Friday, October 30, 2015

Why are medical bills completely inscrutable and full of mistakes?

Within the last two days I received a bill for my glasses and read a post by a friend ranting about medical billing mistakes. This is a huge problem that is so common that it could be considered the norm. It is ridiculously expensive and could probably be fixed.

My exposure to medical bills has been through patients who show them to me, hoping I can make sense of them, my occasional foray into the world of being a healthcare consumer and the woes of friends and family. I can say, with confidence, that I have never read a medical bill that I understood. When I do choose to dig a bit deeper, overcharging and errors are more common than not.

It is very hard to get good statistics on this, but the lower end of what I'm seeing suggests that one in 10 bills contain errors. It's probably higher than that.

Common billing errors include being billed for procedures that were cancelled, being billed twice for the same thing, under different names, being billed for a more complex version of what was actually done and being billed for more time than was actually spent. How do these happen? In general the errors aren't deliberate fraud. Frequently staff in the billing office do not talk to doctors but produce bills based on what the doctors write. Doctors don't document what happened right away if they are busy and so by the time they do make a note, details are often fuzzy. In the case of billing for canceled procedures, the only paper trail available to billers may be the order for the test, and the cancellation may have been communicated by voice, on the fly. When doctors do bill for themselves, it may be difficult to find the correct code, so, in a hurry, we just settle on the first one that resembles what we did. Most of us are not interested in getting better at billing because we hate it. We weren't trained to do it and it takes us away from patient care.

Patients often (but certainly not always) know what did happen. Their bills, though, are written in some long forgotten Martian dialect which makes it really difficult to correct the errors.

My bill for glasses, which turns out to have been correct (after two phone calls) is a good example of what is wrong with medical bills. I apparently owed $137 for “lens sphcyl bifocal 4.00d/0.1, and $155 for “progressive lens per lens” and also more money for “lens polycar or equal” (which I would have assumed was my lens sphcyl, but I guess not), also the anti-reflective coating and a miscellaneous vision service and a miscellaneous product which apparently meant that they charged to drill a hole in the lens and polish it. Sales tax I could figure out on my own. Also the bill didn't say anything about insurance, which does pay some portion, and the biller was not planning to submit it. A separate bill has arrived detailing the cost for my exam, also written in some language that I don't speak. The bills are dated a week apart, for unclear reasons. Theoretically I should be pretty well positioned to understand this sort of thing, after 3 decades in the medical field. I'm guessing others, who might be less educated, sicker, more fatigued or less assertive would simply give up and not check the bill at all.

My friend's issue was being billed for copays that he actually paid at the time of service, then getting notices that he was delinquent for not paying them, having to call the billing office multiple times and eventually having to appear in person in order to get it fixed.

Because billing in excess of services usually leads to making more money, there is no real economic incentive to do this right. A responsive and intelligent problem solver in the billing office may actually lose the practice money, if he or she uses the relevant skills to solve customer complaints. The only economic reason to reduce inadvertent overbilling is to avoid being caught and penalized by insurance companies. There are definitely medical billing specialists who delight in doing their jobs accurately, but there is no cash reward for this sort of behavior.

The most effective first step toward taking care of the problem would be a requirement (it could even be a law) that medical bills be descriptive enough that regular people can actually understand them. The affordable care act made health insurance companies describe their services in ways that average people could know what they were buying. If people could actually read and understand their bills, they could see if they were correct. We could even tack on to the law a time limit for resolution of a query. Wouldn't it be sweet if a billing question would be fielded in 24 hours and resolved in a week? That doesn't sound too difficult.

The whole issue of medical billing is, of course, wrong in a very big way, since its existence is based on fee for service. As long as providers can make more money for doing more things and more complex and difficult things, there will be economic pressure to do more intense medicine on more people, thus creating more people who have been medicalized into being sick. We do, though, have fee for service medicine at present, so it's time to support the (not yet written) “Medical Bill Clarity Act of 2015.”

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.

Being black and a doctor in America

Imagine you've a new medical student. You're trying to prove yourself among your professors and your peers. You dress the part, you work hard, and early on you start feeling like you can do it.

Then 1 morning as you enter the lecture hall, the professor says, “Oh, you're here to fix the lights. What took you so long?”

You turn around, thinking he can't be talking to you. But there's no one behind you. He has simply assumed that you've come to answer his maintenance request, because of the color of your skin.

Now imagine you're a resident, a doctor-in-training, working in hospitals to diagnose and treat patients at all hours of day and night. You enter a cubicle in the Emergency Department to evaluate your next patient, and he blurts out, “I don't want no n**ger doctor.” Welcome to the profession.

Such are the experiences of many African-American medical students and doctors in the U.S. Not only must minority medical students excel with the content of medical science, they must develop strategies for coping with people's pre-conceived notions about them based on their race.

A new memoir by 1 black doctor, Damon Tweedy, recounts his journey through these travails to become a faculty member in psychiatry at Duke University.

I was fortunate enough to interview Dr. Tweedy recently, and I found him to be just like the self he presents in the book: thoughtful, warm-hearted, and very open and engaging. His memoir is an excellent read, one that I would strongly recommend to anyone thinking about joining the health care field, or anyone who likes memoir, recent U.S. history, or the study of race relations.

His book has generated reviews in major news sources, and while all of them laud his candor and writing, some criticize Dr. Tweedy for not fully addressing the policy questions surrounding the dearth of blacks (particularly black males) in the medical profession. I think this is an unfair criticism, because in telling his story, Tweedy moves the discussion forward and teaches Americans not in the medical profession something that the folks in charge of medical education already know.

Tweedy's book will move us forward in creating more inclusivity in Medicine. It's incumbent on all of us in health and education to think through ways of improving this imbalance.

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.
Thursday, October 29, 2015

Going viral is bad for your health

CNN hosted the 2nd Republican presidential debate, and unfortunately, the topic of vaccines came up. Donald Trump had previously suggested that vaccines can cause autism. When asked about this he responded, “You take this little beautiful baby, and you pump—I mean, it looks just like it is meant for a horse, not for a child, and we had so many instances, people that work for me, just the other day, 2-years-old, beautiful child went to have the vaccine and came back and a week later got a tremendous fever, got very, very sick, now is autistic.”

He went on to say that he's not against vaccines, but just thinks the same total dose should be given in smaller doses and spaced out more.

Donald Trump is not a doctor, so why is he giving medical advice? Republican presidential hopeful Dr. Ben Carson, a retired pediatric neurosurgeon, said, “We have extremely well-documented proof that there's no autism association with vaccinations. But it is true that we are probably giving way too many in too short a period of time.” Although he at least discredited the theory that vaccines cause autism, he agreed with an alternative dosing schedule. Fellow debater Senator Rand Paul, who is also an ophthalmologist, said, “I'm all for vaccines, but I'm also for freedom. I'm also concerned with how they're bunched up.”

The American Academy of Pediatrics put out a statement saying there is no alternative dosing regimen. Based on lots of scientific literature and much expert opinion, the current schedule was designed to optimize benefit versus risk. Delaying vaccinations increases the risk that children will catch the disease before they have been protected. It's also psychologically more traumatic. Studies have shown that a child is just as traumatized if they get 1 shot or 3 shots at one visit, but 3 visits with a shot at each 1 is worse than one visit where they get 3 shots. Spacing out the vaccines also means more cost, and more exposure to sick kids each time they are brought for a vaccination.

