Friday, July 31, 2015

The joy of boredom

It's been a very slow week in my office. Today we almost pitched a no-hitter, having only one patient come in toward the end of the day. Overall, we've been quiet in nearly every way - few phone calls, few patients stopping by, few appointments, few secure messages.

What's wrong?

That was a trick question. This is exactly what should be happening when things are going right. My patients are happy. My patients don't need me now. My patients are satisfied with my care. This would be a problem in most offices, as revenue depends on people having problems, having questions about their care, or anything else that would fill the schedule. In practices like mine, however, this is what we want; after all, I am paid just as much for an empty office as a full one.

The hardest thing about weeks like this (which seem to happen in June and July) is to fill our time with tasks (other than going on Facebook, playing Candy Crush Saga, or having a happy hour with the staff). These slow times are not the norm, especially as my number of patients nears 600. Some days are quite full. I had one day a few months ago where I actually had more than 10 patients come in for appointments!

Seriously, that's busy around here. I used to see between 25 and 30 patients on normal days, and sometimes ended up seeing more than 40 (once saw over 60). So my current definition of a “busy day” is quite laughable in comparison. Remember, however, that I am not limiting care to office visits. It doesn't matter to me if patients' problems are handled in the office, via messaging, or on the phone, as long as it is good care. Office visits are just one form of communication.

Prior to leaving my old practice, I kept tabs of what percentage of visits actually required the patient to be physically in the office. 3/4 of the visits weren't necessary. Of the remaining 1/4, a small percentage of the actual visit required face-to-face time. So now that I am out of the gravitational pull of obligate office visits, I give care however it will work best. I love it. My staff loves it. My patients really love it.

Still, on these slow days we are challenged to do the tasks we can't do when we are “busy.” Those tasks aim at two main goals: to improve the quality of care we give and to make our system more efficient (so those busy days aren't as busy). The nice thing is that I can do that task with Van Morrison playing loudly in my office.

So yay for boredom! Yay for healthy patients! Yay for a job that doesn't encourage me to have sick patients and to spend as little time with patients as possible! Yay for Van Morrison! It's so quiet in here. These are the days. That's what Jackie Wilson said. It's a marvelous night for a moondance. My momma told me there'd be days like this.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.
Thursday, July 30, 2015

Becoming a clinician--observations from third year students

The transition between the basic science years and the clinical years in medical school are jarring, mystifying, exhilarating and thought-provoking. Yesterday, I did an hour conference with approximately 30 medical students. About half started their clinical year 5 weeks ago, while the remainder have only 3 weeks left before they finish the year. They gave me permission to share our discussion. We focused on their (and my) observations about the adjustments they were making. The following list is not complete, but rather what we talked about for an hour. We welcome your comments on additional observations.
1. Clinical students work independently, talking with patients, examining them, and developing their own assessments prior to presenting/discussing those findings with residents and attending physicians. The students found this both exhilarating and scary. Several endorsed the “imposter syndrome“. Patients see students as learning physicians, but they actually understand that students are on a trajectory and they are not imposters. This transition is a challenge for many students, interns, residents and newly minted attending physicians. We discussed and acknowledged the feeling. But we also observed that thousands of students have gone through the process and succeeded.
2. Students must learn to ask for help. Those physicians in position to help understand that the students need help. Not asking for help is a huge mistake, but brand new 3rd year students start out feeling intimidated. Successful students learn how to ask and receive excellent help.
3. One quickly learns that you cannot invent the stories that patients tell you. Many stories are incredible. The best physicians appear non-judgmental, although we all have judgments. To get the best story, we cannot appear to be judging patients. Students, interns, residents and physicians cannot really share their interesting or incredible stories with non-medical people. What we find interesting and worthy of discussion bores or disgusts our “regular” friends. I suspect that is one reason 3rd year medical students often appear boring to their non-medical significant others. Our story telling to our peers is therapeutic and necessary, but only in our own groups.
4. Once you start the clinical years you begin receiving calls, texts and e-mails from friends and relatives about their medical problems. This phenomenon never ends. The students were happy to hear that this is a common problem and that they needed strategies to answer such inquiries. Everyone else sees us as experts.
5. Third year students enjoy reading about the clinical problems that their patients have. Adult learning observations support this phenomenon. Reading about medicine during the first 2 years is a job; reading about your patients becomes an obsession and that obsession is necessary, enjoyable and rewarding.
6. Beware cynical health care workers. Beware having cynicism intrude into your personality. We discussed why cynicism develops. We discussed patients trying to manipulate us. One student shared a thought that I had given him. We should trust all patients, but we should always verify their difficult to believe stories. We also talked about the problems of pain and opiate seeking patients.
7. A great observation from a student – Doctors use Google – a lot! She realized that she had always had doctors on a pedestal assuming perfect knowledge. The third year exposure confirms that we physicians are human. We stressed that having physicians look up drug doses or information about a diagnosis while rounding is a very positive trait. We also all agreed that physicians do not live on a pedestal.
8. Medical students should act like medical students, understanding the systems expectations of their knowledge and behavior. They should not act like residents or attending physicians. They should work to become great medical students and prepare for the next step in their climb.
9. We discussed the difficult exposure to mortality. Some students shared their observations of watching a patient die. These episodes impact us dramatically. At first they are very difficult; they never become easy, but we learn to accept mortality and strive to make all deaths good deaths if at all possible.
10. Understand that the retrospectoscope trumps everything. When something bad happens to patients, we always obsess over our actions and decision making. We must learn to own our mistakes and learn from them.

Throughout our careers we always fret about possible mistakes. We often overestimate our potential for having been able to prevent bad outcomes.

We must share our experiences with our colleagues and as colleagues we must be supportive. We must learn from our mistakes and our colleagues mistakes. And we all make mistakes.

The session was informative and therapeutic. The students recommend that we do this again. They really appreciated learning that they were not the only ones who had these feelings, doubts and mental exercises.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.
Wednesday, July 29, 2015

Demonstration of 'tweeting the meeting'

I had the privilege of writing a paper recently with Dr. Janine Zee-Cheng on Live Tweeting in Medicine: ‘Tweeting the Meeting’, which came out a few months ago (and allows free open access to all articles through the end of June, 2015). In it, we highlighted the importance of lifelong learning through the use of Twitter at conferences. I also encourage a quick read of this other great piece giving suggestions on how to live tweet in conferences.

Dr. Zee-Cheng, a pediatric critical care physician from my institution, is giving a presentation on a social media-related project she did as part of her fellowship, at a conference currently going on this week in Chicago. The hashtag is #smaccUS (to reflect social media and critical care). I highly encourage those who are reading this blog now to check out the tweets from this conference. The discussions, on a variety of topics, are truly epic, and range from general content in the management of critically ill patients, to the emotional side of medicine, to introspective reflection about one's practice, to frank humor.

While I am not at the conference (we are orienting new incoming interns to begin their clinical duties), I have learned so much from reading tweets from participants. I encourage all interested in this topic, and literally, medicine in general, to check out the #smaccUS hashtag—you will not regret it!

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, July 28, 2015

Is gastric bypass the right choice?

Bariatric surgery, including gastric bypass surgery, has become a popular remedy for obesity in this country. Hospitals have weighed in on this issue and are marketing this service directly to the public who are ever willing customers of this slenderizing surgery. I have many patients who have undergone the procedure and the results have been variable. It's too dismissive for me to refer to gastrointestinal bypass (GIB) as a ‘procedure’ as it is major surgery with major potential complications. There are several types of bariatric surgery available today, but GIB is the standard surgery performed.

