly 80 percent of all chronic disease and premature deaths. Factors that could be leveraged to add years to life, and life to years. If we were inclined to sublet any given hen house to the oversight of foxes, we could scarcely have made a worse choice.

These, then, are the critical considerations that must reverberate for for us all when the #RepealTheSeal campaign has run its course, as it will:

1. We are not clueless about the basic (care and) feeding of Homo sapiens! We know the truth about good nutrition. Hyperbolic headlines, and competing fad diets create cover for the manipulations of Big Food, because they suggest there are no actual “experts,” and that if there are, no two agree. This is false.

True experts may disagree about details, but overwhelmingly agree about the fundamentals. The former makes for titillating and ever-changing media commentary, and marketing opportunity; the latter is vastly more important and substantially ignored. The True Health Coalition is a new initiative of mine, dedicated to fixing this very problem; please visit here, and join us.

2. Nutrition deserves respect. If we would all roll our eyes at Charmin as judge and jury for the toilet-paper-of-the-year award, it's hard to fathom our tolerance for just such conflicted nutrition guidance. Junk and food never belonged together as descriptors of the same substances, and junk guidance has no place in the mix, either.

3. In unity there is strength. The dietitians are demonstrating the importance of unity with their petition, but it can't be a flash-in-the-pan. There is a tendency to prioritize personal concerns in a way that sacrifices shared, evidence-based truths. We can all choose preoccupations born of private conviction, but we must also stand together in defense of those shared, evidence-based truths. To do otherwise makes us all cooks of a rather unsavory stew.

4. There is a better alternative to nannies, than ninnies. There is a strong anti-nanny-state contingent in our culture. To some extent, this reflects real conviction about personal liberties. To some extent, it is confabulated nonsense, such as when an organization called “New Yorkers Against Unfair Taxes” rallied against a proposed penny-per-ounce tax on sugar-sweetened beverages. That provocatively named organization was founded entirely and exclusively by the beverage industry, and represented no interest other than their own. Be that as it may, we can all agree that we don't want government regulations determining what we can or can't have for breakfast; but also don't want marketing by the makers of stuff like Fluffernutter masquerading as nutrition guidance. There is something in between the nanny state, and the land of exploited ninnies. I would hope we might all find common ground, and common cause, there.

5. It's bigger than dietitians. I mean no offense, here; it's bigger than physicians, too, and all health care professionals put together. In those places around the world where people eat the best, it's not because their clinicians get it right and provide terrific guidance; it's because their culture gets it right, and no guidance is necessary. The Blue Zone populations live, and thrive, in places where all available food is true food, and there is no predatory, profit-driven nonsense to compete with the truth about food. We ought to have what they're having.

Truth and food go together and belong on the same menu; junk and food do not, and never did. The truth about food should issue from those devoted to public health, not be manufactured by those apt to profit at its expense.

The dietitians have mutinied, but that simply means they have, rightly, taken over the ship in this instance. There is more to be done. The wind that fills those sails is bigger than any one group; it derives from our culture. Culture is a medium of our collective devising, subject to our priorities, and control. We decide which way this wind blows. Maybe the time has come for smart choices, after all.

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, April 22, 2015

BCBS gets stripped, and why you should care

GlassHospital & Co. were in California last week, where a huge story was reported by Chad Terhune in the Los Angeles Times.

The story was picked up nationally, but given the fact that it's about a large non-profit health insurer and a state bureaucracy, you could easily have let your eyes scan elsewhere. Or glaze over.

But I'm here to tell you why this is both fascinating and really important:

Blue Shield, the third largest health insurer in California was stripped of its tax-exempt status. For a non-profit, that smarts. And it's nearly unprecedented.

Non-profit institutions like hospitals, schools, charities, and religious organizations do not pay taxes, because their “business models” are about public service and/or community benefit; not about pure profit. Nevertheless, non-profits do need their revenues to exceed their expenses, typically to get re-invested in their missions, rather than, say, as dividends to shareholders, else they risk not being able to continue in business.

With more and more non-profits being urged by the public and their executives to be run “like businesses,” efficient, cost-effective, and strategic, it's no wonder that many non-profits now operate essentially like their for-profit counterparts.

Here's the rub: When that happens, attention can drift from the mission. For a hospital, it can mean focusing more on competition and market share than on serving the public. Same for a health insurer. Blue Shield has amassed a financial reserve of $4 billion, more than 4 times what its parent organization requires.

What's a non-profit doing hoarding that kind of cash?

An obscure entity called the California Franchise Tax Board issued the ruling stripping Blue Shield of its tax exempt status last August (why it took so long to become public is another story). The Tax Board determined that the business practices of Blue Shield are not consistent with the public purposes of a true not-for-profit entity [my phrasing].

Blue Shield is appealing the decision. Apparently, this all occurred due to a whistleblower, who went to Blue Shield's management to make his case that the company needed to act more in the public interest. Sadly, his ideas were dismissed.

Taking away a non-profit's tax-exempt status is a harsh punishment, and very rarely implemented. Exactly 5 years ago, I blogged about an Illinois hospital that had its tax-exempt status stripped. That gives you some sense of the rarity of such an action. What could this decision portend for other revenue-starved states?

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.
Tuesday, April 21, 2015

Should the word 'hospitalist' be more protected?

Our specialty of hospital medicine has grown exponentially over the last decade and now finds itself at the forefront of American medicine. I'm proud to be part of such a growing movement and must say that I find the job just as rewarding as when I first became an attending physician when the specialty was still in its fledgling stage. As the number of us soars towards the 50,000 mark, the vital work we do across the country every day is rightly becoming more widely known and recognized.

The term “hospitalist” was first coined in 1996 in a New England Journal of Medicine article and has now become our job title. But at this point let me break from my esteemed colleagues who champion the phrase. I've written previously about my personal dislike of the word “hospitalist,” including in this article published last year on a top social media site entitled “Please don't call me a hospitalist.” I received a lot of emails after writing this—both positive and negative. I know a lot of our colleagues right now are celebrating the fact that the head of the Centers for Medicare and Medicaid Services and the new surgeon general are “hospitalists.” Isn't this great for the specialty?

Don't get me wrong, I mean no personal disrespect to our founding fathers who first came up with the job title or the thousands of hard working hospital doctors, but I've personally never used that word to describe myself, find it a slightly ridiculous term, and have always gone an extra mile to avoid putting the word on my business cards or even my name badge. For me, being known to my patients as their “attending physician” or “internal medicine doctor” is all I want.

But I will move on from the points I raised previously to another central question: If this is the name that we've adopted, should it be more protected? This question arises because over the last few years on my travels up and down the East Coast, I've noticed more and more people banding around the word “hospitalist” to describe what they do. For instance I've heard many specialty colleagues such as nephrologists and endocrinologists who find themselves working mainly in the hospital describe themselves as functioning as a “hospitalist.” I've heard final year residents and even medical students on-call openly say that they are working as the “hospitalist.” Nurse Practitioners and PAs frequently describe themselves as the “covering hospitalist.” I've even heard respiratory therapists and wound care nurses who are covering multiple floors describe themselves as the “respiratory therapy hospitalist” and “wound nurse hospitalist!”