So where did this idea of spacing out vaccines come from? Pediatrician Dr. Sears published “The Vaccine Book” in 2007 that proposed alternative vaccination schedules. But that was just his opinion, and was not based on studies to show that it's safe and effective.

The belief that vaccines can cause autism came from a study published in 1998, that has since been retracted because it was found to be based on fraudulent data. Some people still choose to believe it.

You might argue that spacing out the vaccines is better than nothing. That's true, however that's like saying that only wearing seat belts every other day is better than nothing. That's true, but it's still much better to use it the way you're supposed to.

Republicans don't have good record when it comes to vaccines. Four years ago Rep. Michele Bachmann (R-Minn.) attacked Texas Governor Rick Perry for mandating that young women get HPV (human papilloma virus) vaccine. He later backed down. That vaccine prevents women from getting cervical cancer.

I may not agree with politicians when it comes to issues regarding such things as immigration, taxation, use of the military, domestic spying, or abortion, but those are legitimate areas for politicians to debate and legislate. They can even debate the wisdom of the Affordable Care Act (ObamaCare), but they should stay out of the science of medicine. That includes politicians who happen to be physicians, unless they are stating medical facts, rather than pandering to what their constituents want to hear.

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.

Let's stop all this 'provider' stuff

It's a change in nomenclature that's come a bit out of the blue over the last few years. The forces appear to be aligning to gradually push the word “doctor” out of the center and toward the periphery of health care.

Whether we are talking about administrative communication or health care information technology order entry, it seems that we are no longer “physicians” or even “clinicians,” but we have all become grouped together under the non-specific term of “provider”. This is a huge change, and from what I've seen has gone barely challenged or even questioned. Even calling a pharmacy a few years ago has changed from “Doctors press 2 now” to “Prescribers press 2 now”!

Now I make no judgment about my non-physician colleagues, who are increasingly providing care at the frontlines of medicine. It's not about them, or what they do (in fact, “Nurse Practitioner” or “Physician Assistant” sounds far more professional than “provider” anyway!). The issue is with the term “provider” and how a group of highly trained physicians who have in most cases spent well over a decade in training have allowed themselves to be grouped under this umbrella term.

Why does this matter? Well, there's a lot in a name. Can you imagine another group of professionals, whether they be attorneys, accountants or dentists, allowing themselves to be lumped together under terms like “legal provider”, “finance provider” or “dental care provider”? Unlikely. It's so non-specific, and is used almost anywhere including referring to “cable TV providers”, “electricity providers” or “telephone providers”! It's a pattern in life that if you want to lower the power and clout of a group of people, start first by changing what you call them, and replace a respected title with a murky one.

In fact, I am equally surprised by how so many of my physician colleagues have jumped on the bandwagon, especially those in leadership positions. I've seen them openly be in a room surrounded by their physician colleagues and talk about how many “providers” are on-call for the weekend or how many “providers” are joining the new group (even though it's all physicians).

So here's a suggestion, if we mustn't refer to doctors as doctors anymore—why not use a slightly better term than “provider”? How about “clinician”? At least that sounds remotely more scientific and distinguished?! In the meantime, here's how you can avoid becoming a “provider”:
• When you are emailed by an administrator who is referring to you and your fellow colleagues as “providers”, correct them immediately and never use that word to describe yourself or your physician group
• If you are involved in the design of any new system's wording, whether it's on the computer or on a written form, if “physician” is really too specific, encourage use of the word “clinician” instead
• Ask your hospital IT department why the word “provider” is everywhere across the IT system and politely ask them if they can change the wording
• When you are filling out any paperwork that is asking for the “provider's signature”, add in the word “physician” or “MD”
• Be proud to call yourself a doctor!

We belong to an ancient profession. The word doctor is more than 2,000 years old, aptly derived from the Latin doctus, meaning to teach or instruct. Physician was used traditionally to describe a medical doctor, and King Henry VIII granted the first charter to form the Royal College of Physicians in 1518. In almost every country in the world, a medical doctor is considered to be among the most noble and prestigious professions, the title only conferred after 1 of the most rigorous university courses in existence. It is a privilege and honor to be one. You worked hard to become a fine doctor and clinician. If you don't allow yourself to be called a “provider”, you won't be one. If however, you allow yourself to become a “provider” at every turn, then that is what you shall be.

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.
Wednesday, October 28, 2015

Speaking freely of guns

I am about to speak freely of guns, because I can. When I do, many of you will no doubt be inclined to mutter “amen,” quietly to yourselves. Others of you will no doubt feel compelled to throw up all over me, as you have done under similar circumstances before. I expect to hear preferentially from the latter group, because they seem perennially inclined to shout; but frankly, Scarlet, I don't give a damn. Whatever their current predilection for projectile vomiting, I was there first. I am sickened and disgusted by us. But first things first.

Before speaking freely of guns, I am inclined to speak freely of speaking freely, again because I can. I can, because of the First Amendment to the U.S. Constitution. I think we should spend a little time there, before wading into weeds for the sake of the Second. The First Amendment is … first. It comes before the Second. It is primary, numero uno. If the Second Amendment is sacred, the First is, if anything, more so. It is, if anything, more American, more patriotic, more … constitutional. Those inclined to go beyond the reverence we all feel for the Founding Fathers and impart to them attributes they do not warrant—omniscience, infallibility, immunity to the law of unintended consequences—must be in for a pound if in for a penny. Those inclined to defend the utmost literalism in every utterance from 1789 as if immutable in ever-changing context are thus obligated to defend comparably the choice to make the First Amendment first, and the Second Amendment second.

The First Amendment is a complicated and multifactorial bit of rhetoric, as are the other entries in the Bill of Rights. It is the one that encompasses freedom of religion, freedom of assembly, freedom of the press, and the freedom to petition the Government. Of note, that capital “G” is the work of the founders, not me. I invite the literalists to ponder the implications for the respect of government they may have felt, relative to what seemingly prevails today.

In any event, the First Amendment does go off in several directions, but I only want to speak about speech. It stipulates that Congress shall make no law “abridging the freedom of speech.” For a moment, let's treat that with the same literalism applied by a particular faction to the Second.

When the founders talked, and wrote, of speech in 1789, there were only two ways to do it: talking, and writing. Our species invented its approach to talking before the advent of any technology. The specific origins of the printing press are now somewhat subject to the revisionism that bedevils all of history, but reliably date back to long before 1789, to the mid fifteenth century at the latest. Everything else came after.

We didn't have Morse code or the telegraph until Samuel Morse and others invented these in the 1840s. We didn't have telephones until 1876, give or take. We didn't have radio until 1895.

And, of course, we didn't have the Internet until Al Gore invented it rather recently, and we didn't have the iPhone 7 until sometime tomorrow.

Yet, all of these technologies are now clearly subsumed within the category of “speech.” Right now, for instance, you and I are engaged in speech. This is clearly protected under the Constitution of the United States. But what, exactly, is “this”? It involves my computer, and yours; my word-processing software, and yours; my Internet service, and yours; and so on. It may even involve orbiting satellites. And since it is “speech,” any law “abridging” any part of it is unconstitutional.

Houston, we have a problem. Not everyone has a computer, or cell phone, or Internet access. Freedom of speech is thereby abridged.

There is a defense, I suppose: the costs of phones, computers, software and Internet access may be permissible under the laws of the land, but are not themselves established by the laws of the land. Congress has not made a law stipulating what Apple or Microsoft can charge us.