It profoundly reroutes the guts and changes every day of your life. This is not like undergoing a heart bypass surgery when after a period of recovery you resume your normal life. After GIB, there is no normal life afterwards. Your life is irrevocably altered. Meals are such a significant and personal part of our lives. Think of all of life's celebrations and you will recognize that food is a part of them.

I point out these strong caveats to remind folks that the decision to proceed with GIB is not a casual one. It requires careful deliberation and an understanding of the lifelong changes that one is committing to. In addition, this operation is no quick-fix cure. A patient who is a food addict, for example, will regain the lost weight after surgery, a sad and predictable outcome. This is why high quality bariatric programs screen patients very carefully psychologically. If a program accepts nearly all applicants, then one must wonder about the quality of the institution.

Personally, I feel that bariatric programs pull the trigger too quickly and that the public is too willing to serve as targets. These surgeries, which should be regarded as last resort rescues are increasingly offered as front line therapies. Eligible patients are rightfully told that GIB weight loss can melt away diabetes, sleep apnea and hypertension.

Before consenting or seeking GIB, have all other methods of weight loss been exhausted? Has the individual received intensive dietary and nutritional counseling from weight loss professionals? Has there been an adequate system of coaching and accountability? Quitting a diet or two after a few weeks does not constitute exhausting all efforts. I think that the existence and marketing of bariatric programs has influenced patients to leapfrog over conventional weight loss programs directly to the operating table.

I absolutely believe there is an important role for bariatric surgeries. I am less sure that we are performing these surgeries only when they are the most appropriate option. It's weighty issue for sure. Feel free to weigh in yourself.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Monday, July 27, 2015

Nutrients, nutritionism, and historical nuttiness

The current issue of JAMA features a commentary by two colleagues, calling for an end to what they term the “ban” on total dietary fat. More specifically, the authors are endorsing the report of the 2015 Dietary Guidelines Advisory Committee, of which I too am a fan, in which there is no specific reference to an upper limit for total dietary fat intake.

There are a number of important implications in this.

First, the case for abandoning an emphasis on limiting total dietary fat intake is clearly legitimate and overdue. The world's healthiest populations vary widely in their total dietary fat intake, but vary far less in the basic theme of their diets. In all cases, they consume diets of wholesome foods in sensible combinations; real foods, not too much mostly plants- to borrow from Michael Pollan.

We have long had abundant evidence that reference to total dietary fat was a stark failure to differentiate baby and bathwater. Some classes of fat, notably manufactured trans fats, are consistently and uncontestably harmful. Some classes of fat contain specific members that are harmful and others that may be innocuous; this is where the evidence currently stands for saturated fat. The current enthusiasm for attributing health benefits to saturated fats may be a product of wishful thinking, reactionary excess, or ulterior motives, but is not a product of the current weight of scientific evidence. Of note, the Dietary Guidelines Advisory Committee report, and the new commentary in JAMA, both preserve the recommendation to limit total saturated fat intake.

Some fats may be beneficial or harmful, depending on total dose and proportion to their counterparts; this is our current understanding of omega-6 polyunsaturates. Like omega-3 fats, omega-6 fats are essential nutrients; but we are prone in modern diets to a relative deficiency of the former, and a relative excess of the latter. Because our intake of omega-3 polyunsaturates tends to be relatively low and these fats are essential nutrients, more would be better in most cases. Monounsaturated fats, indelibly associated with the Mediterranean diet, are generally thought to be health promoting.

Second, as noted in the JAMA piece, we have other nutrients of concern these days. Our fixation on fat for many years resulted in marked increases in our intake of refined grains and added sugars. These are both major liabilities of the modern diet, and an obsolete emphasis on limiting total fat intake may lead inadvertently to ills in this other direction.

Third, there has long been a disconnect between the lingering reference to total fat and recommendations for specific foods. Fish, especially fatty fish, are consistently associated with health benefits, and are recommended in the Dietary Guidelines for Americans. The health benefits of the very-high-fat avocado are widely recognized. And, in particular, nuts and seeds are consistently and decisively associated with health benefits, and recommended rather prominently in both the 2010 Dietary Guidelines for Americans, and the 2015 advisory committee report. It does not make a lot of sense to advise limiting intake of nutrients while advising increased consumption of foods in which those nutrients are found.

Fourth, and finally, there is the precautionary tale of our recent nutritional history, which has been, in a word, nutty. For literal decades now, we have fixated on some particular nutrient while looking right past foods, and overlooking the overall dietary pattern. We have managed to invent an unending variety of junk foods, each under the halo of some particular nutrient “virtue:” low fat; low carb; low fructose; vitamin fortified; gluten free. We have invented a parade of ways to eat badly, and are, predictably, mostly fatter and sicker as a result.

So while the plea in JAMA to lift the “ban” on total dietary fat is valid, the silence on the topic in the DGAC report may be even more so. The DGAC decided to de-emphasize nutrients altogether, and instead to emphasize the very items we have been overlooking, foods and dietary patterns. Their 572-page report is perhaps best encapsulated by this passage from the executive summary: “The overall body of evidence examined by the 2015 DGAC identifies that a healthy dietary pattern is higher in vegetables, fruits, whole grains, low- or non-fat dairy, seafood, legumes, and nuts; moderate in alcohol (among adults); lower in red and processed meats; and low in sugar-sweetened foods and drinks and refined grains. Additional strong evidence shows that it is not necessary to eliminate food groups or conform to a single dietary pattern to achieve healthy dietary patterns. Rather, individuals can combine foods in a variety of flexible ways to achieve healthy dietary patterns, and these strategies should be tailored to meet the individual's health needs, dietary preferences and cultural traditions. Current research also strongly demonstrates that regular physical activity promotes health and reduces chronic disease risk.”

While a cap on total dietary fat intake has proven to be unhelpful, it's worth noting that the wide range of variations on the theme of eating for optimal health all fall within a predictably judicious range. While some of the world's “best diet” contenders are very low in fat, and some as high as 40% of calories or more, none is extremely high. In all cases, though, this balance is achieved by an emphasis on foods. Diets proven in both research and real-world settings to be good for life-long health all emphasize vegetables, fruits, beans, lentils, and whole grains, all of which are natively low in fat. When these are prominent, or predominant, in a diet, there is a limit to how high in total fat that diet can be.

History is the best judge of our actions and inclinations. The judgment of our proclivity for mono-nutrient fixations has been rendered, and it is quite harsh; we have been harming ourselves with its unintended consequences for decades. In contrast, the 8 years of history since Michael Pollan wrote about “nutritionism” in the New York Times have judged his insight to be of profound importance. Get the foods right, and nutrients will take care of themselves; focus on any given nutrient, and there is good chance of inventing yet another way of eating badly.

When we know that some dietary fats are rather sinister, and others quite salutary, failure to unbundle the two is obsolete nonsense. When we know we are prone to remove healthful fats from our diets and replace them with sugar, an emphasis on total fat intake in dietary guidance is obsolete nonsense. A clear verdict has been rendered in the case of nutritionism, and it is guilty of crimes against humanity.

But let's be careful. The right response is not to canonize the nutrients we once vilified, but to de-emphasize nutrients and emphasize wholesome foods. Recommending for the intake of nuts, but against the fat content of nuts, was always just plain nutty. Failure to learn from the follies of our nutritional history would be even more so.

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.
Thursday, July 23, 2015

Learning to wait and observe by avoiding the 'do something syndrome'

A wonderful blog post made me think – Do Something Syndrome. It reads, “We all have moments where we fall victim to the curse of Do Something Syndrome. In fact the modern organization is full of do something syndrome. The key is to try and realize when we are doing it and back away.”

This post makes we wonder about the entire “quality” movement. As I recall, many advocates for performance measures have argued that we should start measuring things because we just have to start.

