Monday, February 29, 2016

Old Fangak, South Sudan, bedside ultrasound and other stuff

I just got back from a couple of weeks in Old Fangak, a community of people living by the Zaraf River in South Sudan. It's normally a small community, with an open market and people who live by raising cows, trading on the river, fishing and gardening. Now there are tens of thousands of people there, still displaced from their homes by the civil war which has gone on intermittently for decades. There are even more people now than there were last year.

There is a hospital in Old Fangak, which is run by Jill Seaman, one of the founders of Sudan Medical relief and a fierce advocate for treatment of various horrible and neglected tropical diseases, along with some very skilled and committed local clinical officers and nurses and a contingent of doctors, nurses and support staff from Medecins Sans Frontieres (Doctors Without Borders, also known as MSF) who have been helping out for a little over a year. The hospital attempts to do a lot with a little, and treats all who present there with whatever is available to combat their myriad ills. There are special programs for children with severe acute malnutrition, for patients with tuberculosis, kidney disease, Kala Azar, including food distribution for a subset of people with chronic illnesses.

I've been to Old Fangak 3 times now, always in the winter (warms my toes for a few weeks) during their dry/cool season. Cool means that it doesn't get much above 100 degrees during the day and cools down to sometimes below 70 at night. My stated purpose in going is to teach Jill and anyone else who wants to learn how to do bedside ultrasound. I love teaching people to do ultrasound and it means that a 2-week trip can actually have some long lasting benefits. I also get to be a general, all-purpose doctor who can give shots to babies, sew up lacerations, trim down leprous calluses, ponder the etiology of obscure illnesses and cook dinner. I get to see how the staff at the hospital manages to do the loaves and fishes trick with far too many diversely sick people and far too few resources.

They have a work horse of a Sonosite MicroMaxx ultrasound machine which is good for anything from babies to hearts to fractures and abscesses. I got to teach a midwife who has seen other people use ultrasound but hasn't been able to do it herself, an ER doctor who had only previously learned to do ultrasound to identify blood in the abdomen in patients with blunt trauma, and a nurse who will likely make international medicine her career and was an awesomely quick study. Jill was already quite good with obstetrical ultrasound but became more confident with hearts and abdomens. Everyone learned how to make gel with glucomannan powder for when the carefully hoarded real ultrasound gel goes mysteriously missing. I brought my Vscan (little pocket ultrasound) for ultrasounding on the fly, and that was really useful as well.

An ultrasound machine paired with a person who can use it makes a big difference to care in the U.S., but is life-alteringly amazing in a rural hospital in Africa. What, you might ask, was it good for?
1. An old woman limped in with a hard lump sticking out of the top of her foot. It had been swollen in the past, but now just hurt. It started when she kicked a tree. I can check it out by putting her foot in a tub of water and using the ultrasound transducer to see whether the little lump is a foreign body or a bone. Unfortunately it was a bone, sticking out of the top of her foot. Ouch. Not a lot to be done for that in this situation.
2. Babies. So many babies! One night there were 2 sets of twins delivered in 1 hour. The ultrasound could confirm the positions of the little tykes and predict the ease of delivery. The first pair were both head down and came out without a hitch. The second pair were smaller, worrisome for prematurity, and after the first 1 emerged (squalling nicely) the second 1 was lying in a transverse position. With a little manipulation from the outside, she was able to flip so that the head was down and was delivered without incident. There were slow or obstructed labors and being able to know that the baby was alive and well meant that the mother could be motivated to push hard even though she was really tired.
3. Abdominal pain in a person with known hepatitis B: Hepatitis B is unfortunately still quite common, and vaccination is not standard. One relatively young woman had been treated for hepatitis B but was having pain in her abdomen. The ultrasound showed a small nodular liver and ascites, but a small enough amount that removing it might be dangerous and certainly wouldn't make her feel better. Treatment with anti-viral medications was indicated, paracentesis (removing fluid from her belly) was not.
4. A pregnant woman was very anemic and also nauseated and unwilling to eat. On ultrasound her baby is still doing OK, but her amniotic fluid level is a bit low. When the transducer peeked around the uterus there were multiple loops of large bowel that are filled with fluid and thickened. In this situation the most common cause of such a finding is giardia, an endemic intestinal parasite. She got intravenous hydration, treatment for her giardia and her nausea magically resolved. She had lain in the hospital for over a week being miserable, but the ultrasound was able to point us towards the right diagnosis.
5. Heart disease is common there as it is here, but in Old Fangak it is primarily due to birth defects or rheumatic fever. A man presented to the hospital with swelling of his legs and shortness of breath. He was exhausted. He hadn't been able to lie down to sleep for months. He was treated with diuretic medication and beta blockers to slow the heart and improved quite a bit. The ultrasound showed advanced rheumatic heart disease, with a stenotic mitral valve and a leaky aortic valve. It was nice to know, and perhaps an e-mail to specialists in Khartoum, the nearest city with really high quality medical care could secure him the heart surgery he needs. Probably not, but it's worth a try. There were children with signs of heart failure due to ventricular septal defects and a young woman as well, probably with an atrial septal defect. They could live relatively normal lives with heart surgery, but the Italian group that used to do this for free in Khartoum is no longer providing that service. They will get medicines which will work a little bit and they will probably die young. Stuff like that is hard to watch.
6. Pus. People come in with swollen hands, fingers, thumbs, feet. There was a guy with a swollen thumb. After the obvious pus was drained there was still pain and swelling. We could see with the ultrasound that there was very little pus left to drain, but that the bone in the last joint of the thumb had broken due to the infection, suggesting a need for amputation of that bone. Another guy had a swollen finger, with pus on both sides of the tendon. This guided the drainage procedure. He didn't have obviously infected bone and might well recover the full use of his index finger.
7. People also became desperately ill sometimes, short of breath, low blood pressure, that sort of thing. A woman with a history of heart problems in the past came in unable to catch her breath, with a fever. Ultrasound showed that her heart was doing just fine and that her inferior vena cava was very small supporting a diagnosis of sepsis and pneumonia and leading to successful treatment with fluids and antibiotics. Another woman had known kidney failure and came in with a cough. The ultrasound also showed normal heart function, an abnormal left lung and dehydration in her. She was treated with intravenous antibiotics and fluids. The next day the inferior vena cava was full, meaning that she did not need more fluids, and her bladder was full as well, showing that she did have some residual kidney function. Her overall prognosis is terrible, but she was able to survive another few days at least.

