Tuesday, June 30, 2015

Congress and Dr. Bayes

I was driving to work the other day, and there was a story on the radio about the Congressional reaction to the latest recommendations for breast cancer screening from the United States Preventive Services Task Force (USPSTF).

Here's the background. USPSTF published recommendations in late 2009 for the use of screening mammography in different age groups. For women between 40 and 50 years old, the panel concluded “that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.” In other words, they did not recommend biennial mammograms, which they did for women between 50 and 74 years old, for the younger cohort. That led to a firestorm of criticism that younger women would be “denied” mammography, and Congress wrote into the Affordable Care Act that “exchange” (Obamacare) insurance plans cover regular mammography for women over 40.

Fast forward to now.

The USPSTF has put out for comment new draft recommendations about screening mammography. Once again, there is no blanket recommendation for regular screening in women between 40 and 49. Instead, the document contains the following statement: “The decision to start screening mammography in women prior to age 50 years should be an individual one. Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49 years.”

Which leads me back to my car ride. As soon as I heard the lede about the continued lack of endorsement for routine screening in younger women, I thought, “OK, here it comes.” And then it came.

What followed was not a discussion of the risks and benefits of screening, or how those risks and benefits vary with the prevalence of disease (and hence the age of women being tested) or the process by which the medical evidence was synthesized by the panel to form the basis of the recommendation or even, frankly, the details of the recommendations themselves, which were much more nuanced than reported. Instead, there was an interview with a woman in her 40s who had had breast cancer detected by a mammogram. And not just any woman with early breast cancer, but a Member of Congress. She spoke about her own experience and then, based only on that experience, went on to denounce the recommendations and vow to protect insurance coverage for early mammography, which she said might again be threatened. Out with the science, in with the anecdote.

Sadly, the reporter further completely missed the point that the USPSTF did not recommend against mammography in younger women. Instead, the panel pointed out that “Screening mammography in women ages 40 to 49 years may reduce the risk of dying of breast cancer, but the number of deaths averted is much smaller than in older women and the number of false-positive tests and unnecessary biopsies are larger.”

Aside from some shoddy reporting, the deeper issue is that thinking about breast cancer screening requires you to hold both of the following facts in your head at the same time:
1. Some people will benefit from a screening test done in a population of asymptomatic individuals, even if there is a low prevalence of disease
2. Statement #1 is not a justification for screening.

Of course, the utility of any screening strategy assumes that patients' outcomes can be improved by earlier treatment of whatever is being screened for. There is no sense in looking for something if finding it won't influence treatment.

The reason why the anecdotal “save” like the Congresswoman's shouldn't be used to justify screening in all populations is because it ignores the teaching of Dr. Bayes. Bayes' theorem reveals that even a highly sensitive and specific test, if applied to a population with a low prevalence of disease, will lead to many more false positives than true positives, and the lower the prevalence of disease, the higher the ratio of false to true positives.

Here's another way to look at it. No one suggests that teenagers should get mammograms, because the chances are, based on the extremely low prevalence of breast cancer in such young women, that any “positive” mammogram is overwhelmingly likely to be a false positive, and not an indication of real disease. Those false positives have real consequences, further testing, biopsies, treatment, and the like, all of which have negative consequences of their own. On the other hand, women in their 60s have a much higher prevalence of disease, and thereby a much lower ratio of false to true positive tests. An abnormal mammogram in a 62 year old is much more likely to be an indicator of breast cancer than the same finding in her 19 year old niece. That's why screening older women makes sense. What the USPSTF did was basically say that for women in their 40s, the results are sort of in-between. Not as crazy as screening teenagers, but not as helpful as screening older women.

Makes sense to me.

What do you think?

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.
Monday, June 29, 2015

Actinic Keratoses and Carac (fluorouracil) cream: Why is this so expensive?

First, a disclaimer: I don't know why Carac (0.5% flourouracil cream) is so expensive. I will speculate, though, at the very end of this blog.

Sun and the skin: what happens

If a person reaches a certain age, has very little pigment in her skin, and has spent lots of time in the sun, bad stuff happens. The ultraviolet radiation of the sun does all kinds of great things: it makes us happy, causes us to synthesize vitamin D which strengthens our bones and it gives us this healthy glow until we get old and wrinkled and leathery. And even that can be charming. The skin cells put up with this remarkably well for a long time, partly aided by melanin pigment which absorbs the radiation, which is why we tan and freckle, if we are fair skinned. Eventually, though, we absorb enough radiation that it injures the skin and produces cells which multiply oddly. It also damages the skin's elasticity which creates wrinkles.

The cells which reproduce in odd ways peel, creating dry skin or dry spots, or warty growths or even small hard horns. The scaly spots are called “actinic keratoses” which just means sun induced scaly spots. Sometimes the skin cells become cancerous and lump up and create non-healing sores. This is when we regret going out without a hat or sunscreen, but, of course, it is too late.

Topical chemotherapy: good idea or great idea?

In 1957 scientists published a paper showing that flourouracil, a flourine attached to a nucleotide (RNA building block), inhibited liver cancer cells. This became one of our early chemotherapy drugs, and is still an important drug in treating colon cancer. When mixed up in a skin cream, it can kill the abnormal skin cells which grow on our sun exposed skin, allowing the normal ones to take their place.

The way fluorouracil cream was initially used was awesome and terrible. It was applied daily for 4-6 weeks to the affected area and the skin became a war zone. The abnormal cells died, leaving red swollen places where sun damage was most severe. Generally people using it looked pretty bad for weeks or longer. Eventually they healed and got rid of their scaly spots. Many people still use it this way, to good effect. We also found that we could treat just small areas at a time, and even just the scaly spots themselves, and that we could use the cream for shorter courses and avoid the intense inflammation. This was a major advance in therapy since our other main option was to freeze the spots with liquid nitrogen, which was a painful, expensive and seemingly never ending process, and which left little white scars.

A slight catch was that the fluorouracil cream was expensive. It was over $100 for a 30 gram tube. Maybe insurance would pay, but it was top tier, and at least some of the cost made its way to the consumer.

Several years ago my husband was prescribed Carac, one of the first fluorouracil creams. It was expensive, so we have made it last, far longer than the expiration date. It is a prized possession, that tube. We have both spent far too much time in the sun without protection, loving every minute of it, and regretting it now in hindsight. When the scaly spots become too annoying, we use the cream until they go away. But the tube is almost empty. Time to buy some more.

Pretty pricey

I looked online to find out how much it would cost if I bought it internationally. I found a product from India that was not too expensive. It was 5% flourouracil rather than the 0.5%, but that is the percentage in the brand name Efudex which is one of the alternatives in the U.S., so it seemed reasonable. I got the cream in the mail and tried it and it was slightly granular and didn't work. The effect of the Carac was dramatic. The effect of the Indian cream was essentially nothing. “You get what you pay for,” I thought. I asked a compounding pharmacist acquaintance to make me some. I respect this pharmacist. He mixed up flourouracil in a skin cream base at a concentration of 5%. The cream was also grainy and didn't work. It seemed to do a little better than the Indian cream, but nothing like the Carac. Finally I decided to just get the Carac. I asked my friendly neighborhood pharmacist what it would cost. She told me that a tube of Carac, 30 grams, costs around $2000. NO! I will not do that! The amount of active chemical in that little tube, the fluorouracil that is used as intravenous chemotherapy, would cost about $40 retail. It is possible to get generic or brand name 5% fluororuacil creams for prices ranging from $170-$500 for a tube, but that is still horribly expensive, and if they didn't work, that would be an annoying next chapter in this tale of woe. Looking a bit harder I found that there is now a 2% solution which is a little less pricey, though there is nothing that I've read that tells me how or if this works. Maybe I should just make some, but playing around with chemotherapy drugs sounds like a bad idea.

