Monday, August 31, 2015

Drug-company funded research in the New England Journal of Medicine feels like a conflict of interest

I thought I'd read the New England Journal of Medicine (NEJM) and learn something deeply meaningful. I usually love the NEJM (Wikipedia says it is “among the most prestigious peer-reviewed medical journals and the oldest continuously published one”) because I feel like it has such a strong history of academic excellence that whatever they print will have value. This is probably not true.

In 2009, Marcia Angell MD, a senior lecturer at Harvard University and the former Editor in Chief of the NEJM wrote an article entitled “Drug Companies and Doctors, a Tale of Corruption” in the New York Review about the way drug companies skew research to encourage increasing and inappropriate use of medications. It was based on what she had seen published in the NEJM and others. This might have been a hint that there was something amiss in the contents of my favorite professional publication.

In 2012, the Washington Post published an article about a diabetes drug, Avandia (rosiglitazone), which has proved to increase the risk of heart attacks and heart failure. The NEJM decided to publish articles which reported results of studies funded by GlaxoSmithKline, the company which produced the drug. These articles concealed information that showed that the drug was harmful. Editorial decisions were made which, at least in hindsight, were bad. The Washington Post article discussed the many ways in which a drug company which funds research for a medication can manipulate the presentation of the data and get that version published in a prestigious journal which doctors like me tend to believe.

The NEJM has several sections, but the Original Articles is the one I like best. This is the section where new research is reported. There is also the Perspective section, which has gotten more prominent in recent years, and consists of articles by people who are in the thick of something, maybe mass casualty situations, maybe health policy, big picture articles. There are also editorials, usually about the original articles, and there are letters and image challenges and case presentations and educational updates about specific topics.

Recently, the NEJM's Original Articles were primarily about new drugs, and were mostly funded by the drug companies that will or do make money off of those drugs. Oh yeah, and 1 about a new diagnostic test, funded by the company that will make money off of that diagnostic test. There was 1 article not funded by industry which looked at the causes of pneumonia in patients who were admitted to the hospital with it, reporting that the majority were caused by viruses.

The first article was funded by Pfizer and reported a new chemotherapy drug for breast cancer that, combined with another chemotherapy drug which costs over $10,000 per month, results in longer survival. The new drug's is not yet marketed and so a price has not yet been decided.

The second was funded by a Boston company, Vertex, for their new product that can reduce the lung problems that go along with cystic fibrosis, a genetic disease that causes pneumonia and problems with breathing. If the cost of other drugs for cystic fibrosis is a guide, its cost will be sky-high.

The third article is funded by Merck Sharp and Dohme, and studies their drug sitagliptan (Januvia), one of the many drugs that reduce blood sugar in patients with type 2 (generally adult onset) diabetes. The study was primarily to see if their drug caused heart problems, because people thought that it might. They studied more than 14,000 patients for about 2 years and found that their drug did not cause heart problems at least over the course of those two years. It also didn't work very well to reduce blood sugar, but not much was made of this in the conclusions. The drug, which helps reduce blood sugars by just a smidgen, costs $3,000 a year or thereabouts, far more than generic medications which work better.

The fourth article evaluated a test that could be done to more accurately determine if a person has lung cancer at the time of a bronchoscopy. Since the test can simply be ordered at the time of the bronchoscopy it will probably be ordered nearly all of the time this test is done, and, I'm just guessing, may just about double the cost of the procedure. The first noted funding source for this study was Allegro Diagnostics, which will be marketing the product.

Then came the pneumonia article (yay, information I can sink my teeth into.) If viruses cause most cases of severe pneumonia, there may actually be some argument for not putting everyone we see with pneumonia on antibiotics.

The final article which was funded by GlaxoSmithKline looked at the ability of an antibody to clear amyloid from the liver in a very rare condition called systemic amyloidosis, which mainly causes death and disability through deposits of a protein in various tissues, of which the liver is one. If this is released it will be very very, very expensive and will probably serve only to palliate a very rare disease.

Not to put down miracle drugs, because they are pretty cool, but perhaps the Original Articles section should be renamed Articles Funded by Drug Companies Supporting the use of Very Expensive Medications.

Drugs and Doctors

Doctors are increasingly prescribing more and more expensive drugs for just about any complaint. Even the Onion has noticed (read this brief article and chuckle.) This is in no small part because we believe that drugs are the answer, because the research tells us so. The research that tells us so is funded by the companies that make the medications, because they have the money to fund expensive studies. There is much less money in research on cool stuff like what causes severe pneumonia. According to the Washington Post article, the NEJM had published 60 articles about new drugs that were funded by drug companies in the year prior to the report in 2012. Since it publishes 54 times a year, that's just a touch over 1 article per issue. This week's issue had 4 such articles plus the one about the lung cancer test. It seems like they may be escalating.

But why does the NEJM publish this stuff? I think this may be a big part of it: we all love magic potions; it's in our basic makeup as people. Even societies nearly untouched by pharmaceutical companies delight in miracle cures. Doctors and chemists love to dabble in potion making and testing, hoping for that amazing discovery that abolishes misery and old age. They have even been successful. Look at penicillin and many others. But when big money backs these endeavors to the exclusion of other good science, we tend to focus on them, and our professional publications will reflect that in what they publish. Unfortunately the economic forces at work favor creating potions that sell, and not necessarily ones which work. Even though I think I understand the rationale, it's pretty disappointing that one of the “oldest and most prestigious peer reviewed journals” is filling its pages with research that is funded by the companies that financially benefit from positive results and therefore is likely to be skewed and misleading.

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.

Talking about death

A few recent experiences have me thinking about death.

The first was hearing a story on the radio about how physicians “manage” their deaths. The gist of it was that physicians are more likely to die at home without aggressive life-extending interventions than the general public. The implication was that more people would have a “better” death, more in accord with their own wishes, if frank discussions about end of life care were more common.

I didn't think too much about the story, which registered only a “no kidding” in my mind when I heard it, until I thought about it in the context of two deaths that touched me this past week.

The first was a medical school classmate of mine who died after a long course with prostate cancer. A message from a mutual friend who shared the news of his passing concluded with this: “at least it all developed as he and [his wife] chose, at home, with peace.” It conjured up a scene of serenity, and I was oddly glad that I was able to imagine him, comfortable and surrounded by his family, gently slipping away.

That scene was nothing like what was described to me as the final days of a friend's elderly father, who died in a hospital with advanced heart failure. He had had a long history of heart disease. Over several months, he was hospitalized half a dozen times for worsening heart failure. He spent his final days, I learned, “in agony,” uncomfortable, thirsty, and short of breath. Sounded absolutely horrible. And here's the thing that really got me: She was surprised that he died.

Really? How could she be surprised? To the cardiologist in me, it was clear that he had been in steep decline for months. The prognosis for an elderly man with progressive heart failure leading to multiple hospitalizations is obviously grim. Maybe this was just the subconscious denial of a loving daughter, who could not imagine losing her father. I am sure that played a role.

But there was more. She told me that she was surprised, in part, because she was so engaged with his doctors over the details of his care that she “lost the forest for the trees” and did not see the bigger, inevitable picture. Also understandable. It is easier for many to fight the day to day battles than to think about the bigger questions of “why” and “where is this going” or “how is this going to end.” I don't blame her.

But I can't help but think that his doctors failed him, and her. Maybe his doctors tried to engage them, and maybe they didn't want to hear what was being said, but over months and multiple hospitalizations, it seems that there was no effective conversation about these bigger questions. No chance, apparently, for her and her father to have it end “as he chose.” Instead, he was miserable and she was shocked.