So bedside ultrasound clearly rocks. Living in South Sudan and being sick does not.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.
Friday, February 26, 2016

More than a notion

“She needs a nursing home,” someone said.

It was all matter of fact; the way such things are always mentioned on rounds with those frail elders who've slipped into the cognitive abyss. And I didn't know all the details. I mean, not enough to go arguing and pushing back on a plan that had been rolling forward for this hospitalized patient for the last week. So I responded with a simple word. “Why?”

“Dementia,” I heard them say in response. “Like, she's delirious 1 minute and then sort of inappropriate the next. It's weird. And honestly, it's mild but the problem is that she lives alone and doesn't really have anyone to help.”

“Why is she delirious?”

“Part of it is adherence to what she needs for her health. The other part, we think, is some underlying dementia. She does have someone to make decisions for her, though. Even though they can't really take care of her like we'd like.”

“No one around to see about her?”

“Well. No family that can give her what she needs. So we're pursuing nursing home placement but it's drama since she's majorly pushing back on it.”

“Dang. So she's aware enough to let you know she's not feeling that plan, huh?”

“Yeah. We just want to safely discharge her, Dr. M. So her durable power of attorney will have to sign her in against what will she has remaining.”


Now that? That punched me in the gut and made me gasp a bit. “What will she has remaining” felt like we were playground bullies. Something about that grabbed me hard and said, “Pay attention. Go and talk to her. Think.”


Oh, and let me be clear: The team that was caring for this patient before was thoughtful and empathic. I know I had the luxury of being the Monday morning quarterback. The delirium portion was mostly resolved so I was looking at her through fresh lenses. Fresh enough to feel unsure about sending her to a nursing home.


And so. When we went in there, I listened to her speaking. This woman was older than my mother and stated proudly that she was a “Grady baby,” meaning she'd been born in this very hospital. That always resonates differently with me when I hear it from my Grady elders. In a city of transplants, the true-blue natives enamor me. She was true-blue.

Yes indeed.

And so. Admittedly, there isn't some really elaborate story that follows. I'd imagine the preamble of it all serves as a bit of a spoiler alert that she was, indeed, as sharp as the proverbial tack. And while I can't say that there weren't a few wrinkles in the fabric of her cognition, I can say that none of it was substantial enough to rip her away from the place she'd called home for the last 50 years.


And that? That's the thing. That is the piece I put my kickstand on when thinking of her, discussing her and laying out plans with my team. This notion of uprooting people with very, very deep roots and recognizing that it's a big fucking deal.

Pardon the f-bomb.

In 2006, Harry and I had a young toddler, Isaiah, and were expecting our second child, Zachary. Harry, who has a background in real estate investment, had found this amazing home in a wonderful in-town Atlanta neighborhood, literally walking distance from my employer, Emory University. The schools in the area had great reputations and the entire environment was everything we'd dreamed of having. It certainly had some “fixer upper” necessities, but that didn't deter my husband at all. And his faith in the potential this house had was enough to get me on board.