Other options

What, then, should someone do with their actinic keratoses? It is just not reasonable to pay $2,000 for a tube of cream. Uptodate, which is an online resource used by many physicians to keep abreast of expert management of diseases, says that the treatment of actinic keratoses, besides 0.5% fluorouracil cream, includes use of sunscreen to prevent further appearances of the little spots, dermabrasion to remove the affected skin (ouch)and that the use of topical retinoids (vitamin A derivatives) can help. They also mention that ingenol mebutate and imiquimod creams (both horribly expensive) are better than placebo as is chemical sensitization plus light therapy (I can only imagine what that costs.)

I have decided to use a retinol preparation which is pretty darn cheap and calls itself “wrinkle cream.” It is in the cosmetic section of my local drugstore. Retinol is one of several retinoids that are approved for use on the skin, and also treat acne. I will also wear sunscreen and a hat. So far the retinol, when applied to the whole sun-damaged area (for me, the forehead) is helping reduce my sun induced roughness and scaling. Retinoids appear also to reduce the risk of developing squamous cell cancer, a common malignancy in sun exposed skin. For now, at least, my path is clear.

Mysteries persist

But there remain mysteries which I have been unable to solve using books and the interwebs. Why is 0.5% flurouracil 10 times more expensive than 5% fluorouracil, even though the latter is theoretically 10 times stronger? Why do they even make 5% flourouracil cream if the 0.5% stuff works just as well? Is it in some way very difficult to mix flourouracil into a cream? Why does UpToDate recommend 0.5% flourouracil and not 5%? I have no idea. I can speculate a bit about the costs, though. It's possible that the cost of the 0.5% flourouracil is made to be as high as the newer creams, like imiquimod, which were priced that high because they were relatively new, and are still not generic. All of these creams are still financially viable because they were cheaper and more acceptable than going in to the doctor every few weeks to have him or her freeze a bunch of spots, resulting in what looked like a mild case of chicken pox which healed to make white scars. It's still really hard to believe that anyone would pay $2,000 for a little tube of skin cream and that we, as physicians would regularly recommend that they do so.

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.
Friday, June 26, 2015

Final thoughts on my India tour

I spent 9 days in India, giving 13 talks in 6 days in 3 cities, Chandigarh, Hyderabad and Cochin. India is a country of contrasts and extremes. When it is modern, the modernity equals anywhere in the world. When it is not, the poverty is striking.

I spent much time with physicians, especially internists. Internists are the same wherever I travel. We have the same concerns about patients and interference from the government or insurers.

Internists find the diagnostic process interesting and most important. Indian physicians as well as American physicians understand this. Patients understand that diagnosis is the sine qua non of internal medicine.

We all cannot understand trying to assess value when we cannot easily assess diagnostic accuracy. We cannot understand giving a physician a good “report card” for treating the wrong diagnosis perfectly.

We all understand that medicine evolves and thus we must work to stay current. We all understand that discussing patient presentations leads to the best education.

Patients remain our best teachers. We must all learn to listen to our patients and think carefully about the lessons their presentation teach us. We can use patient stories to emphasize the importance of the natural history of disease or the appropriate pathophysiology or the side effects of treatment.

During my India trip, one physician told me this story. I will try to get the gist of the story correct. He told the story in response to my lecture on the dangers of guidelines and performance measures.

He was practicing in England at the time this incident occurred. England had just started their pay for performance project. An older woman was going to see her physician. She was having symptoms of uterine prolapse. Her daughter accompanied her, but she did not let the daughter come into the examination room because of embarrassment.

The physician comes into the room and starts reviewing each of her known medical problems with a focus on those issues that would impact his performance measures. He never asks for her agenda, and abruptly finishes the meeting.

The woman goes back to the waiting room, and has to tell the daughter that she never had a chance to seek help for her concern.

Performance measures can change the physician patient interaction. We are told that medical care should become more patient centered, while focusing on performance measures changes the physicians priorities. We do not have a good measure this concept.

Since quality has many dimensions, we must worry that focusing on some dimensions will decrease our attention to other important dimensions. This story describes a bad medical visit. But the physician likely scored perfectly on his measures.

Talking with Indian physicians has helped me understand the philosophical underpinnings of excellent internal medicine. Their insights in response to my talks opened my mind to important underlying concepts.

And I really did enjoy the sights and the food.

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.
Thursday, June 25, 2015

Is office colonoscopy ethical?

While I consider myself to be an ethical practitioner, I am not perfect, and neither is the medical profession.

I will present a recurrent ethical dilemma to my fair and balanced readers and await their judgment.

Our gastroenterology practice, like all of our competitors, has an open access endoscopy option. This permits a physician to refer a patient to us for a colonoscopy, without the need for an initial office visit.

Patients can also schedule procedures themselves, such as a screening colonoscopy, without a physician referral, if allowed by their insurance carriers. These patients enjoy the convenience of bypassing an office visit. We agree that an office consultation should not be required for routine screening procedures or to evaluate minor gastrointestinal symptoms.

Of course, if a patient wants to see us in the office in advance—and some do—we are happy to do so. I enjoy these pre-op visits which allows me to develop some measure of rapport with the patient and to discuss the upcoming endoscopic adventure, before the patient is naked with an IV dripping into his arm.

When these open access procedures are scheduled, we carefully screen patients on the phone to verify that bypassing an office visit does not pose any safety risks for the patient. We do not want to meet a patient for the first time for a screening colonoscopy, who is on kidney dialysis and uses an oxygen tank.

Here's the rub. There are times when I meet an open access patient who is prepped and primed for a colonoscopy that is not necessary. In the most recent example, I greeted a patient who was poised to have a colonoscopy because there was a prior history of colon polyps. However, according to current professional guidelines, the patient didn't need the exam for a few more years. I was meeting this patient for the first time. She had taken a day off of work and had a driver with her. She had enjoyed the delight of the gentle cathartic agent that colonoscopy patients imbibe with gustatory pleasure on the prior evening. She believes, of course, that the procedure is necessary as her physician had recommended it.

What should my response, if any, to her be?

One of the pitfalls of open access is that we can never screen patients as carefully as we do during an advance office visit. Should we halt a procedure that an internist has requested even if we may not believe the procedure is of medical necessity? Should we be willing to serve as technicians for referring doctors in the same manner that radiologists serve their colleagues? When we order a CAT scan, for example, the procedure is always done whether it's needed or not.

I sit in judgment now awaiting your verdict. May it be as probing and enlightening as a colonoscopy.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Wednesday, June 24, 2015

More on the epidemic of prescription opiate use and abuse

Facts (from the Centers for Disease Control Health report, 2013) :
1. The consumption of opioid pain medications (like morphine, hydrocodone an oxycodone) increased 300% between 1999 and 2010.
2. The death rates from poisoning by opioid pain medications more than tripled during that time.
3. The greatest increases in deaths from opioids were seen in non-Hispanic whites and American Indian/Alaskan native populations, who showed a 4 fold increase in deaths.

I have written several blogs on this, most recently talking about the experience of working with a large group of outpatients who are habituated to these drugs and are experiencing side effects, including addiction, along with small improvements in pain that are clearly not worth the devastating consequences of taking these drugs long term.

“What is so devastating?” you may ask.

