Monday, November 30, 2015

Fats, carbs, and what Jane Brody meant to say

Jane Brody published a very sensible reality check about diet in yesterday's New York Times. That it proved sensible was all but inevitable, as her column was clearly much informed by an interview with the eminently sensible, and extremely knowledgeable Dr. Frank Hu of Harvard, late of the Dietary Guidelines Advisory Committee, and newly elected to the National Academy of Medicine. I happily take this opportunity to offer my public congratulations to Dr. Hu for that last item, among the highest honors a biomedical professional can receive, and certainly very well deserved in this case.

As noted, Ms. Brody's column was very sensible, telling us there are good and bad fats, good and bad carbohydrates. But with all due respect to her august journalistic pedigree, I think it fell slightly short of the mark by failing to go beyond macronutrients altogether. What Jane Brody meant to say, in other words, is what I was privileged to say jointly with Dr. Hu: wholesome foods in sensible combinations. Dr. Hu and I in in turn owe a debt of gratitude to Michael Pollan, who first threw down that gauntlet with: food, not too much, mostly plants.

Ms. Brody's column rightly belies the currently prevalent, cacophonous nonsense about saturated fat. No, there is no evidence that eating more saturated fat is “good” for us, and certainly none that health (of people, let alone the planet) is promoted by eating more meat, butter, and cheese. As recipes go, that argument has been egregiously overcooked from the start.

Similarly, and obviously guided by Dr. Hu's wisdom, she notes that it matters what we eat instead. This crucial consideration, so often ignored by those with dubious motives where a devotion to public health ought to be, was the subject of a recent paper in the Journal of the American College of Cardiology, which concluded on the basis of science precisely what sense would predict. Replace saturated fat calories (and the foods providing them) with sugar and refined starch calories, and health outcomes are comparably poor both times. Well, what else would one expect as an outcome of inventing more than one way to eat badly?

However, replace those saturated fat calories with either whole grains or unsaturated oils (and the foods that provide them, notably nuts, seeds, olives, avocados, and fish), and health outcomes improve markedly. I am sure there must be something related to relativity or quantum physics in the mix here that I am overlooking, but as far as I can tell, this translates to: eat food that is good for you, and it will be good for you.

Yep, that's the punch line, folks. Food that is good for us is good for us. And that's what Jane Brody meant to say, and didn't: it's not about macronutrients at all; it's about food. Eat wholesome foods, mostly plants, in sensible combinations, and the macronutrients, and micronutrients, and glycemic load, and all the rest- generally sort themselves out quite handily.

The evidence for this proposition is overwhelming. Dr. Hu and I have both had cause to look it over from altitude, in the service of independent review papers in the Lancet, and Annual Review of Public Health, respectively. Our confluent conclusions in those two unrelated projects are what prompted us to write together about “wholesome foods in sensible combinations” in the first place.

In my own case, even more evidence figured in the mix in the writing of the most recent edition of my nutrition textbook, spanning some 50 chapters, 750 pages, and approximately 10,000 scientific citations. There are admittedly excruciating details in that mix, but the gist condenses to: wholesome foods, mostly plants, in sensible combinations. And that was the very conclusion reached by the 2015 Dietary Guidelines Advisory Committee in an extensively referenced, 572 page report.

Finally, it's just what one sees through the lens Dan Buettner has provided us to the Blue Zones of the world, those places where people live the longest and the best. Their diets vary considerably, but all vary on a common theme. You guessed it: wholesome foods, mostly plants, in sensible combinations. No Blue Zone is mostly runnin’ on donuts, any more than any Blue Zone is mostly runnin’ on meat, butter, and cheese. Rather, the emphasis is consistently where the evidence suggests it ought to be: on vegetables, fruits, whole grains, beans, lentils, nuts, and seeds.

Why not let Jane Brody have the last word? Because the last word really needs to be food, not nutrient. We have already demonstrated our nearly endless capacity to pervert almost any nutrient preoccupation into a public health boondoggle. A fixation on nutrients plays directly into the hands of industry elements that can design new inventories of junk food faster than most of us can say “monosodium glutamate.”

For decades, we have fixated on one nutrient at a time, and wound up with lipstick on a pig for breakfast, lunch and dinner. Rather than renouncing the folly of subjugating foods and dietary patterns to mononutrient preoccupations, we have instead reacted with all the subtlety of a block of rock subject to Newtonian impulses: equal and opposite reactions. If saturated fat wasn't the right scapegoat, let's try carbohydrates; or sugar; or fructose; or gluten. Let's not.

Let's eat wholesome foods, mostly plants, in sensible combinations- and put an end to this era of fatuous fixations, and profits over public health. That's what the evidence has long indicated. That's what a massive, if as yet little known, consensus among the world's leading experts favors. That's just what the 2015Dietary Guidelines Advisory Committee concluded.

And it is, I presume, what Ms. Brody meant to say.

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

The high cost of high cost

“You don't charge enough.”

I've heard this from a lot of folks. I've heard it from my accountant (of course), other doctors, consultants, and even some of my patients. I've had some patients who are especially complex offer to pay me more because of the difficulty of their care. I think they feel guilty and worry I'm upset that they are being “too demanding” for what they are paying. I don't ever take extra money.

When I recently told an elderly patient's family that I was willing to do house calls if/when the woman needed it, their question was: “how much extra does it cost?” No extra charge, actually. They were delighted at how “old fashioned” I am. Yep, Dr. Smartphone is certainly old fashioned.

Doesn't this seem like a stupid move for a guy who did a major life change while three kids were college age, who spent most of his retirement money after he turned 50, who has lived the past few years doing a balancing act with both work and home bank accounts? Shouldn't I charge more? Shouldn't I try to get more money now so I can sustain the business better?

I don't think so.

I recently had a conversation with a friend who has a practice that is very similar to mine. He complained to me about how “high maintenance” his under-30 patient population is to him. I was surprised, as this same population in my practice is nowhere near the label of “high maintenance.” After further investigation, the big difference between our practices (besides location) is that I charge only $30 per month for folks under 30, while he charges $50. Then everything made sense.

I initially came upon the $30 price when I considered the young families I had taken care of in the past, and the likelihood they would tolerate a price of $50 per month. It seemed to me that people would be much more willing to pay a dollar a day for access to my care than they would a higher price. Since my model of practice (a monthly fee without copay or other profitable procedures/products) benefits most from people paying for my service without heavy use of those services, this seemed to be prudent. It seems that I was right about this, when comparing experiences with my colleague. People are much less likely to pay $50 per month (or more) unless they have significant need, so a higher price essentially selects for more complex and/or demanding patients.

This is why I can reasonably handle 640 patients today with only two nurses (one of whom is away on vacation). Yes, I don't get as much money as I would for 640 patients at a higher monthly rate, but I wonder if I could actually handle that number of patients with only two nurses if I selected out for more demanding patients with that higher rate. I doubt it. The longer I consider this, the more I'm convinced of its truth, and the less I am inclined to raise my rates (much to the chagrin of my accountant).

But this doesn't just apply to my practice model; it applies to all of health care. I have family members who don't get routine care for their blood pressure or undergo routine screening tests because of the cost (and yes, they do have insurance). I've had many patients who wait until the value-proposition becomes overwhelming to seek care. Treat blood pressure? Not worth it. Treat congestive heart failure? I guess I can fork out the money. This is not out of stupidity or carelessness, necessarily, but instead it is an ignorance of the potential long-term harm of seemingly small, treatable problems.