The home we were in at the time was lovely, for sure. That said, it was significantly further from all that we do both professionally and personally. Getting closer in would be game changing for our family. And no, we didn't need more space or anything. But this? This house was uniquely special. An opportunity just presented itself and, even better, involved my better half utilizing the skills that he'd been fine tuning for the last several years, negotiation and renovation. We didn't look back.

No one knows what the future holds, economically or otherwise. But barring any major changes, we came into that home—now our current home—believing that, God willing, we'd grow old there. I imagine myself slowing down and easing out to that same mailbox someday. Asking Harry if he fed the dog or picked up eggs or even if he wants a cup of herbal tea. And us sitting in our sunroom where the kids watch television now, shaking the hand of some young woman that one of our boys desires to marry. Then later, holding the hand of the grandchild or grandchildren that come from that union, walking through this very neighborhood to do the things that I'd been doing since I was a pregnant thirty-something.


So after that, I picture my mind getting foggy. Not full on foggy, but foggy enough to cause some people to do a double take. Still okay enough to take a shower and make some grits and sweep the porch and feed the dog. Fine enough to wave at the mailman and grab the bills and even get on line and pay them one mouse click at a time. But maybe just off some. Not able to remember which Bush or which Clinton is president or even how to stay on track with every day conversation. Then, I pray, that there is someone who is ready to step in and see about me, you know? To be a go between in the gap of what I can still do but the fog of what I can't.


If, for some reason, that person or those people aren't readily presenting themselves, I think about someone having me in a cold, sterile hospital bed that some 911 call sent me over to on a whim because I'd fallen and couldn't get up. And then I think that, kind of like when people were put on ships and taken to the western world against their will, it must be awful to suddenly be told that you are never, ever going back to live at what has become the only home you really, truly know. Especially if my wits were still about me enough to feel that loss.

So yeah. I think of that and hope like hell that my doctor or doctors or nurse or nurses or social worker or social workers come busting in that room with their hands all splayed out screaming to everyone to WAIT, WAIT, WAIT and THINK, THINK, THINK before just signing that form to send me off and away from the home I spent my whole life building. I want them to look hard, go find someone, anyone or some kind of resource to help me. Or at least try, man. At least fucking try.

Because 30 years from now, if you take me up out of my house without warning, I won't want to go either. And I swear on my sister's life that I will fight you tooth and nail with what will I have remaining. Yes. What will I have remaining. Damn right I will.

My patient said she wanted to go home. Her insight wasn't poor and, as it turns out, there are some people around who could see about her. She was a bit forgetful and tangential but she still knew that Cam Newton was going to the Super Bowl and that he was a hometown hero, straight out of southwest Atlanta where she'd lived her entire life. And she wanted to be home to watch that game on her own damn couch where she could clap her leathery hands and drink a light beer.

And you know what? If I have any say in the matter—and I do—that's exactly what she's going to do.

Hell 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.
Thursday, February 25, 2016

Of drugs and rectal pain

I had a patient who was a real pain in the ass. Wait. No. He was actually a really nice guy. He wasn't a pain in the ass, he had a real pain in the ass. Literally.

I was initially concerned about a pilonidal cyst, given the unfortunate fact that he was previously afflicted with this condition (which I consider to be incontrovertible proof of Satan). But, fortunately to him, his pain was literally “in the ass,” and that rules out the evil diagnosis, moving my thoughts to a condition called proctalgia fugax (which is a Latin person's way of saying: “butt pain that comes and goes”).

I realize this doesn't sound much like good news on my patient's part, but, as opposed to the lousy surgery necessary for treatment of a pilonidal cyst, an effective treatment for this is fairly simple (and surprising): nitroglycerin ointment applied to the rectum. Nitroglycerin, it turns out, relaxes smooth muscles and dilates blood vessels, both of which somehow can improve the distressing symptoms of this strange condition (as well as pain from other related proctological demonic attacks). I'm not sure who had the idea to first try this, or what their inspiration was. Perhaps they misheard the term Angina Pectoris as Angina Rectalis.

I did my usual search at (a website everyone should use as often as possible) to see where the drug is cheapest. It turns out that Kroger won the contest, but the price was $479. According to the literature, the appropriate strength of nitroglycerin for rectal use (cleverly called “Rectiv”) is 0.4%. This seemed a pretty high price for a medication which has long been generic, so I searched for generic nitroglycerin ointment (used for pain due to heart disease) and found it for $35 at Walmart. The only difference between the 2 that I can tell is that that preparation (called NitroBid) is 2%.