We have had harm from performance measurement! The famous 4 hour pneumonia rule provides one example: “The four-hour rule was based on 2 large retrospective studies, one of which appeared in the March 22, 2004, Archives of Internal Medicine. That study concluded that receiving a dose of antibiotics within four hours of arriving at the hospital was associated with ‘a 15% relative reduction in 30 day mortality,’ which calculates to a 1.1% absolute reduction.”

But adoption of that “rule” led to vast overuse of antibiotics – an overuse that continues to this day, despite the removal of the rule.

We have harm from tight control of diabetes measures and tight blood pressure measures.

The “quality” gurus took the attitude, do not just sit there – do something. We can see the “do something” syndrome cause unintended harmful consequences.

We should not do anything until we evaluate that something. We must understand that performance measurement development might let to care improvement, have no impact or actually harm overall care. If we can get everyone to understand that an adopted performance measure could harm care, then perhaps we will see true evaluations of each proposed measure.

Sometimes we need to take our time and not just “do something”.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.
Wednesday, July 22, 2015

Reconcilable differences

During med reconciliation with a patient recently

“You're taking the pills in this bottle?”

“That bottle there?” The Grady elder picked it up and studied it for a few beats. “Yes, ma’am, so this bottle here. I takes one pill with my breakfast and one with my supper. Every day.”

“Hmmm. It looks like you have a lot of different pills mixed up in here together. Is that on purpose?” I know that sometimes people do all sorts of things for convenience. I didn't want to assume anything.

“Well. I don't see so good so I jest know which bottle is the 1-time-a-day ones and what bottle the 2-time ones.”

“So this one, you just open up and take out 1 in the morning and 1 at supper, correct?”

“Yes'm.”

“Okay.”

And you know? I have no idea how those pills got mixed up like that. This kind of thing—that is, this exact thing—is not unusual for us to see at all. And you know what else? It's easy to look at this medication mashup and generalize it to his life, and then make a sweeping statement about his need for a nursing home ASAP. Or to, at least, push to make sure he isn't able to live alone. I get that it seems like a no-brainer when you see something as worrisome as this and then try to wrap your brain around someone taking a random assortment of cholesterol, antihypertensive, and memory pills all willy-nilly.

But.

Let the record show. This man lived alone. He was dressed and groomed appropriately and had taken public transportation to the hospital (no easy feat in downtown Atlanta.) Every day he cooks for himself, cleans for himself, does for himself and, for the most part, seems to get on just fine. He does. And has. For more years than most of his doctors have been alive.

Yep.

And see, this? This is one of the hard things we navigate in patient care, particularly when it involves our geriatric population. The lumpy bedspread that the patient can't quite smooth out on their own any more. The one that requires a little help to lay flat but that isn't to the point of needing to find new linens altogether.

Does this even make sense? Sigh.

Okay. So check it: This sweet man, this dear, dear elder needed somebody to—as the southerners say—”See about him.” And he didn't have that. He'd outlived or out-healthed a lot of his family members. And a lot of the other ones had lives and families and he didn't want to be a bother.

Nope.

Yeah man. This man needed somebody to see about him. To come by and check in and make sure things like this were okay. He wasn't significantly cognitively impaired or visually disabled that he couldn't get along. He did have a very limited education and admitted to being uncomfortable with most reading. But he'd worked for nearly his whole life and had managed his life quite fine. Taking him out of his home—the one that he built and paid for—is way more than a notion. Way, way more.

Fortunately, at Grady we have a lot of things we can offer someone like this patient. Some of it simple, some less so but all mostly doable and reasonable options to allow him to both remain safe and in his home at the same time.

Yeah.

Do I sometimes facilitate getting people into nursing care facilities? Definitely. But not without stopping what I'm doing and really, truly thinking about it. I reflect on the magnanimity of it and how it will make the patient feel. Will they be sad? Happy? Lonely? Scared? Will they feel robbed of dignity? Betrayed? Relieved? Or will they be none of these things?

A lot of folks are completely okay with nursing home placement. Others not so much. And a lot of times the patient doesn't seem to fully grasp what is happening one way or the other.

But I think about them, too.

I guess what I'm saying is that there are so many people who are in, what I believe, is this limbo space. The one where they can live independently just fine if somebody just sees about them regularly. Checks to make sure area rugs aren't heaped up and creating a fall risk or taking a box off of the porch. Runs to the store for them or throws a few old things out from the fridge. Resets whatever got unset when the electricity blinked and puts new batteries in the remote controls. And who asks about the pills and, if they can, does things like arrange them in daily pill containers and throws out the ones that the doctor either discontinued or changed.

And if that person or those people exist, I try to find them. And talk to them. Before jumping to nursing home placement or moving them out of their home to live with someone else. I talk to our pharmacists and social workers and nurses, too. We explore who their support is, like, if they have a church home or some other people out there who really care but who just didn't know. And who would help with something like reconciling medications or pulling the garbage cans to the curb and back if someone asked. Or just slowed them down long enough to think about it.

Moving too fast to notice doesn't mean folks don't care. I mean, not always it doesn't. In fact, many times it doesn't.

Sigh. I'm rambling. I know.

Look. I pray to grow old in this life. There is much that I want to do and see and experience and I think having the wisdom of an elder will make some of those things just that much more awesome. It is my wish to keep my wits about me and my ability to do things on my own indefinitely. But what I know for sure is that, over time, that latter part can hover somewhere between very possible and impossible. I guess what I'm saying is that when that time comes, I hope someone steps in see about me and advocate for me, too.

Oh, and before someone misunderstands this as me being anti-nursing home, please recognize that nothing could be further from the truth. My point is that function is a spectrum. I'm learning to consider that more. Sometimes there are reasonable work arounds. And sometimes there aren't.

Yeah. Sometimes there just aren't.

But this time? There were some things that we could do. And so we did them. We did.

Yeah.

And shout out to the social workers, the family members, the neighbors and the community people out there who see about our elders. You make a difference. You do.

Now playing on my mental iPod …

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

How doctors can handle online trolls


 How do you deal with trolls on the web?

Whenever you’re online you’re going to have people who disagree with you, and they can do so in ugly and inflammatory ways. These people are known as trolls.

I’m going to borrow from marketing legend Guy Kawasaki. He suggests going 3 rounds. Let’s say you write a post and someone responds. That’s round 1. Then you answer back. That’s round 2. A person replies in kind. That’s round 3. If the conversation isn’t productive by this time, I would just end it and move on to a more productive use of your time.

Dealing with trolls, unfortunately, is a reality especially in the areas of medicine and health care. I’ve dealt with many on my own site as well. Going 3 rounds has certainly helped me move on.

Kevin Pho, MD, ACP Member is co-author of Establishing, Managing, and Protecting Your Online Reputation: A Social Media Guide for Physicians and Medical Practices. He is founder and editor of KevinMD.com, where this post originally appeared.
Tuesday, July 21, 2015

Taking a proper history and physical

The history and physical (H&P) is the cornerstone of initial patient care. For those of you who are non-medical reading this, it simply means the interview and examination that occurs the first time the doctor sees their patient.

I was trained in the United Kingdom—Cardiff Medical School—to give due credit to a great institution that was big on teaching the importance of taking a complete history and performing a thorough physical examination. I'd be lying if I said my skills hadn't been diluted a bit over the years, but I always try to stick to a broad template of how to go about performing an H&P on all my patients.

At the end of my final year of residency in Baltimore, the nominated teacher of the year was our Intensive Care Unit Director, who was a quite brilliant physician. Hopkins-trained and perhaps regarded as a bit “old school”, he was my personal role model and mentor. He gave a speech at our graduation ceremony in which he said something that has always stuck with me. Offering advice on how to be a good physician, he simply said; “Do it the same way every time for all your patients.” This means you should have a systematic approach and never cut corners. I feel his words are more important today than ever, especially as the current healthcare information technology templates unfortunately now threaten to reduce the famed H&P to a pile of gabble—meaningless and incomprehensible in many ways.