Here are some stories* (names and details changed for privacy):
• Crystal is 43 years old. She was diagnosed with fibromyalgia, a painful condition of muscles without a clear cause, 20 years ago. She was started on pain pills 15 years ago and has been on them ever since. The doses have gradually increased and she is no longer able to work because of the sleepiness and confusion that goes along with the pain pills. She has been started on laxatives to treat the constipation and muscle relaxants which make her mouth drier than it already was with the pain pills, and takes an anti-anxiety pill to sleep and to calm down during the day. She still feels terrible and can barely get out of bed, so she has gained 40 pounds. She lives on disability. People ask her if she will sell them her drugs when she comes out of the pharmacy. She has had her car broken into on several occasions by people looking for pills. She can barely afford rent and food and doctor bills on her disability check.
• John is 50 years old. He hurt both of his shoulders doing drywall installation 10 years ago. He found it difficult to sleep and so they gave him pain pills to take at night. He had his right shoulder operated on by an orthopedic surgeon but it still hurts, as does the left one. He now takes the pain pills all the time so he can do a little work around home. He has been disabled for work for several years. He has gained a lot of weight from being inactive and he feels useless and depressed. His weight has caused him to have knee arthritis and so it hurts when he tries to go out for a walk. He's hoping he can get a knee replacement so maybe he can be more active and lose the weight. His chronic opiate use means that his chance of a successful outcome from knee replacement is substantially poorer.
• Bill fell off a horse when he was young and has had a tricky back ever since. He used to get prescriptions for pain pills every so often when it acted up, but since it was acting up so often he has started to get a prescription every month, for 240 hydrocodone pills, so he can take 2 of them 4 times a day. He tells the doctor he has to take them all the time or else the back is so bad he can hardly stand it. He has been selling or bartering most of his hydrocodone for several years. Sometimes he takes it for pain, sometimes recreationally and with his girlfriend. If he gets caught, this is a felony. It is also his main income.
• Nancy has multiple sclerosis. She uses crutches and has back and arm pain. She is on muscle relaxants and pain pills. It is clear to any doctor why she would need these medications, so they are refilled monthly. She lives with her boyfriend and his grown kids. She doesn't take the pills herself. Her boyfriend and his kids use them or sell them. She is vulnerable due to her disability and they threaten to kick her out if she doesn't bring home the pills.

What seems to be happening here is that people get injured or sick, physicians put them on controlled substances in the mistaken thought that it will make them better, and because of the addictive potential and side effects of the medications, they continue to take them and become progressively poor and marginalized. They find relief only in the drugs and end up unable to perform at work, which results in either job loss or being unable to excel and rise in status and income. They get depressed and anxious, often, and are put on more medications. The pain pills can actually make them depressed, but this is rarely obvious to the patient because of the little bit of euphoria that often comes with each dose. They are hassled for their pills. Sometimes they sell them because they are poor, and then they are outside of the law and have a secret that further separates them from people who might help them, such as their doctors. They often smoke, and sometimes drink. The smoking gives them lung disease which puts them at increased risk of death from the respiratory depressant effects of their pain medications. Combining their medications with alcohol can kill them. They get put on medications which lead to obesity and this increases their pain, disability and lack of self-confidence.

Turning this process around is going to be hard, but so very worth it. Patients are addicted, but so are we, that is the whole healthcare system. Drug companies make lots of money on these medicines and the medicines used to treat the side effects of the medicines. Doctors get to provide a quick fix and make patients (temporarily) happy just by writing a prescription. Return visits for these patients keep clinics busy. Eventually, though, increasing demands for controlled substances crowds out our ability to see other patients and to provide care that might actually reduce disability. Our opiate using patients burn physicians out because, with rare exceptions, they will never get well. Not writing these prescriptions in the first place or developing alternative strategies that get patients off of them is important work. It will help build healthy communities by reducing the supply of illegal substances. It may even help bring these people back to a place where they can move beyond their identity as chronic pain patients and get on with their lives.

*I am not presently telling the stories of the few patients for whom chronic opiate therapy is a good thing. They do exist, but they are uncommon. They are also usually on low doses and don't take them all the time. I am also not talking about patients with acute pain from injuries, illnesses or surgeries that will resolve. They, too, can have terrible consequences of opiates, but can also benefit a great deal from using them cautiously.

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.
Tuesday, June 23, 2015

Let's consign shared hospital rooms to the dustbin of healthcare history

The medical world has made terrific scientific and technological progress over the last century. Previously incurable diseases can now be treated as day cases and patients no longer have to accept a paternalistic, 1-sided relationship with their doctors. Hospitals too, have a come a long way if you look at pictures of what they used to look like in those old black and white photographs. Whatever the current challenges of health care, nobody can doubt that patients now receive first class care each and every day across the nation's hospitals.

I remember when I first came to the United States a decade ago to start my medical residency in Baltimore, one of the things that impressed me most was the fact that no hospital room ever seemed to contain more than 2 patients together. Having just come from the United Kingdom's National Health Service, which on many levels I still admire, I would regularly round in rooms which would have up to 8 patients in a single large room—sometimes even more in the older hospitals. In this respect, the United States has been well ahead of almost every country in the world for a long time (some of which shockingly still have males and females together in mixed rooms). Nevertheless, as we propel ourselves further into the healthcare future, we can do even better and strive for that ultimate goal: single-bed rooms for all hospitalized patients.

Last year I wrote an article titled “Single bed rooms are a must for future hospitals” in which I listed a number of reasons why we need to move towards this goal. Chief among these are infection risk, patient satisfaction and privacy. These reasons cannot be overstated. I've seen concerns arise on an all-too-frequent basis in hospitals I've worked in. For example, the number of complaints I hear from patients who are disturbed by their neighbor and have found it difficult to rest are too numerous for me to count. I've also been asked many questions by anxious patients and families about whether their neighbor could pass on any infection to them. These are difficult questions for any physician to answer, because we know that for many conditions, it's theoretically possible.

As new hospitals are being built, it is heartening that lots of them are advertising the fact that they will only have single, private rooms. This should become the gold-standard. Think it's expensive? Imagine all the positives in terms of reduced infection risk, happier patients and a generally better reputation compared to nearby hospitals that don't have single rooms. I hope that in the not too distant future, certainly within my career, sharing a hospital room will become just as unacceptable as checking in at a hotel and being told that you have to share your room with a complete stranger! This is, after all, about so much more than convenience and personal preference. For our patients it's about dignity and respect at a low point in their lives.

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, June 22, 2015

Newton, nutrition, and the tweets of doom

For all his contributions to science, controversial and otherwise, in modern context Sir Isaac Newton is most indelibly associated with one rather succinct assertion of physical truth: For every action, there is an equal and opposite reaction.

Were the governance of this third law of thermodynamics limited to the domain of physics, as was Newton's apparent thinking on the subject, we would spare ourselves a great deal of grief. Unfortunately, the laws of thermodynamics are in turn, it seems, subject to the law of unintended consequences. So it is the hegemony of the third law has trespassed into the realms of human psychology and sociology, and public health is much the poorer for it.

I have been lamenting for years that not only have we managed to be serially wrong about nutrition, we have been wrong about how we went wrong. When, for instance, the salient guidance was to “cut fat,” it was wrong in some of the particulars. Not all dietary fat is created equal. Not even all saturated fat is created equal. But any deficiencies in the admonition were greatly subordinate to its willful exploitation for profit.

What do I mean? When those in the vanguard of the movement first suggested reducing dietary fat intake, there was really only one way to get there from here: Eat more vegetables, fruits, beans, lentils, and whole grains. Since those foods are salient, if not overtly predominant, in diverse diets around the world associated with the greatest longevity and vitality, this could only have done us good. But we never had a moment to renounce mounds of salami to make room for more spinach, or to get a bit more of our protein from pinto beans and a bit less from pepperoni. Before ever we paused to consider such judicious opportunities, Snackwells had been invented, and the era of low-fat junk food began.

No nutrition expert ever said: Eat fat-free junk food, and all will be well. But that's what we did. And these days, we act as if that is somehow a failing of epidemiology, rather than assigning blame where it belongs: those elements of supply willing to subvert public health messaging for profit, and those elements of demand willing to believe that what seemed too good to be true was true nonetheless. Eating cookies will make me healthy? Bring ‘em on!

Regrettable as that digression was, it might have been worth it had we learned anything from it; but we did not. Or, rather, we seem incapable of learning from the follies of nutritional history, because our responses are surprisingly constrained by the stipulations of Newton.