There are several possible explanations for this huge price discrepancy:
1. The dilution of nitroglycerin is a dangerous and expensive process, as it is quite explosive.
2. The cost of coming up with the name “Rectiv” by the marketing department was extremely high. It is far more clever than NitroBid, to be sure.
3. There is a secret ingredient in Rectiv that raises the cost. Perhaps they have to get anal secretions from unicorns.

While these seem reasonable, I suspect a different reason: the company which makes Rectiv, Allergan (which also makes Botox), has cornered the market on 0.4% nitroglycerin, and so can charge exorbitant amounts for a medication with no other discernible reason to be expensive (it certainly took little R & D cost, and doesn't regularly get advertised during the evening news).

I'm sure my anally distressed patient would have paid $1,000 for relief, but this wasn't my first ride at the proctalgia rodeo (which has recently been nominated as an Olympic event), and I knew he could use the more potent cheaper version with the boring name (and has nothing to do with unicorns) without problems. He did, and he got immediate relief. Now, like Androcles, I have someone who owes me a great debt for my kindness and wisdom.

This incident is just 1 example of the terrible gaming that routinely occurs with the prices of drugs. There are plenty of others. Why, for example, do brand name medications continue having such high prices after the medication has gone generic (often 10-20times higher)? The reason is, if the generic no longer available, they get a cash windfall.

For example, Carafate (a medication for stomach ulcers) went generic a many years ago and so you can get 120 tablets of the generic for $33.

But recently the suspension form (which I've used for mouth ulcers and esophageal problems) became unavailable as a generic and so now is only available as the brand name drug. The result is that the once inexpensive suspension now comes with a premium price tag of more than $150. Note that this price is for 420 ml, which is the equivalent of 42 tablets, so the mark-up is more than 10-fold.

Pharmacies join in on the price gaming by pricing 1 drug much lower than competitors, while going way higher than the market on others. Generic Topamax (a drug used for seizures and migraine prevention), for example, costs $11 at Publix and $68 at Rite Aid.

So should you go to Publix for all of your medications? Unfortunately, if you get your Topamax with a Lipitor chaser, the generic cholesterol drug costs more than $90 at Publix, where it's much cheaper at other pharmacies.

All pharmacies do this, in my experience, so you can't count on any 1 pharmacy to have cheap prices. To get inexpensive medications, you must shop around and be willing to go to multiple pharmacies for multiple medications. It's a game they play that usually works, as most folks either don't know about this, or they just don't want to bother going to multiple pharmacies.

These games come at a great cost, dramatically raising the cost of care for millions of Americans. It is legal. It is done all the time. And it is gouging. And this gouging isn't unique to the pharmaceutical industry, as labs and radiology providers have their tricks to make enormous profit margins on the services they provide.

Fortunately for this my patient, I was not only able to reunite him with the joys of sitting, but I was able, with a little research, to find him his proctological savior at a low cost. Unfortunately, most patients don't have docs who are economically incentivized to save them money, and most people don't realize all of the games played by pharmaceutical companies and pharmacies to routinely perform wallet biopsies, nor do they know how to find the cheapest prices for their medications.

I don't know what can be done about this kind of thing aside from increasing awareness. I'm not real confident in any government solution. People just need to be smarter shoppers when it comes to their care. It's just a shame that people who are dealing with health problems (even if it is just trouble sitting) have to outsmart the gaming done by those supposedly trying to help them.
Wednesday, February 24, 2016

Students generally like being asked questions

My colleagues and I ask students and residents questions constantly. I talk with students and residents constantly about their educational experiences. The great majority like being asked good questions.

But what is a good question? A good question refers to something that they need to know. The good question frames the importance of the topic. A bad question is pure trivia that will not really help them. (What percent of alcoholic ketoacidosis patients have a negative urine ketone? The answer is approximately 10%) Knowing that some AKA patients have negative ketones and why is useful.

Additionally, to ask questions the questioner should establish the proper learning climate. The learners should understand that the questions are asked to help them learn, not to embarrass them. I use a technique that I call question and rescue. When the learner obviously does not have a clue, I quickly move to the next person.

When several learners do not know the answer I will proclaim something like, “Excellent question, but difficult. We have an opportunity to learn something.” This succeeds when the learners understand that questioning is used to make the education process directed to helping them with things they do not already know.

A good question should include teaching thought process. Students and residents want to learn to think. They (and I) look about data regularly. On rounds I often task one of the learners to quickly look up a fact that evades me, or that I never knew. Yesterday we were talking about the age onset of Crohn's Disease. An acting intern reminded us of the bimodal age distribution. That fact evaded me and the entire team. We all learned something.

Good questions help frame the thought process necessary to help the patient. I could not teach well without using questions.

Is that pimping or grilling or just questioning? JAMA recently had another article about pimping.