But, on the other hand, if the Constitution guarantees us freedom of speech in just the same way it guarantees us the right to “keep and bear Arms,” perhaps Congress is obligated to remove barriers to access. Note that the Second Amendment only refers to a right to the thing, whereas the First Amendment refers directly to the thing itself. In other words, if the Second Amendment universally protects the right to bear arms, the First commensurately protects not the right to freedom of speech but freedom of speech itself. Read the text here, and see the difference for yourself.

Whether or not Congress is obligated under the Constitution to remove all barriers to everyone for every new technology ever invented that serves as a medium for speech, it is expressly precluded from abridging such access itself. The case could be made that if financial barriers preclude some of the people from freedom of speech by New Age, technological means, and if sales taxes figure in that prohibitive cost -- then Congress, and the laws of the land, are implicated in abridging. The view from that bridge is of a Constitutional crisis.

Or not. In the area of speech, for whatever reason, we don't seem to have an analogue to the NRA. We don't have a radical group with blatant ulterior motives imposing on the majority a torqued interpretation of the Founder's words, and requiring their application to things uninvented in even the wildest imaginations of their time. Were such a group to exist, we would have far more reason for turmoil about the tyrannical abridgment of freedom of “speech” in all of its modern incarnations than anything to do with guns.

Which brings us back to guns, about which I am constitutionally at liberty to speak freely. But of course, there isn't much to say that hasn't already been said.

If the opposition of the NRA and its cronies to gun control derives truly from concerns about tyranny, then they are hypocrites for the imposition of minority will on the majority is tyranny. The majority does not want to interfere with the Second Amendment; we just want it interpreted sanely. The argument that it requires no interpretation is a non-starter. Clearly, convicted felons in prisons aren't covered; that's an interpretation. Clearly, the amendment doesn't cover nuclear arms, chemical arms or biological arms; that's an interpretation. To my knowledge, not even the NRA wants everyone stockpiling smallpox and anthrax. Interpretation is unavoidable, and some of us think it ought to be sane.

As for the NRA and its allies, most of us know the motivations are all about liking guns, and/or liking the money that comes from selling them. We also know of many places around the world where guns are seemingly ubiquitous, and tyranny prevails just the same. We know of places with far stricter gun controls than we would ever consider in the U.S. with stable and fully accountable democracies. We even know what ensues when a country with loose gun control tightens it; a dramatic decline in gun-related deaths, not the advent of tyranny.

But for today, though my speech here is of course motivated by the latest calamity of our gun-related insanity in this country, I am inclined to focus it on speech itself. Guns are given their Constitutional sanctuary only in the Second amendment; speech is ensconced within the First. First things first, or so it should be. Minimally, what's good for the goose should be good for the gander. If the Second Amendment is obligated to cover “arms” uninvented and unimagined in the days of the Founders, why is the First not subject to just such terms for “speech”?

More reasonably, if the First Amendment is not interpreted to cover every technological means of “speech” unimagined by the Founders, that logic applied to the First should surely extend to the Second. We have, therein, a basis for societal opposition to high-capacity, semi-automatic weapons flowing freely, with no peril to Constitutional toes.

For now, we have an endless litany of tragedies to which we react with collective pathos and impotence, knowing for certain that we await the next. We have a bizarre double-standard, in which the First Amendment is spared the tortured literalism imposed upon the Second by those with ulterior motives.

And we have achieved a lamentable milestone in the annals of hypocrisy that would surely have the Founders more inclined to throw up than any of us. Under the guise of defending against tyranny, a well-organized minority denies the majority the expression of its will. That is, in a word, tyranny.

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.

Some thoughts on diagnostic errors

The Institute of Medicine released a new report, ‘Countless' Patients Harmed by Wrong or Delayed Diagnoses

We will read many opinions on the problem. Readers know that I have a great interest in this problem. I have thought about it often, and talk about it frequently. Here are a few tweetable thoughts.
1. Allow patient admissions without a diagnosis. Insisting the emergency department label the patient w/ a diagnosis often leads to anchoring heuristic which can lead to errors.
2. Receiving physicians (either consultants or hospitalists or outpatient physicians) must be skeptical of any diagnosis.
3. If the patient's course does not follow the textbook, you are likely reading the wrong page.
4. Teach learners to flirt with, even sleep with, but be certain before they marry a diagnosis (h/t Dr. Lourdes Corman).
5. When you feel confused, start again from the beginning, retake the history, redo the physical exam, and review the old records and the lab data.
6. Allow the responsible physician to delete incorrect diagnoses from the medical record.
7. Above all else, we must remain skeptical every day.

I remember prior to starting medical school hearing the phrase “great diagnostician.” During medical school I continued to have role models who championed the diagnostic process.

The IOM report focused on diagnostic errors, but we should also focus on the road to diagnostic excellence. Many diagnoses are straightforward and simple but some require time and thinking. Here are some more thoughts about how we get to diagnostic excellence and what interferes.
1. Many difficult diagnoses require time to think. Unfortunately, our payment system does not encourage spending more time on the diagnostic process.
2. The first clue to a diagnostic conundrum is the presence of a red flag or the absence of expected findings.
3. Diagnostic excellence requires deliberate practice. We must learn from every diagnostic conundrum, the ones we get correct and the ones we miss.
4. When we have to rush, we order tests rather than take a careful history and the history provides major clues most of the time.
5. We receive no rewards for correct diagnoses yet the patient often suffers from incorrect diagnoses.

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 as 2 parts here and here at his blog, db's Medical Rants.
Tuesday, October 27, 2015

Gone to Carolina

“Can't you see the sunshine?
Can't you just feel the moonshine?
Ain't it just like a friend of mine to hit you from behind?
Yes, I'm gone to Carolina in my mind.”
—James Taylor

For 13 days straight, I've asked the same questions. “Where are we this morning? Do you know where you are?”

Most days, it's something vanilla like, “We are right here.” You point down at the sheets on the bed. “Right, right, here.” You look up at me hopeful. And on some days fretful.

“Where is here?” I press.

“Right over here. Not yonder, but here.”

Which is technically true. But false at the same time.

Is this delirium or dementia? Or is it both of them stacked on top of one another? Your mental distance is yonder. It saddens me so I keep trying and asking the same questions over and over again. Hoping I'm wrong.

Yeah.

Your family says that you're pretty much “back to how you normally are.” And at an age too young to even qualify for Medicare, I wish they were all wrong. So I keep asking.

As of this morning, you were better with regards to what had you hospitalized. Your heart failure exacerbation had improved. The swelling in your legs had dissipated and the oxygen requirement caused by the fluid filling your lungs had waned. From a medical perspective, you could return home. And even though I'd already told your loving family, I still felt the need to tell you, too.

And so I did. You just looked through me with a vacant stare, smoothed out the covers, and sighed. A little hopeful but mostly fretful. I didn't really know what to do with that so I returned to the basics.

“Where are we this morning? Do you know where we are?”

“Oh. We here. We right, right here.”

I rubbed your cheek with my hand and smiled. “Where is here?”

This time you smiled back. “Greensboro, North Carolina.”

My eyebrows raise. This was new, on the last day no less. I'd never heard you say that answer before. Instead of following it up with my standard, “We are at Grady Hospital in Atlanta, Georgia,” I left it be. Because this time your eyes were dancing and your expression was so sweet, so innocent.

And, for once, not vacant. Or fretful.