Not to get stuck on names, but this situation would never occur with most other specialties. For example, neither a resident, respiratory therapist, nurse practitioner or physician assistant would boldly describe themselves as the “cardiologist” or “nephrologist” on-call.

I understand that this may not be a big issue to lots of our colleagues, but remember that you have gone through medical school and residency to call yourself an attending physician—why make yourself anything else? Without sounding arrogant, there isn't a professional out there who would ever describe themselves as anything of less magnitude than their true job title. A chief executive officer of a company wouldn't introduce him or herself as “one of the managers” and a 747 pilot would never describe him or herself as “one of the airline staff.”

We belong to an ancient profession. The word “doctor” is more than 2,000 years old, aptly derived from the Latin doctus meaning teach or instruct. Physician was used traditionally to describe a medical doctor, and King Henry VIII granted the first charter to form the Royal College of Physicians in 1518. In almost every country in the world, a medical doctor is considered to be among the most noble and prestigious professions, the title only conferred after 1 of the most rigorous university courses in existence. It is a privilege and honor to be 1.

I'm afraid to say that in my own experience, whether we like it or not, “hospitalist” in the eyes of many says “I am a shift worker,” or “I am transient,” or “I am some type of resident,” or I am “owned by the hospital.” If you are the attending physician—now that's something a lot more meaningful.

So should the word “hospitalist” be protected like a cardiologist or radiologist, and specifically is a hospitalist always a physician practicing hospital medicine? That's a question for the wider community. For me personally, as someone who doesn't use the word, it doesn't matter! But if any Tom, Dick or Harry who works in a hospital and is employed in shift work, physician or not, now feels able to call themselves a “hospitalist,” what does it mean for you to primarily use that as your job title?

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.
Monday, April 20, 2015

What is community acquired pneumonia?

Back in the 70s when I was training, we diagnosed pneumonia, and then tried to understand the likely bacteria causing the pneumonia. We knew the clinical presentations of various bacteria. We had a clear illness script for diagnosing pneumonia.

Then, if I recollect correctly, we had a new diagnosis: community-acquired pneumonia (CAP). Perhaps I am too old school, but CAP seems like a “cop out” diagnosis. Moreover, the label has become a crutch for hospital admission. Patients come to the emergency department with at least one symptom suggesting a chest X-ray. The CXR suggests an infiltrate and bingo we have an admission diagnosis.

I love admission diagnoses of CAP because these patients so often have something else. We can exercise our diagnostic muscles to either confirm or deny the original CAP diagnosis.

Why has this happened? I blame the Centers for Medicare and Medicaid Services (CMS)! In 2004, based on flawed data, CMS started reporting the percentage of pneumonia patients who received antibiotics within 4 hours of emergency department arrival. A wonderful series of articles then demolished this rule! Another performance measure bit the dust because the rule led to a significant increase in inappropriate antibiotic use.

But I believe the rule has a lingering impact. The rule told us that we cannot afford to miss pneumonia. Therefore, when in doubt we label patients with a pneumonia diagnosis. And too often we ignore the patient's history, focusing merely on a chest X-ray infiltrate.

Another factor comes into play, a very unfortunate factor. We seem to need a diagnosis to admit a patient, even when making the diagnosis is really the reason. I hope that sentence made sense. We no longer seem to admit patients for abnormal chest X-ray, diagnosis uncertain. Rather we place a label on the patient, one that induces the anchoring bias.

So I accuse the system that was trying to improve quality as actually causing diagnostic errors and inappropriate treatments. I accuse the system of fostering diagnostic delays. And I still do not know why we use the crutch diagnosis of CAP.

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

Post-exposure vaccination for Ebola

The ongoing Ebola virus outbreak in West Africa continues to underscore the importance of a strong international public health infrastructure and continued investment in both basic and clinical research targeting infectious pathogens. The first line of defense for infectious diseases, if available, is a safe and effective vaccine. However, approved vaccines do not exist for many pathogens like Ebola, so well-designed personal protective equipment becomes critical. But even the best available personal protective equipment can't protect us from sharps injuries. Which brings us to a fascinating case report of post-exposure vaccination of a physician with a needle stick injury obtained while working in an Ebola treatment center in Sierra Leone.

The report by Lilin Lai and colleagues was published online in JAMA along with a very well-written editorial. The 44-year-old physician from the U.S. was stuck by an 18-guage hollow-bore needle through 2 layers of gloves after caring for Ebola patients with very high viral loads. Because doffing procedures had to be followed, there was a 10-minute delay in cleaning the wound with bleach, soap/water and chlorhexidine gluconate. The patient was evacuated and while boarding the jet received an experimental vaccine, a first-generation recombinant vesicular stomatitis virus-based Ebola vaccine (VSVΔG-ZEBOV) 43 hours post-exposure.

Post-vaccination, he developed fever and malaise but made it safely to the National Institutes of Health Clinical Center for further care and evaluation. His course was a bit rocky the first few days with fever, lymphopenia and diminished oxygen saturations, but symptoms and signs slowly improved over 3 to 5 days and he was asymptomatic by day 7. He was discharged to complete the 21-day mandatory isolation-period at home. Ebola virus was never detected.

You can read the full report (free online) if you're interested in the many tables and figures outlining his immune responses. Briefly, the vaccine did elicit a strong innate and virus-specific immune responses. Most importantly (per the editorial) it was “able to induce an IgG antibody response against the Ebola virus glycoprotein at a level that has been associated with protection of nonhuman primates.” However, the editorial correctly notes that no definitive conclusions can be drawn since it is unclear if the patient was ever infected with the virus and the adverse events the patient experienced could have been secondary to his concurrent travelers' diarrhea.

What is important is that while numerous candidate Ebola vaccines have been shown to effectively prevent transmission in nonhuman-primate models, post-exposure treatments and vaccines have been harder to develop. I wonder if a trial seeking to reduce sharps injuries in Ebola-treatment settings is in the works or if NIH would fund such a trial? Last time I checked, sharps injuries were on the rise, so investment in prevention research remains critical.

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, April 15, 2015

Your syndrome's missing benefit

The prestigious Institute of Medicine recently issued a comprehensive report on the vexing condition long known as both “chronic fatigue syndrome” and “myalgic encephalomyelitis.” The report, commissioned because of the frustrations engendered by the enigmatic condition for patients and providers alike, runs to 305 pages.

For our purposes here, just a few lines will do. First, the committee recommended that the condition be renamed to: systemic exertion intolerance disease. The functional reference, that people with the condition are generally intolerant of physical exertion, is important. More important, though, is that last word: disease.

The use of “disease” was clearly no accident, as it recurs in the opening paragraph of the summarized recommendations. That paragraph reads as follows: “The primary message of this report is that ME/CFS is a serious, chronic, complex, multisystem disease that frequently and dramatically limits the activities of affected patients. In its most severe form, this disease can consume the lives of those whom it afflicts. It is ‘real.’ It is not appropriate to dismiss these patients by saying, ‘I am chronically fatigued, too.’”