The logical, and genuinely salutary reaction to the boondoggle of lipstick on low-fat pigs was to conclude that we should not fixate on any one nutrient, but rather think in terms of wholesome foods in sensible combinations. After all, if we eat truly wholesome foods in genuinely sensible combinations, there is no way to get it wrong. But alas, that kind of thinking would not have been equal and opposite, and that's how we roll.

What was equal and opposite to “just cut fat”? Obviously, “just cut carbs.” We never worried much about some potentially vexing details, such as: ALL plant foods are carbohydrate sources. Equal and opposite is a clear and compelling mandate, and if it means we lump together lentils and lollipops like so much baby and bathwater, well then, so be it.

Leaving aside whether or not cutting carbs was a better or worse idea than cutting fat, we can at least give Robert Atkins his due: When he proposed it, he presumably did not have low-carb brownies in mind. But Big Food did to Atkins exactly what it did to Keys, turning his message into an opportunity to invent a whole new inventory of highly profitable junk foods.

And again, we failed to learn from history, perhaps because we are mere pawns to the tyrannies of physics. Perhaps we are incapable of a reaction other than equal and opposite. If just cut carbs did not make us all lean and vital, let's just cut fructose. Or gluten. Or GMOs. Or grains. Or … well, we'll think of something.

Not long ago, I was beginning to grow hopeful that we had run out of ways to eat badly and might actually have to consider eating well. Eating well is not about fat or carbs, it is about wholesome foods in sensible combinations. Get the dietary pattern right, and the nutrients reliably sort themselves out. Fixate on any given nutrient, whatever the arguments for its primacy, and history dishes out nothing but precautionary tales. I had begun to hope we were out of ways to miss the forest through the trees.

But now, I am sadly less sure. The Internet greets me each day with a new barrage of angry tweets. Ideology routinely trumps epidemiology. Far from achieving separation of church and plate, the divergent convictions about diet and health grow ever more zealous, ever more vitriolic, and ever more fanatically sure. The prevailing reaction of each to all others is entirely of the equal and opposite variety.

Science, however, advances incrementally. Rarely is there cause to throw all we thought we knew yesterday under the bus and start anew. Progress is far more probable when we consider the provocations of good, new questions in the context of established answers.

Is it a good idea to cut dietary fat? We now know the question to be bad, and bad questions invite no good answers. A diet will certainly not be improved if it cuts out nuts, seeds, avocado and fish and replaces any of these with Snackwells. Is it a good idea to cut carbs? The question is equally silly. Fewer carbs could mean less refined starch and added sugar, or the renunciation of fruits and beans. Is it a good idea to vilify fructose? Not if it gives Big Food recourse to a halo for their lateral moves.

As for those tweets, they can be painful. Many are ad hominem attacks, and each of them reverberates in its own insular echo chamber. Some are so absurd that people who actually know me and my values don't know whether to laugh or cry. I generally do neither, recognizing that the unintended consequence of our New Age connections is to give every fringe and faction the same megaphone. Those propounding despicable racial slurs against the duly elected President of the United States are, presumably, a population rounding error and a lamentable, lunatic fringe, but in the Twitterverse, they are regrettably audible just the same.

That, then, is the modern challenge to public health nutrition. If every equally misguided and oppositely directed reaction to every prior, wayward action echoes endlessly in cyberspace, do we ever navigate past the din and the discord and advance beyond the follies of history? Or will we have constrained the human mind to the confinement of 140 characters, subjugated human will to the dictates of physics, and exaggerated the purview of Sir Isaac, as we tweet, and retweet, the redundancies of our doom?

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.
Friday, June 19, 2015

Medical talks in India part 3, dangers of guidelines and the pirate's code

Visiting India, I have given several talks. Three times the hospitals asked for my “Dangers of Guidelines” talk. The talk starts with a famous quote from the “Pirates of the Caribbean” that goes, The Code is more what you call guidelines, than actual rules. This talk resonates with all physicians.

In it I talk about the guideline movement, why it started, and what has gone wrong. And much has gone wrong. We have too many guidelines, conflicting guidelines and “guidelines” without adequate evidence.

The worst part of guidelines is their transformation into rules, i.e., performance measures. Some guidelines transform positively into measures, e.g. patients with systolic dysfunction and no contraindications should receive a prescription for an angiotensin-converting enzyme inhibitor, chronic obstructive pulmonary disease patients with a resting oxygen saturation less than 88% should have home oxygen, and we should follow a checklist for central line placement (with a measure of the rate of central line infections).

At each site, the physicians express the same frustrations with “algorithmic medicine.” They smile when I saw that I can prove guidelines are flawed in 2015. The case of conflicting guidelines proves the point clearly. Guideline development succumbs to biases easily. Logic tells us that if guidelines were not subjective that differing organizations would develop the same guidelines. Conflicting guidelines (pharyngitis, screening for prostate cancer, screening for chronic kidney disease as examples) prove that the committees must inject a subjective assessment. Once we have such proof, then we must question the rest of the guideline movement.

We could develop “universal” guidelines, but only on selected problems. We would have far fewer guidelines and thus far fewer performance measures.

The Indian physicians understand this clearly. They see performance measurement coming on their horizon and they are concerned. We in the U.S. must address this incorrect approach to clinical judgment. We should urge everyone to adhere to the Pirate's Code. Allow guidelines to guide us, but not rule us.

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.
Thursday, June 18, 2015

It was not a great idea to prescribe sedatives, opiates, and stimulants to just about everybody

Lately I've had the opportunity to work in an outpatient clinic where the regular doctor is out sick for a prolonged period of time. It is a breathtakingly beautiful little community, with green hills and a crystal clear river. It is also troubled by methamphetamine and prescription drug abuse.

The little clinic in town is unwittingly a partner in this crime. Like the U.S. itself, this small community clinic has been generous with prescribing controlled substances for those who appear to need them. Sedatives in the benzodiazepine (Valium, Ativan and Xanax are brand name examples) family are prescribed for those with anxiety. Opiates, from the family that includes morphine, are prescribed for patients with back pain and knee pain and a host of other long lasting pains, and continue to be prescribed monthly for round the clock use, sometimes at increasing doses, since these long term pains rarely go away, even on medications.

Every young person these days seems to have attention deficit disorder, and many of them have found that they can study better if they take stimulant medications. These medications have been around for years, though there are newer formulations, and used to be called “speed.” In moderate doses they make pretty much everybody able to study better. They have become extremely common on college campuses at exam time, since they also allow a person to go without sleep and sometimes without much food. One person with a regular prescription for this kind of medication can supply his or her friends with drugs as needed. Side effects can include heart rhythm disturbances and erratic behavior, especially in higher doses, as are sometimes used recreationally. Some of the patients in this little clinic get ADD drugs so they can work or study, sedatives so they aren't anxious and opiate pain killers for their bad backs or other maladies. Sometimes they take them, sometimes they sell them or give them away, and often they do both.

There is no good evidence that these medications are either safe or effective when used long term. In fact there is good evidence that they are NOT safe, and quite a bit of circumstantial evidence that they are not effective. We prescribe many times the number of controlled substances now than we did a decade ago, and overall Americans are not less anxious or less in pain or better able to concentrate than they were before. Those of us who prescribe opiates to patients with chronic pain very rarely see the pain become significantly more manageable though we do see the patients become less active and more likely to ask us for ever increasing amounts of the medications which don't work very well.

We have known for years that opiates cause constipation, nausea and vomiting, sleepiness and confusion and can cause people to stop breathing at high doses. We are also recognizing that they cause low testosterone levels which results not only in sexual dysfunction but weakness and mood alterations and bone thinning. In some patients overall tolerance to pain or anxiety is decreased. Combining them with sedatives increases the risk that patients taking these medications will stop breathing and die. Most of the patients who die of these medications do so while taking the medications as prescribed though many overdose deaths also occur in people taking the medications recreationally.