So what's the point of all this? Am I suggesting we make primary care really cheap for everyone? Maybe. But the bigger points are that the economics of healthcare is not always straightforward, and that our emphasis on paying more for high acuity, high complexity patients yields exactly what we are paying for. Somehow we need to find a way to lower the barrier for people to seek care when it has the biggest economic benefit: early. On the other side, we need to somehow reward providers for engaging patients in early intervention and disease prevention. Finally this all needs to be done without penalizing or discouraging the care of complex problems or diseases.

Like I said, it's hard economics. But I've been able to show it is possible in my growing sample. There is still a lot of work to be done, as I try to grow the practice into something that is a viable alternative to our fee-for-service (using the word “service” lightly) payment model. None of this is easy, but at least I (and other docs doing what I do) are trying to show there are viable alternatives.

Many folks initially told me this practice model couldn't work. Many said that I would cater to the rich, excluding the poor. Many said I'd avoid complex patients or time-consuming diseases. Many say my prices are too low. Yet here I stand, 3 years sober from taking insurance, with a growing practice filled with people from a wide variety of economic backgrounds, with a good mix of healthy and sick, and with an ever improving personal economic future. I actually put some money back into my retirement accounts recently.

There. At least that gives something for my accountant to be happy about.
Tuesday, November 24, 2015

Mammograms: find your sanity

Fairly typical week in health news: Mammograms.

The big story is that the American Cancer Society issued an updated guideline recommending that women undergo mammography less frequently than before.

This announcement was denounced on both “sides” of the perennial debate. Those in the “mammograms save lives” camp are outraged that a scientific society dedicated to cancer prevention and treatment would issue a proclamation that seems to run counter to the notion that “early detection saves lives.”

Those in the “putting scientific evidence in the forefront” camp are actually somewhat pleased that the ACS is finally ”moving in the right direction,” but displeased that the society didn't get all the way to the vicinity of, for example, the U.S. Preventive Services Task Force, which has the most heavily-weighted (and least stringent) screening mammography recommendations: for women at average risk (i.e. those that don't have a mother or sister with breast cancer), start breast cancer screening at age 50 and get a mammogram every 2 years until age 74.

The new ACS guideline: start screening at age 45 (well, 40 if you want to) and have mammograms annually until age 55, at which point you can go to every other year.

If a woman at average risk for breast cancer follows the USPSTF guideline to the letter (and is lucky enough to avoid a “call-back,” i.e. further looks for a possible abnormality), she'd have 13 mammograms over 25 years. If she follows the new ACS guidelines to the letter, she'd have 20 mammograms, possibly more. Of course, every mammogram not only increases the cumulative total of lifetime radiation exposure, it increases the odds that an abnormality will be found and a call-back will be issued.

The best analysis regarding the new ACS recommendation (and actually, 1 of the best pieces about the whole breast cancer screening issue in general) is from FiveThirtyEight's lead science writer, Christie Aschwanden, whose piece is titled, “Science Won't Settle the Mammogram Debate.” Aschwanden correctly points out the “right thing” depends on you, the patient, and your values. There is no right answer.

For some, not getting mammograms annually (or even at all) is the right choice. For the rest, following the “rules” such as they are provides the best piece of mind.

And that's OK.

Here's the thing: because choosing to have mammograms or not is a personal decision, we should refrain from blaming people who choose 1 way or the other. People have their reasons. As with many social and medical issues, the personal has become very political, because people's beliefs are strongly held. Ultimately, a lot of economics is impacted by the politics here. Pro-screening partisans are always uneasy when edicts cutting back on screening are issued, because the fear is that the health care “establishment” (i.e. insurance companies) will stop covering the tests.

That's simply not going to happen with mammography.

If we strip the emotion out of the issue and just try to stick to facts, what, at heart, is undergoing a mammogram like?

The video below comes from the UK's Cancer Institute. It's just more than a minute, and is very matter-of-fact. It shows an actual woman undergoing an actual mammogram, and thus includes bare breasts.


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.
Monday, November 23, 2015

So not a provider: part deux

I wrote a piece about the word “provider,” and how physicians have been a bit blindsided to what's fast becoming their new title. It started something of a social media wave. For anyone who hasn't read the article, it can be found here. It was good to see the article encouraging lots of healthy debate, and I was also grateful for the large volume of supportive messages. As we continue this important discussion, I wanted to specifically address 5 follow-up issues:

1. This is not about ego or turf wars

My own dislike with the word provider doesn't come from an egotistical perspective or some desire to inflate my own position. Neither do I feel this is the case for most physicians. Speaking personally, it was my childhood dream to become a doctor. I enjoy what I do, consider the physician-patient interaction sacred, and strive to perfect the art of medicine each day I'm on the medical floors. A good doctor is what I always hope to be. Seeing a different job description and name creep into the equation, one where I'm known as the “provider”, is just as disheartening to me as it would be to any professional who strives to be the best at what they do and takes pride in their work—be it a pilot, an attorney, or even an actor—who wakes up to find they are being called “transport provider”, “legal advice provider” or “entertainment provider” by the people that employ them. Rightly or wrongly, I do consider it a bit of an insult when I'm addressed primarily as a Provider to my patients. I'm quite relaxed and informal, don't insist on being called “Dr.”, and don't mind being called by my first name. But I do insist that my job description is that of being a physician. Period.

2. All health care professionals should get on

Many online comments came from other professionals, including NPs and PAs. As I said in my original piece, this is not about them or what they do. We must all get on at the frontlines of medicine, because our ultimate mission is always the same: to serve our patients. By the same token, why any Nurse Practitioner or Physician Assistant would like the term “provider” also eludes me!

3. This is not just another fight with administration or the government

Although it may seem like the push to use the word “provider” comes from faceless administrators, having talked to (and being friends with) many of them, I don't think administrators necessarily realize the problem with use of the word Provider and might be caught up themselves in a wave without knowing where it all started. Neither would any of them ask for a “provider” when their sick child or elderly parent needs help. There's no “big evil empire” out there wanting to define physicians. Our fate is in our own hands and all ships that have sailed can be brought back to port.

4. Don't forget the power of words

Physicians are on the whole not the most linguistic people (no offense intended), and should understand that words have immense power. Talk to any marketer, business-savvy person or even any attorney—and they will tell you all about this. There's a lot in a name, and physicians can be a bit naive about this compared with other professionals.

5. Our patients don't want to know us as providers

I'm yet to hear of any patient who likes hearing or using that word. If, in the end, we all agree that the patient comes first—let's listen to them on this too!

We face some huge challenges in healthcare. In the overall entirety of things, this may not seem like a major issue. But I personally think about and face these healthcare challenges from the perspective of being a physician who wants the best for my patients. So should every other colleague who values what they do and the honor bestowed upon them of being a physician. The U.S. Bureau of Labor Statistics estimates that there are around 700,000 practicing medical doctors in the United States. Other estimates, including retired and non-practicing physicians, are around 1 million. That's an awful lot of people. Maybe, just maybe, a sleeping giant can be awoken.

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.
Friday, November 20, 2015

Getting diagnostic help through sharing the patient's story

Recently, we had a new patient admission whose presentation confused the entire team. We developed a differential diagnosis, but really did not have great confidence that we were moving in the right direction. We thought we had a good idea of what diagnoses we could not afford to miss. We ordered a few tests to exclude those can't miss diagnoses, but all the tests did not provide an answer. We accomplished this strategy within a few hours.

My resident and I happened upon 2 physicians in the physician's lunch room. One was a resident; another, a subspecialist. Being confused, we shared the story with our colleagues.

The other resident suggested a possibility that we had not considered. I immediately pulled up DynaMed Plus (disclaimer, I am on the editorial board and all ACP members get DynaMed Plus for free for the next 2 years) to investigate this possibility. I think that I had heard about the possibility, but unfortunately had not really learned enough on that subject.