I'd later learn from your daughter that this was where you'd been raised. Milking cows and running through fields with your siblings. The simplest time of your life had been there. Right, right there.

And so. Upon your discharge I left you there. And for the first time since you'd been hospitalized, some piece of me found solace in knowing that you were there. Gone to Carolina in your mind. Instead of here. Right, right here.

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.

Trigger happy?

The University of Maryland group has just published two new papers on the safety of contact precautions. One is an analysis of the data from the BUGG study (published in Clinical Infectious Diseases), which was a multicenter study of intensive care unit patients, and the other is a matched prospective cohort analysis at an academic medical center (published in Infection Control & Hospital Epidemiology).

Here's a quick summary of the 2 papers:

The authors' conclusions for both papers are essentially the same: concerns about the safety of contact precautions should not limit the implementation of contact precautions. One paper showed no difference in adverse events and the other paper showed that contact precautions was actually safer than not being in contact precautions, which I think is a counterintuitive finding for many of us.

The problem that I have with both of these papers is the use of the Institute for Healthcare Improvement (IHI) Global Trigger Tool (GTT) to determine the rates of adverse events. I have 3 concerns:
1. Are all of the events identified by the GTT causally linked to the exposure? For example, in the ICHE study, the strongest association was found for surgical events, and the association was highly counterintuitive: postoperative hemorrhage was found in 1 in148 patients in contact precautions vs 12 in 148 patients not in contact precautions. Given what we know about contact precautions, particularly that it reduces healthcare worker visits, what could be the causal mechanism for a higher rate of post-operative hemorrhage in patients not in contact precautions? Is there a confounder at play here? There may very well be a causal mechanism but I'm hard pressed to think of one.
2. The IHI GTT only looks for errors of commission, not errors of omission, and it seems likely that errors of omission would occur more commonly when a barrier to care is implemented (contact precautions).
3. The IHI GTT sets a 20-minute time limit for the detection of errors when reviewing a patient chart whether the patient was hospitalized for 1 day or 100 days. In the ICHE study, the patients were matched on length of stay; however, I don't think this resolves the problem. The GTT's ability to detect error is time dependent. So when comparing two groups, if one group truly has a significantly higher rate of adverse events, a lower proportion of the events will be detected in the group that has more events, reducing the difference between the two groups. In effect we have surveillance bias.

Even the IHI openly admits that this is an issue. Here's a direct quote from the GTT manual:

The IHI Global Trigger Tool was never intended to identify all adverse events. Experienced reviewers familiar with the IHI Global Trigger Tool will identify almost all events greater than category E in a patient record that can be reviewed completely within the 20-minute time limit. Events in the E category of harm involve more judgment and at times are not as obvious, so these are less easily identified and may be missed. When the 20-minute time limit is enforced not all adverse events are expected to be identified.

In both of the papers, the 3 issues cited above are likely biasing towards the null, making contact precautions to appear to be safer than it is. So I continue to be concerned that contact precautions may result in less safe care. I think that most people in the hospital epidemiology community regard the University of Maryland researchers as some of the best methodologists in the field, and I certainly hold them in very high regard. Nonetheless, I'm curious about their love for the Global Trigger Tool, and hope that they share their views with us on this blog.

Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on improving the quality and safety of health care, and sees patients in the inpatient and outpatient settings. This post originally appeared at the blog Controversies in Hospital Infection Prevention.
Monday, October 26, 2015

Leadership development

One of the things that I am most proud of about the North Shore–LIJ Health System is our institutional commitment to leadership training. There are lots of examples, but the best I know of are the “high potentials program” for administrators and the “leadership development program” for physicians. Both accept a fraction of nominated individuals, and provide a variety of support services, classroom training and mentorship to participants. Not surprisingly, the programs get rave reviews and the graduates are sprinkled in leadership roles throughout the organization.

I was recently asked to address a group of about 50 participants from both programs as part of a series called “executive forums,” in which a senior executive tells his “personal leadership story” and does a Q&A with the attendees. Sounds good, except because of some crossed lines of communication, I didn't realize that was the expectation until I had little or no time to prepare. As it turned out, I am glad I didn't have more time.

Since I was sort of “winging it” I kept my remarks informal and conversational, and just told the story of how my career unfolded, and ended up with me at the front of the room. I then tried to draw some lessons from the journey that I thought might be helpful.

To start, I made 2 observations about my own trajectory:
• I could make the path I took sound methodical and well-planned, but only because I was telling the story in retrospect. Prospectively, I was not “aiming” for where I ended up, there were lots of points in time where it could have gone in an entirely different direction, and the whole thing felt a lot more messy and uncertain along the way.
• I was fortunate to have a supportive spouse and a few key mentors, the value of both being hard to over-estimate.

And here are some of the things I said I learned along the way that I thought would be helpful to the group:
Keep the time horizon short. The world is changing too fast to expect that you can reliably predict what your work environment will be like or what opportunities may arise more than 3-5 years ahead.
Commit. I told the story of my trying to “avoid burning bridges” back to an old job when I was named interim holder of a new job I really wanted. I was killing myself and was not as effective as I could have done in the new role until someone pointed out to me that “it is really hard to steal second base if you never take your foot off of first.” After that, I let go of the old and concentrated on the new.
Say yes. Special assignments, projects, committees and the like often seem like a burden, but they are also a great way to learn new things, connect with new people and open new pathways in your career.
Seek out frank assessments. I can vividly remember a few conversations (some more than 20 years ago!) in which somebody did me a very big favor by pointing out my misconceptions or shortcomings. Those were tough, but incredibly helpful in redirecting me.
Get a coach. It is incredibly helpful to talk through work-related issues with someone who is invested in your success. All too often, the people we work with have their own agendas. In my experience, the closer you get to the top of an organization, the harder it is to sort out who you should be confiding in. A significant other can often fill this role, but be careful not to turn all your pillow-talk into work-talk.
Embrace change. It may sound kind of corny, but the pace of change in health care is so fast that you can't be successful without a willingness to acquire new skills or an openness to new ideas.

In the end, it was 1 man's story. I tried to make it clear that I was sure that there were other paths to take, and other principles to follow, but it seemed like a lot of what I said resonated with the group.

I hope you find it helpful too.

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, October 23, 2015

SPRINT stopped

The National Heart, Lung, and Blood Institute announced that is was stopping the SPRINT (Systolic Blood Pressure Intervention Trial) study early because the early results so emphatically showed that getting the systolic blood pressure (the top number, reflecting the arterial pressure when the heart is squeezing) to 120 or below saved lives.

We've known for half a century that blood pressure below 140/90 reduced heart attacks, strokes, and kidney disease. The SPRINT study was designed to address the question, “How low should we go?”

Apparently, lower than we'd thought.

What's elegant about this study is that it's a randomized controlled trial. This is the best kind of study, which compares groups, one doing the “usual thing” with an intervention arm, in this case the group receiving medication to lower their systolic blood pressure to 120 or below. More than 9000 people were part of the study, and all of the participants were aged 50 or older, which means that the study has oomph. Its results will have real-world applicability.

The study directors found such a significant reduction in the number of strokes, heart attacks, and deaths expected in a population that size in only 3 years that they felt it was ethically imperative to stop the study early to share the preliminary results as they are sure to change medical practice. When that happens, it is big news.

The results have yet to be published in a medical journal, which will take a few months. When that happens, we can more carefully examine what was done and draw more definitive inferences from the research.

Until then, I wonder, how low is too low for blood pressure?