What is bad about questioning? Questioning should not be a way to emotionally abuse learners. Some clinician educators use questioning to embarrass their learners. Good questioning enhances learning.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.
Tuesday, February 23, 2016

Can physicians take vacation?

Years ago, I was having dinner with 2 members of The Cleveland Orchestra, one of the finest orchestras in the world. I asked them, with my kids present, how much time they devoted to their craft. As many parents know, getting kids to commit to practicing a musical instrument is about as easy as splitting the atom. The musicians told us how much time they practiced, which was mind boggling. Any artist or athlete or Green Beret or similar professional, has to demonstrate extraordinary commitment to maintain a superlative level of excellence and preparedness. Every day.

I asked one of the musicians, the violinist, how long he could stay away from playing his instrument before he noted some professional slippage. Guess your answer. At the end of this post, I will relate his reply.

How long can you be away from your job before your performance ebbs?

For most of us, we can take weeks or longer on holiday and return back to our positions seamlessly.

A few examples.
• politicians return to Congress after long breaks and lose not a whit of their skills of obfuscation and duplicity,
• New York City cab drivers return from vacation and can make their first passenger's heart stop without missing a beat,
• an airline customer service representative a few continents away maintains state-of-the-art client service even after a month away from her cubicle.

What about doctors? What about gastroenterologists?

Yes, I do take vacations, but most of them are long weekends. I took 5 days off in a row last August. Now that my kids are grown, I have taken a few longer vacations, but during the most of the past 2 decades, my times away from home have been brief outings. Perhaps, the reason why I maintain such a keen colonoscopy edge is because my absences have been brief. If I took a sabbatical for 6 months, would I be rusty when I approached my first rectum on my return?

I will admit that manipulating a colonoscope, when I bring light into a dark world, is not exactly the same as playing a violin in the Cleveland orchestra. I'll leave it to the reader to contemplate which of these takes more skill.

Seriously, do physicians lose their cognitive and procedural skills after a period of time? I'm not sure this has been tested, but I believe the question is a reasonable one for patients to consider. Hospitals track volume of surgeries from specific surgeons, but a busy surgeon could meet the yearly threshold, which might be modest, and still take several months off. Should a patient who is to undergo a cardiac bypass or a colonoscopy after the physician has been away for a few months be concerned?

Is medicine like riding a bicycle that one can do well after a hiatus of years or more? Or should doctors who have been off the bike for a while put some training wheels back on?

Consider this the next time you are hearing music from a master musician. One thing is for certain. (S)he hasn't been on the beach. The violinist I queried told me that he if doesn't practice for 3 days that he is below par. Would you like to have a job like this?

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Monday, February 22, 2016

The greatest diet myth of all

I was rather disheartened to discover that The New York Times decided to start off the year by pretending to dispel diet myths, while actually propagating the biggest of them all. The great dietary shibboleth of our time is that no 2 experts in nutrition agree about anything, and that expert opinion is both unreliable and unstable. This is nonsense.

The New York Times clearly suffers from its own ambivalence on the topic, perhaps a by-product of discord in the editorial ranks. They have published pieces that highlight clearly and compellingly where the true faults in the modern diet lie, and how we might effectively, and simply (if not easily) navigate past them. They have, on their own rarefied real estate, showcased the basic dietary theme associated with the best evidence of benefit there is: longevity, conjoined to vitality.

But they have gone the other way many times as well, featuring the perspectives of iconoclasts. Sadly, this seems to be the evolving editorial preference, and perhaps for obvious reasons. Diet stories sell. They sell newspaper pages just as they sell morning show segments. For stories to sell segments and papers, there must be sellable stories.

There may have been a time when the New York Times was above such fray, but we all know those days are gone. The competition is no longer just the Washington Post; it's the Huffington Post, and Buzzfeed, and Yahoo. For the New York Times to survive, it must feel a certain compulsion to sell the stories people want to buy. When it comes to diet, the last thing on everyone's shopping list appears to be the simple, unadulterated truth.

And so it is we wind up again with copy telling us about the instability and unreliability of expert opinion, and citing “experts” to make the case. Such things are done quite craftily, however. In a world of hundreds of thousands of true content experts, articles such as these preferentially cite a few contrarians, expert or otherwise, and imply that they represent some kind of expert consensus about the lack of expert consensus. They do not.

This is not wishful thinking on my part. For one thing, if we really did lack any basic understanding or consensus about healthful eating, I would have no wish to refute that. I would be too confused to bother, and too busy trying to figure out what I should eat, what my family should eat, and what on earth I should tell patients. The simple fact is, I am not confused, and know what to practice personally, and preach, because the relevant evidence is clear. Those buying into the “lack of expert consensus” myth should pause to wonder: what do the experts actually eat?