The research confirmed the suggestion. We proceeded to make this possibility our #1 diagnostic target, because it is very treatable and potentially deadly if we missed it.

Of course, the resident was correct. Our lunch conversation made a potentially long and hazardous hospitalization much shorter and with a great outcome for the patient.

As I think about diagnostic dilemmas, I realize that I often “run the story” by colleagues, residents and even students. Sometimes the process of telling the story helps me better understand; sometimes the listener asks a key question; often the listener expands the differential diagnosis.

A couple of months ago, a former student (now an intern) approached me after a teaching conference. He wanted to share a patient story to see if I had any good ideas. His resident and he told me the story. In that instance, I had the proper knowledge to help, and once again the patient benefited.

In both cases, I have told the stories multiple times since. In the first case, most physicians go down the same paths that we originally did. Yesterday, I presented the story to a chief medical resident who had seen a similar patient as a student. He got the answer immediately.

For the second case, few people know the information that allowed me to point the team in the right direction. The presentation was 1 that I particularly had thought about and studied because I have a passion for acid-base and electrolytes.

Our sports role models should not be individual sport champions, but rather the “glue guys” in team sports. ”Glue guys” strive at all times to do whatever is necessary to help the team. The enemy is ignorance of the correct diagnosis. Victory is getting to the proper diagnosis. We cannot afford to have ego about how we get there, rather we must take advantage of interpersonal “crowd sourcing” if that helps the patient.

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, November 19, 2015

Inchworm

“Inchworm, inchworm
Measuring the marigolds
You and your arithmetic
you'll probably go far.
Inchworm, inchworm
Measuring the marigolds
seems to me you'd stop and see
how beautiful they are.”
—Originally performed by Danny Kaye in the 1952 film Hans Christian Andersen

This morning I was in the Primary Care Center seeing a patient with 1 of my favorite residents. The patient was there for a follow-up and despite being on medication already, her blood pressure was high. She was already on 1 medication for it but it appeared that this wasn't enough. And the plan my very able resident had put together was evidence based and perfect reasonable. He wanted to add on a diuretic, or a water pill, to her regimen.

And that was mostly cool.

Except. She was wearing a ring with 6 different colored gem stones. And next to her chair was a red metallic cane with a black rubber stopper on the end. Though mild enough to not warrant joint replacement, the osteoarthritis in her hip was significant enough to cause her to use that walking stick for assistance in her ambulation.

“You want to give her a diuretic?”

“That or a calcium channel blocker. I mean, had she not been a diabetic, my first line monotherapy would have been a water pill, you know?”

I nodded and jutted out my lip.

“That's reasonable, right?” This resident, who is now a senior, was asking this as a rhetorical question. He'd been at this long enough in this clinic to know that it was perfectly reasonable to start an African-American lady with normal kidney function on a water pill for her blood pressure.”Dr. M, what do you have against hydrochlorothiazide?”

I chuckled and shrugged. “Nothing, man. I was just thinking about her Mother's ring with the 6 birth stones and her fancy red cane, that's all.”

He squinted his eyes at me for a beat and then pressed his lips together. “I get what you're saying, Dr. M. But she gets around really well with that cane. Seriously, she trucks it. Honestly, I think she can make it to the restroom, even with a water pill making her have to go a little more.”

“Okay. But did she have 6 vaginal deliveries? Because that's a game changer.” I raised my eyebrows after that question.

“You know? I don't know. But my guess is yeah, she did. Hmmm … okay. Gotcha.”

So that resident went back and chatted with that lady. And he learned that, like many women who pushed out 6 babies, even without arthritis making it harder to get to the commode, urge incontinence was a bit of an issue. Or better yet, it was a major issue. Given that fact, a water pill wasn't something that she felt too excited about, and since there were other options, we went with 1 of those instead.

Yep.

You know? I noticed that ring but never had a big conversation about it. I just saw that it had those 6 stones and that it said “MOM” on it. And I did point it out and call it pretty at which point she said that her children had given it to her more than 20 years before. And that she'd always loved it.

And I could see why. I really could.

Yeah.

“2 and 2 are 4
4 and 4 are 8
8 and 8 are 16
16 and 16 are 32.”

You know? I am not the smartest person in my hospital by a long shot. I forget all the details of certain medical facts and have to look up stuff that many other people have long since committed to memory. I blank on the names of research trials and read probably just as much as a resident to jog my memory or teach me new things when I'm on the hospital service.

But.

I do love people and, for that reason, I notice them and the stuff around them. I do.

Today when I parked in the garage at Grady for that clinic session I was a little late. This older gentleman who appeared to be also heading into work at some office part of the hospital system held the elevator for me which I appreciated. And when I got on, he looked right at me and said in the warmest, brightest way, “Good morning!” And the way his eyes twinkled under his salt and pepper eyebrows, I immediately knew it would be just that.

His shoes were shined. I knew it because my husband shines his shoes and irons everything he wears each day, so I sort of appreciate it when a man is attentive to such things. For a minute I felt slightly embarrassed when he caught me looking at his feet. But then I decided that it wasn't a big deal that he did.

“You shine your shoes,” I said it with a confident smirk.

He threw his head back and laughed deep and hearty. “That I do.”

“My husband gets his shoes shined every chance he gets.”

“Sounds like my kind of gentleman. Military?”

My eyes enlarged. “Wow. Yes. Previously in the army.”

Just then the elevator opened. “Same here,” he replied while gesturing for me to exit first.

“Alright then, sir. You have a great day.”

“It's already done,” he responded and waved good bye.

And that was that.

Right after that, from the corner of my eye, I saw 1 of our residents helping this lady figure out the payment system on the new electronic parking meters. They were both leaned over and peering into that contraption studying the LED lights and trying to make sense of it all. It looked like it was taking a lot of time but he was patient, I could tell just from his body language. I could tell she appreciated it. I did, too.

It had been raining for the last couple of days. The concrete was still brown and damp and the grass was glistening. The air felt more autumnal and crisp which I liked. The heels of my boots were clicking on the asphalt. I'd decided that I'd move into my fall-season attire regardless of the weather. So I was glad that, on this day, the climate seemed to be on the same page with that decision.

As I hustled by, I saw that a broken umbrella was lying on the grass, probably the aftermath of a gust of wind or from some frustrated person who'd reached their wits end with a dollar store special. It looked salvageable if you asked me.

“I like your boots!” That's what this man sitting on one of the smoking area benches called out to me between puffs on his cigarette. And it was kind of sweet, too, because the way he was smiling at me felt sincere and not fresh.

“‘‘Preciate that!” I called back.

“Go ‘head, then, Bootsy Collins!” He laughed loud and so did I. Because I know who Bootsy Collins is. And him saying that was pretty funny.

And that was that.

So yeah. I do this every day. Like, I walk through and around Grady and I just look and notice and take stuff in. The sights, the sounds, the scents, the all of it. I see flowers on window sills and allow myself to appreciate the tiny miracles happening in that place every day. And now it has become a habit. Which I love.

See, medicine is so serious, you know? I mean, you're trusted with caring for human beings and for making decisions that could hurt them if you aren't careful. You want to make the right diagnosis, prescribe the right treatment and stay up on all of the latest medical literature. And that, all of that, requires a level of precision, focus, and diligence that makes it hard to notice much else.

Yeah.

But medicine also opens you up to humankind in the very best ways. Especially at a place like Grady. There are some days where I get so bogged down with the medicine and the details that I forget that part. I neglect to notice the birthstone ring or to have a little small talk about whether or not the Falcons are better than the Saints. When I'm in that place, I miss things. No, not life or death things, but still things that just might change the trajectory of everything. Like the freckles sprinkled across a patient's nose that could create a space for us to start calling each other “cousins” since I have them, too. Which would be bad since sometimes I might be the only “cousin” or family that patient has. So yeah, whenever I get like that, I know it's not ideal. Like, even if the medicine is accurate and evidence-based, without the humanistic component it never reaches the gold standard.