And what about the folks at the older end of the spectrum? Doctors that care for older folks know that there is some inflection point at which physiology changes enough so that pushing down blood pressures and cholesterol numbers becomes counterproductive.

We will need more research to understand when it's right to back off on aggressive cardiovascular risk factor treatment. We don't want to medicate people to the point that they fall down and break their hips. We pledged to do no harm.

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.
Thursday, October 22, 2015

Make America and the medical profession great again

Even those who have but a passing interest in the American political know that Donald Trump is:
• very rich.
• leading in every poll.
• going to build a wall that Mexico will pay for.

One of these 3 statements will remain true even if Trump's campaign tanks. He will still be rich. I've heard some of his flailing critics who are claiming that he isn't worth $10 billion, but only $5 billion. Wow, that's a really potent attack strategy. I think that if his net worth is a mere $5 billion that he will manage to squeak by.

Because he is rich, he is self-funding his campaign. He points out repeatedly that his adversaries are taking millions from lobbyists and other special interests who will expect something in return. Of course, these candidates deny this, but we all know the truth here. Remember, access is power. If you donate a seven figure sum to support a candidate or a president, do you think it would be difficult to get your phone calls returned? Do you think that various corporations donate to specific candidates only because these candidates support “good government”? They do so because they want something in return. Many companies take no chances and donate to both Democrats and Republicans.

The New York Times recently reported on a published study that describes the practice of soliciting rich patients for cash to donate to support the physician's research or the medical institution. Readers are invited to review the article to become better informed. Donating to a medical institution is a praiseworthy and ethical act that merits commendation. If a philanthropist donates to support an institution's Alzheimer's research program or cancer vaccine research, then we should all be grateful. If a wealthy family decides to make a generous gift because a family member's life was saved, then everyone wins.

These examples are ethically distinct from a physician directly asking their patients for cash. Some programs try to carve the doctor out of the process while others don't. Shockingly, some doctors were offered a cash reward if his rich patient gave the institution a cash reward.

One not be a graduate student in bioethics to recognize how improper this scheme is. Here are a few crimson flags. Feel free to add your own.
• Should physicians should look upon their patients as revenue reservoirs?
• What preferential medical treatment would a donor expect and receive?
• Would a patient who declines to donate fear or receive lower quality care?
• Would physicians recruit rich patients with the hope of soliciting funds?
• Would a wealthy patient who is seeking care from a select physician be contacted by the development office for a “conversation”?

Who is going to make the medical profession great again?

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.

To improve patient and family satisfaction, start with this 1 simple thing

Patient satisfaction and improving the hospital experience are all the rage these days in hospital administration circles. Hardly talked about a decade ago, the issue has become the mainstay of many a discussion held in health care boardrooms right now.

Of course, this is due in no small part to the matter of HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) surveys and the fact that much needed federal reimbursements are tied to these ratings (and that's not necessarily a bad thing). The problem however for many hospitals and health care organizations is that the term “patient satisfaction” has become something of a bumper sticker, and we lose the forest for the trees when we try to discover the barriers to achieving better results.

Whenever you ask patients and families what they really want, the answers will actually be very simple and straightforward—like improving communication and making hospitals into more healing and compassionate environments. While hospital administrations lose sight of these very obvious areas for focus, the tendency is to spend massive amounts of time and money on solutions that aren't what patients are asking for, such as giving them glitzy “iPad computer surveys” or making doctors and nurses wear “Have a Nice Day” badges (Yes, that really happens). Speaking as someone who has worked in several different hospitals in very diverse parts of the country, I'd like to give one classic example of an everyday mistake that we make that stares us in the face, but we don't do anything about.

Let's think laterally for a moment. Supposing you are a customer in any other arena, how would you feel if the organization you are dealing with gave you the impression that you weren't welcome and wanted to push you out of the door as soon as possible? Yet this is what happens in the world of hospital medicine all the time.

The background is as follows: hospitals are under tremendous financial pressure to discharge patients as soon as possible and be sure that only patients who are “truly ill” are actually admitted to hospital. This is part of the reasoning behind the unpopular “inpatient” versus “observation” distinction that has swept through the system over the last decade. As hospitals obviously have to respond to avoid financial implications, this pressure is unfortunately passed onto patients, as we give them the impression that we want them to be discharged almost as soon as they enter the hospital emergency room! And while it is obviously in our patients' best interests to recover quickly and not spend an excessive amount of time in the hospital, everyone involved in health care must also avoid coming across as worrying more about the length of stay than the patient's actual illness!

A classic everyday scenario, that has played out in every hospital I've ever worked in, goes something like this: Case managers, who have to quickly determine a patient's admission status and likely length of stay, scrutinize the case as soon as they get into work in the morning. They immediately start making inquiries and will often speak to the patient or call an elderly patient's anxious relative to go over the discharge arrangements. This discussion frequently happens before the doctor has even had a chance to see the patient! So, the relative, who naturally has a number of questions about their loved one's health (and may be in a completely different part of the country), hears first from the case manager, who inadvertently gives them the impression that all the hospital wants to do is push them out the door as soon as possible!

Although the case managers themselves are under huge pressure to do this, the problem is that if we ever give our patients and families the feeling that our number one goal has nothing to do with their medical illness—what sort of hospital experience does that promote? We need to exercise supreme tact and discretion with how we deal with these issues, and be sure that we don't steamroll an already worried person with bureaucratic technicalities. It may be a necessary thing to do, but we can do it better and more compassionately. Every hospital doctor will know the experience of having to pick up the pieces afterwards when they speak to an upset patient or relative, who has just spoken to a non-clinician about their discharge arrangements. We need to first and foremost show empathy and concern. If our patients and families start off their hospitalization on such a sour note, what hope is there for an optimal experience?

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.
Wednesday, October 21, 2015

An open letter to the BMJ regarding us dietary guidance

Dear Editors:

I am rather stunned that the BMJ published a journalist's commentary about the work of the 2015 United States Dietary Guidelines Advisory Committee as if it were an authoritative rebuttal. It's as if someone selling horse paperweights is invited to critique the Olympic equestrian team. It is, in a word, absurd, and testimony to the breakdown in integrity where science and media come together.

With all due respect to the author, she is not a nutrition expert, and not a scientist. She is a journalist herself, and one with a book to sell. She refers to bias, but fails to highlight her own. If the DGAC report is valid, it calls into question her own conclusions, as well it should. She may therefore have suspect motives in seeking discredit this work.

The same author wrote much the same in the New York Times, and I was stunned then, as now, that what was once rarefied territory for truly expert opinion is being allocated so indiscriminately. The notion that the opinion of 1 journalist with a book to sell is in any way a suitable counterweight to the conclusions of a diverse, multidisciplinary, independent group of scientists who reviewed evidence for the better part of two years and relied upon knowledge and judgment cultivated over decades of relevant work is nearly surreal. It is a disservice to the readership in both cases.

The DGAC very correctly draws conclusions from the weight of evidence, including diverse trials, and the real-world experience of large populations, such as the Blue Zones. They very appropriately address a critical issue of our time: sustainability. The author seems inclined to ignore that altogether; perhaps she does not care whether there is anything for the next generation to eat or drink, but I suspect most of us do.

The DGAC report is excellent, and represents both the weight of evidence, and global consensus among experts. It is entirely in line with the persuasive experience of Blue Zone populations. It is the work of people who are actually qualified to address this topic. It is in accord with my own efforts to review relevant literature without bias for a commissioned paper.