Not long after its release, the report was fodder for a poignant New York Times column in which the author, a professional science writer, reveals that she has suffered the condition for the past 16 years. Along with the revelation of some personal elements, the author cites the cynical reactions of physicians to the IOM report, published on Medscape, real estate in cyberspace where our clan gathers to get and share information (when I last checked, there 296 comments on this topic). The column conveys a clear impression of personal hurt, the echo of prior experience, and the apparently familiar addition of insult to injury. Ms. Rehmeyer concludes that a diagnostic test is needed urgently.

The IOM report also emphasizes the need for diagnostic advances, developing specific clinical criteria for the diagnosis in the interim. My principal conclusion differs: it's that we need a profession-wide reminder that the patient is the one with the disease, even when the disease has the misfortune of being a syndrome.

That line, “the patient is the one with the disease,” is from The House of God, a famous, satirical novel about medical training. Published almost 40 years ago, it still resonates.

How could there possibly be need for a reminder that the patient is the one with the disease? Well, it can be hard to feel sorry for anyone but yourself when you are working 100 or more hours a week, and your beeper goes off at 3 a.m. just as you are untying your shoes and hoping for a nap. I am by no means proud to say so, but I recall fighting to remember the patient was the sick one under just those circumstances during my residency. I generally lost that battle while pulling myself back from the cusp of sleep in the on-call room, but had usually won it by the time I got to the ER and looked my new patient in the eyes.

For related reasons, I eventually went into integrative medicine, which I have practiced for the past 15 years. This is not the place for a defense of integrative medicine, or a detailed explanation of its potential merits and liabilities. I will simply say that I went that way because it places comparable emphasis on relief of symptoms we don't necessarily understand, as on treatment of “diseases” we do. Those missions need not be mutually exclusive, but all too often seem to be.

Essentially by definition, a “syndrome” is all about symptoms we don't understand. In contrast to a disease, a syndrome is a condition that has a recognizable cluster of characteristic symptoms (what the patient feels) and/or signs (what the doctor finds on examination or testing), but no known cause, no confirmatory test, and often, no certain approach to treatment. As an example, acute infection with Borrelia burgdorferi is Lyme disease; the symptoms that sometimes linger for years after treatment of Lyme disease constitute a syndrome.

The challenge of living with a syndrome confronts millions of Americans. Roughly 1% to 2% of the U.S. population, or some 4 million people, have fibromyalgia. Chronic fatigue syndrome affects approximately another million. As many as 50,000,000 of us have irritable bowel syndrome. Nearly 40,000,000 women have premenstrual syndrome. Interstitial cystitis plagues some 700,000 women, and nearly 28 million adults in the U.S. have a migraine headache syndrome.

If you are a member of the enormous population that suffers from one or more syndromes, you can get good medical care. But you may have to work extra hard to do so, and you, too, are apt to suffer the addition of insult to your injury along the way.

Because a disease has a cause that is known to one degree or another, it is often verifiable through diagnostic testing, such as blood tests or X-rays. Syndromes often must be diagnosed on the basis of symptoms and signs alone, in the absence of any characteristic laboratory test findings. They are often called “diagnoses of exclusion,” meaning a syndrome is diagnosed when testing rules out everything else. To some extent then, the diagnosis of a “syndrome” leaves room for doubt.

Syndromes tend to be more variable than diseases, probably because the same pattern of symptoms and signs may derive from multiple causes. It is likely that in many cases what is currently diagnosed as one syndrome will someday, when we know more, actually turn into several related diseases. This has happened before. A variety of different types of arthritis that can now be diagnosed quite precisely as rheumatoid arthritis, or osteoarthritis, or Lupus arthritis, were once a syndrome of joint pain all lumped together under the title of “rheumatism.”

But perhaps the most important difference of all between disease and syndrome is the legitimacy attached to them. The lack of confirmatory test results for a syndrome means that there is nothing to “clinch” the diagnosis. Because the causes of syndromes are unknown, treatment is often uncertain, too, and results often less than gratifying.

Doctors don't much care for conditions we don't understand well, can't treat effectively, and can't even confirm with a blood test. The frustration that results often translates into one of medicine's more common, and most regrettable missteps: blaming the victim. Patients with syndromes are often overtly, or at least covertly, blamed for their symptoms and engender an “it's all in his/her head” attitude in their doctor.

That the often truly impressive prowess of modern medicine is ill adapted to the misfortunes of the merely syndromic is not the truly grave problem here. The problem is the cynicism reflected in those comments on Medscape. The problem is failure to recall that the patient is the one with the disease, even when the disease is a syndrome.

The IOM clearly recognizes this, and has lent its imprimatur to the legitimacy of systemic exertion intolerance disease. The report will likely accelerate the quest for objective diagnostic tests, and effective therapies. Those with the condition will certainly benefit from such advances.

But there are many other syndromes out there, and millions of others suffering the conjunction of insult to injury. They, too, would benefit from diagnostic tests and better treatments. But there is another benefit they are missing and need. It requires no IOM report, nor Nobel Prize. It requires only compassion, and humility. It requires only the acknowledgement that it's not the patient's fault their symptoms have not yet found an abnormal scan or blood test to call their own, the recollection that the patient is the one with the disease, even when the disease is “just” a syndrome.

It is the benefit of the doubt.

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, April 14, 2015

Practical emergency airway management--human factors in response to medical emergencies

Physicians need to complete about 50 hours of some kind of continuing medical education (CME) every year. The ideal kind of class is one that we actually attend in person, with teachers who are expert in the field being taught and are somewhere near the cutting edge. CME classes are especially nice when they include something hands-on rather than just a lecture format because much of medicine is hands on and because that wakes us up and keeps us focused. There are other ways to get education, such as studying written materials or attending classes taught via video presentation, and they are an important way for physicians who don't have the leisure to leave their work to refresh or expand their knowledge base. I've always gotten more from the courses that were taught by actual living breathing people, though I have availed myself of lots of the distance options

One thing that physicians are often required to do, and rightly, is to remain familiar with how to deal with emergency situations, ones which thankfully don't happen very often. The hardest things to remain competent to do are the procedures that we perform only in extreme situations and can't be practiced on healthy or nearly healthy people because the procedures carry too much risk. The most perfect example of such a procedure is providing an emergency airway to a patient who is at risk of being unable to safely breathe for him or herself.

In such a situation, for instance if a patient comes in who is so ill and weak that they are unable to support their need for oxygen and/or for elimination of carbon dioxide, breathing must be augmented in some way. Sometimes a pressurized mask, “bilevel positive airway pressure” or “BiPAP” may work, but sometimes even that in not enough and the person must be connected to a ventilator. The ventilator provides the “good air in, bad air out” that normal breathing normally does, but a tube must be placed into the trachea via the nose or mouth to connect the ventilator to the human. This is a tricky and sometimes difficult procedure. A tube stuffed blindly into the mouth will normally go down the esophagus into the stomach, which does not actually connect to the lungs in healthy people. In order for a person to allow a tube to go down the throat (or nose in rare cases), he or she must be heavily sedated and, ideally, entirely paralyzed in order to see the clear path for tube placement.

