Wednesday, December 30, 2015

Is e-mailing with patients a good idea?

Physicians speak with patients every day on the phone for a variety of reasons. Our practice now uses a portal system, giving patients access to some of their medical data and to us. Although I was resistant to having e-mail communications with patients, I have come to appreciate the advantages.
• It relieves our ever congested phone lines;
• It relieves patients from a state of suspended animation as they hope and pray that a living breathing human being will return to the line after being placed on hold; and
• It saves our staff time who no longer have to triage calls as the patient directly reaches the doctor.

While this streamlined cyber communication system is useful, it does have limitations. It can't solve every problem. Indeed, some issues are not appropriate for either a phone call or an e-mail.

Consider the following scenarios. Which can be appropriately handled on the phone and which merit a face to face encounter with a physician?
• I was in the emergency room yesterday and they told me to call you for pain medicine.
• My diverticulitis is acting up and I need an antibiotic.
• My breathing is worse. I think it's a side-effect of the new heart medicine I started last week.
• What can I take for constipation?
• My cousin had the same symptoms and it ended of being her gallbladder. Can you give me the name of a surgeon?
• I'm dizzy and my hemorrhoids have been bleeding for a week. What can I take?
• I have hepatitis C. Is is okay if my grandchildren visit?
• I had some chest pain yesterday when I was shoveling snow. Should I double my Nexium?

The practice of medicine is not fully wireless, at least not yet. Sure, e-mail is convenient for everyone, but if used too casually it can become quicksand. Often, the patient feels an e-mail is sufficient, but the physician may not be comfortable, depending upon the medical facts and how well the doctor knows this patient. When you are face to face with your doctor, the medical history will be more detailed, there may be a physical examination, and there will be a dialogue and review of treatment options. It's a lot easier for us to assess your pain, for example, when you are in front of us. Moreover, when you return to see us for a follow-up visit, we have a baseline to use as a comparison.

What are your thoughts on all this? Feel free to e-mail me, but I'd prefer if you came to see me face to face.

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.
Tuesday, December 29, 2015

Expert opinion on dietary fat: Is the apparent disagreement real?

Answers are seldom, if ever, better than the questions that invite them. We will return to that in due course. (And yes, that luscious Lamborghini figures in it, sort of.)

I had the enormous privilege over the past 2 days of co-chairing a genuinely groundbreaking nutrition conference in Boston. Sponsored by Oldways, the conference convened very diverse experts from around the world, and tasked us all with mapping out the “common ground” of healthy eating. We did so, in gratifyingly decisive style.

But the relevant electrons had only just submitted to the discipline of word processing, and I had not yet left the conference venue when I received an email from one of the attending journalists, hoisting the proverbial red flag. She alerted me that she had received a question from one of her many readers about the best dietary approach for addressing dyslipidemia, and avoiding statins. Specifically, the reader inquired: Should I, or shouldn't I, adopt a low-fat diet?

The journalist, in turn, took advantage of her circumstance to pose that question directly to 2 of the scientists at the meeting, members of the group that had allegedly just come to agreement. One of the 2 is widely known for studies of, and devotion to, low-fat, plant-based diets. The other is a prominent nutritional epidemiologist without any obvious allegiance to a specific dietary pattern, but seemingly most inclined toward the Mediterranean diet.

So, when the reader's question, “Should I use a low-fat diet to address my dyslipidemia?” was posed by the journalist to these 2 august members of our assembly, 1 said “yes,” and the other said “no.”

There are few responses with less ostensible overlap than “yes” and “no,” and the journalist shared her concern with me accordingly. Given this response, in the immediate aftermath of our purported consensus, was the claim of consensus valid?

Yes, it was. The deficiency here is less a matter of diverging answers, and more a matter of a divisive, and ultimately misdirected, question. In other words, the trouble here is not want of consensus. The trouble here, to borrow from Cool Hand Luke, is a failure to communicate well.

The reader's question here, a question we have taught the public to pose by fixating on nutrients rather than foods for decades, invites mutually exclusive replies from experts with differing preferences. That does not belie the true consensus; it merely obscures it. Consider, for instance, asking top engineers from, say, Lamborghini and Bentley: Are the world's best performance cars made in Italy (or if you prefer, England)? The Lamorghini engineer, deeply invested in that culture, would doubtless say yes (for Italy). The Bentley engineer would just as reliably say no, defending the handcrafted virtues of her own brand. Again we have the unbridgeable divide between “yes” and “no” from two experts.

But the problem here obviously resides with the question. If both engineers were instead asked, “What are some of the world's most finely engineered performance automobiles?” we might quite reasonably expect that each would mention the other's brand, along with their own, and several others, however begrudgingly.

So, too, I believe, for dietary fat. Some researchers have devoted entire careers to studies of outstanding, plant-based diets that are, along with many other attributes, low in total fat. Health outcomes have been excellent in such trials, and those invested in this line of inquiry would, naturally, recommend a low-fat diet for modifying cardiac risk. What they actually mean, however, is an outstanding diet, composed of wholesome, highly nutritious foods, that happens to be low in total fat.

Other researchers have devoted entire careers to studies of the Mediterranean diet, the best variants of which are also outstanding, and composed of wholesome, highly nutritious foods. Such diets also happen to be relatively high in total fat. Experts with careers devoted to inquiry in this area would naturally recommend a Mediterranean diet for cardiac risk mitigation.

Note that both agree on the subordinate details, as does the larger universe of nutrition experts. All variants on the theme of optimal eating reliably exclude manufactured trans fats, and are low in total saturated fat if only by virtue of the foods they emphasize. They are, into the bargain, low in added sugars and sweeteners; low in refined grains and starches; and not more than moderate in total sodium. These matters are not belabored here for they are uncontentious, and largely self-evident.

Imagine asking the expert devoted to plant-based, low-fat diets: MUST a diet be low in total fat to be excellent? I am confident that most who truly warrant the “expert” designation would say no, while perhaps appending that they believe the diet may be made even more excellent by keeping total fat low. Conversely, were the Mediterranean diet expert asked, “MUST a diet be high in total fat to be excellent?” I am again fairly confident they would concede it need not be, while perhaps appending that a generous intake of the right dietary fats might well make a diet even more excellent.

These 2 responses still represent the differing priorities of distinct experts, but they allow quite handily not only for common ground, but more ground in common than uncommon to both. That was the very intent of the conference, to demonstrate the predominance of common ground, not to disallow for additional real estate where we might find room to disperse, and ruminate in private.

Better still than this approach to the reader's question is an approach that looks past the issue of macronutrient thresholds in the first place. Outstanding diets can be higher or lower in total fat, higher or lower in total carbohydrate, and higher or lower in total protein. They cannot fail, however, to emphasize wholesome foods in sensible combinations, a preferential focus on plants. They cannot fail to avoid hyper-processed, glow-in-the-dark junk.