Does this even make sense? Lord, have mercy. I know I'm rambling.

But yeah. It's kind of like that inchworm, you know? Measuring these gorgeous marigolds and never once marveling at their beauty whilst making meticulous measurements. I have always loved that song and sing it to my children to this day. I sing it as a reminder because these same lessons apply to every aspect of our lives--particularly family. So busy focusing on the to-do lists that we don't take in the experience. So consumed with making sure our kids are clean and have homework ready and are safe that we don't enjoy them. Yeah. Kind of like that inchworm.

Two and 2 are indeed 4. And 4 and 4 indeed make 8. But what about the marigolds?

At the very end of that clinic visit that patient told me about her grandchildren. Three of the 11 that she had were now in college. And that was a big deal because neither she nor any of her 6 children had attended college. And I told her that she should be proud and she replied that she was indeed very proud. I also loved when she said, “I'm especially proud that I raised the kids who are raising my grandkids.”

Yeah.

After clinic when I crossed the street, it was drizzling again. I popped open my umbrella and began hustling toward our faculty office building. Then, I caught a glimpse of a man in tattered clothing walking down Jesse Hill Jr. Drive in the opposite direction. He was holding what I am sure was the same umbrella that I'd seen earlier on the lawn that morning, and it was keeping him dry. And when he saw me looking in his direction, he waved at me and then called out in my direction, “I like your boots, doctor!”

And in an equally booming voice, I replied, “Bootsy Collins!”

He stomped his foot 3 times and laughed at that. He even slapped his thigh for emphasis. Which I think might have been the best thing I saw all day. In fact, I know it was. Because this probably homeless gentleman had something to protect him from the rain and he also had enough joy in his soul to still smile on a wet and wintry day.

I loved it all.
“Inchworm, inchworm
Measuring the marigolds
You and your arithmetic
you'll probably go far.
Inchworm, inchworm
Measuring the marigolds
seems to me you'd stop and see
how beautiful they are.”

I hope I never get too caught up in the arithmetic of life. Because these marigolds around me? Man. They're too beautiful to overlook.

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.

It's time to kill MRSA exceptionalism

For nearly 2 decades, we've lived in a delusional state where many in the field of infection prevention somehow believed that methicillin-resistant Staphylococcus aureus (MRSA) was so much worse than methicillin-sensitive Staphylococcus aureus (MSSA) that it needed to be treated in a special way. We needed to find all those who are colonized and isolate them (aka search and destroy). We needed to wrap ourselves in plastic before entering their room. We needed to destroy any unused disposable products that remained in the room at the time of hospital discharge. We needed to terminally clean the room in a special way. And on and on and on … all because MRSA was special. We didn't need to do any of those special things for plain old MSSA.

Some of us have been baffled by this magical thinking from the start. After all, MRSA and MSSA are transmitted in exactly the same ways. We're even more baffled after we see the evidence that in the endemic setting search and destroy doesn't work and contact precautions don't work either. And can anyone honestly say that MSSA invasive infections are benign?

A new multicenter study of invasive S. aureus infections in hospitalized infants published in JAMA Pediatrics should drive another nail in the coffin of MRSA exceptionalism (free full text here). Nearly 4,000 infected babies were studied and outcomes were compared between MSSA and MRSA infections. MSSA infections were nearly 3 times more common. Although there was no difference in mortality rates between the 2 groups, twice as many babies died of MSSA infections.

We need to quit chasing pathogen-based approaches (vertical strategies) to infection prevention and focus on horizontal strategies that reduce infections from all pathogens (e.g., hand hygiene, stethoscope disinfection, bare below the elbows, chlorhexidine bathing). Because all pathogens are important. I often joke that I've never had a patient tell me that they don't want a MRSA infection, but they'll take an MSSA. And that is definitive proof that patients figured out that MRSA exceptionalism was a bad idea long before most hospital epidemiologists.

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.
Wednesday, November 18, 2015

Hear ye, hear ye, probiotics cure all!

A probiotic rep came to our office bearing lunch and billions of bacteria. Who on their staff, I queried, counts the bacteria verifying that each packet has 3 billion disease-busting germs? I suspect that these quantities are only estimates and that consumers may be unwittingly subjected to either an inadequate dosage or a toxic amount. Caveat emptor!

I surmise that plaintiff law firms are hiring germ counting experts hoping to establish with clear and convincing evidence that the product's label is false and misleading. Soon, we can expect to see TV commercials when we will hear an authoritative announcer asks, “If you or someone you love took probiotics and developed fatigue, joint pains, weight loss, weight gain, nightmares, daydreaming, lack of energy, excess energy, loss of a sense of humor, extreme frivolity, lackluster performance reviews at work, basement flooding or any other adverse life outcome, then you may be entitled to compensation. Call 1-800-GETCASH. Operators are ready to speak with you in 9 languages.

After the announcer states his message, scary music plays and we see black and white footage of suffering zombies.

Probiotics, unlike conventional prescription drugs, are not subjected to Food and Drug Administration (FDA) approval. Hence, the germ guru who brought deep fried food to our office is free to discuss all possible uses of the agent despite the absence of any scientific basis underlying his claims. Drug reps detailing prescription medicines do not enjoy a similar level of free speech. In fact, they are securely gagged and are prohibited from discussing off label use of their products, even if we ask them about it. If these guys and gals stray off message, not only will they be summarily terminated, but their companies may be heavily fined, as many have learned.

Does this make sense? Prescription drug reps, whose products have been rigorously tested and are used off label routinely, can't even whisper or use hand signals to communicate important but unofficial information to doctors. In contrast, a purveyor of probiotics, whose products are unregulated and unproven, can sing like a canary extolling the benefits of billions of germs that we're told can fight all kinds of illness, foreign and domestic.

I've always felt that the FDA is too strict in restricting the content of conversations between drug reps and doctors. This is an overreaction from pharmaceutical industry abuses with aggressive marketing of off label use to physicians. As a result of this hyper response, physicians are deprived of an important information resource from reps whom have a very deep knowledge of a narrow subject. Who wins here?

Who needs prescription drugs anyway, now that I know that probiotics are the panaceas that can cure all.

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.

White coats contribute to the unsafe hierarchical culture in health care

Following on the heels of Mike's bare-below the elbows debate at IDWeek, I posted a quick survey to gauge your impression of the level of acceptable harm associated with white coats. I'm still working on the power calculations that will be informed by the survey, but wanted to say thank you to the many who answered the questions. In the meantime, I also wanted to post the comments left by you, our readers. I've posted almost all of the comments thus far apart from those with swearing or those that mention their answers to question #1 of the survey.

One thing that struck me when reading the comments is that the white coat is a symbol that perpetuates hierarchy and is part of an unsafe culture. We need to create healthcare systems without hierarchy and it seems that the white coat contributes to a system where 58% of nurses that see harm are afraid to speak up ”and people need to be able to speak up.” Thus, even if you are in the minority who believes that white coats are not involved in pathogen transmission, your white coat might be harming patients by contributing to an unsafe hierarchal culture.

An interesting patient-centered quote that seems to run counter to the current thinking associating white coats with professionalism: ”If there are better options that would reduce transmission of infection then burn the white coats. As a patient I dislike them, intensely. Reminds me of a butcher shop or auto mechanic, not reassuring at all.”