When a person is not breathing adequately, there is still some oxygen exchange going on, but when that same person is heavily sedated and paralyzed, no breathing will happen. Artificial respiration can be performed via a mask and a bag, but that is difficult to maintain and often fills the stomach with air as well, so the endotracheal tube (tube to the lungs) needs to be placed quickly and accurately. If it accidentally goes in the esophagus and the situation is not quickly discovered, the patient will die.

Most of us physicians don't often run into a situation where endotracheal tube placement is a common occurrence so, despite the fact that we need to be very adept at it, it's hard to maintain competence. Even those of us who do it pretty often were sometimes taught in a haphazard manner which we try to overcome by practice. When an endotracheal tube does not go in easily, as planned, we have the option to place a temporary puffy internal mask which fits over the trachea through the mouth, or to perform a surgical procedure to put a tube through the cricothyroid membrane in the neck. That is likewise a procedure that demands competence, and one which is not possible to practice on real people who value their lives.

I just returned from a nearly perfect course in providing airways in emergency situations, taught by Dr. Richard Levitan, a self-proclaimed airway geek. He taught the course in conjunction with 2 other airway experts, Dr. George Kovacs from Dalhousie University Medical School in Halifax, Canada and Dr. Ken Butler, and emergency physician and airway pharmacology specialist from University of Maryland. I say nearly perfect without any real concept as to what would have made it more perfect.

The course started with a day of lectures, heavily sprinkled with video recordings of real situations, anecdotes and student participation. The students were primarily emergency physicians, with a smattering of medical residents and critical care and hospitalist type of doctors. There were not very many of us, maybe 18 total, which gave us all great access to the teachers.

Lunch was at a Greek restaurant a few blocks from the hotel venue, and we all ate together at a large table. We were encouraged to tell an airway story (which are some of the most colorful stories in most peoples' memories) after we finished eating, which meant that we knew each other as individuals by the end of lunch the first day. That is very unusual in medical conferences where it is pretty easy to depart with no new friends. Dr. Levitan has a huge amount of practical and academic knowledge of everything to do with the airway, which despite being small geographically is huge in spectrum. He digested that to give us an uncluttered approach to placing the most appropriate kind of airway device, recognizing that the psychology of stress in times of great urgency of action limits our ability to be able to use complex, multi-branched tree charts.

His co-teachers provided alternate approaches when something was controversial, which I found very helpful and reassuring. He focused on “human factors” in the procedures, a term which I have heard floating around more and more lately, often in regards to computerized documentation. “Human factor” and ergonomics are words used to describe efforts to make processes, cognitive, emotional and physical, fit real humans in such a way that they are efficient and also happier and less likely to be injured. Dr. Levitan was particularly interested in making the ways we think about performing in emergencies add to our success and reduce our tendency to fear and subsequent stupid decisions. He also taught details about holding instruments, positioning patients and breaking down complex procedures into easily accomplished bits. His presentation style was engaging and he combined media with printed data, stories and questions in a way that excellent professors do.

The second day was spent in the lab. There were about 20 relatively recently deceased people whose unselfish decision to donate their bodies made it possible for all of the students to become competent and confident by the end of the day. We gowned and gloved and viewed the epiglottises, larynges and tracheas of each of them, allowing us to become familiar with a tremendous amount of diversity of anatomy. We placed endotracheal tubes in 20 subjects, practiced use of standard, fiberoptic and video laryngoscopes, bronchoscopes and other optical gadgets. We learned exactly what twist of the wrist allows atraumatic passage of a tube. We placed tubes through cricothyroid membranes, thus de-stressing one of the most worrisome procedures in our potential practice. The bodies were softer than the embalmed bodies that I learned anatomy with in medical school, and were much like the patients we might see in this type of situation in texture. I thought it might be a little bit horrible, but it was not. I was kind of attached to our patients by the end of the class, and would have liked to have known their stories.

Beside my profound thanks to the cadaver subjects, I am so very grateful to excellent teachers who spend years learning things of immense complexity and then present them to us, with a generous helping of humor and compassion.

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.
Monday, April 13, 2015

We should do a better job teaching 'red flags'

Over the years, I have written about the short head and long tail. For those who have not considered the long tail, it refers to the approximately 15-20% of patients who are not routine. For each chief complaint, some patients will not have one of the “usual suspect” diagnoses. Our job is to recognize when we need to think of more usual diagnoses.

Experts can tell you what “red flags” lead them to slow down. I did an interview that will likely appear on television (I will link the piece when it becomes available). The interviewer asked me what advice I would give to moms about their high school or college aged children with a sore throat. I have clearly thought about the sore throat “red flags”, so I quickly answered:
1. Worry about a sore throat that is worsening or not improving in 3-5 days.
2. Worry about the “worst sore throat ever”
3. Worry about night sweats
4. Worry about rigors
5. Worry about unilateral neck swelling

For many problems I have a good list of “red flags”. I had to learn these over time. I do not remember my excellent residents and attending physicians teaching them.

Knowing “red flags” can help us know when to rev up the diagnostic engine. This requires us to really understand the natural history of each diagnosis. When we assume a diagnosis, and the patient's course deviates from the textbook, we likely have the wrong diagnosis.

Each specialty and each sub-specialty have unique cues that should make us uncomfortable. We who focus on clinical education should know them and teach them explicitly.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.
Friday, April 10, 2015

Futuristic medicine

I just deposited a check into my bank account by photographing the check with my iPhone and zapping it through cyberspace. I realize this is a yawn to the under 35 crowd. Soon, there won't be any paper checks as the entire transaction will occur electronically. As a member of the over 35 crowd (plus 20 years), I am wowed by this process. I remember being astonished when my kids told me how they performed this same process a year ago. It's the same amazement I experienced when I first read about a new piece of technology called a ‘fax machine’.

“You mean you slide a document into a machine and an exact copy emerges elsewhere?”

In my younger days, depositing a check into a bank account meant waiting in line with my bank book in hand waiting for a living, breathing human to count and record my allowance and snow shoveling earnings. The bank that my kids use today has no physical offices. It is entirely in the Twilight Zone.

Medicine will not be left behind here. The manner in which medical care will be administered will be beyond what we can imagine. We are seeing glimpses of it already, but our vision of its trajectory is limited. There will be huge advances, but as with all technology, there will be a cost. The traditional doctor-patient relationship will fade out and will no longer be the bedrock of medical care. There will be nostalgia for it from those who experienced it, much as I have warm memories of bank books, rotary phones, ice cream sodas, and playing basketball after school in the school yard.

I'm sure there is technomedicine going on today that I'm not aware of and would amazed me. Smart phones and their derivatives will become medical routine diagnostic tools.