So, imagine an answer to the reader's question that goes like this:

Some experts would direct you to a low-fat diet, and some to relatively high-fat diet, but most would suggest you not think about total dietary fat at all, but rather what kind of fat, and from which foods. What experts agree on is that diets that happen to be low fat, because they are made up of wholesome, healthful foods that are low in fat; and diets that are much higher in fat, because they are made up of wholesome, healthful foods that are higher in fat, have both been associated with astonishing improvements in overall health, including the reversal of cardiac risk factors, and the prevention of heart attacks. Both such dietary patterns have been associated with the effects on blood lipids you are seeking. A particular diet tested for effects on serum lipids to rival those of statin drugs did not focus on fat at all, but rather on soluble fiber and plant sterols.

So: Start out by eating a dietary pattern that emphasizes unprocessed and minimally processed vegetables, fruits, whole grains, beans, lentils, nuts, and seeds. This will tend to be rather low in fat. You might, then, choose to place particular emphasis on the nuts; add avocado, olives, olive oil, fish, and seafood, and perhaps some dairy, and your fat intake might well wind up rather high. But you are still safely in the realm of evidence-based disease prevention/health promotion by dietary means. Drink water when thirsty, by the way; and perhaps modest alcohol, preferentially red wine, to enhance the pleasure of meals and cardiovascular health as well. Everything else is rather discretionary. You might or might not choose to include some lean meat; some poultry; some eggs. These foods can be included at certain levels in very healthful diets, but these foods do not seem to be what make any given diet healthful, so the emphasis should clearly be elsewhere.

Experts are people, and people will inevitably tend to favor the variant on some theme to which they have devoted their careers and lives. That's the very reason the “common ground” matters. There are, in fact, low and high fat regions of it, but there are NO “bad fat” regions of it. When fat is high, it comes from foods that even low fat proponents mostly endorse; when fat is low, it is because of foods that high fat proponents endorse.

I have heard colleagues, notably from Harvard, say “There is no evidence for low-fat diets.” This statement, however, is so readily falsifiable as to be a non sequitur. In fact, even Medicare, generally about as open-minded and persuadable as a Spanish Inquisitor, acknowledges such evidence, and reimburses on the basis of it.

What I believe these colleagues actually mean is that: There is no evidence that a diet must be low in total fat to produce health-promoting, disease-preventing effects. There is no evidence that when excellent, low-fat diets achieve outstanding health effects, it is specifically because they are low in total fat. Both of those statements are, to the best of my knowledge, eminently defensible if not just plain true. The difference between the assertion and what it really means is, as noted, less about content expertise, and more about the subtleties of communication, where much of our failure resides.

Similarly, I have heard colleagues argue the virtues of low-fat diets, but they are, ineluctably, talking about excellent diets that happen to be low in fat because of the native characteristics of the foods that predominate. Broccoli is not good for us because it is low in fat; broccoli is good for us because it is broccoli.

Which brings us full circle: There are no good answers to dubious questions. Questions about total fat intake, or fixations on any single nutrient for that matter, tend to be rather dubious, and invite answers that are divisive. They do not belie the common ground -- but they do ask us to retreat to our exclusive patches of real estate, and sing out their competing virtues.

There truly is common ground among the world's leading nutrition experts. The journalist's reader may favorably adjust her lipid profile with an excellent diet that happens to be higher, or lower, in total fat. The seemingly irreconcilable experts would be able to give complementary rather than conflicting answers were we to overcome the challenges of communication, and learn to start asking better questions.

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.
Monday, December 28, 2015

An open letter to the American Medical Association and all state medical boards to stop using the word 'provider'

Dear Organization:

The last few years have been a period of unprecedented change in the world of healthcare. The need to rein in costs, expand access, and ensure higher quality care—all at a time of rapid medical and technological advancements—has changed innumerable aspects of the practice of medicine.

Throughout this, 1 common theme has been the dedication and determination of hundreds of thousands of physicians across the United States, who on a daily basis work tirelessly for their patients. These physicians are among the most highly educated and trained professionals in the country, the majority having accumulated a substantial debt burden to become practicing physicians. At a time when most fellow professionals are starting families, buying homes, and getting settled in life, would-be physicians are still in education, sitting exam after exam to fulfill their dreams.

It is therefore a concern that another big paradigm shift in health care has been a push to no longer address physicians by their true job title, but by the word “provider” instead. This has occurred at all levels of administrative and electronic communication, and is now also being used with patients.

The word doctor is over 2000 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 1.

Today, there are many different professionals caring for patients at the frontlines of medicine. More and more non-physicians who possess a doctorate degree are using the word “Doctor” which the public understands to be a Doctor of Medicine. While many possessing doctorate degrees may legitimately refer to themselves as Doctors, only Doctors of Medicine can legitimately refer to themselves as physicians. So let us further and appropriately begin to distinguish Doctors of Medicine as physicians.

The word “provider” is a non-specific and non-descript term that confers little meaning. We therefore call on the American Medical Association and all state medical boards to consider discouraging and terminating the use of the word “provider” in all administrative communication, in place of “physician” when addressing a medical doctor. If a more generic term is necessary, consideration to the term “clinician” should be given. We believe that this affords the courtesy and respect that is due to a hard-working and dedicated profession.

Sincerely,

Dr. Suneel Dhand
Attending Physician, Internal Medicine
Boston, MA

William J. Carbone, CEO
American Board of Physician Specialties
Tampa, FL

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, December 23, 2015

Are our plates too full? A nation confronts addiction

Thanks largely to the influence and convening power of Mehmet Oz, the nation was invited to talk about addiction. Among those weighing in to lend support, on air and via social media, was the nation's Surgeon General, Dr. Vivek Murthy.

The symbol chosen for the campaign was an empty plate, the image meant to convey that this night, the conversation and related food for thought mattered more than the food. Something additional suggests itself to me, however, especially as I try to get this column written (as I promised I would): catch up and then keep up with demands as furious and frenetic as a swarm of bees. Maybe our plates are generally way too full.

I really have no cause to complain on my own behalf. Yes, I am too busy, and yes, I do often feel like Sisyphus. But I have a loving family and plenty of support. Many are not so fortunate.

Many are on their own. Many are living hand to mouth. Many have plates that are figuratively too full, even if literally too empty. Or, if not empty, piled high with all the wrong things.

We are a nation of chronic insomnia, and a nation of chronic pain. Addiction takes many forms, of course, but often it begins with a prescription narcotic and no meaningful plan to follow. This, in turn, is symptomatic of a disease-care system that is often too pressed to be humanistic, too focused on productivity to be holistic. We are treating symptoms, rather than people.

We are a nation of some 300 million yet often manage to be lonely. We are a nation of phenomenal wealth yet appalling disparities. Even life expectancy gains, as we learned recently to our collective shock, have left an entire segment of the population behind.

We might talk about a particular substance and its perils. We might talk about pain, and the desperate reach for often elusive remedies. We might situate that pain below the neck, or above, and we might talk about granting comparable respect to both.

We might talk about bullying, the decline of empathy, the anonymities of cyberspace that invite diverse abuses in perpetual shadow. We might talk about the societal impulse to judge first and consider after, the demise of dialogue and civility.

We might talk about ever increasing demands on our time, and never increasing time to meet demands. We might talk about deep existential fears, as glaciers melt, and storms rage, and twisted ideologies claim innocent lives for inscrutable causes.