So having said that, I'm going to list below the broad template of how to do a history & physical. All of this can also be found in any standard medical textbook, it's nothing new. No cut corners, don't change the order of this—as none of my Professors would allow me to:

history
1. chief complaint
2. history of presenting illness
3. review of systems
4. past medical history
5. past surgical history
6. medications
7. allergies
8. family history
9. social history

Physical
1. vital signs
2. head, ears, eyes, nose, throat (HEENT), neck
3. cardiovascular
4. respiratory
5. abdominal
6. peripheral
7. neurological (this may come earlier if the main presenting complaint is neurological)
8. other e.g. skin, lymph nodes, joints

I would emphasize particularly to medical students, stick with the above order of things and you will seldom go wrong. Being a professional in any field means that you often have to follow set protocols and adhere to high standards. It's important as you progress in your career to keep holding yourselves to these. After all, being stringent with how you go through systematic processes will not only make you a good doctor, but also ultimately be best for your 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, July 20, 2015

Big, fat transgression

Trans fat is going, if not yet gone, and good riddance to it. The word on the street is that the FDA is acting to “ban“ partially hydrogenated oils from the food supply. The slightly more banal reality is that the agency is finalizing an action, begun two years ago, to formalize the position that trans fat is no longer “generally recognized as safe.” Whereas a ban would be an active prohibition, this is a more passive removal of blanket allowance. Companies might, in fact, still be able to make select use of these oils, but would now have to petition for FDA permission to do so.

But even if the FDA action is more about not saying yes than it is about saying no, it will do. Tans fat will go, altogether or nearly so. The action is welcome.

I have been asked if it will matter much, and the honest answer is no. While the agency has clearly done the right thing, and it is important in principle, the effect in practice is much reduced by progress at the notorious speed of government. The Center for Science in the Public Interest has been making noise about the harms of trans fat since 1993 at least. My friend Dr. Walter Willett has been a leader in the campaign against use of this inadvertent Frankenfat based on data from his own research since at least 1997.

Even my own efforts began nearly a decade and a half ago. We have been advising children, and their parents, to look out for and avoid “partially hydrogenated oil” in any ingredient list since the very earliest version of our Nutrition Detectives program. We have warned as well that “0 grams trans fat” on the front of pack was unreliable, since federal rules allowed for the dubious combination of small portion size, and rounding down. The NuVal system, too, was designed from the start to penalize that hidden trans fat, since zero has not reliably meant zero.

The result of such efforts, and innumerable others like them, has been a decisive verdict in the court of public opinion. Concerned parents have long since cast votes against trans fats at the nation's cash registers. Attentive manufacturers, ever eager to keep the customer satisfied, have removed this toxin from more and more products.

The reason the FDA action will make a modest rather than a great difference is not because it is unimportant, but rather because it is late in the game.

As for the good that will result from the end of the trans fat era, there are reasons for caution even amidst the cheers.

For one, we have, for literal decades, fixed our eyes and our ire on one nutrient at a time, and missed the forest for the trees. What matters to health is the overall composition of foods, and the contribution they in turn make to the overall composition of the diet. The presence, or absence, of any given nutrient does not reliably indicate overall food, or diet quality. We have gotten this wrong before, in a dysfunctional collusion between demand and supply, and could conceivably get it wrong again. Let's be careful, see the big picture, and navigate around any replication of the costly follies of nutritional history.

For another, in a world of commerce, one supplier's loss is another's potential gain. While it's clear that trans fat is far worse for our health than the so-called “tropical oils” it displaced in its heyday, it is far less clear that those oils are the panacea their ardent proponents (and sellers) contend. The saturated fat in coconut oil is predominantly lauric acid, a short (12-carbon) fatty acid that accumulating evidence suggests may be innocuous. But that evidence is not yet decisive, and importantly, “innocuous” is as good as it gets. I have seen no evidence to suggest health benefits, just lack of harm. Those are not the same, however exuberant the marketing claims.

For yet another, we have surrendered the luxury of thinking about our foods and ingredients independently of their environmental impacts. Historically, the tropical oils to which the food industry will likely return to replace trans fat have come from orchards planted where tropical rain forests once stood. Much as I want to avoid trans fat, I don't want its replacement in my food to be the reason why the world's last orangutan can't find a tree to climb.

The propagation of trans fat through the modern food supply was, without doubt, a big, fat nutritional transgression. The FDA announcing the beginning of the end of that boondoggle is most welcome.

But the action is perhaps too late to matter much, since the government is only catching up with changes in both the demand, and supply of food. More importantly, the action is too little to confer reliable benefit. We could, if so inclined, eat trans-fat free junk food, just as we have managed to eat low-fat, low-carb, sugar-free, and now gluten-free junk food, and get fatter and sicker all the while.

The best approach to avoiding trans fat is the same as it ever was, and requires no action by the FDA; it is to choose wholesome foods in sensible combinations. Foods direct from nature, and minimally processed foods were never delivery vehicles for trans fat in the first place. Get the foods right, with a particular emphasis on the usual suspects, vegetables, fruits, whole grains, nuts, seeds, beans, lentils, and the nutrients generally take care of themselves, and us.

In other words, the best diet for our health depends, as it ever has, not on replacing trans fat with any one oil from any one nut up any one tree; but on seeing the forest. That same view is the best hope we have for not just avoiding trans fat, but actually eating well; and while we're at it, of preserving those trees for orangutans to climb; and for sustaining the forests that are the purifying lungs of the world. We don't need FDA authorization to start shopping accordingly today.

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, July 17, 2015

Do Nexium and other heartburn medicines cause osteoporosis?

Every week, I am asked by patients if their heartburn medicine causes osteoporosis. The most effective heartburn medicines are called proton pump inhibitors, or PPIs. If you watch more than an hour of TV per week, then you have seen ads for some of them. Nexium, Prilosec and Protonix are 3 examples of these medicines.

Many of them are now available over-the-counter at reduced dosages.

Patients today are incredibly informed, and sometimes misinformed, about their medical conditions and their treatments. Most of their information is from the internet, and it's easy for patients to become unwittingly trapped in the world wide web.

The information dangling in cyberspace is entirely unregulated. Information can be made to appear authoritative and objective when it actually is a paid advertisement. Many blogs may appear to function to inform the public, when their true purpose is to serve the corporation that sponsors it. If you are learning about probiotics, for example, consider the credibility of the site if you are encouraged to purchase certain products. Caveat emptor.

I personally do not believe that Nexium can break bones, although I have read the same articles in the lay press that arouse my patients' concerns. I understand that a headline such as, Nexium Linked to Hip Fractures, will make my Nexium users so nervous that they might get wobbly and slip and chip a hip.

However, there is no convincing medical evidence that an individual user of Nexium or similar medicines has any significant risk of sustaining a fracture. The belief that they can cause or accelerate osteoporosis is derived from large, pooled medical studies that are not truly capable of concluding cause and effect, a critical point often omitted from your hometown gazettes.

However, no patient should be on Nexium, or any medication, unless certain requirements have been satisfied. Here's what runs through my mind when I am recommending a medication for a patient:
• The drug is absolutely necessary.
• I am prescribing the lowest dose of the drug necessary for the medical task.
• There is no safer alternative medication or other treatment available.

Of course, cost may be an issue depending upon the patient's insurance coverage. However, the patient's financial status should not taint the physician's recommendations. The patient, however, can indicate that the doctor's first choice is not possible, and he may choose a more affordable, but less effective option.