Easy stuff:
• Tell Siri your history and send a photo of your rash to DERM APP and prescription will arrive at your door in 1 hour.
• Place phone on your chest and cardiopulmonary data will be forwarded to your cardiologist who will transmit medication adjustments to you electronically.
• Shine beam of light through a urine specimen which will confirm if urinary tract infection present.

Hard stuff:
• Coronary bypass surgery performed robotically by a surgeon in New York City on a patient in Abu Dhabi.
• Artificial organs created in 3-D printers.
• Miniature cameras journeying through the digestive tract, circulatory system and major organs delivering customized treatment for various diseases.
• Smart phone analysis of saliva sample which will screen for risk factors for 20 common chronic diseases that will have effective preventive strategies.
• Satellite delivery of yet to be discovered form of radiation to the developing world which will decimate food borne illness.
• Patient will place his palm on a glass and an electronic signal will be transmitted to internal organs whose function needs adjustment to treat disease or preserve health.

I still use a stethoscope. It's not a collector's item yet, but I don't think it will be much longer.?

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.
Thursday, April 9, 2015

Let's stop using adjectives to identify patients

We have all heard it; we have probably all said it:
• “My diabetics never follow my instructions.”
• “That schizophrenic is back in the hospital again.”
• “How should I screen cirrhotics?”
• “Did you hear about my CHF-er?”

It might be easy to say but it certainly isn't patient-friendly. Patients are people. Sometimes they have diseases or syndromes or symptoms. But diseases shouldn't describe our patients. Patients are not a disease, and certainly they aren't the “adjectival” form of the disease (e.g. “diabetic” for the disease diabetes). Ascribing these words and phrases to people can have a few effects:
• It anchors the doctors and/or the patients on the disease or diagnosis, when the diagnosis may not be correct or complete.
• It changes our focus from the person to the disease.
• It changes patient perception of the medical profession.
• And worst of all, it demeans patients

So let's think about rephrasing the above:
• “The patients with diabetes in my practice often have difficulty …”
• “The man with schizophrenia we both recently treated has been readmitted.”
• “How should l screen patients who have cirrhosis?”
• “Did you hear about Mrs. X, the patient with CHF I treated last week?”

Yes, it may seem like semantics. Yes, it takes a few extra seconds and a little bit of effort. I've personally had to focus on changing my own lexicon and occasionally find myself resorting to my older habits. But if you pay a bit of attention to colleagues from here on out, you might start thinking about how it sounds and try to make the change yourself.

Ryan Madanick, MD, is an ACP Member, a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain. This post originally appeared at his blog, Gut Check.
Wednesday, April 8, 2015

What part of a complete breakfast?

In the latest educational music video for kids produced by my non-profit, my own 15-year-old son, our front man, essentially asks the question: if multicolored marshmallows in a cereal box are part of a complete breakfast, what part IS that?

By posing the question, I think he is also answering the one Kellogg's seems to be asking, namely: what happened to us? How did we lose control of the American breakfast?

That story is elaborated in a Bloomberg Business profile that chronicles the century-spanning rise, and recent fall, of Tony the Tiger, Toucan Sam, and the rest of the menagerie. I defer to the business experts on the sociocultural trends that figure in Kellogg's travails, such as working mothers, smaller families, and breakfasts preferentially eaten on the run.

From my perspective, at least some of the answers are just about as blatant as the psychedelic glow of those marshmallows in my son's lyric.

There has been a tremendous concentration of attention over recent years to the adverse health effects of miscellaneous food adulterations, from the general harms of added sugar, to the specific ills of high-fructose corn syrup; to the liabilities of refined grains; to the potential harms of food chemicals; to the insidious (and ill-defined) menace of genetic modification; to the willful sabotage of appetite control with hyper-processed concoctions. When dietary worry was all directed at excess fat intake, pseudo-fruit (Kellogg's makes Froot-Loops and Apple Jacks) and multicolored marshmallows (actually, General Mills makes Lucky Charms) were able to fly under the radar. A widening array of worries has cost them that cover.

There is also a movement under way to expunge the magical thinking attached to added nutrients. Historically, food companies have applied vitamins and minerals much like lipstick on a pig: whatever the general character of the product, it would introduce itself with bold assertions about fortification. The banner ad across the front of the package, like some honorific bandolier, never says: “my first ingredient is added sugar!” true though that may be. It is far more likely to say something about “essential nutrients!”

That, in fact, is the basis for the classic marketing line: “part of a complete breakfast!” The typical TV commercial for a kid's cereal features multicolored, madly frenetic antics, followed by the sonorous voice of an announcer, presumably allaying the concerns of mom or dad: “fortified with 11 essential vitamins and minerals, part of a complete breakfast.” The inevitable juxtaposition of the two assertions implies that the latter follows naturally from the former. In other words, our concoction deserves to be part of your family's “complete breakfast” because, after all, it is fortified with these very important nutrients.

But as I have been motivated to opine before, nutrient additions to a vat of gloop cannot exonerate the gloop. The new book, Vitamania, by Catherine Price, about which she and I recently corresponded, apparently develops the same theme.

So the public has learned that low-fat does not a wholesome food make; and that nutrient additions to junk produce, well, nutrient-fortified junk.

And that's where a whole lot of breakfast cereals fall. Kellogg's is by no means alone in those dietary badlands.

The result is that health-conscious eaters are likely rejecting cereals they formerly embraced, and they are quite right to do so. Eaters that aren't at all health conscious weren't eating cereal in the first place, they were having donuts, Danish, and muffins; or maybe sausage and egg sandwiches. Either way, they are probably uninterested in cereal.

Personally, I am an inveterate cereal eater, but have long favored the exceptionally wholesome offerings of especially virtuous companies. My standard choice most days is one of the whole grain offerings of Nature's Path, a cereal line noteworthy for purity, and simplicity, with minimal additions of sugar, salt, or anything else unwelcome, and maximal preservation of the native grain nutrients. My very favorite product of theirs, a cereal called Synergy, is no longer available in the U.S., because I was apparently the only one down here eating it! It is made from eight whole grains, with no added sugar and no added salt. I guess it was a bit like cardboard to the typical American palate, but my taste buds don't have that unfortunate condition, and I loved the stuff.

I have long been a fan of KIND for their simple and wholesome bars, and have embraced their cereal line for the same reasons. There are others, too, including Wholesome Goodness, a company I advise on nutrition; and some of Kashi's offerings (Kashi is owned by Kellogg); and so on. But most of the cereals that cater to the prevailing American palate have far too much added sugar and salt for my taste. Many popular (or formerly popular?) cereal brands have more added salt, relative to calories, than almost anything in the salty snack aisle (go ahead, check the nutrition facts panels). The only reason they don't taste overtly salty to most Americans is because (a) the salt is masked by even more copious additions of sugar; and (b) the typical American's taste buds are in a sugar- and salt-induced coma. Perhaps that's changing, to Kellogg's apparent dismay.