We are human. We are, as ever we were, subject to the thousand natural shocks that flesh is heir to; prone to the slings and arrows of outrageous fortune. The desperate question Hamlet posed to himself suggests itself to far too many, and all too many of them reach for a gun. Others reach for a bottle, or a vial, or a syringe.

We are human, and thus all part of an extended family. Now, as ever, there is no need to send to know for whom the alarm bell tolls. If it tolls at all, it tolls for us all.

We are part of the extended human family, and by extension, conjoined in an astonishing array of triumphs and disasters; a constant concert of sadness, and euphoria. It is all too much, so we must take it in smaller doses. One family, 1 conversation at a time.

We were invited to do just that yesterday evening.

The empty plate is an invitation to talk about the intimate side of epidemiology, the burdens and trials that may in turn make any of us vulnerable to the illusory relief and obnubilating solace of an intoxicating substance.

The empty plate is an invitation to acknowledge that all too often, our plates are too full, and left undiscussed, that is a very dangerous secret to keep.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
Tuesday, December 22, 2015

Presentation and consulting: What is the first sentence?

Today I spoke at the Canadian Rocky Mountain ACP Chapter meeting. As usual I spoke on clinical reasoning. A colleague asked me about how learners should start their presentations. The questioner complained about hearing a long previous medical history (PMH) prior to knowing the chief complaint.

I almost salivated at the question. This question frames 1 of my pet peeves.

When did the presentation initiation switch from the chief complain to the PMH? Who made this decision? Why do I care so passionately?

We should use context to interpret the history, physical and tests. The PMH represents a part of the history, but not necessarily the most important part.

How can the PMH help me with the new chief symptom without knowing that symptom? How do we think through diagnostic possibilities?

As we hear the chief complaint we start developing our thought process. We then continuously modify our thoughts as the history develops, including knowing the past medical history.

Hearing the PMH prior to knowing the chief complaint seems very unnatural. What am I missing here?

Likewise, when we call our consultant, we should lead with our request. For example, we might call a pulmonologist to consider doing a bronchial alveolar lavage. The first sentence makes that clear: We would like you to consider a bronchial alveolar lavage for our patient. She is a ….

Too often I have heard interns and residents start telling the consultant an abbreviated history and physical without framing the information.

Good speaking and good writing follows from great initiation. We should learn this during medical school and residency. Too often we do not, and our thought processes may get muddled.

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.
Monday, December 21, 2015

Health care IT: I was duped

I was playing golf with some friends. The Boston area had been having a bit of an Indian summer, and we were lucky to still be getting out there (long may it last). The conversation during 1 of the holes turned to health care information technology, when my friend, who is also a physician, told me about his experiences with a (certain famous) new electronic medical record that's just been installed in their hospital. I remember this same friend telling me a few months ago that he was looking forward to the change, anticipating that it would make his and his patients' lives better. He turned around to me after taking his swing and said, “You know what, it's all been a big disappointment.” That was a profound thing to say, as I'm sure it sums up how hundreds of thousands of physicians across the United States feel about their EMRs.

A desperate disappointment indeed. There was so much promise and hype a few years ago and nobody really wants to go back to the bad old days of piles and piles of paper charts. So what went wrong? An excellent recent article published on the social media blog KevinMD, sums it up here, as does a parody video by ZDoggMD. In a nutshell: health care information technology interferes with the doctor-patient relationship and physician workflow in ways that nobody could have imagined. Disaster might be too strong a word, but then again maybe it's not, as statistics show that many physicians now spend an absolute minority (as little as 10%) of their day engaged in direct patient care. Physicians are intelligent on-the-go people and definitely not your average clerk or desk worker. Most of us went into medicine with very noble aims and won't accept our job being changed so much from what it is supposed to be.

This is of course a topic I've written a lot about, and readers may be surprised to hear that I was a huge advocate for health care IT as little as 5 years ago. The story goes something like this. I had been an attending physician for almost 3 years, loved my job, was involved in teaching and above all else saw medicine as a calling. I was approached to take part in a huge new project that the hospital was undertaking: creating a Computerized Physician Order Entry system that would revolutionize the way we put in orders for our patients. In my naivety, I hadn't even heard of Meaningful Use or federal incentives for my hospital. So I put my head down and got right to work.

I helped design and implement the CPOE system that our hospital would be using. At first this consisted of weekly meetings, but quickly became more intense. On a personal level, I met some fantastic folks and befriended people from the world of IT, consulting and hospital administration, enjoying the feeling of broadening my own horizons at the same time. I promoted what was happening to my physician colleagues and even made videos explaining what the new system would entail. It was several more months before we were ready to launch and thanks to intense investment in IT support by my hospital, the process went relatively smoothly. After that, came medication reconciliation and electronic progress notes—but by then I had already moved to another hospital in another state.

On my subsequent travels up and down the country, I've worked with almost every major IT and EMR system, and have unfortunately seen the train wreck unfold. I've witnessed seasoned physicians (and nurses) despair and in some cases almost bang their heads on the table as they struggle to navigate the inefficient and cumbersome systems placed before them. I've seen them spend ever less time with their patients. I've seen them moan about the lost productivity and not being able to see as many patients. I've seen patients complain to me in droves about how their doctor never even looks at them in the eye any more. Oh where oh where did it all go wrong?

Looking back, the warning signs were there from the start. Many of the other physicians leading the charge to expand health care IT had no interest whatsoever in clinical medicine. In fact, many of them were looking at it as their passport out of frontline patient care, and am sure are now sitting comfortably in ivory towers contemplating the wonderful world of “big data,” “connectivity,” and “cloud solutions.” I remember 1 of them openly telling me when I once made a suggestion that a certain method wasn't going to make things faster for the physician, that health care IT “isn't being designed to make things faster and more efficient for doctors.” I remember one of the external consultants proudly telling me that their IT solutions represented the way of the future and that he had seen older (and no doubt popular) physicians in previous hospitals leave their practice altogether because of their new electronic medical record.

Now I look back and remember that promise of a brave new world of health care IT. One that I thought would be seamless, efficient and user-friendly. One that would be as simple and pleasant as using my iPhone to place an order in a few seconds. One where I could spend more time seeing patients and less time writing notes. Oh my, I was so duped.

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, December 18, 2015

Gadzooks! There's gluten in my Cheerios!

Gluten is in the news again. Gluten and probiotics are among the 2 dietary issues that most consume my patients. I am asked for my opinion on them several times each week. Although my opinion is solicited, these patients have largely already made up their own minds as they are often avoiding gluten and swallowing zillions of ‘good bacteria’ with zeal and enthusiasm.

Why do they do this in the absence of corroborating medical evidence? Why do millions of voters support Donald Trump's mantra that he will “Make America great again”? Both of these groups do so on faith. When our need to believe something is overpowering, our demand for proof recedes. Many of us need to believe that gluten is the agent responsible for our vague medical complaints that have stymied our doctors. Similarly, our frustration with so many aspects of our society and conventional candidates makes us believe that Trump will turn the nation into yellow brick roads leading to Emerald Cities everywhere.