That's the thing about diet; it's not a hypothetical enterprise. Every one of us has to make real choices in the real world every day. Perhaps you'll be surprised, but frankly I doubt it, to know that the world's nutrition experts overwhelmingly, whenever possible, choose food, not too much, mostly plants. We might all chew productively on the contention that this camp pretty reliably eschews the very glow-in-the-dark foods that populate the aggressively peddled typical American diet. It's not rocket science, folks. We are not confused.

But the New York Times, like all media outlets, may have a vested interest in making sure you are. Diet is rivaled perhaps only by weather in generating daily fascination. Weather, however, has the intrinsic advantage of changing every day. Get diet advice to do the same, as our media, with some unfortunate help from a small minority of scientists, do, and you wind up with a goose laying golden eggs.

Alas, the public's goose may get cooked as a result, as reflected in the notorious obesity and diabetes trends. And speaking of cooking, we might constructively juxtapose this treatment of diet with that of climate change. On that latter topic, the New York Times, if not necessarily media in general, has been a staunch defender of the consensus of experts over the dissent of renegades. Why the difference? Why, in the case of climate change, does the Times seem committed to advancing the consensus of global experts about the weight of evidence, while in the case of diet they seem more inclined to treat the relevant science like a ping-pong ball?

I can only speculate. One reason, I think, is as noted above: pseudo-confusion about diet sells. Another, perhaps too generously, allows for true confusion in the editorial ranks. Perhaps editors at the New York Times think we are fatter and sicker because we followed bad dietary advice. Admittedly, dietary advice has always been imperfect, and while it advances, will remain so. But the great liabilities of modern public health are mostly a result of failure to follow dietary guidance, not because it was so errant. Advice to limit our intake of carbs was never advice to eat low-carb brownies, but that's what we did. No one advocating for low-fat eating recommended Snackwell cookies, but that was our cultural response.

Yet another reason may be the dangerously misguided notion that climate is public, but diet is personal. What I mean is this: I, and editors at the New York Times, can eat perfectly well even if you don't because you are too damned confused. In contrast, we, the Time's editors and I, cannot be spared the extreme manifestations of climate change unless you are, too. Perhaps—and again, I am just speculating—there is precept behind some closed editorial door that stipulates: it's OK to propagate confusion about the basic care of individual bodies, less so with regard to the body politic. After all, our own skin is in the latter.

That would be regrettable thinking if it were even true, but it's not. We've all got shared skin in both games, if only because there is only 1 game. Dietary choices massively influence the climate and the environment. Even if we were confused about the best, basic dietary pattern for human health—and we are not—there would be a perfectly clear mandate to drink water instead of soda, to eat mostly minimally processed plants, and to cut back enormously on beef consumption in particular, and to a lesser extent overall meat intake, for the sake of the planet. That the interests of human and planetary health converge here simply makes the mandate even more decisive.

How, then, is it even possible to propagate the myth of prevailing cluelessness about the basic care and feeding of Homo sapiens? Well, for one thing, as noted, you can always find a renegade or iconoclast if you are looking for one. Were we so inclined, even now we could be handing the megaphone to a line-up of climate change deniers with variable credentials, and might, accordingly, have denied ourselves the hope of the Paris Accord. For another, the appearance of discordant answers is readily generated by a given approach to questions.

For instance, ask 2 nutrition experts if a low-carb diet is best, and 1 will say yes, and another will say no. The same is true of low-fat; or vegan; or Paleo; or Mediterranean. There you have it: no 2 nutrition experts agree! We are hopelessly befuddled!

Nonsense. Those questions could translate readily to: within the basic context of sound, sensible, salutary eating, do you have a particular, personal preference? No one would be surprised to learn that since every nutrition expert eats every day, everyone does, indeed, have a personal preference, and those preferences vary. Re-read those several questions above, and see that they could be perfectly compatible with just such an account.

What reveals that veiled explanation? Posing questions aimed at establishing core principles, rather than discordant preferences. I can assert from evidence in hand, garnered from both an extraordinary conference to close out the old year, and a global campaign to welcome the new, that the worldwide coalition of experts and influencers in the nutrition space agree massively about those core principles. I contend, again from actual evidence, that the agreement in question ranges all the way from vegan to Paleo. I can go further, perhaps just a bit out on a limb, and assert that even most of the seeming contrarians join the chorus when the right questions are posed.