So sad; so unnecessary.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.
Friday, August 28, 2015

Are we really ready for quality-based doctor payments?

The dramatic change in how we pay doctors is well underway. The “fee-for-service” model, in which you get paid for every “thing” you do, is on the way out. Under this model, for example, I can get paid about $60 for helping someone manage their heart disease and diabetes, thereby preventing severe complications. If I simply clean out their ears, I can bill closer to $80 because it's a “procedure.”

Under the newer “quality-based” model, more of my payment is based on outcomes: what percentage of my diabetics have their sugar under control, etc. This noble idea has a number of inherent problems that have been addressed elsewhere, but one of the biggest is bureaucratic.

Every insurer has its own quality measures and reporting schemes. Some companies have several, depending on the insurance product. For example, Blue Cross collects data 1 way for Medicare patients, another way for HMO patients, and other ways for plans purchased by employers.

We have no idea how to keep track of all of these reporting systems. There seems to be an endless supply of data that they request, some relevant, some not, and some insane.

For example, for some of my BCBS patients I have to log in to their website and enter patient data. Among the data is a question asking if the patient has a history of depression. If I answer “yes” it asks for a depression “score” based on a simple clinical tool. Since my patient isn't currently depressed, I enter a score of 0, and get rejected. You're not allowed to have been depressed in the past, but no longer be depressed. When I've questioned BCBS about it their response is often either nonsensical or they tell me to lie. Really; they told me more than once to just answer that the patient has no history of depression.

And that's just for one group of BCBS patients. Others may not require this sort of reporting but another log-on adventure entirely.

It is nearly impossible for me to figure out which of these so-called incentive programs cost me money or make me money or are simply a wash. I cannot for the life of me figure out exactly how many different programs there are and how to satisfy their requirements.

If reimbursing doctors for quality of care is truly the goal (rather than the cynical interpretation of it being a way to avoid paying docs via Byzantine reporting requirements) then we need one system. If we had a single-payer system this would be fairly simple, but since we don't, there should be a data repository that all the insurers fund and are required to use. This way, doctors wouldn't have to take time out of the exam room to try to fulfill each set of requirements, or worse, give up entirely.

It is hard to overstate the amount of time taken gathering and reporting this data. Take, for example, colon cancer screening. Because it may have occurred a couple of years ago (and is still up to date) it may not appear in the insurance company's billing records and therefore is listed as “incomplete”. Then we have to review “x” number of charts, looking for records, dates, etc. And if the patient has changed insurers or doctors a few times, there may be no data at all to work with.

At this point, quality-based reimbursement is a Kafkaesque joke. Doctors will lose money, patients will lose time with their doctors, and quality will suffer as doctors spend more time trying to figure out how to report data than how to treat disease.

Maximum frustration of opiate demands

Ask any primary care physician or hospitalist (and many subspecialists) and I wager that patient opiate demands represent their most frustrating recurrent issue. We are clearly caught between those who demand that we relieve pain and those who point fingers at us for excessive opiate prescribing.

Many people like how opiates make them feel. Many people become addicted easily to opiates. It seems that they use knowledge of the pain imperative to ask us for more opiates.

We clearly have a conundrum. We can receive criticism when we do not address the patient's pain to the patient's satisfaction, and we can receive sanctions when we prescribe opiates too freely.

We also have another serious problem. Once a patient becomes an opiate addict (often when a patient starts with a legitimate need for pain relief), then when we do not prescribe more opiates they may turn to illegal opiates such as heroin.

Heroin use jumps in US as painkiller addicts switch drugs

The CDC reported that over 8,000 people died from a heroin-involved overdose in 2013, nearly twice the number of deaths seen just two years earlier.

Federal officials cited a number of factors causing the rise in heroin use.

As authorities have cracked down on prescription drug abuse in recent years, users who have become addicted to the pills have switched to heroin. The drug is often cheaper and more easily available.

The amount of heroin being brought into the U.S. has also increased, driving down the cost of the street drug.

So what are we to do? This is a most serious public health issue that we must face patient by patient. And we hate the problem. We like patients, but fulfilling their opiate demands is not really a good idea.

Any good suggestions?

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 Maximum frustration of opiate demands">appeared at his blog, db's Medical Rants.
Thursday, August 27, 2015

Saturday night

The other day I went to see 1 of my patients in the evening. The nursing staff had paged and said this patient was feeling anxious and upset and had asked for me. Me specifically. I had some things to do at Grady and was in the vicinity anyway so decided to just come on in.

Yep.

A lot has been going on with my patient. A lot. There was fear involved. A lot of fear. And frustration, too. And the thing about fear and frustration is that they can make us behave in ways that aren't always in our character. And since I get that usually I don't take such things personally. I recite the mantra that I tell my students: “This isn't about you.” Because it almost never is.

But still.

At, like, 8-something p.m. on a Saturday night, I went to see my patient. I tapped on that door and creaked open the hinge expecting to be met with relief. Or at least some raw emotion and readiness to talk which I could have easily worked with, you know?

Instead, fear flipped an ugly switch on and I walked into a barrage of really unkind words and behaviors. Passive-aggressive. Or rather just sort of nasty-aggressive. Not dangerous or threatening. Just mean, you know? And I've truly grown to care for this patient so not only did those words catch me by surprise--they hurt. My feelings were genuinely hurt.

Yep.

When the nurses called me, I was sure that the combination of the rapport we'd built so far and the fact that I was up there after visiting hours when the lights get turned down would allay whatever had been going on. I was wrong.

I removed myself from that room and headed out to elevator. I snapped this photo of myself in the vestibule because I wanted to look at it and reflect on how I was feeling. Because my feelings were complicated.

Very.

The hospital was so empty at that hour that I stepped onto an empty lift and leaned my head against the wall on the way down. I could feel my pulse quickening and my face getting hot. Next thing I knew, my eyes welled up with tears and, before I could even stop them, I started to cry.

Kind of hard, actually.

I can't fully explain what I was feeling. Some of it was that my feelings were hurt. But that was only part of it. Mostly, I was just sad. Sad for my patient and this fear and this ugly behavior that came with it. Because that kind of thing almost always impedes excellent patient care by robbing even the most well-meaning providers of their empathy. And empathy is a necessary element in quality patient care if you ask me. This patient didn't need anything else to work against all that was already happening.

Not at all.

So right now I'm feeling so sad. Like, every time I even think about the gigantic mountains that so many of my patients like this one are up against I want to steal away over and over again into the quietest elevators to weep into the crook of my white coat--just like I did on Saturday night. With no one looking or hearing or judging. Then, just maybe, even crying out into a vacuous airspace to my God or the Grady gods or any being with powers willing to take this on. Something, anything to defy the suffocating pragmatism and wrestle down the hopelessness I feel in such moments.

Maybe that would make me feel better, you know?

Then, when the doors pop back open, I can shadow box before re-emerging. Pop out of that elevator like a rejuvenated ninja with a new fight and a thicker skin. Believing in the little rays of light that sometimes seep through the darkness faced by so many of my patients, this one included. Or maybe even embracing some lofty idea that I could be that ray of light.

Maybe.

I am realizing that our patients aren't the only vulnerable people in the hospital. We are vulnerable, too. We so very are. Our universal precautions don't protect us from one of the most infectious exposures we face in caring for patients. … love.