I, as a cutting edge physician of my generation, prescribed these drugs with enthusiasm, glad to be able to lessen the burden of anxiety, pain or distraction in my patients. Eventually I noticed that these patients were having real problems, including emergency room visits for confusion or for increased pain, worsening of their pre-existing breathing problems, severe constipation requiring hospitalization, one died by deliberately overdosing. Others' deaths were probably hastened. More subtle has been the increasing number of people who are becoming inactive, apathetic and stuck in poverty who appear to live mostly for their prescription medications. This group of people are not being identified at all by statistics on overdose.

I have been away from regular primary care practice for years now, so have not been writing long term opiate or sedative or stimulant prescription for patients. I have also been in the hospital more and have seen more desperately ill patients whose main problem were prescriptions for controlled substances.

Now I get to be on the receiving end of what goes around which apparently comes around. There are a bunch of patients on controlled substances which will likely kill them (unless they are selling them to people, including school children, who will take them and maybe die) for whom I am asked to write for refills. HELP. Can't do it, can't not do it. Patients can have serious withdrawal syndromes if they run out of their opiates or sedatives suddenly. (Stimulants are usually not an issue, though.) If I do prescribe these medications there is a reasonable chance that I will be responsible for some bad and preventable medical tragedy. If I don't, these patients will be shocked and betrayed, since they really think they need these drugs to be happy.

If this was just my (and their) problem it wouldn't be that interesting. What is interesting is that this is just a tiny microcosm of what is happening in the whole U.S. Physicians are discovering that these controlled substances are not safe and that their patients are mostly not doing better on them than they were off of them. A small number of patients are doing better, but it's infinitely hard to figure out who those are. Stimulants may have benefit in children with attention deficit disorder, but this is rarely relevant for me as an internist who doesn't see kids. Adults appear to be overusing them in an epidemic manner.

The medical community of the United States needs to make an abrupt about face while showing compassion for the patients who have been taking these medications and probably deteriorating because of them for years. In our opiate dependent patients, we need to re-assess their pain and the causes of it and research the options that might be helpful. We have to do all this while tapering these patients off of the medications which they think they love. We have to realize that many of the things we might do to improve our patients' pain, such as exercise, meditation, non-opiate type drugs, may not be truly effective until the patients are actually off of opiates.

In my experience in trying to deal with this situation, I have found some unexpected allies: the patients themselves. In every patient who I talk to about tapering off of controlled substances I expect anger and resistance. But this is not always the case. I have met patients who seemed like they had just been waiting for someone to help them get off of these meds. It's not even all that uncommon. People don't actually like to be passive and helpless and weak and sleepy and constipated, and some of them are willing to risk experiencing pain or other discomforts in trade for not being on drugs. I see patients on the other end of the process, too. They say that after their injury or operation they were heavily dependent on drugs and that they eventually got fed up and, with the help of a good doctor or nurse or family, got off of them and intend never to take them regularly again.

Opiate pain medications and benzodiazepines are some of the most miraculous drugs physicians can prescribe, and I am not in any way averse to using them when they are needed. The opium poppy and its derivatives can abruptly change the outlook of a person who has the acute pain of a broken bone, a toothache or a recent surgery. They can make the final weeks, days, or hours of a person's life be more tolerable. Benzodiazepines can immediately relax a person whose anxiety is running away with them. These drugs are amazing. They just shouldn't be used on a regular basis except in extremely unusual cases.

I'm not positive that adult attention problems should be treated with medications. The rise in use of stimulants may be just an indication that our society expects everyone who intends to achieve financial independence to be able to focus on tasks or studies which are mostly irrelevant to them. As we've moved away from hunting and farming and manufacturing there are many round pegs attempting to pound themselves into square holes. Stimulants, with their known significant side effects and their unknown long term effects, should not be used to make people do things that bore them silly. On the other hand, the rare person who has narcolepsy (a disorder which is characterized by sleep attacks) has my whole hearted support in using stimulants on a regular basis. I will even sign the prescription.

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.
Wednesday, June 17, 2015

Using technology for lifelong learning in medicine

Physicians and other health care providers are incredibly busy. The administrative burdens have never been greater, they must learn to keep up in their respective area of practice, and caring for patients is a complex set of skills that takes time to achieve proficiency.

Recently, there has been a flurry of conversation in medical education about lifelong learning, including this piece on the interplay of social media and lifelong learning. Most would agree that lifelong learning (whether self-directed or otherwise) is an important skill. In fact, we teach this early on in medical school, and continue to stress the importance of lifelong learning during residency training and again in practice.

This post by Dr. John Mandrola on the NEJM Knowledge+ blog really hits home with respect to lifelong learning for practicing clinicians. I really appreciate the last point about finding one's own strategy for lifelong learning. I struggle with optimal formats for “teaching” people to have a strategy. Some excel at this skill, and others really need to work at it. I think that maybe modeling it to trainees could have an effect (“Someday, I want to be like Dr. X; she is always striving to learn, even after 20 years in practice”).

I do believe that given the rate of change in medicine, it is paramount that physicians consider the important of lifelong learning. After all, our patients will ultimately benefit from our efforts to be lifelong learners and to stay current in our practice of medicine.

I think that in the current age of “everything at one's fingertips”, in the form of mobile devices like smartphones and tablets, the concept of lifelong learning has never been more important. How does a physician keep up? What are the skills that are important for physicians to have? Dr. Vartabedian has written extensively on the subject of the digital literacy that is needed for today's physicians. Curating, collating, and how to find what one needs are skills that need to be taught, not only to students and residents, but also to practicing clinicians.

Given the plethora of sources available, I am seeing trainees more and more asking “what should I read/study?” This is interesting, since there never have been more resources available than in today's age. I'd like to give just a few examples of tools that I find incredibly helpful. (Full disclosure, I have no financial conflicts with any of these tools mentioned. My spouse is an emergency physician in community practice.)

Browzine. I use this resource on a mobile tablet through my institutional library subscription. It allows opportunity to get full text articles from most of the journals with which our library has a subscription. It is also great to review table of contents quickly, with fast linking to the full text if I want to read more.

NEJM Knowledge+. This resource is a way to review content for internal medicine (and family medicine) through adaptive learning, which is very unique. I think of it as “smart testing”, whereby one inputs both answers to multiple choice questions, as well as her/his confidence in the answer provided. Here is a link to an explanation on this type of learning. I have used my own account to choose questions for residents during education conferences, and the engagement from the residents has been quite impressive. There is also an opportunity to purchase an account for an entire residency program.

ALiEM: This is a compendium by emergency medicine specialists which is an incredible resource for those interested in this field. It includes posts on staying healthy, links to apps pertinent to caring for patients in an emergency setting, resources for teaching in emergency medicine, as well as learning emergency medicine. I especially like the videos describing procedures in the ED setting. For those interested in improving their educator skills, the MEdiC links are incredibly helpful.

Twitter: there is an incredible community of practice related to medical educators on Twitter. I learn so much from folks I have met, and also many I have yet to meet in real life. A Thursday evening, 9 p.m. EDT Twitter chat on medical education topics is a great opportunity to start learning from others. For literature on this topic, see these 2 articles: 1 on using Twitter as a learning tool, and 1 on social media for lifelong learning.

I am curious what other online resources and technology that others are using for their own lifelong learning.