What questions? Questions like these:
1) Do you agree that the best diets generally are abundant in fresh, minimally processed vegetables and fruits?
2) Do you agree that the best diets generally, and generously, incorporate beans and legumes?
3) Do you agree that the best diets generally incorporate nuts and seeds?
4) Do you agree that the best diets generally, if not always, incorporate whole grains?
5) Do you agree that best diets often include fish?
6) Do you agree that the primary beverage in best diets is water, and that sugar-sweetened beverages are excluded, mostly or entirely?
7) Do you agree that best diets minimize fast food, junk food, and hyper-processed food in general?
8) Do you agree that best diets emphasize recognizable foods direct from nature?
9) Do you agree that when best diets include meat and animal products, those animals in turn should be fed a wholesome, native diet?
10) Do you agree that carbohydrate content or fat content is a poor and unreliable way to characterize the overall quality of a diet; that the foods of which it is made up do that job far better; and that best diets can traverse a range of total carbohydrate, total fat, and to a narrower extent, total protein values?

The list could go on, and might well extend to matters of ethics and environmental stewardship, but we can leave it there. Ask a who's who in nutrition, medicine, public health, sustainability, and the culinary arts these questions, and the answers are all “yes.” I am not speculating; I have proof. This is even true for some of the folks apt to be quoted as prominent contrarians. Answers are seldom better or more clarifying than the questions that invite them.

These days, the most common take-away about diet and health is that everything we thought we knew about diet and health is a myth. As best I can tell, however, the notion that reputable journalistic platforms are interested in getting at a reliable, stable truth about diet and health is the myth. The reality is that afflicting the comfortable with sequential doubts, only to comfort the afflicted with a dose of science and sense until they are comfortable enough to warrant more affliction, is the standard operating procedure in our media, and our culture. The harder it gets to compete for attention, the less and less a lofty journalistic pedigree defends against this temptation. To whatever extent the imprimatur of the New York Times was once an alibi against such motivations, those days are apparently gone.

We are not clueless about the basic care and feeding of Homo sapiens. There is a massive, global, evidence-based consensus. The same fundamentals of salutary eating would be warranted for the sake of the planet if not for human health, as well as vice versa. As it happens, fortuitously, they serve both. But we, instead of ingesting accordingly, are served a daily dose of hype and hooey -- and just keep eating it up. If ever there was a vivid display of the triumph of desperate hope and abject gullibility over science, sense, and real-world experience, this is it.

There is, indeed, a great myth about diet, but it's not the one you've heard regarding dissension in the ranks, or misguided guidance. It's the notion that media in general, our culture at large, or the New York Times is committed to helping you eat well. With all due respect to those concerned, they are selling newspapers.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
Friday, February 19, 2016

The secret o' life

The secret of life is enjoying the passage of time.

Any fool can do it, there ain't nothing to it.

Nobody knows how we got to the top of the hill.

But since we're on our way down, we might as well enjoy the ride.

—James Taylor

“What's the key to making 89 and still looking as good as you?” I asked. The resident working with me smiled knowingly since this is 1 of the most predictable questions they hear me ask of the spryest of our Grady elders.

I never miss the chance to unlock whatever secrets my patients might have for longevity in life and marriage. So I always ask. And every time, I get an answer that makes me smile. Some short and sweet. Others long and elaborate. But somewhere nestled in every response is something for me to stick on a post-it note inside of my head for safekeeping.

And so. At the end of our visit, I asked that same question in that same way I generally do when addressing my Grady elders. I use their lingo, too. After hearing it enough times, I decided that I liked the idea of “making” some golden age. “Making” 89 sounds like climbing the rough side of a ragged mountain, and now reaching those elevations that few have achieved. And interestingly, years don't seem to be referenced as being “made” until you get over a certain hump in the birthday game.


“You know I'm gon’ make 90 in one month!” she announced with a proud slap of her knee.

I clapped my hands and nodded. “I saw that on your chart, Mrs. Calhoun! That's so great!”

“Sho’ is.” And from the look on her face, I could tell she meant it.

“So no secrets? You know I'm trying to find out how to make 90 and have it look like it looks on you, Mrs. Calhoun.”

“Oh, baby it's simple. First, you gots to get on up in the mornings. Get on out the bed and move your body. I ain't saying you got to go crazy or nothin’. Jest get on out your door and walk some place. Work in your garden. Walk on over to see about a neighbor or to the store. But you can't jest stay holed up in the house watching the television.”

“I like that advice.”

“Mmmm hmmm. See, folk get up in age and stop moving they body. And now, I understand that ol’ Arthur set in on some folk bones and they can't move. But even with my arthritis, I makes myself get on up and move. Every day.”

“That's good stuff, Mrs. C. What else? You know we're taking notes.” I winked at her and pretended to position my pen to write down her next words.

“Well, now another one is minding your own business, you know?”

I laughed when she said that. “My husband tells me I need work in this area, but yes, ma’am. I hear you.”