On Saturday night, my patient was mean to me. Really mean. And yes, it was about fear but still. I have nothing in my little bag of Internal Medicine tricks to eradicate the effects of all that. I don't.

You know? Sometimes? Sometimes, this job is hard, man.

Yeah.

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.

Warning! Cell phones can kill you!

In medicine and beyond, folks just want stuff to be true. Sometimes, we believe stuff that is unproven, but might be true. We doctors recommend such treatments to patients every day. On other occasions, a benefit of a drug or food item is extrapolated way beyond the data. For example, if Nexium is known to be effective against stomach ulcers, then why not use it for patients with stomach aches who are ulcer-free? There's not a gastroenterologist on the planet that hasn't engaged in this therapeutic mission creep. More interestingly, folks often persist in beliefs that have been disproven. The notion, for example, that certain vaccinations can cause autism has been thoroughly debunked by rigorous scientific study, yet there remain diehards who defy the science.

Curiously, many unproven or disproven practices have gained a fair measure of street cred in the Court of Political Correctness. Keeping a gluten-free diet today is downright chic. Colonic cleansing is the bomb. Kale is king.

If we want to generate some heat in the green crowd, just mention the word “radiation.” Ingesting irradiated food, for example, is believed to be tantamount to swallowing strychnine. No persuasive evidence necessary. Faith will suffice. Nuclear reactors are regarded as atomic bombs in waiting, as if burning coal or hydraulic fracturing (fracking) are as clean and pure as the first snowfall. The sun's radiation, which assaults us daily is somehow not demonized, nor are cosmic rays, high energy radiation which bombards our atmosphere and can reach down to earth itself.

The City of Berkeley, the epicenter of New Age Goofiness, has just passed an ordinance that requires retailers to warn customers about the medical risks of devices that emit radiation, such as cell phones.

Here's an excerpt from the caveat: “If you carry or use your phone in a pants or shirt pocket or tucked into a bra when the phone is on and connected to a wireless network, you may exceed the federal guidelines for exposure to radio frequency radiation. This potential risk is greater for children … “

Luckily, I'm mostly in the clear. I am not a child and do not don female underwear. I secrete the phone into the left inside pocket of the sport jackets I wear each day to work. The phone, therefore, rests above my heart. Perhaps, the gentle radiation from my beloved iPhone is conferring a cardiac benefit on me? While it's just conjecture, perhaps, if my heart gets tempted to beat out of step, that my iPhone's rays keep my rhythm sure and steady.

If I were the cell phone companies, here's how I would fight back. Forget about litigation or trashing the fiends who fear all radiation, foreign and domestic. I would sell my theory of cardiac protection to the American Heart Association. For a proper donation, they might consider cell phones to be “Heart Healthy.”

If your adversary argues without facts, then shouldn't you?

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, August 26, 2015

Zeal, veal and veganism

When my vegan friends and colleagues say that a vegan diet is categorically the best for human health, it is an excess of zeal. We simply do not have evidence to substantiate the claim. I know; I've looked, hard.

If you are inclined to doubt my assertion, just consider what such evidence would look like. I don't think, when we say “best for human health,” that any of us really means: produces the lowest LDL over a 6-month period. I don't think we mean produces the highest antioxidant levels in the blood, or the lowest blood pressure over a span of months either. I think what we really mean is: leads, on average, to the most years in life, and the most life in years over an entire lifetime. The “best health” is enjoyed by people who live long, and prosper from their enduring vitality.

Given that, the trial to show that any given diet is truly “the best” has not been done, and is unlikely ever to be done. First, the outcome measure would need to be a composite of years in life and life in years over a lifetime, meaning something like quality-adjusted life years measured over many decades. The trial would need to run for 100 years.

Second, if we are to measure the effects of diet on health, we have to consider that those effects may be exerted early, late, or in between. For instance, we have some reason to believe that it is the diet and health of young girls that most influences the likelihood of breast cancer in the women they will become. With such considerations in mind, our intervention would need to cover all phases of the life cycle to be robust.

I could keep going, but the conclusion is already clear, so let's just stipulate it. To show, decisively, that any given diet is “best” for human health would require randomly assigning a large number of women soon to become pregnant to each of the competing dietary assignments, since we know that dietary effects begin in utero. Then, each of the neonates would need to be breast fed by a mother adhering to their dietary assignment, and then after all being weaned at the same time, the babies would need to adopt their diet: vegan; Mediterranean; Paleo; etc. They would then need to be followed for the rest of their lives to determine which group “wins.” The investigators planning and running the trial would not live to see it concluded, and the cost would be stupefying.

So, no, it has not been done, and won't be. The result is we have a vast amount of evidence about the fundamentals of healthy eating, and no definitive evidence to say which variant on the well-established theme is truly the best. Claims to the contrary are, as noted, born of zeal.

I note in passing that the direct comparisons of “this” dietary pattern to “that” suffer a variety of important limitations. Generally, they are of rather short duration, and none has ever run for the decades required to give us meaningful data about lifelong effects. Generally, they are directed at a primary outcome of only secondary significance, such as weight, or blood pressure. Most importantly, all such comparisons tend to be conducted by investigators with a particular interest in a particular diet, and that diet inevitably gets favorable treatment. Those, for instance, seeking to show the benefits of a low-carb diet will tend to compare it to a straw man version of a low-fat diet; and vice versa, just as surely. What we really need, and never get, if we are to say what specific diet is truly “best” for health, is a comparison of the optimal version of each contestant to its comparably optimized counterparts. Good luck finding that.

Because of this, claims that any given diet is the one best choice for human health represent the triumph of rhetoric over research. The evidence is not there; not for those in the vegan vanguard, not for the adamant Paleo proponents. Just as surely, the evidence is there- abundantly, consistently, and transculturally -- for the fundamentals of healthy eating that transcend the claims for any specific variant on the theme.

I am not a vegan myself. I eat a mostly, but not exclusively, plant-based diet. But my sympathies angle toward the vegans, for various reasons. Consequently, I generally regret the excessive zeal and unverifiable claims about health made to advance the vegetarian cause; they are unnecessary. There are important considerations in the mix other than human health.

Human beings are, irrefutably, omnivorous. There are specific aspects of our physiology particular to meat consumption, and perhaps even the consumption of cooked meat per se. There are adaptations even since the advent of civilization that are particular to dairy consumption. Valid arguments over the place of dietary meat and dairy in human health are far more challenging and nuanced than the opposing clamors would suggest, and might well come down to: what meat, and which kind of dairy?

But there are considerations other than human health we simply cannot ignore. I cannot improve on a recent headline in IFLScience: “meat is a complex health issue but a simple climate one.” Amen. Whatever the arguments for the merits of game in the diet, they just don't pertain to a population of 7 billion Homo sapiens busily cooking their planet.

I'm mostly with the vegans as well on the issue of ethics. I don't, by any means, think it is intrinsically unethical to eat meat; many of our fellow species do so, and some have no choice. But we humans, obviously, don't just hunt, kill, and eat animals anymore. We at times torture and abuse them. We force feed and fatten them.

Our capacity for double-bookkeeping on the subject is impressive. I imagine, for instance, that some who enjoy a visit to their neighborhood zoo in the spring to see the delightful antics of newly born animals might also enjoy veal parmigiana. Veal, as you no doubt know, is the flesh of calves; animals raised to be slaughtered, and eaten, while in that very phase of exuberant youth that makes closely related animals at the zoo so captivating. While standards of treatment have improved, veal historically comes from calves that are fattened and tenderized by strict confinement all the days of their short lives. There is the comparably incongruous tendency to adopt into our very families some beloved, four-legged mammals; while putting others of equal or greater intelligence and sensitivity on our dinner plates. That's not cannibalism exactly, but it's not entirely rational, either.