I take care of patients with true celiac disease who need to avoid gluten. Most of my gluten-avoiding customers are not celiacs, but feel better on their self-prescribed diet. When these folks see me and relate their clinical improvement, I support their decision. Why do I do so after I just mocked the gluten-free zealots?
• Just because there is no medical evidence, doesn't mean it's not true.
• There is scientific basis of true gluten intolerance in folks who do not have celiac disease.
• Never talk a patient out of anything that seems to be helping him.

Recently, General Mills recalled nearly 2 million boxes of gluten-free Cheerios and Honey Nut Cheerios, because these boxes were contaminated with wheat, which contains gluten. The company voluntarily and properly undertook this recall. If a product is represented to be gluten-free, then it should be. Folks who have life threatening allergies to peanuts, for example, depend upon true labeling for their very lives. However, not every manufacturing goof will result in such a dire risk for consumers. Yet, the Cheerios recall is labeled a Class 1 recall, which means that there is a reasonable probability that it will cause serious health consequences or death. Give me a break. The phrasing states will cause, not even may cause. Gluten is not botulism. If a celiac patients ingests some gluten by error, which every 1 of them does throughout their lives, they live to see another day. This FDA's Class 1 designation is over-the-top hyperbole of the first order, if you will forgive my redundancy. We would expect a Class 1 recall to be invoked for a faulty pacemaker, for example.

Who makes up these definitions? Obviously, the FDA wasn't thinking clearly when they did so. They were probably on a sugar high after wolfing down too many bowls of Fruit Loops.

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.

Dollars, denominators, and risk adjustment

Because not everyone who reads this blog reads the comments, I wanted to highlight these particularly insightful observations about Mike Edmond, MD, FACP's post on denominators for central line acquired bloodstream infections (CLABSI) (emphasis mine):

“The thought experiment works with the assumption these 2 ICUs are indistinguishable except for the frequency of central venous catheter (CVC) use. Historically, I think the justification for comparative rates using CVC denominators was a no-brainer. These devices were critical to saving lives, and the variations in device utilization probably reflected differences in patient populations, even within similar types of locations. Accounting for the overwhelming primary risk (the CVC) made sense, since these devices were critical to care. The problem you're outlining now is very real, as the clinical environment has proven that a lot of the variations in CVC use may in fact be personal preference. Just like the argument with CAUTIs (where Foley use is deemed less critical to care) to use a patient-day denominator is strong, we may be at a time where the CLABSI argument is as strong. Improving the classification of ICU types, by more objective criteria than currently used in NHSN (i.e. the 80% rule), would really advance the comparative metric substantially, and likely provide more valid risk adjustment with patient-day denominators than we currently have with these archaic classification schemes (e.g., “med-surg icu”). Advancing the use of composite administrative data to classify patient locations to a more objective, reliable, and granular level, based on fractions of patient-days that have key underlying diagnosis, procedures, etc. is greatly needed.”

Given the millions of dollars that are now at stake based upon a hospital's performance on health care-associated infection (HAI) metrics, it's hard to overemphasize the pressure that is now being placed on the National Healthcare Safety Network definitions, and the importance of ensuring that the definitions keep pace with evolving approaches to patient care. When I was a medical resident (yes, way back then), the presence of a CVC was a good indicator of severity of illness and likely served well as built-in risk adjustment for the broad categories of ICU. The same cannot be said now; the device utilization ratios (and percentile ranks compared across NHSN units) vary markedly between different ICU types in our hospital, and do not correlate well with illness severity. And as we've learned with CAUTI, the device days that are most amenable to reduction (the “low hanging fruit”) are always the lowest risk device days.

Daniel J. Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. This post originally appeared at the blog Controversies in Hospital Infection Prevention.
Thursday, December 17, 2015

Cleaning the House of Medicine

A recent report in JAMA Internal Medicine highlights prevailing medical practices that should be “reconsidered” in 2015 based on the weight of evidence. The paper, appropriately, is written in the matter-of-fact style customary for the peer-reviewed literature. To some extent, that semblance of analytical calm belies the storm swirling between the lines of the report, and the mess it has long been making in the House of Medicine.

The authors, for instance, note that excessive zeal for cancer screening results in “unnecessary surgery and complications.” As a statement, that is rather bland, and even when statistics are attached to show scale, as the authors do, it likely fails to evoke any deep impression. But consider any time you have been through surgery yourself, either as the patient, or as a family member. Unless you are the rare individual who has avoided the OR entirely, even by proxy, those occasions are likely indelible in your memory, and easy to recall.

Why? Because when we, or loved ones, are the patient, surgery is a very big deal. There is, inevitably, a major disruption to our lives and routines, and often, at least a brief period of truly noteworthy pain. (As an aside, the pain I felt waking from anesthesia after one of my ACL reconstruction surgeries was orders of magnitude more excruciating than any I have otherwise known, and that despite the fact that I have broken roughly 20 bones doing various rambunctious things.) And even these memorable unpleasantries are trivial in comparison to the casually appended “complications,” which may be things that linger a long time, if not forever, and extend all the way to the most permanent of them all: death.

The authors refer to overuse of CT imaging of the head when it is of little value, and the tendency for such unwarranted imaging to yield over-diagnosis, and over-treatment. Here, too, the language is clinically dispassionate, and thus prone to conceal more than it reveals. If unfounded CT imaging of the head is producing over-diagnosis in the form of what we in medicine disparagingly call “incidentalomas,” those unwarranted concerns are, obviously, also directed at the head. That in turn means that if treatment follows, it, too, is directed at the head. I think we can all agree that's not a place we want surgeons directing sharp objects without a darn good reason. Even when surgery does not ensue, follow up testing can result in harms ranging from radiation exposure, to vascular injury, to serious and even life-threatening side effects of contrast material.

The authors note as well a common tendency to over-prescribe narcotics for extended periods of time, especially for young patients of relatively low socioeconomic status. Here, too, the commentary is blandly declarative, and thus lacks the relevant emotional impact. Opioid addiction is recognized as a national crisis, and 1 of the great urgencies of modern public health. If prevailing medical practice figures in its propagation, as seems to be the case, that is far from trivial.

This litany could continue, as it does in the article, but the point has been made. It requires two characterizations, one somewhat extenuating, the other, compounding the indictment.

The first is that modern medicine can be, and often is, truly marvelous. Lives are saved by it every day. We must be careful to forswear the overly common tendency to disregard the baby in the bathwater. From antibiotics to chemotherapy, organ transplantation to arthroplasty, the prowess and promise of modern medicine is abundantly evident. We should be able to chronicle the failings without failing to note the life-altering, and life-saving triumphs.

Second, however, is the rather damning fact that the practices catalogued in the new paper are generally part of the “standard” of practice. The authors are not addressing malpractice, or individual practitioners run amok; they are addressing prevailing practice patterns. This means, quite simply, that in 2015, and despite the volume of noise about “evidence-based” medicine, much of conventional medicine is at odds with evidence these authors were able to find and summarize quite handily. Nor is this, by any means, the first time this indictment has been served. Conventional medicine is, simply, what we tend to do. Some of it is reliably evidence-based. Some of it lacks evidence. And some of it is robustly opposed by evidence.