I don't care what diet is best for health; I don't have a diet to sell. But I do care about truth, and its dissemination. The positioning of one journalist's opinion, and a journalist with abundant cause for bias at that, as a legitimate counterweight to the consensus of an independent, and quite illustrious scientific panel is a discredit to the BMJ, and something of an assault on the trust of your readers. Perhaps expertise, recognition of it and respect for it, are truly dead.

This commentary is not authoritative. It is not a counterweight. It is, at best, a paperweight. I am sorry to say its prominent placement on your editor's desk redounds to your discredit.

Sincerely yours,

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.

Table rounds prior to bedside rounds

For 30 years I have always conducted “table rounds” prior to seeing the patients. Many colleagues champion bedside rounds solely. While we each must find our most comfortable rounding style, I hope to convince other attendings of the value so that they might consider this style.

What are table rounds? We start rounds by quickly having students or residents give a brief report on each known patient. They need not provide every detail, but rather report on test results, consultant recommendations and any major clinical change. We look at pertinent images.

During this time we have several goals. First, the entire team gets an update on the patients. This allows the interns to know each other's patients. Second, we can have a discussion of further testing plans, consultations, or discharge planning. We also can have discussions of test results, or revisit our diagnosis. Third, we can teach and make certain that everyone has an opportunity to participate and hear. Finally, we never embarrass a student or intern in the presence of the patient.

Next we present the new patients. Usually, this time allows for the most teaching. We discuss the approach to the differential diagnosis. We discuss treatment strategies. We point out information that we need at the bedside.

After table rounds (usually 45-60 minutes) we visit each patient. Sometimes we repeat the history; sometimes we demonstrate a physical exam finding; sometimes we just spend time making certain that the patient understands their diagnosis, treatment, and further testing plans. We deliver good news and bad news. We discuss bedside manner at the nurse station after our encounters. When we obtain new information, we change our plan appropriately.

Many learners have told me that they find this style more educational and comfortable. I suspect that some will agree with this style, and some will disagree. What do you think?

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.
Tuesday, October 20, 2015

Is the white coat needed for identification?

If you haven't read Phil Lederer's piece on the white coat at The Conversation, I recommend that you do so. It is very well written and has stimulated a lot of discussion. One of the take-aways for me is that even among many of those who believe we should ditch the white coat, the 1 argument that gives them pause is the role of the white coat as a means of identification. This is particularly an issue for women and racial minorities, groups that have been historically underrepresented in medicine.

I have 2 problems with the argument that the white coat is needed for identification. First, unlike the situation in the 1960s, white coats are no longer exclusively worn by physicians. Members of practically every occupational group in the hospital (with the typical exception of students) may wear a long white coat. It's worn by chaplains, administrative assistants, nurse practitioners, physician assistants, you name it. The white coat no longer signifies that the wearer is a doctor. And we have more specific means of identification. Many hospitals now have large occupation-label tags attached to photo IDs (mine is shown), which should be more effective than the type of coat worn.

The second issue I'll articulate is controversial and will probably get me into trouble, but I think it's an important argument to explore. I'm really bothered when a physician says, “If I don't wear a white coat, patients think I'm a nurse.” To feel insulted that someone might think you are a nurse implies what you really think about nurses, that they are beneath you. Would an internist (male or female) feel disrespected if someone thought he/she were a neurosurgeon or the chair of the department? I doubt it. And I've mentioned previously that I've been mistaken for a nurse or respiratory therapist many times when I'm wearing scrubs in the hospital, though less so now that I wear my name tag on my scrub shirt (I used to wear my name tag on my waist band but that's not allowed at Iowa). I don't find being misidentified insulting in the least. I just simply answer that I don't have the keys to the medication room or that I'm probably not the best person to change the ventilator settings.

Several years ago (long before I began thinking about killing the white coat) my wife and I and several other people were at a dinner with a visiting professor. My wife made a comment during the conversation about something medical and he said, “Oh, are you a nurse?” She said quite nicely, “No, I'm an oncologist.” He replied, “I'm so sorry that I asked if you were a nurse.” And she said, “Don't be sorry! I was a nurse. I loved being a nurse. And if tomorrow I were a nurse again, I'd be very happy.” We discussed that interaction last night. As she reflected on the white coat issue, she pointed out that she thinks it's great when a person is proud of their profession, and how the white coat for many people symbolizes that pride and their achievement of completing a very long journey. For some, it also symbolizes the enormous barriers that they have overcome. But she noted that the white coat should not be used as a symbol of who you are not.

I've come to realize that a physician feeling insulted if someone misidentifies them is yet another negative manifestation of professionalism. We as physicians have been socialized to think that we are elite, that we are at the top of the pecking order, that we are better than all the other people who work in health care. That has been given to us unfortunately by our physician colleagues and is part of our culture.

I don't want to be (or even appear to be) insensitive. I realize that as a white man I'll never know what it feels like to be an African-American woman. But we are trying to eliminate the white coat for patient safety, which should trump all else. Remember that one of the good tenets of medical professionalism, at least historically, is that the patient comes first. Moreover, we are all called, regardless of race or gender or socioeconomic status, to respect all humans (ahh, humanism!). And to verbalize disdain at being identified as a member of another occupation, in my opinion, is classist and incredibly disrespectful.

Ok, I'll get off my soapbox now and let the arrow slinging begin.

Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on improving the quality and safety of health care, and sees patients in the inpatient and outpatient settings. This post originally appeared at the blog Controversies in Hospital Infection Prevention.
Monday, October 19, 2015

Medicare audits, or how I spent part of Labor Day Weekend

Some weekends I go to my office to try and catch up on paperwork. This Labor Day weekend I had to “labor” away part of it to satisfy a Medicare requirement.

I received a fax from a medical supplier saying that Medicare had sent them an, “additional documentation request” for diabetic supplies for a patient of mine from June 2013. I didn't see her on the date of service they listed, nor even see that I prescribed any diabetic testing supplies then, though it's possible I filed out a faxed form and it wasn't saved to her chart.

They requested that I include copies of the patient's blood glucose testing logs. I do not routinely scan those into the chart, so I don't know how that's supposed to happen.

They also say to verify that the records contain the following other items, though it could be considered fraud to go back and add them now:
• patient's diagnosis and prognosis
• patient's testing frequency
• condition and treatment history
• quantity and day supply prescribed
• physical limitations due to condition
• A1c lab report
• insulin/non-insulin
• insulin injections/pump
• medication lists

In addition, they want all documentation from 6 months before the service date up to the present day, and they want it, “ASAP.” That's 2 years and 9 months of documentation, all for a few diabetic test strips I prescribed (which I don't make any money from, for the record)!

What's more, it says that we are not allowed to charge the supplier or the beneficiary (the patient) for providing this information.

That's your government, hard at putting us primary care doctors to work.

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.

Guide for the perplexed

It is clear that the way that health care gets paid for in the United States is undergoing rapid change. What is not at all clear, at least not to me, is exactly what the payment model will look like in the future, or how far off that future is. Although everybody agrees with Yogi's assessment that, “It's tough to make predictions, especially about the future,” this exercise seems particularly challenging because of the wide variety of “alternative payment models,” likelihood that they will co-exist, and the prevalence of regional differences.

It is because of this complexity that I found a recent paper in the Annals of Internal Medicine to be helpful. It is a simple “field guide” to different payment models that starts with distinguishing the “unit of payment” (e.g., per unit of time, per episode of care, per beneficiary, etc.) and then uses these to review efforts at payment reform over time.