Among my many detractors out here in cyberspace are some inclined to beat me over the head with a figurative leg of lamb as a matter of routine. They seem to imply they have personally discovered the tonifying wonders of meat, to which I am oblivious. They state explicitly that my arguments for mostly plant-based eating by the human population at large make me benighted, unenlightened, ignorant, and/or conflicted. But they are wrong.

I am a public health pragmatist, not an ideologue. I know that debate over the health benefits of grass-fed beef will be moot when we've run out of water to grow grass. I know that the relative contributions of salmon to our health will be impertinent after we've eaten the last one.

The vast preponderance of real-world evidence of health outcomes in actual populations argues for diets of food, not too much, mostly plants. That could be enough. If it's not, we might constructively consider the plight of the planet, or the sorry fate of those veal calves.

There simply is no need for overzealous argument to make the case that we are in serious trouble if we keep eating as if the future does not depend on our choices. It does.

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

Not letting a computer come between me and my patients

Ask any frontline physician at the moment what one of their biggest daily frustrations is and you will probably hear a very similar thing whether you are talking to a primary care, emergency room, or hospital physician. The thing that most takes them away from patients and makes them forget the reasons why they went to medical school in the first place, is the need to now spend most of their day staring at a screen and performing data gathering and “type and click” tasks.

I personally am yet to hear of any doctor who is happy with their electronic medical record, and I've worked in many different hospitals up and down the East Coast (that use a number of different vendors). Hate may be too strong a word, but then again maybe it isn't according to some things I've heard physicians say about the computer systems that have been foisted upon them! If we take a step back to when this process all got accelerated, it's largely been a result of the federal government's Meaningful Use program. And while I don't doubt that the program had some very noble intentions, and neither would I ever say that information technology in healthcare is all bad (far from it, a lot of it is quite brilliant in terms of being able to quickly search records), the problem has been in the implementation and the IT solutions that are available currently not being properly reconciled with frontline clinical workflow.

A study in the Journal of General Internal Medicine not so long ago showed that medical interns now spend only 12% of their whole day in direct patient care. That's a shocking statistic if it's the future of medicine.

The fact that doctors are having to spend so much of their time in front of computers, does an absolute disservice to the patients we serve. I've lost count of the complaints I've heard from patients regarding this. “My doctor never even looks at me.” “My doctor just keeps turning around to tick boxes on a computer when I'm with him.”

Because of this, and my absolute resolve to not become like that, I've developed some rules for how I interact with patients in the hospital. This includes never taking a portable computer or attempting to document anything electronically when I'm in a patient room. I always sit down and make eye contact with my patients and if I need to take notes, I do it the good old-fashioned way of writing things down. There's something about entering information on a computer as people talk to you that makes you seem less engaged. We've all experienced this before whether we are at a hotel, airline counter, car dealership, or just about any service situation. When you are being asked for information, it just seems a lot more attentive when someone is sitting right in front of you writing things down as you speak and maintaining eye contact. Computers just don't make the cut. I'm happy to do all the required electronic documentation after I see the patient, but won't let it distract me when I'm with them.

Secondly, I keep close watch on how much time I'm spending with patients during the day. I do everything possible to tip the balance towards direct patient care, including keeping electronic documentation to the minimum required for a good comprehensive patient note and avoiding sitting down at a computer if I'm performing an “on-the-go task” such as placing an order.

Thirdly, every computer system has its own unique quirks and characteristics. As anyone gets used to the system, there are often shortcuts and quicker ways of doing things that become apparent with time. Use these to your advantage. The people who design these systems are not clinically minded (and indeed, many of them are fortunately too young to have barely set foot in a hospital). Neither do they fully understand the world of medicine. It's our fault too perhaps for not insisting on intense clinical feedback when systems are designed, but any feedback you can give or ways of improving the system—be sure to spread the word.

As great as computers and information technology are, medicine is about people, and always will be. It is a uniquely personal and emotional arena. There are certain universal truths when it comes to humanity, and Hippocrates had it right over 2 millennia ago when he offered a pearl of wisdom for everyone in health care: “Cure sometimes, treat often, comfort always.” That's the human side of medicine that no computer can ever touch. For me that face-to-face time with my patients is part of the sacred doctor-patient interaction, and I will not allow any computer to come between us.

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, August 24, 2015

The impending revolution

This weekend I attended (and spoke at) the Concierge Medicine Assembly in Atlanta. My role was to give the perspective of a “successful” direct primary care (DPC) practice. This being the second such conference in 3 weeks, I've learned that my panel of 600+ patients and survival for 2.5 years puts me in the higher ranks of solo DPC practices. The Atlanta conference was actually a combination conference, catering to both the more recent “direct care” style of practices like mine, and the more traditional “concierge” practices, with their higher fees and smaller panels, both grouped together under the blanket term of “membership medicine.”

Technically, the difference between DPC and “concierge” care is not the cost or panel size, but the fact that DPC practices do not accept insurance for payment, while the concierge practices have a membership fee on top of what they can bill to third-party payors. But in my eyes the main difference is the overall movements each of the practice types represent as defined by their patient demographics, and panel sizes. Concierge practices, in general, are focused on giving high-quality care by limiting panel size and giving significantly increased access to their members. In essence, they see fee-for-service medicine as something which gives inadequate care to a large number of people (which it does), and so choose to reduce panel size and give adequate care to a few.

While I see nothing wrong with this approach in the smaller picture, it clearly has limitations when generalized to the larger healthcare system. Doctors in this type of practice choose to not address the greater impact their practice model would have on healthcare. I don't criticize this approach, as it is probably more honorable than the current fee-for-service system which encourages doctors to wantonly spend money in a way that the system cannot bear and to short-change patients by giving them substandard care. But it was this limitation (along with the fact that most people can't afford to be members) that will keep the impact of this type of practice relatively small. It is also the reason I chose the alternative type of “membership” practice: DPC.

DPC is the new kid on the block, and has more energy in its camp. When meeting with other DPC docs, it almost feels like I'm part of the covert meetings of the Sons of Liberty before the revolutionary war; it feels like we are doing something that is raises a fist to the status-quo in a way that improves the lives of Americans. DPC relies on the simplicity of the care model to give enough efficiency to keep overhead low, cost to patients down, and to allow for larger patient panels. Right now I have 600 patients and am able to easily give care with only 2 medical assistants. While this is still a far cry from the thousands of patients on my panel in my old practice, it is significantly larger than most concierge practices.

I am often asked what is my ultimate goal for patient panel size. That's a tough question and I usually obfuscate by saying that I want to have the largest panel possible in which I can continue to give high quality care. I know that's a cop-out answer, but when we started the practice in February of 2013 we had very little idea what my practice would look like, and so just made things up as we went along. So I'd be lying if claimed to know where exactly we are going at this point. Why start pretending I know where we are going now, when following the course set by the needs of our patients and available technology has led me to this position of relative success?

My idealistic ultimate goal, as is the case with many in the “DPC movement” is to make my practice large enough to be a viable alternative for other primary care doctors to adopt without causing the system to implode through a dramatic reduction in panel size (and hence PCP availability). If I can grow to 1,200, 1,500, or even 2,000 patients and still give excellent care, the game would indeed change.