Of the dubious concoctions over which we poured our milk all these years, the cereals preferentially marketed to children are by far the worst. How we ever got the idea that “junk” could be food, I'll never know; but that we then got the idea that the junkiest of all foods could be “kid” food is utterly astounding. Food is the one and only construction material for the growing bodies of children we love. How does “junk” sound now? Apparently, less good. Perhaps health conscious parents are seeing past the bright glow of that lipstick at last.

To the extent that Kellogg's lost breakfast, and I'm not sure the final chapter has yet been written, it is because they were playing the wrong game for much of the past 5 decades or so. They, along with all of the others in this same space, were looking for best ways to put makeup on a pig, rather than looking for ways to make up the best, most nutritious formulations.

They lost the game because we finally caught on, and figured out what game they had been playing, and who was actually losing.

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.

Thank you, New York Attorney General

Thanks to Attorney General Eric Schneiderman of New York state, consumers across America have attained a reprieve.

New York sued the 3 major credit bureaus, Equifax, Experian, and Trans-Union on behalf of consumers because of complaints that there are too often errors on our credit reports, and those errors can be difficult to challenge.

As part of the settlement, the rating bureaus agreed not to include medical bills in formulas calculating our credit ratings for 6 months. This is a big deal because :

Medical debt accounts for more than half of the collection items on credit reports, according to a report by the Consumer Financial Protection Bureau. Among people facing collection for only medical debt, about half have otherwise clean credit reports with no sign of past debt collection problems. [NPR]

A famous study from 2005 was groundbreaking in this realm. The researchers interviewed close to 1,000 people declaring personal bankruptcy at various courts around the U.S., and found that about half of declarations were attributable to medical debt.

Giving consumers leeway to work down their debts before lowering their credit scores seems like a humane and sensible policy. Fewer people with bankruptcies are better for all of us, macroeconomically.

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.
Tuesday, April 7, 2015

We need less virtual medicine, not more

The world of health care will likely look very different in a decade, owing to a variety of diverse factors including medical breakthroughs, political reform, and not least of all the tremendous advances in technology that are occurring at breathtaking pace. The traditional model of the doctor-patient interaction will also continue to change dramatically (as it already has over the last several years).

The days of an unchecked paternalistic relationship are over, one where patients had to accept whatever their doctor said and were not empowered to ask questions or seek answers. In addition to this palpable change in medical culture, technological developments now mean that patients can access their records, do all their own research, and shop around in a way that they couldn't do before. And who would argue that's a bad thing?

A further idea on the horizon, which from some vantage points appears to be the next logical step in the evolution of the doctor-patient relationship, is the notion that even sitting down with your doctor is no longer going to be needed in most situations. After all, when there's telemedicine and the ability to perform “virtual consultations,” why bother? By the same token, many authorities are pushing for increased use of 5-minute retail clinics, where patients can quickly nip in and out of a brisk consultation with an available physician or other health care professional (often in a pharmacy), but with no continuity.

This all sounds very cutting edge and new, but has anyone stopped to ask if it's what our patients really want? Lots of the people pushing for this type of health care are the entrepreneurs and Silicon Valley types, as well intentioned and keen as they may be yet barely old enough to have set foot in a hospital or spent any time working in health care.

Let's think for a moment what they would hear if they actually talked to real health care “consumers.” Because given a choice of which they would prefer, I believe nearly all patients would rather have a relationship with their own good, competent local physician who is easy to make an appointment with rather than bother with telemedicine or any of other stop-gap solution in order to get the health care they need. Patients simply want to be able to sit down with their doctor and be listened to attentively, undergoing a thorough assessment of their problem. Not doing this in front of a real human being won't quite cut it, no less than it would in other social situations which involve people. This applies especially to older patients, who actually require the most health care.

Yes, there may be a big physician shortage at the moment, but surely the answer is to train more doctors and make specialties such as primary care a more attractive career option? In other words, we should deal with the root of the problem of why patients aren't able to get the care they need quickly and efficiently. As for the cost issue, whether virtual medicine will cut expenditure and improve health outcomes over a longer time period is highly debatable.

The medical world really needs to reflect on whether this proposed move away from the traditional doctor-patient relationship is a path we want to tread, instead of doing everything possible to preserve personal interactions in health care. I would argue firmly for the latter. As science and technology progresses, it becomes more imperative than ever to preserve and consolidate human interactions.

If you also ask any of the older generation what their health care used to be like back in the old days, most of them will have extremely fond memories of their own physician, who would be known to their whole family, make house calls and also visit them in hospital. One of their biggest complaints nowadays is that these relationships no longer exist and their health care is too fragmented and impersonal. How will tele- or virtual medicine improve this? Beyond the odd question here or there which could be answered by a doctor in this way, the benefits are very limited. By all means patients should use the wonders of modern technology to make appointments, track their own parameters, and fill prescriptions, but that all runs parallel to the sacred 1-on-1 doctor patient relationship. Wherever technology takes us, humans will always be humans. We crave personal attention and interactions, especially with the emotions that concern our health. It's for this reason that health care is the last place that being virtual and distant will be a long-term success.

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.
Monday, April 6, 2015

Antibiotic resistance--should we blame primary care or ICU physicians?

The title of the post poses a somewhat silly question. But I hope my explication clarifies the point.

Many readers know that I favor empiric antibiotic treatment for adolescent/young adult pharyngitis when the clinical signs and symptoms strongly suggest a bacterial infection. I favor narrow target antibiotics and only in the patients with Centor scores of 3 or 4 (and perhaps some 2s when the patient looks very ill). This would exclude over 50% of patients from antibiotics.

Most organisms already have developed resistance to penicillin, amoxicillin and first generation cephalosporins. Macrolides should not be used for pharyngitis in this age group.

Even if we overused these antibiotics, we are unlikely to contribute to the antibiotic resistance problem.

In the hospital and ICU, we regularly bring out the “heavy artillery” to fight presumed infections. When we assume sepsis, we throw a market basket of antibiotics (and often anti-fungals) in an effort to treat an unknown infection.

The antibiotic resistance problem is not a problem secondary to giving amoxicillin to sore throat patients.

The problem that we do not identify as often is antibiotic selection in very ill hospitalized patients. We use our big guns too indiscriminately because the patients are so sick and we are frantically trying to treat a mystery infection. Often infectious disease specialists write these orders.

We need an honest discussion of careful, appropriate antibiotic use in the hospital and especially the ICU.

We should not overuse antibiotics for sore throats, but we should not refrain from using antibiotics to prevent devastating potential complications (like the Lemierre Syndrome). We should not use antibiotics for colds or bronchitis (other than when complicating COPD). Antibiotic stewardship should focus on thoughtful use of antibiotics, understand the risk and potential benefits. That principle should not differ between the office setting and the hospital environment.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.
Friday, April 3, 2015

Antibiotic discovery: 2 steps back?

We've written often about the need for new antibiotic classes, so called antimicrobial discovery. Over the past 3 to 4 years there have been significant U.S. efforts and European efforts to expand the search for novel antibiotics. Well, as they say, 2 steps forward and 1 step back.