I found this helpful in keeping all of these things straight in my head, and I liked the way it started from “first principles.” I think it is worth the read.

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.
Friday, October 16, 2015

Marketing medicine and the treatment of high blood pressure

I just read a disturbing article about a recently completed study on treating high blood pressure. The SPRINT (systolic blood pressure intervention) trial was conducted at around 100 locations in the U.S. and Puerto Rico, comparing treating blood pressure intensively to usual care.

According to recently adopted guidelines, we now treat blood pressure with the goal of reducing the top number, the systolic blood pressure, to below 140 for adults younger than 60 and below 150 for those 60 an over. The goal for the bottom number, the diastolic blood pressure, is below 90. We recommend lifestyle changes, encouraging exercise, weight loss and reduction in salt intake, and use medications when the blood pressure stays too high.

In the SPRINT trial, a comparison group was treated with blood pressure medications, sometimes 3 or more different types, to lower the systolic blood pressure below 120. The patients in the comparison group (more intensive treatment) apparently did better, with a 30% reduction in heart attacks, heart failure and stroke, and 25% reduction in risk of death.

The SPRINT study only looked at patients 50 years of age or older with other risk factors for cardiovascular disease, including heart disease, kidney disease and a calculated risk of cardiovascular events of greater than 15% in the next 10 years. The data still hasn't been released in a way that we can really understand it, and there may be important caveats, such as subgroups who have particularly better or worse outcomes with intensive management, and other beneficial or terrible effects of the interventions. The news so far is just in the form of a press release, with an actual scientific article eventually to be published.

What bothers me is that now a whole group of people who think they are actually well will be encouraged to take medicine, with associated significant side effects, and will identify themselves as vaguely sick and needing medical attention. Also those patients who already are treated for hypertension and have “good control” will be started on yet more medications with drug interactions, high costs and potentially dangerous side effects. It will be difficult to lower the blood pressure below a systolic of 120 without causing symptoms of dizziness and fainting in some patients, and there will be an increase in the number of doctors “failing” to treat high blood pressure adequately and patients “failing” medications.

Already, at our present definition of high blood pressure (hypertension) 1 in 3 adults has it. Three out of 4 patients 75 years of age or older has hypertension. The CDC (Centers for Disease Conrol) estimates that treating hypertension costs over $46 billion per year. According to data from various randomized trials, at least 100 people must take blood pressure medications for 5 years to avoid 1 heart attack. This number varies significantly depending on a person's age and overall risk for heart disease, so more than 500 fifty year old women must be treated for 5 years with anti-hypertensive medications to avoid a heart attack, whereas 65 year old men can expect more of a benefit, with a “number needed to treat” of 101. If we lower the target blood pressure to 120, essentially every adult, with a few exceptions, will be on pills for their blood pressure, and the vast majority of them will see no benefit.

The side effects of treating high blood pressure, besides the cost of medications and doctor visits, which aren't trivial, include life threatening electrolyte imbalances, kidney failure and facial swelling as well as annoying dizziness, swelling of the feet and a cough. A sizable portion of the people who are treated with blood pressure medications, or would be, will experience side effects and no actual benefits.

Treating everyone with an elevated blood pressure with medications and defining them as having a medical condition was a huge expansion of the scope of medical care. The first effective anti-hypertensive medications were released in about 1958 and now there are hundreds of them, varying in mechanism, price and effectiveness. Hypertension was really the first symptom-free condition to be widely treated and marked a transition in doctors' roles to include more care that was focused on preventing actual disease than treating it. Most of us like the sound of that, but it means that one in three adults “needs” a doctor for their hypertension, and if hypertension is redefined at a lower number, virtually everyone will be under medical care.

There is a complex interplay of values going on here, and it is strongly influenced by the fact that medicine, as an economic entity, successfully markets itself and expands its markets by identifying conditions that increase risk for actual misery. These conditions then become targets for treatment, which increases doctor visits and medications prescribed. Treating high blood pressure has been perfect in this regard because the need is real in many cases and the outcomes have often been gratifying. People with significantly elevated blood pressure, especially those in whom it is persistent, do develop devastating strokes, heart attacks and kidney failure and treatment to lower the blood pressure, if taken regularly and over long periods of time, really does reduce their risk. Still, vast numbers of people are treated for high blood pressure who experience high costs, significant side effects and medicalization with no benefits, at huge costs to society in general.

Research shows that the vast majority of blood pressure measurements are taken in such a way that blood pressures may be artificially elevated. One way to narrow the scope of treatment would be to measure blood pressure more accurately, either by actually having patients rest for 5 minutes before taking blood pressures or by using ambulatory monitors which take blood pressure throughout the day during a person's regular activities. Both of these methods would serve to focus our efforts on people who might actually benefit from them.

What would be a good direction to move with treatment of hypertension that would help reduce overtreatment and increase benefits of treatment? Research focused on truly identifying who needs antihypertensive medication would be great. If 500 people like me need to be treated for 5 years to avoid one heart attack, that means that too many people are being treated. Research could help determine which of those 500 people actually need treatment, if it was designed to answer that question. The SPRINT trial was designed in such a way that it will likely increase both the number of patients in treatment and the number of drugs prescribed. That is not what most of us want. It is, however, the kind of research that grows medicine's market share.

If the treatment of hypertension was focused on patients who would truly benefit, and the intensity of treatment was proportionally higher for those with the greatest need, quite a bit of the tens of billions of dollars spent on hypertension might be liberated. The money not spent on medications and doctor visits could go to other interventions that would reduce cardiovascular disease. The amount of money that goes into overtreatment of hypertension could buy cooking classes and exercise rooms, swimming pools and dance classes. Unlike doctor visits and medications, this type of preventive medicine also makes us happier and helps make our lives richer.

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.

Will you trade me a CLABSI for a pneumothorax?

There was an interesting new study published in the New England Journal of Medicine by Jean-Jacques Parienti and colleagues and funded by the French Ministry of Health. The study aimed to compare the rates of catheter-related bloodstream infection and symptomatic deep vein thrombosis (DVT) in 2,532 adult intensive care unit patients randomized to subclavian (n=843), jugular (n=845) or femoral vein (n=844) sites for nontunneled central venous catheter insertion. Baseline characteristics were very similar across the three groups.

The results are not very surprising with higher rates of infection and symptomatic DVT when catheters were inserted using the jugular and femoral veins compared to the subclavian veins but these were almost cancelled out by a higher risk of pneumothorax when using the subclavian approach.