Pro White Coat:

“Not an issue as long as changed daily and sleeves rolled up above the elbow and they don't carry medical equipment in the pockets”

“The white coat continues to be an important identifier of the profession, and symbols are important”

“It is certainly useful to carry things but also represents antiquated power hierarchy. Although there is no evidence, it plausible that they could transmit infections. Then again so could stethoscopes which have more direct patient contact.”

“Can't prove it is causing resistance—and I think patients like it”

“Needs an RCT. Anything else is nonsense … unless we say all health care providers put on and remove scrubs at work”

“We have white coats with short sleeves. This is no problem in my opinion. But bare below the elbows has become the standard in most Dutch hospitals. Probably the turning point was a documentary with a hidden camera showing that healthcare workers knew that hand hygiene was important that they should not wear jewelry, but they just didn't take the rules serious. Sometimes we don't need science but a good mirror and public response”

“Fashion item”

Pro Bare Below Elbow (OK with eliminating White Coats):

“It's merely a badge of authority and seniority masquerading as cleanliness and something “sciencey”

“A disease-ridden, antiquated symbol. They project the same professional and scientific insecurity as when doctors started wearing them to appropriate the public legitimacy of science.”

“I appreciate that for many, the white coat is a status symbol and helps create an instant first impression on patients. That being said, times are changing. The physician is not the most important person in the room. The healthcare team is what should be the focus now. Tear off the coat and tear down the hierarchy”

“I understand white coats as a part of PPE when you don't want to get something on yourself or to prevent things on you from spreading. But when the white coat goes EVERYWHERE you go, it doesn't maintain its protective qualities. Also, as a pharmacist, I'd much rather have normal, professional or consulting covnersations as a professionally dressed human than a white coat.”

“If it's a vector for microorganisms, eliminate it. Simple”

“Not necessary. Wear scrubs like everyone else. If your ego needs the coat, get therapy”

“I hate it. Adds to elitism and difference. Separates us from our humanness”

“White gets filthy too quickly”

“In the past, it was a status symbol for physicians; this is now translated to our students, ancillary staff and physician extenders. It is not represent amount of fundamental knowledge or the ability to care for patients. It was an extension of the laboratory part of our profession transitioned from black coats earlier in the last century. Currently, it is nothing more than a status symbol or accessory”

“White coats offer no benefit. We should try to prevent infections by any means necessary”

“I don't think white coats are necessary, but then I'm also not American!”

“Don't wear them in Australia. If you're worried about getting dirty, wear scrubs”

“It's part of a bygone age”

“Given the association with pathogenic transmissions, I am appalled we are still handing them out to our medical trainees!”

“I work at a pediatric hospital where most physicians do not wear white coats. Anecdotally, pediatricians seem to eschew white coats in order to be more friendly and approachable. Don't know what impact this has on HAI at our hospital”

“Doctors don't walk around with head mirrors anymore; the white coat makes about as much sense to me. Why do we still have this thing that exists for no other reason than a vector for disease?!”

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.
Tuesday, November 17, 2015

Hormone replacement's "Ah-Ha!" moment

I was privileged to attend a recent continuing education conference about estrogen replacement at menopause, held at the Yale School of Medicine, organized by my friend and colleague, Dr. Phil Sarrel. Highlights for me included both Dr. Sarrel's important insights, and a very poignant, personal story told by Michelle King Robson, founder of EmpowHER. Michelle had what eventually proved to be diverticulitis. Initially misdiagnosed, her condition was erroneously treated with a hysterectomy. Michelle's overall health plummeted due to a surgically induced menopause, until it was restored with judicious hormone replacement.

The conference was a culminating event in a months-long effort, again led by Dr. Sarrel, to provide the field of hormone replacement a much-needed “aha” moment. Having served for 8 years as Oprah's nutrition columnist in O Magazine, that certainly resonates with me. In this case, however, the revelation comes in the form of an “Ah-Ha!“ moment, standing for: advancing health after hysterectomy. We will return to that shortly. For now, here is the back story.

Roughly two years ago, Dr. Sarrel brought to my attention a research study published in JAMA looking at long term health effects in women who did, or did not, receive estrogen replacement after hysterectomy. This sample of women was a subgroup of the larger population enrolled into the well-known Women's Health Initiative, or WHI.

That large trial, funded by the NIH, is largely responsible for reversing the prevailing attitude about hormone replacement at menopause. Observational studies had suggested decreased chronic disease and premature death risk with hormone replacement. As a result, hormone replacement at menopause became rather routine in the service of preventing serious chronic disease, heart disease in particular, for a span of years.

The WHI, the largest of several randomized intervention trials to examine the issue, essentially said: au contraire. The report of no net health benefit, and some net harm, from hormone replacement produced a fairly abrupt and complete about face in public attitude and clinical practice alike. Hormone replacement was suddenly yesterday's bad news.

But as so often happens at the interface of medicine and the media, important nuance was lost. For one thing, the WHI, like the other randomized trials, only studied one variety of hormone replacement, called Prempro. Though popular, Prempro is not considered anything close to optimal hormone replacement by those expert in the field. The attribution of harms from Prempro to all varieties of hormone replacement was an important nuance, lost in the customary oversimplifications and hyperbole of media.

For another, the results of hormone replacement vary widely with timing. It has long been clear that effects of hormone replacement are best when treatment begins early rather than late after menopause. The data showed such distinctions, but they too were obscured by a rush to summary judgment.

For yet another, the net harms of even Prempro in even a mixed population of women starting hormone therapy both early and late after menopause were very sparse. The WHI data actually showed both benefits and harms, and they were pretty closely matched. Headlines shouting out warnings about net harms made hormone replacement sound far worse than objective data ever suggested; the data showed something pretty close to a toss-up.

Finally, and most importantly, the data showed very different effects in women who, because they had undergone a hysterectomy and did not need to take progesterone, could take estrogen only. What Dr. Sarrel pointed out to me those two years ago were published data indicating 13 fewer deaths per year per 10,000 women in their 50s treated with estrogen, rather than placebo. Estrogen alone, used in relatively young women right after menopause, was saving lives.

Provided this crucial observation, my job was to translate the study data into real-world effect. Colleagues and I, working with Dr. Sarrel, did just that, and published our findings in the American Journal of Public Health. Our analysis suggested that over a decade, over-zealous avoidance of estrogen replacement had resulted in tens of thousands of premature deaths among women in the U.S. alone.

It would be hard to overstate the sense of urgency that ensued when we looked at such stark and alarming data. The result of that consternation, and passion, is AHAH, a campaign, and a non-profit organization, devoted to clarifying to women, and their physicians, the nuanced realities of hormone replacement. There are different kinds of hormones; different kinds of women; and different effects as a result. Estrogen therapy in younger women who have undergone hysterectomy saves lives, mostly by preventing heart attacks.

The Yale conference was an example of the kind of education and outreach to which Ah-Ha! is committed. An “aha moment” is great, but moments come and go. It takes a campaign, and time, to change hearts and minds.

Hormone replacement is not right for all women, but nor is it wrong; we have now bungled this in both directions, and failed to distinguish baby from bathwater. Dr. Sarrel is an impassioned, indefatigable champion of the nuanced understanding necessary to optimize hormone replacement, and save lives. By taking Ah-Ha! from a mere moment to an on-going campaign, I believe he can help us all get it right this time.

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.

Improving the evidence

All good physicians want to do the right thing. They want to recommend effective therapies to their patients that will improve outcomes or alleviate symptoms. It is widely accepted that the best way to discover new effective therapies is through the use of clinical trials. Among clinical trials, the reference standard is the randomized, double-blinded, placebo-controlled trial, which is designed to minimize bias in the selection of therapies or the interpretation of results.