That is cause for concern, and a bracing dose of humility, and that much more so when an even wider array of topics is scrutinized. We screened routinely for prostate cancer long before knowing if it was beneficial, only to learn we were imposing net harm. We issued breast cancer screening guidelines with convictions unjustified by uncertainties that prevail to this day. We inserted right-heart catheters routinely in our ICU patients before ever learning how often they were unnecessary, unhelpful, and potentially harmful. We use proton pump inhibitors, with evidence showing they increase mortality. We have managed to be wrong about hormone replacement at menopause in every direction, misinterpreting and misapplying evidence along the way.

Again, I am a practitioner of conventional medicine. I have not come to bury it. But we must concede that the scope of standard, conventional practice encompasses not only what is reliably beneficial and solidly evidence-based, but also what is as yet unsubstantiated, and even what is decisively harmful and at odds with the weight of evidence.

At the same time, and equally important, a certain sanctimony about evidence-based medicine results in contemptuous disregard for the “unconventional.” This broad designation may, at times, refer to so-called “alternative” medicine, where detractors will suggest one is headed toward voodoo. But it also refers to lifestyle interventions that are very far from the worrisome realm of “woo.” If, for instance, schools can do what bariatric surgery can do for severely obese adolescents, is the emphasis of the former and neglect of the latter really about “evidence,” or about the powers that be protecting the profits that are?

In our own work, colleagues and I showed that it was possible to reduce medication use for ADD/ADHD by some 33 percent with a simple, school-based physical activity program. This and related research suggest that we are blithely misdiagnosing rambunctiousness in children as pathology to justify the use of drugs to treat what recess would cure. This is very sad testimony to the state of our cultural priorities.

Finally, I can't help but note our profound cultural hypocrisy regarding health. We routinely market to kids food we know is implicated in such travesties as adult-onset diabetes in childhood, even as we study treatments of these unnecessary harms, up to and including bariatric surgery. I am not conspiracy-theory minded, but it's hard to resist the macabre fantasy of Big Food and Big Pharma behind closed doors, concluding: It's a deal. We will profit from causing the disease, you can profit from treating it, and everybody wins! Everybody except the public, that is.

To the best of my knowledge, a rather boisterous group in cyberspace calling itself “science based medicine“ is silent on all of this. They preferentially malign all alternatives to conventional medicine, implying that problems of evidence and its application lie entirely without, and not within. This, in turn, makes it clear that such protest is itself unconcerned with the underlying evidence, and born instead of ideological zealotry. If evidence matters, it matters equitably, and universally.

Were I tasked with rebutting the very case I am making in this column, I would say: Well, the articles cited here are evidence that conventional medicine is policing itself, seeking ever more evidence and a higher standard. That is just what we would hope to see.

That is the best, and perhaps only argument for the defense, and might matter if it managed to thrive, but alas, it is stillborn. The simple fact is that the products of conventional medicine, Big Pharma, Big Tech, and the associated patents, are routinely promulgated, widely practiced, and massively reimbursed, often for years, before there is evidence to support them. Evidence to repudiate them comes after, and this despite our prime directive: first, do no harm. In stark contrast, the often kinder, gentler, but unpatented offerings of other domains are repudiated for years until or unless evidence comes in to exonerate them, and sometimes, even then.

In other words, the prevailing pattern is that “we” (i.e., conventional medicine) are innocent until proven guilty, but everyone else is guilty until proven innocent. No special olfactory acuity is required to discern how bad that smells.

The House of Medicine is home to much that is powerful, effective, life-altering, and life-saving. But it is home to quite a bit of rubbish as well. The House of Medicine, in other words, could use a good cleaning.

The cleanup will certainly not come courtesy of those calling themselves “science-based,” who live within its glass walls, tossing stones outward. They produce nothing more useful than shards of glass.

It will come courtesy of those who concede, with suitable humility, that no single domain of influence has a monopoly on dirty boots. It will come courtesy of those who like a level playing field, and respect the potential for baby and bathwater in any given tub.

It will come courtesy of those who acknowledge that the blank in “_____ based medicine” has a long and rather unsavory list of applicants: profit;pharmaceutical; habit; preference; patent; turf; privilege; and status quo, to name a few. It is up to us to fill in that blank with a designation that is both desired, and deserved; both what we want, and what we actually do. That requires a much harder task than calling out the dirt on everyone else's boots. It requires a serious devotion to cleaning our own house.

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, December 16, 2015

More ammunition

I have never been a fan of dietary supplements. In fact, I have spent many hours trying to talk my patients out of taking nearly all of them. My reasons for doing so are based on both my conservative approach to medical therapies in general, and on my skepticism about these products in particular. A recent article in the New England Journal of Medicine gave me more ammunition to oppose their use.

Here's what I mean by a “conservative approach” to medical therapies. I believe that there should be a good reason, backed by good evidence, to take any medication, prescribed or over the counter (OTC). Since every medication (or supplement, herb, vitamin, mineral, etc.) carries some risk of adverse side effects, and costs some money, I have never ascribed to the “It can't hurt” school of thought. “Why not?” has never seemed to me a compelling reason to recommend or prescribe anything. There is a profound lack of reliable evidence supporting the use of the vast majority of OTC supplements that patients take.

This is of course compounded in the common scenario where people are taking multiple prescribed medications or OTC products, in which there is also a real risk of unanticipated interactions among compounds.

My skepticism about their use is based on a very practical consideration. I just don't trust that in the world of dietary and nutritional supplements that the label on the bottle reflects the composition of the pills in it. Even though I am convinced that some herbal remedies have genuine therapeutic value, I have no confidence—based on the absence of meaningful regulatory oversight—that consumers can know what they are getting.

Believe me, I am not saying that conventional pharmaceutical companies are run by a bunch of saints, but I do believe that their products have been subjected to way more scrutiny in terms of safety, efficacy, and manufacture.

Here's the new reason I don't believe in these products. According to the work of a group of investigators at the CDC and FDA, there are an estimated 23,000 visits to Emergency Departments in the U.S. prompted by adverse events related to dietary supplements. The events range from diet-pill induced tachycardia to swallowing difficulty and choking episodes associated with micronutrients. I know that the numbers are not that large in absolute terms, but they underscore my earlier point: why would you accept any risk in the absence of any evidence of anticipated benefit?

Makes no sense to me. What do you think?

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

How do patients define quality medical care?

The Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) represents 1 ”solution” to physician payment. The idea seems admirable: Pay physicians for providing high quality care.

Making a new framework for rewarding health care providers for giving better care not more just more care.

Rewarding quality seems desirable. Who really objects to rewarding quality? But quality is a very non-specific word and concept. Who defines quality? What quality dimensions will we reward? From whose viewpoint do we define quality measures?

Put another way, do the quality measures address patient concerns. So I propose a thought experiment. What do patients want from their physicians? How do patients define quality medical care?