The limitation of patient panel size is what relegates membership medicine practices to being a niche practice model instead of becoming the game-changing disruptive force many of us believe it can become. So how can practices like mine improve efficiency enough without falling prey to the forces that drove fee-for-service practices to severely limit access and ultimately to give expensive and substandard care? In other words, how can I grow my practice size without either limiting patient access to me (which is my main differentiating product) or decreasing care quality? I see 2 ways to approach this problem: diversifying my staff and improving my use of technology.

The idea of growing my staff doesn't refer to simply adding front desk and nursing staff (although that will certainly happen); it focuses on specialization within the practice to meet various needs of my patients. A dietician, for example, could handle the problems my patients face due to poor nutrition or lack of knowledge in that area (and do so far better than me). Similarly, a trainer or exercise specialist could come up with ways to improve their physical fitness, a pharmacist could maximize the effectiveness and minimize the cost of medications, and a counselor could help people deal with the emotional aspects (both cause and effect) of my patients' lives.

This is what I have previously referred to this type of growth as the “organic medical home”, which would meet the needs of my patients through offering holistic care that was shaped around their actual needs (as opposed to a government-designed program telling us what we need to offer). The downside to this approach is that it requires a larger staff, increasing my cost and moving away from the simplicity of my current practice. But such growth will definitely be necessary for the DPC model to move from niche to mainstream.

The second key to growth is technology (which should come as a shock to no one who knows me). When I started using electronic records in 1996, there was a feeling of excitement and revolution among the early adopters as there is now in the DPC movement. We really felt that technology, which had dramatically streamlined many industries (destroying immovable monoliths in the process), would improve the quality and efficiency of care.

Unfortunately, instead of increasing efficiency, technology allowed for increased inefficiency by allowing massive over-documentation and codification that would never have been possible in a paper universe. The third-party payor system was the reason EMR's turned out to be a wolf in sheep's clothing. Commercial and government payors controlled the money, and so demanded more and more control of care. They are, after all, the true customers in fee-for-service medicine. So electronic records, instead of improving the quality of care, became a tool to wrest control from healthcare providers and put it in the hands of insurance companies and government regulators. The result is what we have now: care that is not patient-centered and of lower quality, and medical records that focus on billing rather than clinical issues.

But these forces are not at work in membership medicine practices, where the patients are actually the customers. So the technology that develops alongside practices like mine will only be accepted if they improve care quality or access. I saw the consequence of this at both meetings, as I saw the various technology solutions sponsoring the meetings, including:
• EMR's that focused on patient care rather than coding and billing
• Simplified billing systems that allow practices to manage large numbers of subscriptions efficiently
• Care management tools which increase between-visit contact with patients and significantly improved outcomes (one of them advertised that they could “cut office visits by 2/3 - a claim that would result in decreased revenue for fee-for-service practices)
• Communication tools that increased simplified and improved patient contact with care
• Educational tools which give physicians the ability to give only the care patients need.

As these technologies grow, the size and number of membership practices will increase. This will, in turn, increase the number of businesses interested in creating technology for those practices, making adoption of this practice model much less risky. This has clearly happened in the 2+ years I've been in this practice, and only seems to be accelerating. The next conference I will be attending (and speaking at) will actually be a technology-centered “hack-a-thon” with a healthcare track. Pair a disruptive business idea with a bunch of geeks with a chance to solve one of our biggest problems and there is a real chance of getting amazing results. I am really excited to be a part of it.

Like my practice, membership medicine is still in its early phases. Like my practice, the future of membership medicine depends on a lot of things beyond our control. But the excitement I hear regularly from physicians, residents, medical students, patients, business owners, and even politicians about its potential is quite remarkable. Both of these conferences were full of something that I once thought no longer existed: doctors who were excited about medicine and cautiously optimistic about the future.

Don't tread on me, CMS and Blue Cross. Give me liberty from “meaningful use” or give me death!

Load your muskets. The revolution has started.

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.

Doctors and industry

I wrote a column about doctors and conflicts of interest. This is a perennial topic in the field of medicine, but it's been on people's minds recently because of a set of 3 essays that appeared in successive May issues of the New England Journal of Medicine, America's oldest and most esteemed medical journal. You can read the essays if you like here, here, and here. The Journal's editor-in-chief also weighed in with an editorial introducing the three-part series.

Academic doctors have long had relationships with industry, and the history is complicated. Many of us in academe are trained to be very skeptical of our colleagues that take funding from pharmaceutical manufacturers (aka drug companies) and device makers (think hips, heart valves, pacemakers, surgical robots, etc.). We are skeptical because we feel that these colleagues have sold out, or that they are shills for the companies that have them on the payroll. Though seldom admitted, envy plays a role in our skepticism, also.

There's no doubt that the skepticism originates from a good place. After all, those of us in academics prize objective truth and scientific advancement. The idea that researchers and clinicians are beholden to a commercial interest raises red flags for us about integrity. And there have been many reported examples of harm done by folks in thrall to commercial interests.

The outgrowth of all the skepticism is a set of rules and practices that center around transparency in our daily business. We must disclose any potential conflicts to the universities for whom we work. If we speak at a conference or submit an article to a journal, the same principles apply.

We've reached a point where we evaluate information based on the ‘moral purity’ of who is presenting it (and of course, the purported purity of the information itself, i.e. if it's funded by industry, it's automatically suspect). Moral purity is equated here with meaning no ties to any commercial interests.

The correspondent who wrote the 3 essays for the Journal is asking if perhaps we've gone too far to the extreme, suggesting that when we engage in morality litmus tests for the sake of convenience, we are likely overlooking opportunities to do good work that can have mutual and societal benefit.

Predictably, the response to her pieces has been pretty fierce. Two former editors and a former correspondent for the Journal lambasted their former workplace for even mentioning a reconsideration of academic-industry relations in a retort in the British Medical Journal (now know as just BMJ). The gloves are off! Another commentator opined about “Why [NEJM author] Lisa Rosenbaum Gets Conflict of Interest Policies Wrong.” Ouch.

When poking at sacred cows, you inevitably become a target yourself. The fact is that government (i.e. taxpayer) funded research is a 0 sum game: the NIH budget has remained flat for several years, making the most high-minded, “pure” way of funding research harder and harder for young and mid-career scientists. Many of us see collaborating with industry as the only real possibility of moving progress forward. It's OK to have rules about conduct of industry relationships, but to squelch it all as immoral benefits no one except those mandarins in charge of the litmus tests.

Coda: NPR ran an interesting piece on “Dollars for Docs,” a searchable database by the non-profit investigative news source ProPublica that reveals how much your doctor takes from drug companies as part of the Physician Payment Sunshine Act. Apparently I received $24 in 2014. I have no recollection of these inducements. My best guess is that some foodstuffs were brought to our nursing staff to encourage them to administer vaccines against shingles and cervical cancer. I can live with that.

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.
Friday, August 21, 2015

On feedback and deliberate practice

Medical learners often complain that they receive inadequate feedback. Most programs develop solutions of “formal feedback” sessions. To that I say, “Bah, humbug”.

As a devotee of deliberate practice, I understand that formal feedback does not do the intended job. Rather we need to provide immediate feedback and then repeat the practice session with another immediate evaluation.