I have written before about the limitations of clinical research in advancing medical practice. As I have said, it is literally impossible to study every clinically relevant question, and it is also impossible even in theory to use randomized controlled trials as the methodology for many of the questions that can be studied.

A recent article in the New York Times highlighted another challenge to the paradigm of clinical trials as the engine for improving medical practice. The piece was about a change in policy at the National Institutes of Health, being implemented by Michael Lauer, the “newly appointed deputy director for extramural research.” In the interest of full disclosure, I have known Mike for many years (we were cardiology fellows in the same program at Boston's Beth Israel Hospital in the late 1980's) and you would be hard-pressed to find a nicer, smarter or more upstanding guy.

The new policy grew out of a disturbing observation that the results of many studies funded through NIH grants were never published. To paraphrase Lauer, it is as if those unpublished studies were never performed. As a result, the dollars spent to do those studies did not yield insights that could inform medical practice, and the implicit promise to study participants that they would be able to contribute to advancing knowledge was broken.

In response, the NIH is now shifting focus. The stated intent is to fund “fewer, but deeper, studies, to focus resources on efforts with real-world impact and life-or-death implications” and to require that all studies post their findings in a federal database, even if the results were not published elsewhere.

The idea behind these changes is to direct scarce resources to exploring issues that can have a profound effect on medical practice, and to make sure that the results are broadly available. Seems like progress to me.

What do you think?

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.
Monday, November 16, 2015

Theranos: in need of a little sunlight

If you haven't heard of Theranos (a made-up word coming from “therapy” + “diagnosis”), a startup company promising to disrupt the clinical laboratory industry, you might have seen news about it this week. The company has hit a wave of negative press inspired by a Wall St. Journal expose on its early failures.

Theranos has a compelling backstory: Founder and CEO Elizabeth Holmes dropped out of Stanford at age 19, spent 10 years in obscurity developing a new technology for blood tests, then launched the company with a wave of publicity that would make Donald Trump and Steve Jobs envious: Business magazine cover stories, a New Yorker profile, a TEDMED talk. Along the way, she creates an advisory board with names like Kissinger, Frist, Shultz, Nunn, Perry, etc., all high-ranking former government officials. The company garners a valuation of $9 billion, making Holmes, at 31, on paper the youngest self-made female billionaire in the world. (Mark Zuckerberg of Facebook is 3 months younger than Holmes.)

The premise is this: Holmes hated giving blood for routine medical tests. Her phobia was so great she thought there had to be a better way to do it: Microfluidics. Using a finger stick to collect of drop of blood instead of the more traditional practice of puncturing a vein near your elbow, Theranos promises the ability to run dozens of medical tests from that single drop instead of the numerous traditional blood vials. Moreover, Theranos promises to perform the tests at a fraction of the cost of industry leaders LabCorp and Quest.

Disruptive technology indeed.

The problem is that Theranos is highly secretive about its methods, choosing to go the press to announce its new technologies and partnerships, never proving its mettle in a peer-reviewed scientific publication. Medical and scientific skepticism therefore abounds.

In appearances, like 1 moderated by an acquaintance, Holmes seems more like the charismatic mouthpiece for some sinister group than a true wunderkind.

Last week the WSJ reported extensively on the fact that Theranos is outsourcing its blood tests to third parties, not running the tests themselves. Moreover, the microfluidic (finger stick) assays work on only 5 of the company's menu of dozens of tests. The rest of the time their test centers obtain blood via traditional veinipuncture.

What's going on here?

Rather than come out and discuss the company's problems and plans to address them, the company has simply issued denials and obfuscations, hiding behind attorneys rather than letting its CEO speak.

Schadenfreude is the word for it. Now it seems every business publication is piling on after the WSJ story. Nobody likes an upstart that promises to trample the established way of doing business, then fails to measure up, especially when dis-inviting scrutiny at every turn.

This is shaping up to be a story of colossal underperformance for such high promise, if not outright fraud in the hype and publicity departments.

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, November 13, 2015

An ICD-9 story

Medical billing and epidemiology relies on a classification of diseases maintained by the World Health Organization. On Oct. 1 we transitioned from ICD-9 to ICD-10, a major change that increases the number of available diagnoses from some 17,000 codes up to more than 155,000. In a strange cosmic twist, that was the same day that most retailers needed to install readers for credit cards with chips or be liable for bad purchases.

With that in mind, I present a short story in ICD-9, with a translation into English.

ICD-9

It was E900.0. That, combined with E904.1 and E904.2, not to mention V69.4, is what led to 780.2. I admit it, I have V69.0 and V69.1. I usually sleep well, but that night was different, thanks to 780.55 due to 780.92. That morning I understandably drank 969.7, leading to 785.1. During E924.2 while E013.0 I felt 780.4. Stepping out I had 368.45 before I 780.2.When I was V49.89 after my E884.9. I had a 784.0, as if I had a 305.00. I used my E011.1 to call work to say I'd be late and hoped to avoid V62.1. He greeted me with a 784.42 indicating 300.4.

Last year I V49.89. The flights are arduous, subjected to E918 or being in V01.9 with a 780.92 E979.6 at E902.0. After landing I'm 780.79 due to V69.4 and 780.55, leading to excessive 786.09.

I was in 309.29. At least, thank to the ubiquity of E849.6, I didn't have to suffer from 292.0.

If you think this makes for 315.00 and is a 729.1 to read, just wait for ICD 10! Ever see a V91.07XA?!

Translation

It was too hot. That, combined with lack of food and water, not to mention lack of sleep, is what led to my fainting. I admit it, I don't exercise or eat right. I usually sleep well, but that night was different, thanks to interrupted sleep from my son's crying all night. That morning I understandably drank one too many cups of coffee, leading my heart to skip a beat. During a hot shower I felt lightheaded. Stepping out my vision narrowed before I passed out. I awakened after my fall to the floor. I had a headache, as if I had a hangover. I grabbed my cellphone to call my work to say I'd be late and hoped I wouldn't be in trouble with the boss. He greeted me with an edge to his voice, indicating he wasn't completely happy.

Last year I traveled to foreign countries. The flights are arduous, subjected to being squeezed in with other passengers, or being next to a crying, germy child at altitude. After landing I'm worn out due to lack of sleep and jet lag, leading to excessive yawning.

I was in culture shock. At least, thanks to the ubiquity of vendors, I didn't have to suffer from caffeine withdrawal.

If you think reading this is difficult and is a pain in the butt to read, just wait for ICD 10. Ever see a burn due to water-skis on fire?!

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.

Hyponatremia, and he fell--a case study

A 78-year-old man was admitted after a fall with no fractures.

His labs on admission:

125, 89, 33, 128

5.2, 22, 2.1

He has a history of B-cell lymphoma.

His serum osm was 273 and urine osm was 263.

Clinically he is euvolemic (i.e., not orthostatic). He is bradycardic (we stopped his beta blocker given for previous CABG).

He is new to our hospital, we do not know his previous renal function.

Your question: What further tests do you want? Can you speculate on his diagnosis?

One doctor had the proper instincts. The patient had a random cortisol of ~4 (normal 8 or greater). His stimulation test had a peak cortisol of 8. His ACTH was significantly elevated.

A CT scan showed bilateral adrenal involvement.

Hydrocortisone (25 b.i.d) and fludrocortisone (0.1mg) led to a dramatic improvement in his energy level and his laboratory data.

This is a classic presentation of adrenal insufficiency secondary to a tumor destroying glandular tissue.