At the risk of hubris, I will offer some thoughts:
1. Patients want a physician to listen carefully, look them in the eye, and address their concerns.
2. Patients want correct diagnoses.
3. Patients want to understand “the plan”: What is the diagnosis, what is the proposed treatment, what diagnostic tests are ordered and why?
4. Patients want access to their physician, timely appointments, e-mail, text, and phone calls, and do not want unnecessary visits scheduled.
5. Patients want to avoid medication side effects.
6. Patients want cost considered when at all possible.

As we travel down the quality road, I would like to see patients interviewed and consulted about what defines quality. I would bet that their concerns differ from current performance measures.

Like most physicians, I am a patient also. When I have medical concerns, I consider the above attributes.

Please add to or subtract from this list.

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.
Monday, December 14, 2015

Could scribes be the ultimate answer to the frontline woes of hospital care?

Statistics suggest that physicians are now spending a minimal amount of time in direct patient care, shockingly as little as 10% of their day. This proportion of time that physicians (and nurses) actually spend interacting with patients has been shrinking year by year. There's the need to communicate with other members of the expanding health care team, increased bureaucratic requirements, and over the last several years, the need to navigate and use the electronic medical record to enter notes and place orders. Of course, it's not realistic to suggest that it's possible for any doctor to spend 100% of the day in direct patient care, but 10% is, quite frankly, a little sick.

If you ask any frontline physician or nurse at the moment what 1 of their biggest daily frustrations is, they will list health care information technology at or near the top of the list. It's not that IT isn't the future (because it definitely is). It's just that the current crop of systems are largely slow, clunky and inefficient to navigate. They are not reconciled correctly with frontline clinical workflow and are turning physicians into “type-and-click-bots”. Unfortunately too, this problem particularly affects the generalist specialties including primary care, emergency, and hospital medicine. These are the specialties where interactions with patients matter the most. For example—over a dozen clicks and a couple of minutes of time just to order a Tylenol? 5 minutes with a patient and then 30 minutes documenting it on a computer? Come on!

Having been in clinical practice for the best part of a decade and seen first-hand in several hospitals this huge problem unfold, I am increasingly coming to the conclusion that medical scribes may be the ultimate answer to the problem of taking doctors back to where they belong. In direct patient care. For anyone reading who is not familiar with what a scribe is, as the name suggests, it's basically an individual who takes care of all the documentation requirements for physicians. They usually shadow the doctor who then tells them what to document, later co-signing the note after they've reviewed it. I've personally seem them working with emergency room physicians but am yet to use them myself (although am very keen to try). Scribes are becoming more popular, and a recent article in a major hospital medicine journal discussed them in detail. Here is a summary of why they could be a win-win solution:
• Physicians have more time to engage in direct patient care;
• Physicians can see more patients and be more productive;
• Increased physician job satisfaction, retention and lower burn-out rates as they spend more of their day doing what they were trained to do and less time staring at a screen;
• The scribes themselves are often college age students who want to get into a healthcare profession. They are paid an hourly rate and are very happy to be there learning about medicine; and
• Hospitals benefit from happier staff, patients and higher productivity.

In fact, I'm sure many physicians would gladly pay $10-15 an hour out of their own pockets if it meant more overall productivity/RVUs, efficiency and a happier time at work. But it shouldn't come to that, because if used correctly, they are an asset to any hospital or clinic.

The job of being a scribe is an ancient one, and has its roots in ancient Egypt, where a scribe was considered 1 of the most important professions. Back then, they were used primarily for copying texts and making records using hieroglyphics. They were part of the royal court and did not have to pay taxes. With the advent of printing over the next few millennia, the scribe profession became obsolete. Wouldn't it be interesting if 5,000 years on from ancient Egypt, the scribe profession came to the rescue of frontline health care?

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, December 11, 2015

How to increase medical school enrollment

Lawyers and physicians have so much in common, despite some benign grievances that occasionally reach the level of homicidal rage. Just kidding. Calm down, juris doctors.

Consider the similarities. Both professions serve a public who needs help. Both wield professional advice and judgment that must be tailored to an individual's unique circumstances. Neither professional is ever 100% certain of anything, and an outcome cannot be guaranteed. Both are charged to put their clients' and patients' interests above their own. (Snickering permitted here.)

Let's see what our legal brethren are up to. Law schools in America are having a serious problem that they are struggling to remedy. They need more students. Of course, they could fill their classrooms by recruiting qualified candidates to apply to their institutions. This strategy apparently couldn't fill the seats, assuming that it was even considered. So, here is their plan, brilliant in its simplicity. I will state it here in boldface, italic type.

Lower admission standards!

Dozens of law schools are deliberately lowering admission standards to increase their class sizes, as reported by The New York Times. Of course, these students will face a high bar of passing the bar, assuming that they make it to graduation. Apparently, generating highly qualified legal professionals is not the objective. The true objective: $$$.

My blog's readers are among the sharpest in the blogosphere. Let me post some queries, which I hope will stimulate some insightful responses.
• You don't think law schools are accepting unqualified applicants just for the money, do you?
• Will the exorbitant debt they will incur benefit them and society?
• When these struggling students fail the bar exam, have they still enjoyed a valuable life experience?
• Should we support lowering the admission standards to conform to the emerging norm that excellence is overrated and every competitor should go home with a trophy?
• Should we encourage this process as society desperately needs more lawyers, particularly underqualified professionals?

What's next? Lowering the passing rate for the bar exam?

Maybe there's a lesson here for the medical profession. We all hear that many areas of the country are medically underserved. Surely, there is some way we can recruit more doctors?

Any ideas?

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.
Thursday, December 10, 2015

Junk food: from confusion to clear and simple truth

I was somewhat startled, and quite concerned, to learn directly from the source while sipping coffee together, that my wife was confused by the latest study on junk food, generating headlines such as: “Junk Food Not to Blame for America's Obesity Epidemic.” I was startled because my wife, an expert cook and mother of 5, has become very knowledgeable about nutrition over the years in her own right, because she is highly intelligent and because she is embarrassingly well educated, with a Ph.D. in neuroscience from Princeton. In other words, if she's confused, everybody's confused. That's why I was concerned.

There is no legitimate cause for confusion in this study. Rather, we have painted ourselves into a corner with a plethora of misguided “either, or“ and “action, opposite reaction“ approaches to nutrition that have generated a whole lot of heat while dousing the common light. This is fixable, of course, and the timing is good, because 2 noteworthy fixes are imminently in the offing. We'll get back to those after addressing the new study.

Let's start here: In the contrived context of hyped up and dumbed down “either, or” approaches to diet, weight (and health), junk food causes obesity, or it doesn't.

This new study did not carry out any kind of intervention to answer that question. Rather, using a nationally representative sample of 5,000 adults from a federal survey, researchers looked at intake of candy, soda, and fast food and found little difference between the lean and overweight members of the group. They did, however, find particularly high levels of fast food intake, and the lowest reported intake of vegetables and fruits, in both tails of the bell curve: among the heaviest of the heavy, and among the skinniest. These 2 traits, underweight and severe obesity, have long been strongly associated with adverse health outcomes. In those bad lands, junk food prevails.

But again, across the broad middle of the bell curve, lean and obese were both consuming candy, soda, and fast food at rather high levels, something we have certainly heard before. Does this then prove that fast food is unrelated to obesity, as the clamoring headlines seem to suggest?