Here are my thoughts on the paper:
1. This is a very nice study that confirms the results of prior smaller studies in the field.
2. The overall complication rate is low with approximately 97% of catheters in each group inserted safely without a pneumothorax and without infection or DVT.
3. When all complications are included, it doesn't appear there is a preferred site for catheter insertion. However, since hospitals are penalized for infections [NOTE: co-blogger Michael Edmond, MD, FACP kindly informed me that hospitals are penalized for iatrogenic pneumothorax through an AHRQ patient safety indicator, which is included in the CMS Hospital-Acquired Condition Reduction Program. Thus, selecting a subclavian site could lower your central-live acquired bloodstream infections (CLABSI) penalty but raise your pneumothorax penalty. Of course!] there has been a preference for choosing the subclavian site, since it is associated with fewer infections. Unfortunately, the subclavian site had a much higher rate of pneumothorax.
4. One important comment that the authors make is that how long the catheter remains in place can greatly increase the rate of infections and blood clots. So, if the doctor expects the catheter to remain in for a short period of time, she might chose a femoral or jugular vein approach to limit the pneumothorax risk, with very little infection or clotting risk since the catheter will be removed before the complication can occur. However, if the catheter is to remain in place for many days, it is probably worth the higher risk of pneumothorax associated with the subclavian site, which only occurs when the catheter is inserted, in order to reduce the long term infection and DVT risks.
5. The study sites did not use daily chlorhexidine bathing and did not place chlorhexidine-impregnated dressings at the catheter insertion site. Both of these interventions have been shown to reduce catheter-related bloodstream infections. Thus, these results might not be generalizable to hospitals that use chlorhexidine bathing and/or chlorhexidine dressings. It's possible that either of these interventions or both could mitigate the infection risk rendering femoral or jugular vein approaches safer than they appear in this study.
6. Overall, it looks like fears of using the femoral vein are exaggerated, especially when you consider the rates of other complications like pneumothorax. It may be that in our efforts to get to zero CLABSI, we're putting patients at higher risk for other complications. Perhaps a more nuanced target of “any complications per catheter inserted” could replace CLABSI as a quality metric?

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, October 15, 2015

Is your hospital crooked?

I read an interesting piece this morning about a medical renegade who turned his back on one of the most powerful health care systems in the world. It's not easy to push back against a leviathan. If I give you an oar, I doubt that you could change the direction of a cruise ship. But sometimes, a single person can make a wall fall down. Remember, the brave Chinese man who faced down an approaching tank in Tiananmen Square, which was captured on an iconic video? On a lesser scale, an orthopedist, formerly employed by The Cleveland Clinic Foundation, decided that his Clinic bosses were preventing him from offering his patient's the best medical care possible. He fired them.

The Clinic, in a cost cutting move, restricted orthopedists to using artificial joints from only two device companies. The surgeon had been using artificial joints from another company for nearly 3 decades, and he reported excellent results. This orthopedic surgeon had a bone to pick with his bosses, but their edict was as rigid as a steely plaster cast. There would be no exceptions.

Usually, when stuff like this becomes public, we are greeted by nauseating and sanitized statements from the PR office that generally seek to distract and deflect. That's when the PR Prism is so useful. Consider some examples.

Facts: A sneaker company is discovered to be using child laborers in Southeast Asia for 10 years.

PR Prism: Our company never knowingly hires underage works and always strives to adhere to the highest corporate ethical standards. We have started a full investigation and promise transparency and accountability.

Translation: We got caught.

Facts: A presidential candidate deletes tens of thousands of e-mails that were housed on a personal server that was kept in her basement.

PR Prism: I never violated my well known stratospheric standards for probity and integrity. To the best of my recollection, I never knowingly sent or received any e-mails that any reasonable Secretary of State would have regarded as Confidential, Top Secret or even Semi-Secret in accordance with written Policies and Procedures. I wish I could share these P & P manuals with you, but of course, they are classified.

Translation: Ha! Ha! Ha!

In what I suspect was PR lapse, the statements from The Cleveland Clinic contained some glimmers of actual truth. I would have expected some doublespeak about how the Clinic is ‘always striving to provide World Class Care…”, but here's what the Chief of Staff said after acknowledging that their corporate and coercive decisions can give individual practitioners vexing choices

“It doesn't make everyone happy. There is a tremendous amount of change going on in health care as we work to drive quality, but do it in a more affordable way.”

I congratulate the Clinic on at least admitting that they trying to save money, and not disguising the cost-cutting under the veil of medical quality. I support practicing cost-effective medicine, as I have expressed repeatedly in this blog. However, I suspect there is an important part of this story that was not reported in 9/10/15 Cleveland Plain Dealer article.

How did these 2 orthopedic device companies get the Cleveland Clinic gig? Was it based on cost? Did the Clinic or any of their physicians have financial ties to the companies? While the Clinic claims that physicians had input into the choices of these two vendors, was the process in truth a preordained corporate decision? Did artificial joint competitors have a fair shot to bid for the business? If a competitor sold artificial joints to a Clinic competitor, would this company be shut out?

This issue goes well beyond artificial joints. Every hospital in the nation makes deals for artificial joints, heart valves, intravenous catheters, medications, surgical instruments and radiology equipment. Increasingly, these are as much business decisions as they are medical decisions. If a product or service can be delivered more cheaply with no loss of quality, than we all support it. Who do patients trust to make these judgments? Your doctor or the hospital's accounting department?

I'm not suggesting that the Clinic, or the hospitals where I practice are crooked. But, the medical industrial complex has many tense conflicts of interests that are sequestered far beyond the view of the public. I'm sure there are troves of hospital e-mails that would be fascinating to review, unless the servers have been wiped clean.

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.

In defense of aging

“When 900 years old you reach, look as good, you will not.”
—Jedi Master Yoda

“Live long and prosper.”
—Vulcan benediction

My patients occasionally ask me, “Do you have something that will make me younger?” Sometimes they're just joking and want to complain a bit about some indignity of getting older. But frequently they're serious and would like me to reverse some ravage of time. What I find fascinating is that they don't ask “Do you have something for wrinkles?” or “Can I have a medicine for erectile dysfunction?” or “My hot flushes are terrible. Can you do anything for them?” They blame their symptoms on their age and have decided they've had enough of aging.

I hope I'm not the first to break this to you, but your age is just the elapsed time since you were born. The only way to be younger is to be born later. If you're unhappy with when you were born, take it up with your parents. But if you're unhappy that you've gotten old, I'd like to try to change your mind.

Lots of my older patients are nostalgic about their youth. And many are much less healthy than they were a decade or two ago. And seen through the haze of imperfect memory, it's tempting to romanticize the past. But would any of us really want to relive our youth? Would we give up the wisdom and experience that we've amassed over decades in exchange for painless joints? Would we trade the deep committed relationships we have now to fall in love for the first time again? If we could get rid of every one of our chronic illnesses to reenact all the mistakes we made in our twenties, would we?

I hope not.

We live in a youth-obsessed time in a very youth-obsessed place. But like youth itself, this phase must pass. All philosophies that have stood the test of time and all civilizations that have lasted more than a few generations venerate their elders. Movements that celebrate youth are either shallowly materialistic or radical revolutions. Eventually both consumers and hippies grow up and the bubble bursts. Pete Townsend, who wrote the lyrics “Hope I die before I get old,” turned 70 this year, and I hope he has many happy healthy years ahead of him.

In Los Angeles, patients are likely to be exposed to many types of quackery. There's the chronic Lyme disease quackery, the intravenous vitamins quackery, and the homeopathic herbalist quackery. But the quackery that makes me saddest is anti-aging quackery. It's just as ineffective as any other form of quackery, but it's sadder because it's based on a double lie. It preys on patients' irrational fear of aging, and rather than convince them otherwise, it sells them hormones and supplements and other nonsense. There's never been a better time to be old. I'm a pro-aging doctor; if I do my job well my patients get older.

My oldest patient is 101. I saw her this week. She walks without a cane. She's mentally sharp. She's happy. Her biggest complaint is that her friends are so much younger than her. She's never asked me to make her younger.

Learn more:

Some Notes on “Anti-Aging” Programs (Quackwatch)

Meditations (Marcus Aurelius)

On the Shortness of Life (Lucius Annaeus Seneca)

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.