If you want a second opinion on any of this, try the internet. That's where I go when I need reliable medical information.

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.

Removing C. difficile spores from hands

It is well known that hand washing, particularly with soap and water, is critical for preventing the transmission of Clostridium difficile in hospitals. Evidence suggests that the mechanical friction of hand washing is the mechanism behind spore removal. However, is there a way to improve the friction when practicing hand hygiene?

To answer this question, investigators at the University of California, San Francisco reported results of a study that compared C. difficile spore removal after washing with 5 different methods including: (1) negative handwashing control: 30 seconds of rubbing with 5 mL of water and 30 seconds of tap water rinsing; (2) 30 seconds of rubbing with 5 mL of 0.3% triclosan soap and 30 seconds of rinsing; (3) 30 seconds of rubbing with a paste consisting of 15 mL of sand mixed with 15 mL of tap water and 30 seconds of rinsing; (4) 15 seconds of rubbing with 5 mL of a 50% baking soda–50% vegetable oil mix and 15 seconds of rubbing with 5 mL of liquid dish detergent followed by 30 seconds of rinsing; and (5) 60 seconds of rinsing.

Lo and behold, washing with sand and water was superior to both the water rub/rinse (0.36-log reduction in spores) and tricolosan soap (0.50-log reduction).

The authors claim that the sand/water method was well tolerated after a single use, although it's hard to imagine that repeated use would be well tolerated. Still, this study raises many interesting questions. For example, what if we used Lava soap containing pumice, or Brillo pads or what if we placed our hands in a rock polishing machine after seeing patients? All kidding aside, you could imagine high-density soaps that have increased friction without the nasty abrasion. In the meantime, I'm going to keep rubbing my hands on my corduroys.

Reference: D. Isaacson et al. AJIC, May 2015.

Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands). This post originally appeared at the blog Controversies in Hospital Infection Prevention.
Thursday, July 16, 2015

Lessons learned by studying sore throats for 35 years

Thirty-five years ago I started collecting data in a non-acute emergency room. Over approximately 3 months the residents enrolled slightly more than 300 patients into the initial sore throat study. Spending the next 3 months learning how to analyze the data, I began a long journey that continues today.

Learning medicine rarely includes having epiphanies. Learning medicine requires patients and reading. But we who teach medicine can help our learners speed that process if we help them focus on some key features.

My colleagues and I often cite Judy Bowen's classic article: Bowen, Judith L. “Educational strategies to promote clinical diagnostic reasoning.” New England Journal of Medicine 355.21 (2006): 2217-2225. In that article she introduced many to the concepts of problem representation and illness scripts.

Lesson #1 We need to be precise in defining illness scripts. Problem representations depend upon illness scripts as these 2concepts interact. Back in 1980 when this journey started, I thought of a sore throat rather simply. Today I understand that there are a series of potential sore throat illness scripts.

Script #1 Acute sore throat 3 days or less in duration with or without various other symptoms (cough, coyrza, fever and difficulty swallowing) and various examination features (exudates, adenopathy, measured temperature, erythema, tonsillar swelling). The discomfort should be in the throat, not the external neck.

Script #2 Non-resolving sore throat that starts as an acute sore throat, but worsens rather than improves. It may include asymmetry of the neck, unilateral tonsillar swelling, deviated uvula, persistent fever, rigors and/or night sweats.

Script #3 Neck pain but no actual throat pain. This usually is recognized as different from the other 2 scripts. Script #1 and #2 have very different implications. However, few clinical educators have taught that difference, and probably few have considered sore throats enough to distinguish between scripts #1 and #2, yet the underlying differential diagnoses are quite different.

The problem is actually more complex, because over the years it became quite clear that pre-adolescent pharyngitis differed greatly from adolescent/young adult pharyngitis (Mitchell, Michael S., Annalise Sorrentino, and Robert M. Centor. “Adolescent Pharyngitis A Review of Bacterial Causes.” Clinical pediatrics 50.12 (2011): 1091-1095.) While the general scripts are the same, the potential etiologies differ. Adolescents/young adults have a much broader infectious differential diagnostic spectrum and that differential has major implications.

We should apply the general concepts here to teaching clinical medicine. For example, consider your illness script for community acquired pneumonia. How long should the patient have symptoms and at what point does the history no longer fit CAP? How do classify patients who do not improve with adequate antibiotic coverage? Do we think differently about atypical infections from classic bacterial pneumonia? And you can ask some further questions.

Take chest pain, how many illness scripts could you develop for chest pain? How does one proceed to match these illness scripts against a careful patient problem representation? The illness scripts should influence the data you collect.

We must define data carefully. A wonderful question asked in Japan helped me understand that many listeners had a different understanding of the term data. In medicine I consider 4 classes of data: the history, the appropriate physical examination, laboratory tests with accurate interpretation, appropriate imaging studies.

Each illness script should include at least the first 2 data classes, but often we should add the third and fourth. And the illness script influences how we describe the patient, and what data from classes 3 and 4 we need. But the illness scripts also influence our history and physical data acquisition.

Lesson #2 We must appropriately keep an open mind as we learn new concepts that might apply to the clinical problem. I learned this slowly over the last 13 years as the Fusobacterium necrophorum story started to crystallize. Again I did not have an epiphany, but rather I developed a profound curiosity about this bacteria and its potential role in explaining some adolescent and young adult pharyngitis.

This concept seems simple, but actually we resist changing our understanding of disease. Two great examples come to mind – Helicobacter pylori causing ulcer disease and beta-blockers treating systolic heart failure. We resisted these changes even as the evidence supporting the changes were becoming very clear.

Lesson #3 Demographics can matter. In pharyngitis, I have already written about the differences between pre-adolescents and adolescents & young adults. Some illness scripts differ by gender, or socioeconomic status, or country of origin. We should not ignore these factors.

Lesson #4 Every medical problem is complex. Many physicians and patients consider sore throats as a simple medical condition. But our sore throat illness script should include some red flags. Duration of symptoms is a red flag. Sweats or rigors is a red flag. An asymmetric bulge in the neck is a red flag. Every medical problem has red flags and we must do a better job of teaching those indicators of seriousness.

As educators we have a responsibility to understand clinical problems in a different way and to teach clinical medicine in the way expert clinicians think. I suspect that some readers can identify a few clinical educators who approach clinical teaching in such a manner, but that most educators do not have this understanding. Am I right or wrong?

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.

Crowdsourcing CPR

I have written previously about the potential impact of mobile apps and ubiquitous computing on health and healthcare delivery, but I admit I did not see this one coming. The current issue of The New England Journal of Medicine has a report from a research group in Sweden that developed a system and tested it in a randomized controlled trial to use smartphones to alert CPR-trained bystanders when there was a nearby cardiac arrest.

In the trial they describe, the standard EMS response was always activated, but the text to bystander was randomly activated only half the time.

The primary outcome of the study was the frequency with which bystander CPR was initiated, and it was too small to demonstrate that the differences in bystander CPR rates improved survival or other outcomes. Other studies (including one in the same issue of NEJM) have shown that increased rates of bystander CPR improve survival, so the improvement in bystander recruitment demonstrated here is both statistically and likely clinically significant.

An editorial that accompanied the article pointed out the challenges of replicating this kind of system in the U.S., including our more fragmented mobile phone infrastructure and EMS systems and our more litigious environment (so what else is new).

Despite that, I found a few things about this pretty interesting. First, I was surprised at how frequently bystander CPR was done in the control group (48% of the time). That is higher than in the US, where averages about 40% of the out-of-hospital cardiac arrest. Second, it triggered a bit of a “why didn't I think of that” response, since there was no new technology used, just a clever repurposing of what we all have in our pockets already. Finally, it gave me a feeling of “You ain't seen nothing yet” since we are sure to see the ongoing application of common technology in uncommon ways.