This quotation from a blog post (Deliberate Practice: What It Is and Why You Need It) should help:

The 4 Essential Components of Deliberate Practice

Research into the history of education (dating back several thousand years), combined with more recent scientific experiments have uncovered a number of conditions for optimal learning and improvement. Again, from K. Anders Ericsson, here are the 4 essential components of deliberate practice.

When these conditions are met, practice improves accuracy and speed of performance on cognitive, perceptual, and motor tasks:

1. You must be motivated to attend to the task and exert effort to improve your performance.

2. The design of the task should take into account your pre-existing knowledge so that the task can be correctly understood after a brief period of instruction.

3. You should receive immediate informative feedback and knowledge of results of your performance.

4. You should repeatedly perform the same or similar tasks.

It's important to note that without adequate feedback about your performance during practice, efficient learning is impossible and improvement is minimal.

Simple practice isn't enough to rapidly gain skills.

Telling a student after 2 weeks that their presentations are confusing will not help the student. Interrupting and giving immediate feedback on the deficiencies (as they occur) will make the points much more clear. Providing immediate positive feedback will reinforce their improvements.

We have a responsibility to give specific feedback throughout our rounds (whether in the inpatient or outpatient arena). We must tell our learners that we are giving feedback. We must celebrate good work and suggest how learners can improve in a balanced fashion.

We should not be so obsessed with “formal feedback.” It does not lead us to expertise.

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, August 20, 2015

Should physicians profile our patients?

Profiling in this country is highly discouraged and is illegal in many circumstances. Anti-profilers decry this technique which, they argue, unfairly targets innocent individuals violating their rights. Our beloved Transportation Security Administration, or TSA, is charged not to use profiling as a screening tool. Personally, I object to this prohibition. While an individual's rights are important, it must be weighed against the rights of the community. Our cherished rights to free speech and assembly are not absolute.

I have flown on El Al airlines, whose personnel actively profile in an effort to keep its passengers safe. Anyone who has been a passenger on this airline will likely agree with me that he has never felt safer on an airplane. I have a right not be blown up, and if profiling further minimizes this risk, then call me a fan.

Last year, my mother, who appears as threatening as a school librarian, was patted down twice when she traveled to visit me in Cleveland. I'm sure that the patter-downers were following the rules and regs, but this doesn't seem to be a well targeted effort.

I'm familiar with the argument against law enforcement using profiling to reduce crime and protect public safety. I understand that this can lead to abusive practices by overzealous police officers. But I wonder if, as El Al believes, this can be a legitimate tool in law enforcement's armamentarium. I'm open to the debate here.

I'm a physician and I certainly profile my patients. I don't have a single template for treating abdominal pain in all patients. For example, if I see a recent immigrant from China with stomach issues, a part of the world where gastric cancer is relatively common, this may affect the speed and intensity of my evaluation. If an American born patient comes to my office with the same complaint, my response might differ. If breast cancer is more common in Ashkenazi Jewish women, shouldn't we factor this in when we are advising them on risk reduction? Certain populations have different health risks. Physicians are always trying to separate out patients who might warrant special attention.

If you are trying to reduce a certain disease that is largely restricted to 1 segment of the population, doesn't it make sense to target this segment rather than everyone?

I realize that health and law enforcement may not be analogous. I also realize that profiling in law enforcement is a very sensitive issues, particularly for minorities who have been victimized by this technique. But, if we abandon the procedure entirely, are we forfeiting a tool that could keep us all safer?

El Al has a different view. Here, in America, TSA is trying to detect evil stuff. El Al is trying to detect evil people. Which makes more sense?

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.

We need to rethink professionalism

A new study in JAMA Pediatrics (free full text here) should make hospital epidemiologists and infection preventionists cringe. All physicians and advanced practice providers at Children's Hospital of Philadelphia were sent a survey on presenteeism. Of the 929 providers surveyed, 58% responded.

The big findings were as follows:
• 95% felt that working while sick puts patients at risk
• 16% would come to work with fever
• 30% would come to work with diarrhea
• 5% would come to work with vomiting
• 56% would come to work with acute onset of respiratory tract symptoms
• asked several ways, >90% stated they would come to work while sick out of a sense of professional obligation

What I find most interesting about this paper is not how often sick health care workers come to work (though it's a big problem), but why they do so. And once again, professionalism rears its ugly head. Professionalism revolves around expectations and norms set by the profession. It seems to me that if we viewed this more through the lens of humanism rather than professionalism, we'd be better off.

From a humanistic standpoint, which holds a universal rather than parochial view, all would agree that individuals who are ill with potentially contagious diseases should not come to work (doesn't matter whether you're a doctor, a teacher, or a plumber). Similarly, in the white coat debate, professionalism drives the argument that physicians should wear a white coat. Humanism would dictate that attire should be practical, comfortable, safe, and personally desirable.

Several years ago, Judah Goldberg wrote a great essay in Academic Medicine that I often quote and recently re-read on the conflict between humanism and professionalism. It really crystallized for me the differences between the two philosophies, which are often in conflict, and once the differences are made clear, it's easy to see the corrupting influence of professionalism. It's worth a read.

Michael B. Edmond, MD, FACP, is the Chief Quality Officer at the University of Iowa Hospitals and Clinics. This post originally appeared at the blog Controversies in Hospital Infection Prevention.
Wednesday, August 19, 2015

Health care rationing: the roar and the silence

I have gotten the impression over my years in medicine that essentially no one likes to talk about rationing care. Those who oppose the concept on ideological grounds certainly don't want to talk about it. Those who are in acute need of care for themselves or someone they love are potential “victims,” and especially don't want to talk about it. Policy makers who may want to talk about it have learned not to like doing so, because no one seems to like hearing what they have to say.

Despite that, the relentless imposition of a simple fact, resources are never infinite, has resulted in some experimentation. Notably, the state of Oregon initiated a program in the mid 1990s that was called health care rationing by most observers. Defenders were prone to say it never really rationed health care, but rather was a system for “prioritizing funding for health care through systematic and public ranking of medical services.” But add finite resources to that characterization, and run it through a universal translator, and “rationing” pops out. By whatever name, the experiment in Oregon lost support over time, and eventually, came undone. To my knowledge, there has been nothing like it in the U.S. since.

That is not to say rationing has become irrelevant. Quite the contrary, health care economists, medical philosophers, and policy makers across the political spectrum, have suggested that we ration health care resources routinely in the U.S.

There is an unavoidable consequence of doing something you aren't willing to talk about doing: you do it badly. No discussion means no probing, no deep thinking, no careful exchange of ideas. We do, indeed, ration health care in the United States; we just don't talk about it, with the result that we ration it altogether irrationally.

What do I mean? There is almost no limit to what we will, and routinely do, spend on the often desperately futile care at the very end of life in very elderly people with multi-organ-system failure, a long history of serious chronic disease, and virtually no chance of getting back to a quality of life any of us would be willing to accept. But we routinely fail to cover the costs of effective preventive services that can save both lives and money, and impose substantial barriers in the form of co-pays and deductibles on care that is essential. One could argue that rationing of dollars is even more extreme in the research context, where we spend a lot on treatment advances and near-to-nothing on prevention; lavishly on learning what we don't know, and negligibly on putting what we do know to good use.

At the peak of attention to health care models, before the Affordable Care Act came off its assembly line, colleagues and I published a proposal for a tiered model. We suggested that certain varieties of care, both effective preventive services, and urgently needed treatments, should be available to all with no financial barriers. A tier of services of slightly lesser value or need could be available to all, but might reasonably involve some barriers in the form of copays. Finally, a tier of quite discretionary services might come entirely out of our own pockets. This is one example of potentially rational rationing.