Of course not, and a thought experiment will clarify quite readily.

Let's go back in time to the 1950s and ‘60s when nearly half the U.S. population smoked. Now, imagine a nationally representative sample of 5,000 adults at that time, including a large number with, and a certain number without, smoking-related lung disease, such as emphysema. Smoking would be quite prevalent in both groups, because it was so prevalent in the entire population. Those results, if interpreted like the new study about junk food, would result in this headline: “Tobacco not to blame for America's emphysema epidemic.” Given what we now know, and to put it in appropriately blunt terms: That fails to pass the sniff test. It smells bad, like tobacco smoke itself, because it is bad; it's bunk.

Where is the problem with that study? Everywhere.

Unless a “toxin” of any kind is so potent that it produces obvious and nearly immediate harms in absolutely everyone exposed, there will be variation in the effects observed. Some people will be more vulnerable, some less so. Some will succumb quickly, some slowly. Some will show one kind of adverse effect, some will show another.

This is all true for tobacco, and in no way attenuates our certainly about its implication in emphysema, lung cancer, and a long list of other awful things. If everyone in the population smoked, a snapshot of the population at any given time—and that's exactly what the NHANES data used in the new junk food study provide—would show both sick and healthy smokers. The interpretation that tobacco is thus exonerated is not just wrong, but flagrantly and self-evidently so. Rather, it means that: (a) not everyone gets sick from tobacco at the same time; (b) not everyone gets sick from tobacco in the same way; and (c) a comparison of individual health within a population can result in missing the larger truth about the health of the whole population. In a classic illustration of missing the forest for the trees, a compare-and-contrast between apparently sick and apparently healthy smokers in a given population would fail to reveal that the entire population had much more disease than a comparable population of non-smokers.

This is exactly the story for junk food. It doesn't make everyone fat, but we, as a nation, are a whole lot fatter than we would be without it. It doesn't make everyone sick in the same way. In fact, a recent emphasis on the adverse effects of “thin obesity“ is directly germane. Some people with the most dangerous variety of “obesity” do not have an elevated BMI, the measure examined in the new study. Rather, they have a normal BMI, but excess fat around the middle where it does the most mischief. What dietary pattern is associated with that ominous body composition? You guessed it: a junk food laden diet, otherwise known, to our shame, as the typical (or standard) American diet.

There is another important limitation to the new study I have not seen addressed. The researchers defined the trifecta of soda, candy, and fast food as “junk.” Alas, the bounds of comestible American junk extend far beyond those narrow confines. What about breakfast cereals with some kind of sweetener as the first ingredient? What about multicolored marshmallows as part of a complete breakfast? What about cheese puffs and pork rinds; donuts and muffins; toaster pastries, Snackwells, Doritos, and deli meats?

NIH data suggest that roughly half of the calories in the diet of the typical American child come from this broader swathe of foods reasonably catalogued as “junk.” When an exposure is this universal, it becomes virtually impossible to determine its overall impact on a group by comparing those succumbing, to those managing to resist. Another thought experiment should convince you.

This time, we compare survivors and those not so fortunate among the Titanic's passengers. Since exposure to a ship wreck in the North Atlantic did not differ between those who died and those who survived when the ship went down , apparently North Atlantic ship wrecks are “not to blame” for drowning. Who knew?

There are, just the same, 2 genuinely useful messages in the new study's mix.

The first is that, despite the strange cottage industry that has sprung up to argue otherwise, calories count. In a reprise of the notorious “Twinkie diet,” the new study showed that some people with a very high intake of junk food were skinny, not fat. If total food and calorie intake are low relative to the body's metabolic demands for energy, the result is weight loss, not gain, no matter how bad or good the fuel in question. Conversely, studies have shown that overweight results when even high-quality fuel is over-consumed.

Calories count. But of course, so does the quality of food. The fallacy propagated by a noisome minority is that there is any need to choose between the two. In general, the higher the quality of one's food choices, the more readily one controls the quantity of calories it takes to feel full and satisfied. The more dubious one's food choices, the more one plays into the designs of Big Food to maximize the calories it takes to feel full, as so brilliantly chronicled for us all by Michael Moss. Quality and quantity both matter, and the best way to manage the latter is to attend to the former.

The second important message in the new study is that the BMI does not measure health. At the population level, there is a strong correlation between BMI and health outcomes, justifying the use of this rather crude measure in epidemiology. But heavy does not always mean unhealthy, any more than skinny means vital. The adverse health effects of junk food extend far beyond the BMI, and by not addressing that, the new study reminds us of it.

So, only in a world where tobacco is not to blame for emphysema, and shipwrecks in frigid waters not to blame for drowning, is junk food unimplicated in obesity. Junk food, per se, does not make us fat; as the new report suggests, overeating makes us fat. But junk food is engineered to make us overeat, and while that doesn't always work, it clearly works often. And even when junk food isn't making us fat, it can make us unhealthy in many other ways that are harder to see, until it's too late.

The truth, then, is simple: We, the people, would be much healthier, and many of us leaner, if junk were not a food group.

This, in turn, is part of a larger, and comparably simple truth: The fundamentals of healthy eating, and living, are clear, evidence-based, and consensus-based. But since this is obscured by a confederacy of fools and fanatics; by an analysis of parts that only serves to hide the whole; by seemingly erudite answers to misguided questions; by hyperbole and titillation; and by predatory profiteers, there is a need to shine a light on it. The truth here is simple, but alarmingly hard to see through a dense haze of business-as-usual.

As noted, two timely efforts are directing their high beams at these very shadows.

The first is a remarkable conference, sponsored by Oldways and taking place in Boston just over a week from now, devoted to mapping out the ground common to diverse experts in nutrition. I for one am highly confident there is room there for all of us, and I look forward to standing there with colleagues and singing a rousing chorus of Kumbaya. The second, a campaign rather than a conference, is the just-launched True Health Initiative. This effort, predicated on a genuinely intimidating mountain of evidence, and an unprecedented coalition of influential voices spanning the globe, is all about turning what experts know about healthy living into what everyone knows, and actually uses. Check us out, and if persuaded, please join us. For whatever it's worth, my wife already has.

So there you have it: Eat well, don't smoke, beware of haze, and look out for icebergs.

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, December 9, 2015

Disabled parking and needless paperwork

In Washington State, if you want a disabled parking permit you need your doctor to fill out a form. Effective July 1, a new law also requires a written prescription to help combat forgery.

Physicians already have to deal with far too much paperwork. Their latest form ridiculously asks us to write down the place signed. I made up a stamp that has the latitude and longitude of my office. They want to know where I signed it? They got it!

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.

White coat vote

Does your doctor/health professional wear a traditional white coat?

Do you favor it? Or do you think it creates a barrier that makes it harder to connect with or question her?

What about infection? Studies show that health professionals in general don't launder their white coats often enough. Other studies show that the garments harbor potentially pathogenic bacteria. But no studies or reports have yet demonstrated specifically that white coats have been a vector of transmission.