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.
Wednesday, July 15, 2015

Peace and permission

My paternal grandmother, my Mudear, was out on the West Coast visiting family for the holidays when it all started. She had these abdominal pains and a few other symptoms that eventually nudged her children to take her to a doctor. One hospitalization and a few scans later, they'd found an answer for it.

Cancer.

They offered her treatments, which included chemotherapeutic agents and the like. The particular kind of malignancy that my Mudear had was one that could only lead to meaningful recovery via two ways: a miracle (which can happen sometimes) or a major abdominal surgery. Mudear was in her ninth decade and had already lived through her share of health scares. “Getting cut on” wasn't an option.

Nope.

And so. The doctors offered her palliative chemotherapy which, in my opinion, probably isn't terribly unreasonable for any patient to consider. But sometimes an offer sounds like an endorsement. Patients may not realize that they have a choice and that saying “No, thank you,” in some circumstances is perfectly sane to do.

Yeah.

So somewhere in all of this, my Mudear had my auntie and dad call me in Atlanta. I'd just become an attending physician at Grady that year and I had the distinction of being the only human doctor in the family. And so. Mostly I asked my grandmother about her wishes. I asked her what things she loved doing and got an idea of her general philosophy on the time of her death.

“I don't want nobody cutting on me. Nawwww. I don't want that at all,” she said in her Alabaman accent.

“Okay. Mudear, you don't have to have surgery. But you also don't have to have chemo. You could just go home to Birmingham and spend the rest of your days doing the things that make you happiest.”

“That sound good.”

“What do you like doing, Mudear?”

And that's when she told me that, given her way, she'd just like to sit in her chair and watch her “stories,” cook a little something in her kitchen, visit with folks on her porch and maybe do a little something in her garden. And all of that sounded wonderful to me and exactly like what my grandmother should go to do.

And so she did.

My daddy got her out of Los Angeles before I could even hang the phone up good. And let me be clear, my Mudear was a smart and elegant woman. She'd made up her mind long before I spoke to her and this was her decision. But I will always appreciate her giving me the honor of weighing in as counsel.

Anyways. By the time Mudear got to Alabama, she was still fine actually. There was no immediate awful that punctuated it all. She wasn't stuporous or on all fours. Nope. Mostly, she was fine. Fine enough to sit in her chair and watch her stories, cook a little something in her kitchen and visit with folks. It was actually January when all of this happened so the garden part and the sitting out on the porch part I can't fully recall happening. But the point is that she decided to forgo the hellacious cancer treatments suggested for her 89-year-old body for the things that gave her the most peace.

Yep.

Family came pouring in. And since she had 11 kids and more than 25 grand babies, that was a lot of kinfolk. And mostly, it was the ones who were closest to her. One of those grandkids was my sister, Deanna.

Deanna had gone to law school in Birmingham. She grew close to Mudear during that time and, at this point, was up in D.C. working for the U.S. Patent and Trademark Office. She called me in her Deanna way and asked me to “break this shit down” to her. She wanted to know what she needed to expect out of this cancer news with her grandmama.

“You need to book a flight or get in your car and drive to Birmingham—right away,” I told her matter-of-factly. And this part I do remember perhaps better than any other part.

“When? Now?” Her voice sounded incredulous. “I thought she was doing okay. That's what daddy and them said.”

“Mudear is about to be 90, Deanna. She is at her home and all of her kids are coming to see her. She's at the house she shared with the love of her life doing everything that makes her happy. She is doing well but I've learned that once folks get to a certain point of peace of mind, they will themselves away long before the health part catches up.”

“Wait. You think Mudear is going to die really, really soon?”

“I think she sounds peaceful. And I think if she has permission from the family, she will make her transition soon. So yes. I think that.”

“Damn.”

“Are you coming?”

“Leaving in a few hours.”

Which is exactly what Deanna did. She got down there and saw her Mudear. She sure did. She stroked her face and laughed and cried and talked to her. She hugged on my daddy and our aunties and our uncles and cousins, too. And, from what she told me, all of it was magical. It was.

The last person to talk to my grandmother was my father. She'd called all of her living kids in 1 by 1 to speak with them and he was last. And my stoic, pragmatic daddy was dutiful and diligent in all of those logistical things that you don't want to think about at times like this. But she also knew that that same spirit of his would permit her to let go.

“I'm counting on you to make sure everything works right,” she told him. “I'm tired. And I think I'm ready to go now.” And he knew that this wasn't just about her funeral or anything like that. She meant everything. The family. The harmony. The everything.

“Mudear,” daddy told her. “You've lived a good life. It's okay.”

And you know what? Mudear looked at her son, took 3 big breaths and closed her eyes. And that was that.

I just want to be sure that one piece isn't lost here. Mudear wasn't gasping for final breaths or in and out of consciousness. In fact, if someone had just gone by the medical data points available to them, nothing about her condition suggested she'd pass away on that day. But once you live long enough or work in a hospital like Grady long enough, nothing about her transition would come as a shock.

Nope.

When I was an intern, I had this amazing patient who had a non-healing ulcer on his foot and 2 gangrenous toes. After a significant number of pack-years of smoking, his circulation was pretty much nonexistent. That same tobacco history had left him with advanced emphysema and COPD. The only way to help him would be to amputate his foot above the knee. But there were two problems with that:
1. His circulation was so poor that an amputation would be unlikely to heal.
2. No anesthesiologist would be willing to intubate him for the surgery given his bad lung disease.

And so. Mr. Farrell, my patient (name changed), was essentially left with a dead limb attached to his body. And that? That isn't compatible with life.

Nope.

Mr. Farrell had this little Jack Russell terrier that he absolutely adored that was home during his hospitalization. Though his grandson was caring for him, he worried about his pup incessantly. And mostly, I just listened because there wasn't really much I could do about it.

After several days of wound care, pain control and futile antibiotics, my attending—1 of the most senior physicians in that hospital—decided to refocus our goals of care. He sat the team down and laid out his game plan. And then, in true big boss fashion, he left the ward.

My marching orders were pretty simple: He told me to call as many of Mr. Farrell's family members as I could, urging them to come in and see him—today. I admit that I was confused by the urgency because, much like Mudear, he hadn't taken some acute turn for the worse. But I did as told and made those calls.

Family trickled in and out all day. They hugged Mr. Farrell's neck and laughed and spent time with him. Daughters, sons, nieces, nephews. Neighbors, old coworkers, bowling team mates. Grandkids and the kids of those grandkids, too. All had gotten the word that it was time to come see him and all, like me, shocked on arrival to find him looking so great.

Finally, around 4 p.m. or so, my attending physician reappeared on the ward. He was a tall man with great presence, so any time he came into any space, it was noticeable. But this time, it was even more unforgettable. While we made those phone calls to family, he was upstairs flexing his big boss muscle to do something rather unusual.

Yup.

Suddenly, there was the skitter of puppy claws on the slick hospital linoleum and tiny yips interrupting the ambient hospital sounds. Yes. A dog was on the ward. My big boss attending had gotten the green light for Mr. Farrell's grandson to bring his dog in to see him. His dog, y’all!

Maaaan. That sweet little Jack Russell terrier nearly exploded with excitement the moment he heard Mr. Farrell's voice. Oh how happy that man was! He stroked that dog's back and nuzzled his face into his fur. And his grandson promised him that he would care for that dog as long as Mr. Farrell needed and Mr. Farrell wept when he said that because he knew it was true.

Yup.

My attending pulled me aside and told me to not to be too surprised if Mr. Farrell passed away that night. And again, I thought he was sort of overreacting but since he was such a big boss, I nodded and went along with it.