The Boston Business Journal is reporting that Merck is closing Cubist's entire 120-person early drug discovery unit. Per the report, “Merck remains committed to the development of antibiotic drugs, and an unspecified number of drugs still in pre-clinical testing will continue development in other sites. All of Cubist's drugs in clinical trials will continue to be developed.”

On the other side, Derek Lowe over at Seeking Alpha, a crowd-sourced financial site, writes: ”So anyone who thought that this might be about some sort of long-term commitment to antibiotic discovery, well, think again. This is about getting Cubist's existing drugs, back to some unspecified point in development, but the discovery work gets raked off into the compost pile.

I suspect many others will be upset with Merck's move. Given the oversized role that Cubist has played in antibiotic discovery recently, the unit's closure is frustrating. Where will new antibiotics come from if large pharmaceutical companies do not invest in novel antimicrobial discovery? Maybe they just aren't the right place.

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, April 1, 2015

My milk manifesto

Folks, grab a few of your favorite cookies—I recommend these—pour yourself a glass of … well, whatever; and settle in. This won't take you nearly as long as it took me, but it's a bit of a commitment just the same.

Working ourselves up into an ideological fervor, and frothing at the mouth in disparate passions over topics in nutrition that could, and frankly should, be a matter of calm, evidence-based consensus, is simply what we do.

So, for instance, it's not enough to agree that we consume a large excess of added sugar, and then come together to do something about it. We need an unending parade of self-proclaimed Messiahs to carry on as if each was the first to discover that we consume an excess of sugar, and that it's a bad idea, despite the Jack La Lanne videos telling us just that some 70 years ago (and he was not the first). Sugar can't just be bad, it has to be poison, and then we have to bog down in spirited arguments over which sugar is worst, creating cover for Big Food to celebrate much ado about nothing.

It's not enough to agree that a sizable minority in the population is gluten sensitive, and should avoid gluten for that reason, while still deriving health benefits from a variety of natively gluten-free whole grains. We have to throw gluten under the bus for everybody, then wheat, then all grains, renouncing even the distinction between whole and refined grains, and ignoring the weight of evidence simply because it proves, well, inconvenient to the argument.

And of course it's not nearly enough to acknowledge that not all saturated fat is created equal, and that we have known so for a long time. It's not enough to note that some saturated fatty acids appear to be innocuous, while others still appear to be otherwise, and to date none is demonstrably beneficial. It's certainly not enough to concede that when an excess of saturated fat is replaced with an excess of refined starch and sugar (or perhaps not even replaced, but compounded by them), health does not improve. No, we have to take just such evidence and pretend it suddenly means lard is Manna from heaven.

As far as I can tell, though, no nutrition topic is in a more constant state of vitriolic froth than dairy. The vegans are pretty much appalled by the whole category, and in a very rare confluence, the true Paleo devotees agree. Mom's was the only milk in the Stone Age, after all.

A mass of nutrition moderates can take dairy or leave it. The scientists involved in the DASH studies have naturally drunk rather deeply of their own work, as we are all somewhat prone to do, and generally espouse the virtues of milk, and quite effectively, I might add. Good public relations and the imprimatur of the NIH are likely why DASH wins the US News and World Report Best Diet competition every year.

Mediterranean diet proponents advocate for the inclusion of dairy in the diet, but don't tend to emphasize it, finding that other attributes of the diet seem to matter much more. When they do talk about it, they don't generally mention the fat content at all. Scientists working for the dairy industry understandably circulate flattering studies preferentially. And what we might call the non-vegan New Age enthusiasts, are adamant that dairy should be full fat at least, and possibly raw.

As a result, it's a rare day when I am not lobbied, prodded, chided, stirred, and shaken down by some faction or another over some claim or another about dairy. I am taken to task for views I do hold and shouldn't, or don't hold but should, via email, tweets, and blogs.

Well enough of that. From atop my tuffet, here's what I think about dairy, and why.

1. Isn't it true we simply aren't adapted to consume dairy other than in infancy? Isn't it “unnatural?”

Only if the very same logic is applied to iceberg lettuce, whole grains, refined grains, tangerines, beefsteak tomatoes, grain-fed beef, salami, baloney, pepperoni (figure any “oni” is on the list, there were, apparently, no Stone Age “onis”); coffee, chocolate, wine, beer, nectarines, zucchini, Idaho potatoes (after all, Idaho wasn't there yet … ); and, well, you get the idea. Almost nothing we eat today existed in its current form in the Stone Age. If we need to have been consuming something for more than 15,000 years to grant it entry into our diets, well, folks, enjoy the hunger strike.

It is true, of course, that in general mammals are adapted to consume milk only in infancy. Throughout the mammalian family, the gene that encodes for the enzyme lactase, required to break down the complex milk sugar lactose, turns off at the time of weaning. Were that true of all humans, we might convincingly argue that it isn't “natural” for adult humans to consume dairy.

But it isn't true. In some human populations, notably, those with the longest traditions of dairying, the gene stays turned on permanently in almost everyone. Why? Evolution by natural selection. Apparently, there was a survival advantage conferred upon those who could continue to consume dairy when it was available and other foods scarce, so they adapted and passed on their fortuitous genes, or didn't adapt, and consigned their alternative genes to oblivion.

If lactose tolerance among human adults is a product of adaptation, and it clearly is exactly that (populations without long traditions of dairying remain predominantly lactose intolerant, never having experienced dairy digestion as a survival advantage), then it represents the very argument we generally invoke about the Stone Age: it's good for us because we are adapted to it. By just such logic, every lactose tolerant human SHOULD consume dairy routinely.

2. Should every lactose tolerant human consume dairy routinely?

Only if they want to do so, and even then, not a whole lot. To the best of my knowledge, we have no evidence, zero, that adding dairy to balanced, prudent vegan diets improves health outcomes in any way. On the other hand, we also have no evidence to my knowledge that such optimized vegan diets produce better health outcomes than comparably balanced, optimized Mediterranean diets that do include dairy.

Many studies of dietary intake in the U.S. do suggest benefits of dairy, for children in particular. This may be because dairy is directly beneficial, but it may also be because of the generally ignored pebble-in-a-pond aspect of dietary intake: more of X as a percent of total calories means less of Y. So, perhaps in the context of the typical American diet the inclusion of dairy is consistently beneficial because it tends to mean less soda, among other things. I have seen next to nothing in the literature on how the overall profile of food choices varies between those who routinely include and those who routinely exclude dairy in the U.S., and such studies would answer very interesting questions.

In the interim, we shouldn't pretend to have answers to the good questions we have yet to ask. I know it's horribly nuanced to say this, and I know we seem to hate shades of gray unless handcuffs are involved, but: we have a choice.

You can have an optimal diet that includes or excludes dairy. For that matter, you can have a crummy diet that includes or excludes dairy, too.