But as noted, we don't like to talk about rationing. So we just keep doing it badly.

As some of you likely know, I have for several weeks now been championing the case of a 23-year-old college student with the dreadful, dual burdens of a rare, life-threatening cancer; and an insurer refusing to cover the costs of care recommended by his oncologist. I write today partly to announce that the Change.org petition I started on behalf of Manny Alvarez and his family, directed at getting Blue Cross Blue Shield of Florida to reverse its denial of coverage, has over 100,000 signatures. That is a roar.

But I am puzzled by the silence. We are, after all, a population of some 3 million here in Connecticut, so 100,000 is just over 3% of us. We are, in the U.S., some 300 million; so 100,000 is just 0.03% of us. That's a lot of silence.

Of course, we can trim those silent majorities from 97% and 99.97%, respectively, by eliminating all who are too young, too old, have no Internet access, don't speak English, or just never got the memo. Still, there's a lot of silence left.

There are many reasons for it, but I am quite confident that agreement with Blue Cross Blue Shield of Florida is not on the list. If anyone, anywhere believes that the right time to ration care is when a formerly healthy, vibrant 23-year-old has his one best shot at surviving by use of care chosen and recommended by an expert oncologist, I've never met them. I am quite sure they don't exist, outside of insurance companies.

Frankly, I would like less silence, so if you have not yet shouted your signature on Manny's behalf, I ask that you do. Please chip in and help the family directly while you are at it, if you can. But either way, Blue Cross Blue Shield of Florida should know that agreement with their decision is not among the explanations for your silence. In contrast, impassioned disagreement is exactly the reason for the roar of over 100,000 who stand with Manny Alvarez.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
Tuesday, August 18, 2015

Still caring

I got a call from a patient who had a family member sick and in the ICU. She wondered if I could come over “to offer support.” Even though the family member wasn't a patient, I thought it would be good to go.

The ICU brought on flashbacks to my residency years, in which I spent a lot of time in the ICU. There was a weird mix of it being both foreign and familiar, as I haven't cared for adults in the hospital for many years, let alone the ICU. There were the familiar walled-off rooms with beeping IVs and the sighs of the ventilators, the nurses documenting, and walking from room to room. Despite the intense nature of the place, there was an overall sense of calmness and control.

I went to the room where my patient was with her family member, and got a run-down of his current status. Things were bleak, and the situation very complicated. A nurse came in and explained the most recent status changes. Things had improved since the night before, but were still tenuous. ”I actually think it's pretty miraculous that he's still here,” she told us.

The intensivist's nurse-practitioner then stopped by and gave me a more detailed story of what had gone on. I asked questions, more for information than to help in care (what could I possibly contribute?). There were lots of terms she used which brought on echoes from my past: levophed, peak inspiratory pressures, wedge pressures, paralytics, DIC, hemofiltration … the list went on. It was if I had been fluent in a language, but had not used the tongue in many years. Familiar/foreign words flowed and brought me back to passable fluency.

She gave me 15 minutes of her time explaining the situation, when 2 more people stepped up: the intensivist and the nephrologist on his team. Both doctors were people I knew fairly well but from whom I had drifted, as our clinical paths had simply not crossed. Had it really been 10 years since I last saw them? They looked older. I guess they were saying the same about me.

Following a quick explanation of the changes in my life and a chance to catch up on theirs, we got back to the topic of the patient. Clearly they had invested much time and energy to his care. I was again flooded with the familiar/foreign medical dialect of the ICU. It was a delight to see these people and to reconnect after a prolonged time apart.

As I talked to all of these clinicians, my patient (the one who had called me to be there for support) stood and listened intently, contributing frequently to give her interpretation of the situation. The nurses eased in and out of the room, doing their tasks as I listened to my colleagues and asked my own questions.

With the story told and catching up on our lives lived apart, my colleagues left and I was again alone with my patient and her ill family member. ”The doctors and nurses here have been absolutely wonderful,” she said. I couldn't argue with this assessment. Apart from the fact that I got to catch up with old friends, it was impossible to miss the attentiveness everyone gave, not only to the patient, but to the needs of the family. ”We fell like they've adopted us here into the ICU. It's been real amazing.”

So much bad stuff is (justifiably) said about the health care system, and how it is becoming distant, frustrating, impersonal, and dehumanized. That is certainly true in many settings, as we value data, documentation, diagnosis codes, and checklists over the humans for which it's supposedly built. My office is a sanctuary for me, my staff, and my patients from that impersonal world. But the time I spent in the ICU encouraged me greatly, as I saw that people there, in the middle of one of the most stressful settings in my profession, are still caring. They are caring about the work they do, caring about their patients, caring about the families, and caring about doing what is right. In the midst of the hectic world of the ICU, they took the time to talk to me even though I was not at all involved in the patient's care.

The heart of health care is still beating, despite the ACOs, EMRs, PCMHs, ICD-10s, and all the other sideshows demanding to be center stage. I was proud of us as medical professionals to see what I saw in the ICU. It's easy to be cynical, and it is important to be critical, but it's also important to tip our hats to the people who, despite the demands of the work, are still caring at the end of the day.

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.

Still caring

I got a call from a patient who had a family member sick and in the ICU. She wondered if I could come over “to offer support.” Even though the family member wasn't a patient, I thought it would be good to go.

The ICU brought on flashbacks to my residency years, in which I spent a lot of time in the ICU. There was a weird mix of it being both foreign and familiar, as I haven't cared for adults in the hospital for many years, let alone the ICU. There were the familiar walled-off rooms with beeping IVs and the sighs of the ventilators, the nurses documenting, and walking from room to room. Despite the intense nature of the place, there was an overall sense of calmness and control.

I went to the room where my patient was with her family member, and got a run-down of his current status. Things were bleak, and the situation very complicated. A nurse came in and explained the most recent status changes. Things had improved since the night before, but were still tenuous. ”I actually think it's pretty miraculous that he's still here,” she told us.

The intensivist's nurse-practitioner then stopped by and gave me a more detailed story of what had gone on. I asked questions, more for information than to help in care (what could I possibly contribute?). There were lots of terms she used which brought on echoes from my past: levophed, peak inspiratory pressures, wedge pressures, paralytics, DIC, hemofiltration … the list went on. It was if I had been fluent in a language, but had not used the tongue in many years. Familiar/foreign words flowed and brought me back to passable fluency.

She gave me 15 minutes of her time explaining the situation, when 2 more people stepped up: the intensivist and the nephrologist on his team. Both doctors were people I knew fairly well but from whom I had drifted, as our clinical paths had simply not crossed. Had it really been 10 years since I last saw them? They looked older. I guess they were saying the same about me.

Following a quick explanation of the changes in my life and a chance to catch up on theirs, we got back to the topic of the patient. Clearly they had invested much time and energy to his care. I was again flooded with the familiar/foreign medical dialect of the ICU. It was a delight to see these people and to reconnect after a prolonged time apart.

As I talked to all of these clinicians, my patient (the one who had called me to be there for support) stood and listened intently, contributing frequently to give her interpretation of the situation. The nurses eased in and out of the room, doing their tasks as I listened to my colleagues and asked my own questions.

With the story told and catching up on our lives lived apart, my colleagues left and I was again alone with my patient and her ill family member. ”The doctors and nurses here have been absolutely wonderful,” she said. I couldn't argue with this assessment. Apart from the fact that I got to catch up with old friends, it was impossible to miss the attentiveness everyone gave, not only to the patient, but to the needs of the family. ”We fell like they've adopted us here into the ICU. It's been real amazing.”