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, November 12, 2015

The miracle workers

“Oh, if you were like me
You didn't have a lot of gold
Possessions or money
You didn't own wealth untold

But I'm glad
You didn't look on the things that I had
But you looked on the things you were able to give me.”
—CeCe Winans, “In Return”

I saw this woman once in clinic. It was December and she'd caught 2 buses to reach us just to get her blood pressure checked and to get her medication refills. And at the end of that visit we were talking about the holidays and such and she let me know that Christmas used to be her favorite but now wasn't. And I won't belabor this with some elaborate tale but instead will go ahead and cut right to the predictable chase and let you know that it had to do with her financial situation. She had an 11-year-old daughter and a 9-year-old son who wouldn't get a single gift because she couldn't afford it.

Yeah.

But they had food and a warm home, you know? And she seemed cool with all of that. Like, she wasn't all super melancholy or mad dramatic about it. It just was what it was. And even that—the fact that this was her normal and clearly she'd figured out how to navigate it—isn't the point. I really tell you this to tell you about something else that happened after this encounter.

Oh.

And let me just preface this by saying that what happened after that encounter wasn't exotic or unusual at all. Instead it was something that happens on a daily basis in hospitals like Grady all over the country.

Yup.

I called our social worker. And all I did was tell her about this woman and her situation. Then, like our social workers do, she came over to the patient and sat down and spent time finding out her situation. Next thing I knew, some community resources were identified that happened to service the area right where my patient lived. And they were willing and also able to help this woman give her kids just a little bit of magic on Christmas morning.

Yep.

It was short notice. We were like 3 days shy of Christmas, so that social worker went to wherever she got those resources, retrieved some gift cards and personally went out and bought things for those children herself. Then she delivered it to my patient's home along with some stuff for her to present it to her kids as gifts.

She sure did.

A man I cared for on the hospital service had been ill and was estranged from his family due to a multi-year drug stronghold. He'd been unstably housed and mostly on his own or in the streets. But this illness was serious and sidelined him in that way that no one ever wants to be sidelined. “Where are your people?” I asked. And I asked that because in a place like Georgia everyone has “people.” Or even “peoples” as some folks say. Anyway. This man said he did have people but that he didn't know where they were or how to reach them. The names were patched all together in a ragged little tapestry that fractured into pieces the minute any of us tried to pull it all together.

But.

Then I told the social worker. And that social worker stepped in and got to work. And if you work at a place like Grady or have had any contact with a great and dedicated social worker, you know that there is no need to even say “spoiler alert” before anything else. She found that man's people. And his peoples, too. And those folks were worried and glad and thankful to be able to come to the side of their family member during that time.

Now.

Finding somebody's people or peoples may not seem like a big deal to you but it is. And when things like drug addiction and untreated mental health issues and time stand as looming barriers, many times it's a downright miracle when those pieces get put together. And even more of a miracle when something right and good happens as a result.

But this—these sorts of ordinary miracles—happen every single day at Grady. And in this moment I am reflecting on our social workers, the miracle workers who open the doors and windows that have been painted shut for so many for so long. I cannot do what I do without them. The obstacles are too great; my caring alone is not enough.

Earlier this month, one of my favorite Grady social workers of all time died. She fell ill swiftly and was gone in the twinkling of an eye. And when I heard the news it truly broke a piece of my heart. Truly, it did. Because she was my friend. Or rather, we were very friendly. And I realized that I loved her. And no, not in the eros sense but something different. More like some hybrid between the brother-sisterly philos love and the nebulous agape-type love that one experiences spiritually. Somewhere in my deep appreciation for the selfless contributions of every single social worker I've known through the years, my heart felt a particular sadness at this loss because of that love.

Yes. That.

She, Mrs. Veronica Smallwood, was a wonderful human being. Let me not trivialize that piece. But no, she was not the social worker involved in those 2 aforementioned encounters. That said, in countless other ways she was.

Does that even make sense? I know. I'm probably rambling.

Either way, I'm feeling this weird mixture of sorrow and deep, deep gratitude. It's hard to explain, but I'm trying.

And so. To honor her life, today I honor her peoples—the social workers like her. The selfless legion of women and men who stand ready to help people find soft places to land. The ones who navigate the red tape of socioeconomic speed breakers and mysterious Medicare rules and nefarious nursing home situations. The fearless servant leaders who run into the burning houses armed with nothing more than clipboards and willing hearts and who, on my watch, are often the ones who pull the screaming baby or decrepit elder from the asphyxiating plumes of black smoke before anyone else. Just in the nick of time. Yet so interestingly they quietly hand them over to someone else just in time for them to get the glory.

That last sentence just brought tears to my eyes. Because it is so, so true.

Sigh.

Mrs. Veronica Smallwood and her peoples have helped me help others more times than I can count. Surely I could fill an entire blog up with daily tales of these very moments like the two above. I could fill one book alone with just stories of things Mrs. Smallwood specifically did to assist my care of patients for the last fifteen years. I surely could. And I am deeply grateful for it all. I am.

You know? I told Veronica how much I appreciated her every single time I called her or saw her. Not because I foresaw this, but just because it was how I felt and she always gave me space to be honest. I take some solace in that. I do. But I guess today, I felt the need to go and tell it on the mountain. Not just how thankful I am for Mrs. Smallwood, but instead putting a bullhorn to my lips to shout to the world who the real miracle workers are in a place like Grady. In a place dedicated to serving the undeserved? It's them. The ones stealthily making dollars out of fifteen cents day after day after day and leaping from often dilapidated buildings in a single bound--the social workers.

The bible says, “The greatest among you will be your servant.” (Matt 23:11.)

Yes. That.

That. That. That.

Yeah.

***

Happy Wednesday. And thank you for being the greatest among us at Grady, Mrs. Smallwood. You will be missed. And today you are remembered.

*And shout out to Mrs. Valerie Beaseley and Mrs. Dorothy Zimmer, respectively, the 2 miracle workers who made things happen in the two 100% true stories above.

Now playing on my mental iPod, for you and all of your peoples, Mrs. Smallwood. “In Return” as sung by the matchless CeCe Winans. Perfect lyrics for the ones who bless our patients every day at Grady and ask for nothing in return.

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.

National nutrition policy, imperiled by bullies

I know a guy who writes blogs rather prolifically (for which he is uncompensated, by the way). The audience for his blogs is, presumably, people interested in his opinions and his writing; why else would they be there? He writes books, too. And once, he wrote a blog in which he expressed, to this audience presumably interested in his opinion and his writing, his opinion about his writing.

The guy in question is me, and the blog in question was written, like the paragraph above, in the third person, because the writing in question was an epic work of fiction written under a nom-de-plume.

I am guessing that doesn't immediately jump out at you as one of the great scandals of 2015, and I must confess, I am with you. It does not, for instance, seem to be up there with the political theater of the so-called Benghazi hearings, which are exploiting the tragic deaths of our fellow citizens for partisan advantage. It does not seem to rival the ill-gotten gains of fantasy football; the hush money intrigue of Dennis Hastert; or even the well-funded sabotage of America's dietary guidelines.

But there is a group carrying on as if what is confessed above is a great scandal, and there is a good reason. They are the very group employing every means at their disposal to scuttle dietary guidance dedicated to public (and planetary) health to serve their own pecuniary interests, and I have been among those calling them out for conflicts of interest; errors of content; and want of qualifications, every step of the way. They don't like me, in other words.

I suspect most of you know that the report of the 2015 Dietary Guidelines Advisory Committee was issued some months ago. I suspect many of you know that I think it quite stellar. I strongly favor the inclusion of sustainability, which our Congress, in its apparently limitless capacity to subjugate conscience to cash, has already expunged at the shrill insistence of Big Food and Big Ag, and their front people.