3. Shouldn't dairy be full fat?

I don't think we know for sure, but to the extent we do know, I think it's all a matter of dietary context. On the one hand, some studies do suggest that full-fat dairy may confer greater satiety, a lasting feeling of fullness, and thus confer a weight control benefit. But the context here seems again to be the typical American diet, where low-fat junk foods abound. Such foods are often the very opposite of satiating, and high in added sugars. Dairy is subject to the same adulterations, such as non-fat yogurts that, as pointed out by Rob Lustig in his book Fat Chance, serve as delivery vehicles for more added sugar than is found in a soft drink.

Do we have studies that keep all other factors constant, and compare health outcomes based on intake of plain, unsweetened dairy products across a range of fat content? I have not found any, and I have looked harder than most.

When dairy is discussed in the context of the Mediterranean diet, fat content is almost never mentioned. This likely means that the dairy in question is full-fat, but it may also merely mean it doesn't much matter, because dairy is a relatively unimportant contributor to the health effects of such diets.

Overall, my impression is that there may well be some benefit, to satiety at least, of full-fat dairy for those who consume dairy in the first place, and who otherwise work to avoid dietary fat, but don't do it very well, i.e., by eating the fat-reduced junk foods that prevail in our culture. As noted, those who get low-fat eating right, by eating a wide variety of plant foods, derive no established benefit from the addition of dairy, fatty or otherwise.

If, however, one's diet is not restricted in fat, the fat content of dairy is unlikely to confer any proven benefit at all. For one thing, the very best thing that can be said of the saturated fat in dairy is that maybe it does not increase cardiovascular risk much, although I remain very dubious about that claim. But there is no evidence that it reduces risk, and since when is “absence of overtly harmful effects” the standard-bearer of high quality nutrition? We have abundant evidence that natural sources of monounsaturated fats, and a balanced array of polyunsaturated fats including omega-3s, are associated with actual benefit, not the far less propitious “possible lack of serious harm.” So if inclined to liberalize dietary fat intake, there are far better places to get it than in that glass of milk. I recommend you grab a few walnuts, and chew on it.

For another, when protein and fat intake are moderate; and intake of refined starch, added sugar, and hyper-processed, willfully addictive junk low to negligible, there is unlikely to be any satiety problem left to fix. In such context, fat comes from nuts, seeds, olives, avocado, fish, seafood, and for those so inclined, meat. Why add dairy fat? On the basis of available evidence, I have found no good reason.

So here, too, we have a choice. If dairy makes up a small percentage of your calories, as it generally does in the truly wholesome variations on the theme of the Mediterranean diet, it probably doesn't matter much whether it's full-fat, fat-free, or in between. But in the context of such relatively generous fat intake, there is certainly no established advantage to adding more fat from dairy. The only real liability of prioritizing fat-free dairy is the common tendency to conflate fat-free for “nutritious” no matter what else is in the mix. Avoid that mistake, by all means.

If, however, you choose simple, minimally processed dairy; have ample, healthy fat in your diet; and are not struggling with appetite control, I still think fat-free dairy is the way to go. The rather small role of dairy in my own diet is played by just such actors, notably plain, fat-free Greek yogurt to hold together my breakfast of berries, nuts, and whole grain cereals.

4. Shouldn't milk be raw?

No.

I searched Pubmed, the on-line library of peer-reviewed scientific papers, for the very general terms “raw milk health” in the title and came up with 19 citations. I tried “raw milk benefits” and found just 1, a commentary (not a research paper). In contrast, there are 2004 papers with “onchocerciasis” in the title.

In other words, all of the passion about raw milk is just so much foam. There is virtually no science behind it. In fact, the relevant papers have generally concluded the opposite, finding that risks are almost certain to outweigh any theoretical benefits, and that nutritional differences are negligible. Those who think the current generation discovered this preoccupation will be interested to know it was around, and debunked, back in the early 1980s. That, by the way, is the native life cycle of dietary fads; most of them are reheated versions of fads we forgot from a decade or so ago. Raw milk, it turns out, is no exception.

Pasteurization caught on for a reason. There is a real risk of infectious disease with raw milk, and no established benefit. Of course, that doesn't mean there isn't some benefit as yet unproven, but that's a leap of faith. If inclined to leap accordingly, at least look carefully before you do so at the track record of the farm in question. Know your cow, in other words, before putting your lips to an udder.

5. Should dairy be organic?

Yes.

We don't have “proof” that the antibiotics and hormones that find their way into the milk of “factory farm” bovines are harmful to humans, but the circumstantial evidence is hard to ignore. Besides, the precautionary principle applies: when sense suggests the likelihood of potential harm, the first job of science is not to prove that harm, but to disprove it. In the absence of disproof, adulterations of our dairy may be presumed guilty. When you can choose organic dairy, by all means do.

6. What about the cows?

My friend John Robbins famously renounced the Baskin-Robbins family fortune to which he was heir to become an activist for animal welfare, environmentalism, and plant-based eating. This was prompted by the abuses of cattle he observed first hand, a story he told in The Food Revolution.

The simple fact is that if a population of 7 billion Homo sapiens make dairy, or meat for that matter, a major component of their diets, methods of mass production are applied to the animals involved. This, inevitably, engenders corner-cutting, and wanton disregard for expendable concerns, like decency.

But if you are decent, cruel and abusive treatment of our fellow creatures must matter to you. To keep dairy on the menu and take cruelty off, be sure to know something about the treatment of those cows who gave the milk.

I note that I do get tweets from some who sneer at the idea that how animals are treated matters at all in our decisions about food. All I can say to that group is that you are an embarrassment to the better angels of our nature, and neither the angels, nor I, give a damn what you eat. The angels hope you choke on it.

7. What about the planet?

The husbandry of large herds of cattle for both meat and dairy is a very important source of green house gas emission. Excessive appetites for meat and/or dairy therefore conspire directly against efforts to curtail climate change.

The notion that we humans can eat however we want and ignore the implications for the planet at large is stunningly benighted. The good news, of sorts, is that the thinking is unsustainable, because calamity will put an end to it. Unfortunately, none of us will get the last laugh. We will all be crying together, over spilled milk, and lost opportunity.

In summary, then, vegan claims that healthy diets must exclude dairy are belied where Mediterranean diet meets Blue Zone. Steadfast Paleo opposition to dairy is hoisted on its very own petard, since specific genetic adaptation to dairy consumption is on overt display in hundreds of millions of modern Homo sapiens, with no such obvious adaptations to most of the other stuff they are eating.

We can take milk, or leave it; take milk fat, or leave that. Either way, we can have a good diet of wholesome foods in sensible combinations, or not. But either way, we need to take seriously the reverberations of our dietary choices across the landscape of a shrinking planet, and the legacy of kindness or cruelty by which history will be invited to judge us.

If I may borrow from Taylor Swift, the dairy lovers are gonna’ love, love, love it. The dairy haters are gonna’ hate, hate, hate it. Tweeters gonna’ tweet, tweet, tweet. Everybody's gonna’ stir their particular glass, and shake up the subject as they see fit. Frankly, I think the topic has been milked for much more than it's really worth. So as I continue to encounter the daily attempts to shake me down, I'm just gonna’ shake it off, and carry on.

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.