So much bad stuff is (justifiably) said about the health care system, and how it is becoming distant, frustrating, impersonal, and dehumanized. That is certainly true in many settings, as we value data, documentation, diagnosis codes, and checklists over the humans for which it's supposedly built. My office is a sanctuary for me, my staff, and my patients from that impersonal world. But the time I spent in the ICU encouraged me greatly, as I saw that people there, in the middle of one of the most stressful settings in my profession, are still caring. They are caring about the work they do, caring about their patients, caring about the families, and caring about doing what is right. In the midst of the hectic world of the ICU, they took the time to talk to me even though I was not at all involved in the patient's care.

The heart of health care is still beating, despite the ACOs, EMRs, PCMHs, ICD-10s, and all the other sideshows demanding to be center stage. I was proud of us as medical professionals to see what I saw in the ICU. It's easy to be cynical, and it is important to be critical, but it's also important to tip our hats to the people who, despite the demands of the work, are still caring at the end of the day.

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.

5 things that doctors learn from their patients

For all the talk about patient-centered care and a new health care paradigm, which is of course the right way forward, the doctor-patient relationship will always remain relatively one-sided because of the nature of the profession itself.

Essentially, patients come to doctors for help, and the knowledge transfer, advice and guidance flows in one main direction. But that doesn't mean that doctors, who are among the most highly educated professionals out there, aren't constantly learning and being inspired by their patients too. Go into any “doctors' workroom” in a hospital, and you will hear these conversations taking place every day. The practice of medicine is a uniquely humbling profession. Here are 5 things doctors learn from their patients all the time:
1.People are brave and have a remarkable capacity for resilience
Patients courageously put up with terrible illnesses and refuse to give up in the face of adversity. Whether we are talking about cancer, disabling cardiovascular disease or infections, our patients inspire us with their bravery and determination. How many times do we also see patients surrounded by their loved ones, still managing to laugh, smile and remain optimistic, despite the horrendous circumstances.
2.Family is everything
The way we see families come together during times of illness to support each other, reminds us through all the “background noise” that occurs during the hustle and bustle of daily life, that it's really true that nothing whatsoever comes before family and loved ones. They are the only ones that matter and will support you during those bad times.
3.Things can change in an instant
Illness strikes out of the blue. One minute everything is okay and you seem not to have a care in the world (or what you cared about now seems trivial), and then everything is turned upside down by a shock diagnosis. It can happen to anyone.
4.What we do matters
The practice of medicine, for all its challenges, remains a very important and special profession. Doctors (and for that matter nurses) have the opportunity to do more good in one day than most people have in a month. It could be going back to see your patient again, comforting and consoling, or talking about something that is important to them. It's easy for doctors to forget this as they churn through their patient lists, but patients remember and appreciate every nice interaction.
5.Life is short
How many elderly patients talk to us about “wishing they were 50 years younger” or changing the way they did something years ago? If doing what we do doesn't give us perspective and force us to get our priorities right—nothing will! It's a cliché, but life really is short and whatever we want to do, we owe it to ourselves to do and be happy. Enjoy the little things and have no regrets

Health care will always be about personal relationships and be an emotional arena to work in. As Hippocrates himself said over 2 millennia ago, “It is more important to know what sort of person has a disease than to know what sort of disease a person has”. It was true back then, and it's still true. Every doctor has stories to tell about incredible patients they've met and been inspired by.

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, August 17, 2015

CME, industry, and outcomes

Medical literature describes the challenges of demonstrating the impact of CME on physician learning (with a focus on the lack of impact), and the need to reform the current system. Writers suggest that it really is not having the impact that it should, given the financial resources provided. Others have questioned how it is funded, suggesting that it may be biased given the resources provided by industry, and that it should be changed.

While I admit my own bias as an associate dean for CME for a major medical school, I feel that it is important to study the peer-reviewed literature to best understand this important topic.

First, is the industry influence really that significant? A piece by Cervero discusses this, and found limited evidence of the impact of industry influence on CME. In the recent ACCME 2014 report (Table 8), only 11% of accredited CME received commercial support from industry. My interpretation of this is that the commercial support is certainly not an overwhelming part of CME programs (our own institutional data would definitely mirror this finding).

Second, what is the real impact of CME? The same above author recently published a piece in JCEHP (full disclosure: I am the social media editor for this journal, but was not involved in any way in the creation, revision, or decision to publish this manuscript) that concluded that CME can indeed impact patient outcomes and physician behavior (the former more than the latter).

Third, improvements in how CME is disseminated should occur. Within this realm, patients should be included, and interprofessional learning should occur in team environments; this is highlighted by the new President and CEO of the ACCME, Dr. Graham McMahon, in a Viewpoint piece in JAMA.

So where should we go from here? I think there are several things we can consider. Most importantly, physicians and other health care providers should continue to learn in order to provide optimal care of their patients in a changing environment; CME is one way to aid this learning. Those in the field have been thinking about how to restructure it for many years and have made major strides in focusing on quality improvement. Second, we should also consider learning health care systems as a way to promote learning for those who provide care for patients. Lastly, we should be diligent about using technology to make our learning more effective. Examples include online journal clubs and virtual communities of practice. Given the complexities that abound in medicine in the current environment, anything that can make the process of learning how to “keep up” and best care for our patients easier should be welcomed.

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.

Rethinking a no-brainer

What does someone having a heart attack look like? I think the New York Times captured what many of us probably have in mind, when they published this picture as part of a recent series on advances in cardiovascular care:

Here is the iconic middle-aged guy, in extremis, pointing to his chest, with a team of health care professionals at the bedside. There are also signs of initial management: He has ECG electrodes on his chest, an IV in his left arm, what looks like monitor/defibrillator pads on his right chest and below his left arm and, of course, an oxygen mask.

What is wrong with this picture?

Well, a recent study from Circulation suggests that the oxygen mask may be doing more harm than good. Australian investigators randomized over 600 patients with suspected ST-segment elevation myocardial infarctions diagnosed by paramedics in the field to get either standard pre-hospital oxygen supplementation (8 L/min via face mask) or no oxygen supplementation. Among the 441 with confirmed STEMI, those who received the O2 had larger infarcts, as measured by cardiac enzyme release and follow-up cardiac MR scans. They also had a higher incidence of recurrent infarction and cardiac arrhythmia. The study was too small to detect differences in mortality or other clinical endpoints.

An accompanying editorial points out the practice guidelines for MI care, developed by the American Heart Association and American College of Cardiology, have downgraded the recommendation for supplemental O2 over several revisions, citing a lack of credible evidence to support its use. The current guidelines (2013) make no recommendation.

I think there are a couple of important lessons here:
• Even the most “sensible” treatments need to be put to the test to see if they really work. Just to continue with the MI theme, it wasn't that long ago that we routinely treated all STEMI patients lidocaine, then kept them in bed for weeks while we tried to suppress their post-MI PVCs with quinidine. All of those practices made compete sense, and all were later shown to be more harmful than helpful.
• Practice guidelines should be very “humble” about what they recommend, especially in an age when adherence to “standards” is used to assess the quality of care. Guideline developers should stick to making their recommendations on the basis of good evidence, and should, as in this case, revisit even the most tried and true recommendations as they raise the bar on quality of evidence and new information becomes available.

What do you think?