Alexander M. Djuricich, MD, FACP, is Associate Dean for Continuing Medical Education and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis. This post originally appeared at Mired in MedEd, where he blogs about medical education.
Tuesday, June 16, 2015

The hero case managers

As someone who has practiced hospital medicine up and down the East Coast for the last several years, I've had the fortune of working with some absolutely terrific colleagues. The hospital environment is by its very nature a busy and hectic 1—where we all put our heads down and work tirelessly at the coalface for hours on end. Doctors are among the most hard-working professionals out there, often practicing our skills under extreme time pressure in life or death situations. But I'm not going to write here about how hard myself or my peers work, because we already know that (or should do). Not so long ago, I wrote a piece about nurses being the Superstars of Healthcare. The article received a lot of positive responses, which I was glad about. Think hospitals, and the first frontline professionals that usually come to mind for the general public are doctors and nurses. But I'd like to write here about my appreciation for another group of dedicated professionals: case managers, and the great and important work they do every day all across the nation.

Hospital physicians know that the case manager is the go-to person any time we are discharging a patient, especially if they need home services or are entering a rehabilitation facility. But having worked closely with some outstanding case managers, I believe that the work they do to discharge our patients and keep the hospital door revolving, is not always fully appreciated by all those around them.

Typically case managers are qualified nurses, which gives them a solid clinical background. Before a physician has even seen their patient, the case manager will have often “screened” them to help work out what they may need upon discharge. They will usually initiate communication with families, and by the time the doctor has seen the patient for the first time, it's not uncommon for the case manager to actually know more about the patient than the MD!

I've seen first-hand the mountain of paper and computer work that is required to discharge any patient. The dozens of phone calls, emails and pages to doctors. It's a very tough job. To compound this over the last few years, case managers are now intimately involved in determining whether a patient's admission status is appropriate and discussing this with the physician (i.e. observation versus inpatient). Anyone in health care right now knows that this is an often crazy and frustrating maze to navigate. Add to the mix the general push to discharge all patients as soon as possible, their workload is becoming exponentially more difficult with these increasing pressures and asks.

Without the case manager, the job of any hospital physician is impossible. So whether you next speak with them at random times during the day, or at organized multidisciplinary rounds, take a moment to appreciate the awesome work that they do to keep our patients moving.

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.

Mistakes about 'patient satisfaction'

I had 2 experiences recently that reminded me that many doctors and nurses remain resistant to measuring and improving how patients experience the care we provide. One was a face-to-face discussion with a senior physician. The other was reading an article by a nurse. Both the doctor and the nurse denounced the growing focus on the patient experience by citing the threat to quality of care, and I believe both of them were totally wrong.

The encounter with the physician came as I addressed a group of newly hired physicians. As I typically do in these circumstances, I outlined our Medical Group's commitment to increasing the visibility of the results of our patient experience surveys. We have been providing our physicians with reports on their patients' feedback for the better part of a year, and we anticipate posting physician-specific results on our public website within a few months. During the Q&A, one of the physicians objected to the plan, saying that “patients can't judge the quality of care that we provide.”

The article was entitled “The Problem with Satisfied Patients“ and decried the effort being made to boost hospital-specific patient satisfaction scores by adding hotel-like amenities and scripting staff, both of which she characterized as threats to clinical care and patient safety.

In both cases, the case against focusing on the patient experience was based on flawed “logic” and, sadly, probably more than a small dose of self-interest.

The doctor's mistake was that while his observation about patients' inability to judge quality may be correct, it is irrelevant. We are not asking patients to judge quality. In fact, there is considerable evidence that patients—precisely because they can't judge technical quality—just assume we are all competent. Instead, we are asking them to judge their own experience (which, of course, only they can judge), and the 2 are not in conflict. Since when are empathy and good communication, key determinants of patients' experience, anathema to quality?

OK, here it comes … what about all those crafty doctors who will practice “bad medicine” to boost their satisfaction scores? You know, prescribing antibiotics to kids with viral syndromes so as not to “disappoint” those pushy parents, or handing out narcotics to make patients happy. Well, what about them? Is this “threat” any more pressing than the one posed by some doctors doing more tests than they should to boost their income? Do we stop paying all doctors because some may bill in unethical ways? Why would we stop caring about finding out how patients experience their care because some doctors may respond unethically? No one is saying that patient experience scores are more important than quality, any more than we are saying that “productivity” is more important than quality.

The logical error is to reject the use of ANY measures of patient experience because using ONLY measures of patient experience would create perverse incentives.

The nurse made a similar goof. Sure, if patient experience scores were the ONLY measure used to judge hospitals, we would be in deep trouble. And sure, some institutions respond foolishly to the pressure to improve their scores (instead of their patients' experience) by trying to goose up trivial amenities instead of really understanding what matters to patients. Neither of which invalidates the importance of understanding and improving how patients experience the care we provide.

Here's something else to consider: True empathy, respect, and effective communication, which are cornerstones of providing a good patient experience, can improve clinical outcomes by reducing patients' stress, fostering sharing of critical information and boosting adherence to care plans. Nothing in conflict with quality there.

What do you think?

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.
Monday, June 15, 2015

The family dinner

The family dinner may itself be an endangered species in this modern era of fast food, electronic distractions, and isolated eating on-the-fly. The composition of that meal may be among the reasons other species are endangered, and that confluence is today's harangue. But we may begin with our own species.

We know what Homo sapiens should eat.

In this context, “should” has no moral implications, despite our tendency to think of diet and health as expressions of virtue, and the vexing modern proclivity to defend competing dietary dogmas with nearly religious zeal. There is a basic way Homo sapiens should eat, just as there is a way that koala bears, giant pandas, and spiny anteaters should eat. All creatures should eat some variant on the theme of the dietary pattern to which they are adapted. A diet in accord with adaptations tends to foster health; a diet at odds with native requirements tends to conspire against it. Lions must eat meat; caribou cannot.

The basic dietary pattern to which our species is adapted is reasonably clear. Clearer still are the variations and theme of optimal eating decisively associated with human health and longevity. Despite our penchant for emphasizing, in books and television segments and daily headlines, the minor differences among contenders for best diet laurels, and our comparable predilection for exaggerating the importance of each isolated study to issue, the fundamentals of healthy eating are both clear and consistent. They are the product of scientific research spanning decades, diverse methods, and widespread populations. They are validated by real-world experience in large populations. They are the product of both science and sense, evidence and consensus, cultural traditions and time-honored practices. We are not clueless about the basic care and feeding of Homo sapiens.

Our species is constitutionally omnivorous, and has been so since even before our species became one. According to the best anthropological evidence and thinking, Homo sapien antecedents, such as Homo erectus, were hunter-gatherers as well. If our ancestry is extended back far enough, we become vegetarian or very nearly so, as are most of our extant primate cousins. But we clearly have physiologic adaptations for a mixed diet, and perhaps even specific adaptations for the ingestion of cooked meat.

Exactly how important hunting has been to our lineage remains a contentious area for paleoanthropologists. Some use the traditional appellation, “hunter-gatherer,” to place emphasis on hunting in the first position, and the relative primacy of animal foods in our native diet. Others, however, flip that order, and contend that gathering was the greater brace for our Stone Age sustenance.

As is true of so much else in nutrition, that discord masks the greater and more salient accord. Expert paleoanthropologists debate whether plants provided the majority of our calories, or just half, but all agree that our native diet was comprised principally of wild plants and the flesh of wild animals. Domestication of other species had not yet been invented.

So, our traditional diet is limited to real foods, direct from nature. There were no added sugars- other than what little honey we wrestled from the bees. There were no artificial sweeteners. There were no food chemicals. There was no trans fat.

As for meat, it was obtained from animals that in turn had recourse to their native conditions. They were wild animals that roamed their native, wild spaces; exercised their muscles in the various imperatives of survival; and ate their own diet, generally wild plants. There were no factory-farmed animals, fed an expediently non-native diet, denied space to move, dosed with antibiotics and hormones as profits dictate, or subject to indifference or even brutality during incarceration or at slaughter.