“Peace is a mighty thing. That and permission,” he said.

“Permission?”

“Yes. Some people just need permission to die. They need to know that it's okay for them to go.”

And that? That made sense to me. It did.

The following morning, I went straight to Mr. Farrell's room. The bed was empty and the sheets were off of the bed. I scurried to find his nurse who quickly notified me of what had happened.

“He went on to glory early this morning. Sure did.” And she said that with a warm, knowing smile.

Sure did.

I think of those pivotal moments so often. The one with Mudear and the one with Mr. Farrell. Now when patients are facing some irreversible illness that has brought them near the end of life—or for those blessed near-centurions who've simply stopped thriving—along with the management of symptoms and pain, I focus on those two things as a part of my treatment plan: Peace and permission.

Yep.

Last week, I told the family of one of my patients about my Mudear and her final days. They'd asked me what else I thought they should do for their loved one who was very advanced in age and now on the way to hospice care.

“Give her your permission,” I said. “Let her know that you'll be okay and that it's okay for her to go on home.” And that is exactly what they did. She was gone less than 48 hours later.

Yep.

I guess I'm writing about this because it isn't really scientific, you know? But damn is it important. Sick people nearing the end of their days need those things more than we realize. Peace and permission, man. It was important to my Mudear to know that things would work right. And my daddy promising her that they would helped her to have peace. That and seeing those loving faces of all of those special people and being in her home. And Mr. Farrell? Well, my attending was wise enough to recognize that getting that Jack Russell terrier into the hospital was the very best thing that he could do. And wisdom for doctors? It's one of the most important yet impossible-to-find-in-a-book things there is.

You know? I think lack of peace and angst are often mistaken for vitality. Holding out for peace and permission can translate into will to live. And now I know that, even when the monitors aren't wailing impending doom nor are the vital signs circling the drain, just handling those two items--peace and permission--cuts the O2 off on the will part. But in the very best and most beautiful way.

Yeah.

I'm glad for the lessons I received in death with dignity from Mr. Farrell and my Mudear. They've given me a new way to advocate and a different way to fight. So now? I'm thinking. Constantly, constantly thinking. And trying to find whatever it is that will get my patient closer to having peace and permission. Then fighting like hell to help them achieve both.

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

Best treatment for chronic insomnia is cognitive behavioral therapy

I'm having trouble trying to sleep
I'm counting sheep but running out
As time ticks by …
And still I try …
—”Brain Stew” by Green Day from the album Insomniac

Sleep that knits up the raveled sleave of care,
The death of each day's life, sore labor's bath,
Balm of hurt minds, great nature's second course,
Chief nourisher in life's feast.
—Shakespeare, Macbeth

Chronic insomnia affects 5% to 15% of Americans. It is far from only a nighttime problem. As all of us know from occasional sleepless nights, the following day is unproductive and sometimes dangerous. Sleep deprived people are more prone to accidents, and are more likely to have depression, anxiety, diabetes and high blood pressure.

It is no surprise then that many patients seek relief from sleep medications. But most medications are only modestly effective. Many medications also slowly decline in efficacy over time, and some have worrisome side-effects.

Cognitive behavioral therapy (CBT) has been known to be effective for chronic insomnia for some time. CBT is a specific kind of psychotherapy that focuses on thinking and on behavior. It is unlike older kinds of psychotherapy (like psychoanalysis) in that it's much more brief and pragmatic. It has been proven to be effective in many anxiety disorders, and unlike medications, the benefits of CBT have been shown to persist long after the therapy ends. (Four years ago I wrote about the utility of CBT in chronic fatigue syndrome.) CBT for insomnia (CBT-i) usually involves weekly hour-long meetings with a psychologist. The course of therapy can be as brief as 4 to 8 sessions.

Annals of Internal Medicine published a review of prior studies of CBT-i. The study reviewed 20 randomized controlled trials involving over 1,000 participants. CBT-i significantly improved sleep and did not have adverse outcomes. On average, subjects who underwent CBT-i fell asleep 20 minutes faster and spent 30 fewer minutes awake during the night compared with people who didn't undergo CBT-i. This may not seem like a large benefit, but it is the same magnitude as the benefits seen in trials of sleep medications, and without the side-effects that medications can cause. Like other studies of CBT, this review showed that the benefits of CBT-i persist after the therapy ends. This is another positive comparison with medication. At best, the benefits of sleep medication end as soon as the patient stops taking it. At worst, stopping the medication leads to rebound insomnia making the symptoms worse than before the medication was started.

Much of CBT-i focuses on teaching good sleep hygiene–behaviors that promote healthy sleep. These behaviors include avoiding caffeine in the afternoon, avoiding alcohol at bedtime, and not staying in bed for longer than 20 minutes if you can't fall asleep. That last bit of advice may seem counterintuitive, but going to another room until you're feeling sleepy will train you to associate your bed with sleep. For the same reason you should avoid reading, watching TV, or using electronic screens in bed.

A related editorial in Annals of Internal Medicine makes the point that changes in attitude and behavior are necessary to treat other health problems like high blood pressure, obesity, and diabetes. Drug therapy alone is not adequate for these chronic problems. We should not be surprised then that this is also true for chronic insomnia.

So doctors should do a better job of referring patients with chronic insomnia to CBT-i. And patients should realize that there is a safer and more effective option than medication. Of course finding a psychologist who has been trained in CBT isn't always easy, especially outside of large cities. There is also an online CBT-i program for those who can't find or can't afford in-person therapy.

We've known for a long time that chronic sleeplessness is a serious problem. But it turns out that before we can fall asleep we first have to knit up the raveled sleeve of care and balm our hurt minds. As of now, the best way we know to do that is CBT-i.

Learn more:
The Evidence Points to a Better Way to Fight Insomnia (NY Times)
To Beat Insomnia, Try Therapy For The Underlying Cause Instead Of Pills (Shots, NPR's health blog)
Cognitive behavioral therapy offers a drug-free method for managing insomnia (Harvard Health Blog)
Sleep Hygiene (National Sleep Foundation)
SHUTi (an online CBT-i program)
Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis (Annals of Internal Medicine article, abstract available without subscription)
Cognitive Behavioral Therapy for Chronic Insomnia: State of the Science Versus Current Clinical Practices (Annals of Internal Medicine editorial, subscription required)

Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.
Tuesday, July 14, 2015

A high-tech call schedule

Typical of many physicians, I have to take turns being on call. This mostly involves taking calls in the evening, at night, and on weekends for my patients, or those in my call group. I belong in a group with 6 other internal medicine doctors. We no longer have to go to the hospital to admit patients, since that is now done by dedicated hospitalists, but may answer calls about patients in our practice that show up in the emergency room, or are in a nursing home and having issues, or have significantly abnormal laboratory results that come back after hours.

My group takes call a week at a time, and the schedule is made each December for the following year. Each person in the call group submits a list of days they do not want to be on call, and the person making the schedule does their best to accommodate everyone. If someone needed to make subsequent changes, they would need to check the schedule and try and find someone to switch, or others would take their call in the event of a personal or family emergency. The call schedule was 12 pages of a printed calendar with the call person written for each day.

Last year the person making our schedules retired and I took over the duty, with the agreement that the schedule would be computer based. I created a Google Calendar, for the call schedule. I assigned each person their own color and created the schedule, after working it out on paper first to make sure I accommodated preferences, made the schedule as fair as possible in terms of amount of call and holiday coverage, and trying to spread out call.

I sent out invitations through Google Calendar. Now everyone in the call group can see their schedule on their computer. They can also use an app on their phone, as shown below. If changes need to be made to the schedule they notify me or our office administrator to make changes to the calendar. Everyone in the group then automatically gets the updated version if they check their calendar.