There's been a flurry of media around the topic recently: At various infectious diseases society meetings, many member physicians have been advocating for a change in our white coat culture — trying to get health care workers to remove their white coats and go “bare below the elbows.”

I won't rehash the points of view here; instead, there are several links you can peruse if you're interested in this topic that I will provide below.

Philip Lederer, an infectious diseases doctor in Boston, has been one of the main advocates against white coats: He wrote about it here, then blogged about it here.

I interviewed Dr. Lederer about the topic for Tulsa Public Radio here; then the Boston Globe ran a front page story about the debate here.

I tried to summarize the viewpoints (and offered a bit of personal narrative) for NPR here; then Dr. Lederer wrote a response here. His website provides a fine array of information about this issue.

What are your thoughts? Vote by leaving a comment here or tweeting me @GlassHospital. If you're not a tweeter, send a SnapChat (just kidding … kids these days!).

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.
Tuesday, December 8, 2015

Should he go to medical school?

I received this e-mail last night:

“I am 21 and recently graduated with my BS in Computer Science this past May. I took a shining to computing at a young age, never really considering any other field to pursue. I have been working in the field for only 6 months but I don't know if I feel fulfilled in it. Yes, it may just be this position I am currently in but I am learning about medicine, just in case.”

“I have been taking some Coursera.org medical courses from Stanford and other great universities online. I find that I am truly enjoying these courses and I may want to pursue this field of study. I don't seek prestige, wealth or anything else. I want to be fulfilled by what I do, regardless of how hard it is. I have always wanted to help others and I love solving difficult problems.
1. How do you determine your calling in life? I know you said you could never consider doing anything but internal medicine in your KevinMD article.
2. Is it too late to pursue medicine?”

First, I did not know that I was an internist until the 3rd year of medical school. When I entered I was considering pediatrics or psychiatry.

Second, it is not too late.

Now for the brief written lecture/advice.

I know many physicians who love the profession. I know many physicians who would quickly leave medicine if they could just maintain their lifestyle. Since you are considering a major life decision, you need more information.

I would highly recommend spending time with a physician (the typical term is “shadowing”). You should see what their life is like. Ask them about the rewards and the costs of becoming a physician.

Try to talk with some 3rd or 4th year medical students and some residents. You should strive to understand the path to being a physician. The path is difficult, long and sometimes frustrating.

I personally am grateful each day that I went to medical school and became an internist. Each day we strive to help our patients, and as an educator strive to help our learners (students and residents) grow into caring physicians.

Your road would start with enrolling in a special pre-medical course to meet the entry requirements. Most students can do this in 1 year (you must have taken biology, chemistry, organic chemistry and physics). Then you would take the MCAT. Your score will influence your chances of gaining acceptance. Your previous medical experience (shadowing, volunteering, etc.) will also influence acceptance.

After acceptance you will have 2 years of mostly classroom work learning the basic sciences of medicine. For many students, these are the dark years. When you finally get to the clinical arena, you will find that much of the basic science you learned is important, and much seems irrelevant.

You are clearly not too old, but you should gain some experience and interactions with physicians, and students prior to committing to that road.

Thanks for asking, I hope this answer helps you with your decision making. I hope some readers will add their opinions and likely correct any mistakes I made in typing this advice column.

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.
Monday, December 7, 2015

Lowering physician and patient satisfaction 1 click at a time

The use of information technology (IT) in health care holds so much promise, and potential yet to be realized. Ask any frontline physician and they will list electronic medical records (EMRs) as one of their biggest daily frustrations. A brilliant video by Zubin Damania, MD, also known as ZDoggMD, recently parodied the current situation and the pain felt by doctors on a daily basis. But it really isn't all about doctors. Patients too are on the receiving end.

Talk to many patients who interact with their physicians, especially in office settings, and they will cite their personal annoyance with the fact their doctor hardly looks them in the eye anymore. “Every few seconds the doctor just kept turning around and looking at their screen and typing away,” is a common complaint. Moreover, studies suggest that newly graduating physicians are spending an absolute minimum amount of time every day in direct patient care (as little as 10%). And I can well believe it. As I look around at lots of my hospital medicine colleagues, they are easily spending over 75 to 80% of their day staring at screens.

The proliferation of health care IT over the last decade has come about mainly due to the federal government's Meaningful Use program, and the fact that hospitals and clinics are incentivized financially to become fully computerized. And while I don't doubt that the program had some noble intentions, the way that systems have been rolled out across the country has been rushed and haphazard, with little thought put into the effects on the frontlines of medicine. Even away from physicians, seasoned nurses have been reduced to tears by the enormous data entry requirements now heaped upon them. Glance down any modern day hospital floor, and you will see nurses, who are the very heart of direct patient care, glued to their computer carts, eagerly pushing them around and barely having time to look up at their patients.

Make no mistake, we have witnessed something of a disaster happen in terms of what healthcare information technology has done to the doctor (and nurse)-patient relationship. The answer, however, is not to go back to the bad old days of pen and paper, mountains of charts, and illegible handwriting. The answer lies closer to home. The world of healthcare IT, administrators and entrepreneurs, who sit in ivory towers contemplating the “wonderful world of health innovation and computing solutions”, need to collectively do a much better job in understanding the realities of everyday medicine. The humanity, the compassion and the strong personal relationships. Which is exactly what they would want for themselves or their loved ones if they were sick. That's why we need to develop better systems that are designed to be seamless, efficient and quick to use. Above all else, there should be a recognition that the best health care IT of the future will be seen and not heard. In other words, take the physician and nurse back to where they belong: at the bedside.

We need a revolution in this arena of medicine, before the newer generation of physicians believe that being a doctor is a computer desk job with minimal human interaction. Until that happens, we are wasting the practical skills of hundreds of thousands, if not millions, of doctors and nurses. As for our patients, the new “type-and-click-bot doctor” is inadvertently lowering satisfaction and the health care experience 1 click at a time.

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.

CAUTI SCHMAUTI! (part 3)

I've blogged before about the waste of time, effort and resources being utilized to prevent catheter-associated urinary tract infections (CAUTI) (see here and here), and a new paper in Infection Control and Hospital Epidemiology adds fuel to my fire. This 2-year study was performed in the adult ICUs at the Mayo Clinic and analyzed 105 CAUTI episodes. In 97% of cases fever was the primary indication for obtaining the urine culture, but on analysis two-thirds of the patients with CAUTI had alternative diagnoses to explain the fever. Thus it appears that CAUTI is highly over diagnosed. Moreover, preventability is relatively low and secondary bacteremias are uncommon.

The authors “question the utility of surveillance for this low-frequency, low-morbidity HAI, which does not serve as a valuable patient-centered outcome.” And they conclude: “CAUTIs, as currently defined by NHSN (even with the 2015 definition changes), are not clinically relevant, and efforts to reduce CAUTI may be better directed at other more serious health care infections.”

The paper is accompanied by an excellent editorial by Dan Livorsi and Eli Perencevich. They thoughtfully dissect all the problems with the CAUTI metric and offer some alternatives. They note that it is debatable whether a NHSN-defined CAUTI represents an episode of preventable harm. And they remind us that the opportunity cost is significant.

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.