The familiar expression, “you are what you eat,” has a corollary we all too often ignore: what we eat is what it eats. In light of this consideration, the meat that predominates today in the typical American diet is nearly as different from its native lineage as is high-fructose corn syrup from that apple in Eden. By means of illustration, the flesh of grain-fed, sedentary cattle may provide as much as 35% of calories from fat, much of it saturated. In contrast, the flesh of antelope, thought to resemble that of our Stone Age prey animals, provides as little as 7% of calories from fat, nearly all of it unsaturated, and some of it omega-3. So-called “fish oil” only became that once we had domesticated it out of other animals.

Whatever the arguments for meat in the human diet, they should pertain to the kind of meat that is native to that diet. The meat intake of modern cultures is a marked departure.

But there is another, more radical distinction between the dining of modern humans and that of our Stone Age forebears. They did theirs in scattered, isolated clans surrounded by vast, wild spaces. We do ours as members of a voracious, planet-wide horde. For the current population of over seven billion Homo sapiens to make a living the Stone Age way would require roughly 15 times the surface area of our planet, and even that assumes we could hunt and gather over every square foot of it, from the South Pole to the Sahara.

Eating is more than just sustenance, of course; it is a medium of social exchange as well. Food has always been central to human concourse. In modern context, as social traditions are anachronized with increasing expedition, we have evidence to suggest advantages in going occasionally back to our future. Family meals, for instance, are associated with better dietary practices and health than eating in distracted isolation.

There is cause now to expand the definition of that family, as the concerns of public health and conservation converge. Sustainability is, rightly, a consideration in dietary guidance. Climate change may now be so salient a menace to humanity that the infamous imperium of chronic diseases may need to surrender to it. That does not suggest we should choose between them, but rather look for strategies that can address both.

Among such strategies is the adoption of the very dietary pattern most decisively associated with human longevity and vitality: wholesome foods close to nature, predominantly plants, in various, time-honored, sensible combinations. A more plant-based, and less hyper-processed diet offers advantages far beyond chronic disease prevention, extending to sustainability of food sources; reduced environmental degradation; less propagation of antimicrobial resistance; reduced fresh water depletion; kinder, gentler treatments of any animals we do raise for food; and conservation of wild spaces required to protect biodiversity.

That last consideration may seem to be more about them- those other species- and less about us. But there is no meaningful distinction. The forests that produce our oxygen are in turn dependent on animal species that are sustained by them, and pay it back in various ways, such as by dispersing seeds. The vast interdependence of life is a bedrock principle of biology, from bees to buffalo to banyan trees. As glaciers melt and sea levels rise, our fellow species and we will sink or swim together.

E.O. Wilson, a Harvard biologist and Pulitzer Prize winner, puts it compellingly well in The Social Conquest of Earth:

The obliteration of biodiversity in the living world has received much less attention than climate changes, depletion of irreplaceable resources, and other transformations of the physical environment. It would be wise to observe the following principle: if we save the living world, we will also automatically save the physical world, because in order to achieve the first, we must also achieve the second. But if we save only the physical world, which appears our current inclination, we will ultimately lose them both.

How Homo sapiens choose to eat has profound implications for our own medical destinies. But what's for dinner and who has a seat at the table reverberates beyond the years in our lives and the life in our years, to the fate of virtually every other species as well. That, in turn, has implications for our own survival as a species, and any hope we have of bequeathing to our children and grandchildren a world in which they may hope to thrive.

All of life is an extended family, at 1 remove or another. As is the case for the nuclear family with which we share our daily intimacies, members of this extended family are interdependent, and the family dinner has implications for us all.

We should chew on it accordingly.

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.
Friday, June 12, 2015

Medical talks in India, part 2

The trip is wonderful thus far and very interesting. Yesterday and today we are in Hyderabad in southern India. Hyderabad has a large IT presence and is famous for its biryani, which we had for dinner last night. It was outstanding.

Some observations thus far:
1. Internists throughout the world treat mostly the same diseases and have the same concerns.
2. Infectious diseases are decreasing in India with improved public health. Cholera has become much less common.
3. Non-communicable chrnoic diseases such as diabetes, heart disease, hypertension, etc. are increasing rapidly in India. They have significant numbers of chronic kidney disease and cirrhosis.
4. Medical care in India includes the same highly specialized treatments that we use in the U.S., such as transplantation, extracorporeal membrane oxygenation, emergency dialysis, interventional cardiology, etc.
5. Professors worry that learners are not as good at taking a history and doing a physical examination as were trainees 20 years ago.
6. Residents work much harder here than in the U.S., the types of hours we worked back in the 1970s.
7. Each talk is well received with the same types of questions that a U.S. audience would ask.
8. Medications are much less expensive, giving the physicians the ability to use meds that some of our patients cannot afford.
9. Likely health care has greater disparities (based on socio-economic factors) than we do in the U.S. We have visited both government and private hospitals and the clientele and atmosphere have major differences.

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.
Thursday, June 11, 2015

Is medical research rigged?

Practicing physicians like me rely on scientific medical journals to keep us current on medical developments. We learn about new treatments for old diseases. New diagnostic tests are presented as alternatives to existing methods. Established treatments, which are regarded as dogma, may be shown to be less effective or less safe than originally believed. It's a confusing intellectual morass to sort among complex and conflicting studies some of which reach opposite conclusions in the same medical journal. What's a practicing physician to do?

While the medical journals that physicians read are fundamental to our education, paradoxically most physicians have only rudimentary training in properly analyzing and assessing these studies. For example, the quality of medical studies often depends upon statistical analysis, a mathematical field that is foreign to most practicing physicians.

Doctors like me hope that our peer-reviewed journal editors have done their due diligence and vetted the studies they publish ensuring that only high quality work reaches readers. On a regular basis, a study in a prestigious medical journal is challenged by other experts in the field who refute the study's design or its conclusion. Medical progress does not proceed linearly.

Although I am a neophyte here, I will offer some examples to readers highlight defects in study design that can lead to tantalizing and exaggerated headlines and sound bites.

The study is too small. If a new treatment is tested on only 5 patients, and one of them happens to get better, is it really accurate to announce that there is a 20% response rate? Would this hold up if the study had 100 patients?

Where's the control group? Doctors know that many patients get better in spite of what we do. If a new treatment brags a 35% response rate on a group of sick individuals, was there a second group of patients called the control group in the study who were not treated and compared? In many cases, the control group shows a significant ‘improvement’ without any treatment, for various reasons. If the treatment group and the control group both show a 25% improvement, then the drug is not quite the magic bullet.

Is the study randomized? Ideally, the treatment and the control group should be identical in every respect except for the treatment being tested. This is why higher quality studies randomly assign patients into each group. Randomization maximizes the chance that the two groups being compared will be very similar with regard to all kinds of variables including smoking, weight and other risk factors.

Beware the false assocation! This is a very common and deceiving practice where investigators try to link events that are much too far apart to be connected. Newspapers and airwaves love this stuff as they have sizzle. “Study shows that Gym Membership Reduces Cancer”. This “study” might be sponsored by the Society of Calisthenics and Aerobic Medicine (S.C.A.M.). Sure it might be true that gym members have lower cancer rates, but this has nothing to do with pumping iron. These folks are more health conscious and are likely to be fit, non-smokers who pursue preventive medical care. Get the point?

These are just a few examples to give readers a glimpse of the issue. Of course, I just barely peeled the onion here.

Designing medical studies is a profession. Most physicians have barely a clue on how to properly design a study or to interpret it. Most of us rely upon others to perform the quality control function. However, just because it's a published study, doesn't mean the study is worthy of publication. Medical research may contain sleight of hand, confusion, obfuscation, all of which can be hard to recognize. The fact that our highest quality medical studies are routinely challenged shows how difficult it is for ordinary doctors to make sense of it all. Medicine can be murky. Caveat lector!

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Wednesday, June 10, 2015

Champagne on our deathbeds

I attended a recent conference where the keynote was given by a well-known writer who also happens to be a doctor: Abraham Verghese.