GINSBERG2

Recently I added a new twist. Having purchased the Amazon Echo, I added my Google Calendar to the app. Now I can ask Alexa what's on my schedule, and she will read who is on call!

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

The discharge paperwork makeover

It could be the title of a new primetime show (maybe it should be): The Great Discharge Paperwork Makeover. Assemble a group of bright and creative minds from across the country and put them together in an exotic location for a week to talk about something that will affect all of us one day—either ourselves or a relative. Task: Take the average tatty piece of paper that is given to patients when they leave the hospital and make it into something worthy of the great profession of medicine.

A bit of history first. Before electronic medical records became universally adopted, patients used to get a handwritten piece of paper when they left the hospital, usually within a set template. This was frequently illegible and far from optimal. Since the introduction of computerized discharge papers, sadly things have hardly got better. In most hospitals, patients receive printed pieces of paper in a dull typeface, often indecipherable using technical terms, with additional random information scattered across it.

The real-world implications of this are tangible at the coalface of medicine. Recently, I had just discharged a patient and was told by the nurse that the family was confused with the instructions that they had been given. I went to talk to the patient and the family, and when I saw the print out that was generated by the computer, I was quite shocked myself. The daughter, highly intelligent, then went on to describe in great detail what she thought was wrong with the paperwork—ranging from difficulty understanding the medications listed, to confusion about where to find the important information regarding follow-up. The type was also way too small for an older person to read. She described the paperwork looking as if the hospital “was careless”. By the end of her time talking, I was honestly left agreeing 110% with what she was concerned about, and couldn't help but to apologize for the state of the standard paperwork we use. In fact, I already knew many of the things she was worried about—I've seen the same problem in lots of different hospitals up and down the east coast.

But back to The Great Discharge Paperwork Makeover. The contestants should be a mixture of the sensible and creative. Clinicians, IT professionals, administrators, patient advocates and designers. They have one week to make a gold-standard template discharge paperwork that is eye-catching, logical, intuitive and makes it easy for anyone to read. It should be colored, have bigger writing, and plenty of space for all the important clinical information—especially the follow-up instructions. The prize for doing this: a big thank-you and blessings from the millions of discharged patients every year.

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, July 13, 2015

The irrational rationing of health care

As I detailed in my prior column, Manny Alvarez is a 23-year-old college student with the misfortune of having not just a devastating cancer, but the wrong devastating cancer. The chemotherapeutic agents shown to be highly active against his specific tumor cells are FDA approved for the treatment of leukemia, but not for the stunningly rare kind of sarcoma with which Manny has been diagnosed. Nothing is FDA approved, or standard care, for the stunningly-rare cancer with which Manny has been diagnosed.

That potentially effective drugs have been identified at all is thanks to Manny's exemplary oncologist, Dr. Breelyn Wilky at the University of Miami Health Center. Dr. Wilky sent specimens from Manny's tumor, resected from his leg and requiring partial reconstruction of his femur and knee, to be tested in a lab against some 200 potential medications. Dr. Wilky did this because Manny had no other options; as noted, there is no established treatment for his cancer, and the drug he had received in a clinical trial at the NIH was entirely ineffective. Dr. Wilky is the kind of doctor we all hope to have in a really tough situation; the kind that doesn't stop until she finds a way to help.

She found a way. The particular leukemia drugs she tested were completely effective against Manny's tumor in the lab, killing off all the rogue cells. That does not guarantee the same results in the complex system of Manny's body, but it is more than a sound basis to justify their use.

Unfortunately, Manny's insurance company, Blue Cross Blue Shield of Florida, has chosen to see it differently. The drugs in question are very expensive, with costs of treatment running to some $300,000. Since they are not established as standard therapy for Manny's particular cancer, the insurer has declined to cover those costs.

Does that make Blue Cross Blue Shield of Florida the bad guy in this scenario? Both yes, and no.

Yes, because it's perfectly clear what needs to happen here. No family, no doctor, no decent person could sanction denying potentially life-saving treatment to this 23-year-old who should have his whole life ahead of him. There is reason to believe effective treatment has been identified; there is a moral obligation to administer it. That in turn means the bill needs to be paid, if not by the insurer, then by the family. If there are actual human beings at the insurance company under the veneer of dispassionate bureaucracy, they must be aware of that. They must know that they have, in effect, said to the family: deal with your son's devastating cancer, and at the same time, find a way to raise $300,000 and/or go bankrupt. Whether or not that makes them the “bad guy,” I think we can agree it's a long way from customary “good guy” behavior.

But there is a defense of BCBS of Florida in that the problem is bigger than them. They clearly can't cover every therapy requested in a desperate situation, many of which might be misguided and futile. In the absence of a national standard and clear criteria for differentiating valid from invalid requests, their fallback position is the same as every other insurer: cite chapter and verse of the company rule book.

But I don't think that satisfies. We should have, and could certainly establish, a national standard for denying insurers the right to deny coverage of care. Manny's case would certainly satisfy any reasonable criteria. For instance, we might say that insurers are obligated to cover non-standard treatment if, and only if:
1) there is no standard treatment being overlooked or untried;
2) there is a desperate need for treatment, as affirmed by a qualified physician;
3) there is a specific treatment being recommended by a qualified physician; and
4) there is evidence to support the potential efficacy of the treatment.

If the bar is set anywhere in this neighborhood, Manny's case clears it readily.

When I expressed some of these same sentiments previously in my columns, one of the many, mostly very supportive comments received included this: “The insurance company is not a bottomless well and chooses to help as many people as they can with the highest probable success outcome. If they cover three kidney transplants instead of this one case, saving three lives, but not helping one, is that the right call?”

This argument could have validity if any such either/or decisions were actually made. But with the exception of an abandoned health care rationing experiment in Oregon, they are not. If a treatment is considered standard, it is covered, no matter how many other lives might be saved with a reallocation of those same resources. Consider, for instance, how much of the total health care expenditure in our country is directed to the end of life. Much of this care is for what we might call “heroic” measures, but misguided might be a better word. The recipients are often very old, and extremely sick, with little to no prospect of getting back to a decent quality of life. Hundreds of thousands of dollars are spent routinely on nearly futile efforts in such scenarios. So, the rebuttal to my commenter is: How many Mannys might we save if we avoided futile care with no hope of restoring anything resembling health, and little hope of doing more than postponing death by some scant number of miserable days?

The reality is that we have not even grappled with the question. What is routinely covered is covered, what isn't is not, and if that results not only in rationing, but totally irrational rationing, we all seem to be OK with it. Until the patient needing some treatment not situated in this silly scenario is our son, or our daughter. Then it's not OK, which really means, it never was.

We need to help Manny, and can, by helping to change the insurer's mind and by lending what direct support we all can to his family. He is in the expert and caring hands of Dr. Wilky, and getting the treatment he desperately needs as we speak. Let's do our part to make sure that doesn't bankrupt his family.

But we need to change the prevailing standards, too, because there will be another Manny, another family, and another insurer, and if the same rules apply, if will feel a lot like déjà vu, all over again. Some other family will be the victim. We need a national standard, not bureaucratic and profit-driven knee jerks, to guide coverage of non-standard care. I will be working on that, and seeking the help of my friends in Congress.

We also need to consider that we have just three options for the allocation of health care resources. We can choose not to ration at all, in which case the lone argument against coverage of Manny's care is undone. We can choose to ration rationally, in which case Manny's care would be a priority on almost any scale imaginable. Or we can ration irrationally, and deny care when it is medically indefensible and morally repugnant to do so, even as we spend extravagantly on misguided futility. Alas, until we address it, that last, bad option, is the status quo.

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.