I suspect many of you also know that I consider the death of expertise an important loss to the standards of modern journalism. No, it is not a “debate” when a group of highly qualified, carefully selected, scrupulously vetted, multidisciplinary experts says “A,” and Joan Shmo with no relevant qualifications and an obvious financial interest in the outcome says “B.” Presenting such nonsense to us as if a legitimate debate is, in my readily accessible opinion, an insult to our intelligence, and an abdication of journalistic standards.

What many fewer of you have cause to know is that the conflicted parties seeking to profit at the expense of public health by undermining the almost unbelievably noncontroversial conclusions of the Dietary Guidelines Advisory Committee, are bullies. If you challenge their content, as I have done, they seek to assassinate your character. Violence is the last refuge of the incompetent in cyberspace, too.

Through colleagues, I know that I am far from alone in invoking this group's ire, but invoke it I have, simply as a result of doing my job. It is my job to defend public health, and express my opinions accordingly. Those opinions are about objective elements of content, and qualifications, not character.

In return, I have been subject to various forms of harassment for months. The cabal in question has interrogated my lab staff, seeking information about funding sources, then sharing that information via social media in the form of disparaging innuendo. Yes, my lab has conducted industry funded, in addition to publicly funded, research, as is true of most labs. Industry funding is fraught, and cause for precautions, but the derisive innuendo that one's opinion or conclusions are for sale by virtue of it is not merely unjustified, but flagrantly nonsensical. Anyone who has benefited from a modern antibiotic, diabetes drug, statin, or chemotherapeutic agent is a beneficiary of industry-funded research, the pathway to FDA approval for virtually every entry in the modern pharmacopoeia. Modern medicine would not function in the absence of industry funded research.

Along with the social media smear campaign, inquiries were directed to the offices of the Deans of both Medicine and Public Health at Yale, not asserting, but rather implying, non-existent improprieties. All the while, the cabal in question kept re-tweeting one another to make it seem that this fringe group protecting only its own interests actually represented a groundswell; such is the liability of Internet echo chambers.

The latest chapter has been further harassment of this sort, but now focused on the fact that I did, indeed, write a blog about a book of my own in the third person. That story is rather banal, but here goes:

On my own time, and with only my own funding, I wrote and published an epic fiction novel, the first book of a trilogy (now nearing completion). For reasons related mostly to the integrity of the tale, the “author” could not be me, so the book was written under a nom-de-plume. Attempting to preserve that separation between myself and the author, I soon realized that left me with no way to tell anyone interested in my writing about this book, which I honestly consider the best thing I've written. I decided to write a blog about it in the third person, and express my opinion. As noted, the writing in question was not compensated.

But of course, that was a naïve solution. It still left me with no reasonable basis to refer to the book again. So I disclosed that reVision was indeed mine, although it is more correct to say that my imagination is parent to the author, Samhu Iyyam, than to say that she is me. I do, indeed, commend the book to those of you interested in my writing and opinions, since it is a product of the former and expansively probes the latter, in the context of a rollicking adventure. My mother loves it.

Why waste your time, or mine, with a rendering of this utterly underwhelming tale of intrigue? Several reasons.

First, I believe only those of us directly in the line of fire know that the same group committed to scuttling the Dietary Guidelines is quite prone to, and reasonably adept at, harassment and intimidation. The same resources mobilized to pervert dietary guidance away from the health of humans and the environment and toward both corporate and personal profits are being allocated to silence informed opposition. I, obviously, have not been silenced by this campaign, but for all we know, others have. That's ominous.

Second, Edmond Burke, assuming he said it, was quite correct: all that is necessary for the triumph of evil is that good men do nothing. But doing something, particularly in the face of any semblance of “evil,” comes at a cost. I take advantage of this opportunity to say: we should bear that cost.

Third, Supreme Court Justice Louis Brandeis pointed out that sunlight is the best of disinfectants. It is an antidote as well to the disingenuous aspersions and innuendos of bullies keeping to the shadows, be they in alleyways or on the Internet.

Fourth, I take some pride in the fact that the worst thing a cabal seeking to silence me for months could find when they went rifling through my virtual closets was: for an audience interested in his writing and opinions, he wrote his opinion about his writing. I am an honest guy.

Of course, none of us is infallible. Our judgment may go awry even when our intentions do not. If by writing about reVision in the third person I did inadvertently violate anyone's trust, my apologies. But frankly, I rather doubt anyone without ulterior motives was ever troubled by that scenario. The opinions I expressed about the book were entirely sincere, if immodest, representing a blend of intentions, reflections, and aspirations.

Fifth, we should all recognize that when our adversaries are unscrupulous and prone to bullying, we are all potentially vulnerable to smear, no matter how free of skeletons our closets, no matter how devoid of scandal our personal histories. All it takes, for instance, for me to look foolish and defensive is an anonymous call to a university official asking: “isn't it true that Dr. Katz should stop beating his wife?” Providing the response- I never started- nonetheless situates me under the intended overcast of implied impropriety. Such is the work of clever bullies. They don't need to be right, and they needn't even risk the injury of direct assault when innuendo will suffice.

That, then, is the story that does need to be told: a genuine scandal, richly deserving of disinfection, and a bracing dose of daylight. The same constellation of forces and resources that can be used to subvert national health policy to private interests can be marshaled to the purposes of harassment, intimidation, and defamation. The same forces can be applied to deflect and misdirect; imply and insinuate; and propagate the cover of shadows where conflicts are concealed, motives camouflaged.

Make no mistake, whatever the smokescreen: this is all part of a campaign to undermine the public health for private profit. The nation's official position for the next five years on diet for health is on the line, imperiled by bullies. I am speaking out simply because we don't know how many others, encountering the same forces, have decided doing so is not worth the abuse.

I am speaking out because it is.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
Wednesday, November 11, 2015

The Daraprim debacle: The smell test sniffs out price gouging

You don't need to be an ear, nose & throat doctor to be conversant with the smell test. We use this technique in everyday life. This diagnostic test is used to determine if a situation is an egregious deviation from established norms. The beauty of the smell test is that one need not be encumbered by facts and data. It relies upon emotion and instinct, which greatly simplifies its use. Let me illustrate.

Situation when smell test does not apply
• Grading the SAT Examination. Sniffing and smelling just won't work here.

Situation when smell test applies
• A city mayor hires his brother in a no-bid contract as a consultant.

Are you catching on here?

I surmise that my erudite and insightful readers would sniff deeply through flared nostrils if they confronted the following situations:
• “A double dip ice cream cone, which yesterday cost $4.25, is now $57.85. A severe shortage of sugar cones developed last night.”
• “The Sunday New York Times is now priced at $82. Middle East turmoil has caused the price of newsprint to skyrocket!”
• “Your overnight Fed Ex envelope will cost $325. We haven't had a price increase in 4 months and will use this revenue to serve you better.”
• “Yes, I can reschedule your airline ticket with a keystroke for only $150.”
• “Call this number and I will send you absolutely free my fool proof system to make millions in real estate without any money or experience!”
• “One fat-burning pill a day will melt the pounds away without changing your diet or exercising!”

No explanation, even when delivered by an authoritative PR pro can make the bad smell go away.

Recently, Turing Pharmaceuticals acquired the drug Daraprim, which is used to combat toxoplasmosis, a potent parasite. The new company decided that a slight price adjustment was necessary. So, the price per pill was increased from $13.50 to $750. No typo here. Feel free to use your preferred search engine to seek out the company's explanation for their mega-gouging. While I always try to remain open to opposing views, can any explanation exist that would justify this increase?

This is an example of corporate excess that will boomerang right back to strike the perpetrator. Wanton greed and arrogance will surely provoke anger and bring a hammer of reform crashing down. Ask your doctor. Physicians understand what happens when a profession refuses to heal itself.

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.