Verghese is the author of a memoir called “My Own Country” that I consider formative in my own career. It was about his life as doctor specializing in infectious diseases in small town Tennessee during the early days of the AIDS epidemic. After I read it I wrote him a letter, and he was kind enough to reply. I still have the letter.

He wrote a second memoir about a trainee called “The Tennis Partner,” a very powerful story of the trainee's demons. For his third book he crossed over into fiction with the novel “Cutting for Stone.”

During his keynote Verghese discussed mortality, reminding us that in spite of gains in longevity, the death rate for human beings still is 100%. Immortality, he argued, is overrated.

He also distinguished between curing and healing, making the claim that we strive so hard for the former we essentially forget about the latter. If your home is robbed, your personal sense of security is assaulted. If your possessions are returned, you are ‘cured’ of the property crime, but won't feel healed for some time.

As another example, he discussed caring for young men with AIDS for whom there was no treatment in the 1980s. Yet by attending to them on their deathbeds, he provided solace as they reunited with their families. This was a form of healing.

He also read a passage to the audience about the death of Anton Chekhov, late 19th-early 20th century Russian doctor and writer of plays and short stories.

Chekhov, stricken with tuberculosis, asked his wife Olga to take him to a Black Forest spa when he knew death was imminent. There, she recalled in her own memoir: “Anton sat up unusually straight and said loudly and clearly (although he knew almost no German): Ich sterbe (“I'm dying”). The doctor calmed him, took a syringe, gave him an injection of camphor, and ordered champagne. Anton took a full glass, examined it, smiled at me and said: “It's a long time since I drank champagne.” He drained it and lay quietly on his left side, and I just had time to run to him and lean across the bed and call to him, but he had stopped breathing and was sleeping peacefully as a child …”

Verghese encouraged us all to think about how we want to leave this earth—and to tell our loved ones—lest we wind up in hospitals tethered to machines.

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.
Tuesday, June 9, 2015

Health care IT: the secret barrier to patient satisfaction nobody wants to talk about

I was recently talking to a patient about having some extra help at home when she left the hospital with home nursing services. The elderly lady, highly intelligent and fiercely independent, politely declined with the reply: “No, I'm fine thanks Dr. Dhand—all they've done before is just come in with their computers, barely talk to me, enter a few things on their keyboards and then leave.”

This reply really struck a chord with me (as someone who has written extensively on all that we need to do to improve the use of information technology at the frontlines of medicine). We then engaged in a brief conversation about all the changes she's seen over the years and how medicine now seems so fragmented and impersonal. I finished with a strong feeling inside that I really couldn't blame her for declining additional “robotic” services, and that she was talking absolute sense about her experiences.

Her reply is typical of dozens, if not hundreds, of similar complaints I've heard over the years about how doctors (and nurses) are simply too pre-occupied with their keyboards and screens and barely look at a patient nowadays. This problem particularly affects the more generalist medical specialties—including primary care—which should be the cornerstone of all health care.

The last decade has seen the proliferation of information technology, mainly due to Meaningful Use and the government's incentives for the computerization of the healthcare system. Let me pause right here and say that I am far from advocating a return to the paper chart or the archaic days of yesteryear. Many of the aims and goals behind Meaningful Use are noble ones. We simply need to redesign the current systems so that they are fully optimized for frontline medicine, and design them to be as seamless and efficient as possible so that doctors and nurses can get back to where they belong: with their patients talking face to face. Likewise, doctors and nurses need additional training on how better to use the information technology so that it doesn't come in-between them and their patients.

A study published not so long ago in the Journal of General Medicine showed that medical interns now spend only around 10% of their day engaging in direct patient care in hospital and almost half their time with computers. That's a shocking statistic and an unfortunate imbalance. I'm sure if a comprehensive study was done on primary care doctors and how long they spend looking at actual patients versus their screens, the results may be even more disappointing. If it were expanded, the same study would probably also show that one of patients' biggest let-downs would be when their doctor keeps glancing in-between them and their screens. So if we are really serious about improving patient satisfaction and the healthcare experience, how can we let this situation go on?

I hope that in the not too distant future the world of frontline medicine, IT, and hospital administration, can all get together to solve this problem. I gave a presentation last year in Boston titled: “Healthcare IT: what the frontline of hospital medicine really needs”. The audience was a mixture of entrepreneurs, techies and clinicians. The biggest round of applause I got was from the clinicians when I opened with the provocative statement that healthcare IT has done more to destroy the doctor-patient relationship over the last 5 years than any other 1 single thing. I stand by that statement and hope that we can change things. Until that happens, we continue to massively let down our suffering patients.

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.
Monday, June 8, 2015

Reducing variability in health care delivery--maybe not such a great idea

I attended the annual meeting of the American College of Physicians, an organization of internal medicine physicians with about 140,000 members. In the annual meetings organizational things take place, such as recognition of particularly hard-working members and a kind of graduation ceremony in which members who have achieved a certain level of accomplishment are advanced to fellowship. Mostly, though, the tens of thousands who attend are there to go to lectures and discussions by doctors who know things that we all want to know.

It is possible when attending these meetings to get a general idea of what the leadership in internal medicine thinks is important or acceptable. This year one of the themes seemed to be “reduction of variability.” Only one talk actually used those words, but many of the speakers mentioned that they were encouraged to present the “party line,” meaning published guidelines by specialty organizations within ACP. Guidelines are carefully built recommendations for managing various conditions, from diabetes to urinary tract infections, and are extremely helpful in swaying our practice away from things that don't work and toward things that do. They were never intended to be the last and final word.

The one talk that actually used the verbiage “reducing variability” was also addressing the Choosing Wisely campaign. A few years ago, the American Board of Internal Medicine championed an initiative to reduce the number of wasteful and useless things physicians did in caring for patients. The idea was that specialty groups would point out the tests or treatments that were being done that really didn't make sense. There are lists now of what not to do (like a head CT scan for a fainting spell or an X-ray for uncomplicated back pain without “red flag” symptoms or antibiotics for the common cold). These lists will help doctors to feel supported when practicing good medicine. They are also an attempt to reduce variability by presenting a unified approach to common problems. I would have liked to see the talk about Choosing Wisely and reducing variability, but for some reason it required an advanced reservation.

I am actually a big fan of Choosing Wisely, since I think that many physicians do more testing and treatment than really makes sense, thus wasting their patients' time and money and cluttering their consciousness with useless and excessive data. But I am not entirely on board with reducing variability.

When I go to a lecture at the ACP meeting, what I hope for is to hear a physician speak who has immense experience in the practice of medicine and who will tell me what he or she does that works well. Sometimes there are controlled trials to support their practice but sometimes their subtle and individualized approaches are not amenable to controlled trials. This is as it should be: much of medicine is an art, and amazing and committed physicians are among us and we can learn a great deal from them. Sometimes different great teachers practice differently from one another. Doing things differently often means that thinking and innovation is going on and that people are not simply acting like sheep.

I heard 1 speaker, who seemed quite good at what she did, speak of the research regarding her field. She presented data to show that a certain medication worked no better than placebo for treating the condition in question. She said that when her patients asked about using the medication, she told them that they could try it but that it would work no better than a placebo. But she was wrong. The study showed that on average, for a group of patients the medication worked no better than placebo. But for some patients it, of course, worked significantly better than placebo and for some it worked less well. In saying this she made the assumption that there was no variability among patients and that her patient would have the same results as the average patient in the study. Because of this interpretation, those patients of hers who might have benefited from the treatment were probably unlikely to try it.

Because our patients are individuals and not groups of average subjects there should be some variability in how we practice. Because there are more ways than one of doing a job well, we should continue to rejoice in our variability, while striving not to do things that are clearly stupid. It is right that what we do as physicians should be informed by clinical trials and controlled studies, but we should not be convinced by them to ignore the individuality of both physiology and goals of the patient who sits in front of us.

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.