“See, when you gets up in age, folk get to thinking they got the green light to weigh in on whatever they see fit. Like telling young folk what all they s'posed to be doing and how they s'posed to do it. Saying stuff about how folk run they house and who they decide to be with. And see, me, I figured out that staying worried ‘bout stuff that ain't your business ‘specially when it come to your kin as they start coming of age make you old. So, I jest mind my own business, you know? Even when folk used to try to get me to chime on in on something, if it ain't my business I jest shrug my shoulders and say, ‘Ain't my business.’” Mrs. Calhoun shrugged for emphasis.

My resident nodded slowly and looked over at me. “That's great advice, actually.”

“I never thought about the part about growing older and giving your opinion on something. That's a really good word.”

“It's true, Miss Manning. Look like people excuse they elders for saying crazy stuff that ain't none of they business. So I think that make people judge folk and get to talking about a whole bunch of stuff that jest make everybody uncomfortable, you know? And I still got my thoughts on stuff but if it don't affect me and mine, I don't really fret about it. Saying a whole bunch on people's lives lead to arguments and hurt feelings and all that. Plus it make people not want to be around you. All that make you old.”

“I really should have been writing this all down, ma’am.” I squinted an eye and went on. “I can tell you mean what you're saying, too.”

“I sho’ do.”

“Okay. So move my body and mind my business. Got it. Anything else we need to do?”

It's funny. Mrs. Calhoun was genuinely entertaining my questions about living to be an octogenarian. Though most of my patients answered me, few were so thoughtful in their replies. Her lip jutted out and she rolled her eyes skyward as if sifting carefully through her words. Finally, she lifted a long crooked index finger and looked straight into my eyes. “One more,” she said in her gravelly voice.

I scooted my chair forward and leaned in. She didn't speak immediately. Instead, she held my gaze with narrowed eyes for a few beats, curled in that finger and brought it to her lips. I stayed silent, waiting for what I knew would be worth the time.

Her finger extended again to point at me and then the resident physician beside me. “This probably the most important thang. You got to see about yourself. I mean look out for your own happiness and don't let nobody treat you bad, you know? Like, when you a kid or even a young person, it ain't always easy. But once you grown, you got to love yourself enough to not let nobody get away with being ugly to you. And that include you-yourself, too.”

“Okay …” I lulled her to go on, leaning even closer.

“Put on some clothes every day. Brush your hair and care ‘bout how you look. That's all a part of seeing about yourself.”

“Got it.”

She paused for a second and then patted her hand on the desk. “Oh! And I almost forgot. Make sure you got you a good stick a red lipstick in your bathroom drawer. And that you wear it sometime.”

Red lipstick?” My resident glanced over at me raised her eyebrows. We both returned our attention to Mrs. Calhoun, intrigued with this unexpected statement.

“Yes, sugar. A good one, too. One that make you feel like a woman. Not no gloss or tint neither. I'm talking ‘bout a R-E-D red that can't nobody mistake. You keep it there for when you need to feel strong and good. Or sometime jest for no reason at all. Paint it right on your mouth and look yourself in the face.”

Damn. I was taking this all in in giant gulps. I wanted her to go on and, lucky for us, she did.

“See, putting on some red lipstick; that's saying something to yourself. You telling yourself you worth noticing. But then you got to walk in that. Wit’ your head all the way up like you know something they don't.”

Whew. This woman was preaching, do you hear me?

My resident feigned a frown and groaned. “But Mrs. C, what if you look terrible in red lipstick? I can't even imagine myself with red lipstick.” She laughed when she said that but Mrs. Calhoun didn't.

“Every woman can look good in red lipstick once she find the one that suit her. But the key is jest that she just got to make up her mind that she deserve the attention it brang, see. It ain't never the color. It's that part that hold women back from it.”

And that? That I knew I wouldn't want to forget. Like, ever.

No, I would not.

A little later, I saw Mrs. Calhoun in the hallway, cane in one hand and discharge papers in the other. I stood there watching her and reflecting on her words as she took those short deliberate steps toward the exit. At the last minute, I decided to sprint up to her to hold the door, but mostly to tell her goodbye.

“It was so good talking to you, Mrs. Calhoun. Thanks, hear?”

‘Oh, Miss Manning, you know I love talking to you young people.” I beamed at her reference of forty-five year-old me as a “young person.” She nodded in acknowledgement of me propping open the door for her and headed into the lobby.

Just as she was right in front of me, I spoke. ”Mrs. Calhoun? I'm just wondering … do you still have a red lipstick?”

She turned to look me in the eye and smiled wide. “Sho’ do, baby.”

“I love it. Think you'll wear it next month when you make 90?”

“Maybe. But it ain't got to be no special occasion, do it?” Mrs. Calhoun reached out and patted my shoulder when she said that. Without saying a word, I dragged in a deep breath and nodded hard to let her know I received her good word.

Because I did.

Move your body.

Mind your business.

See about yourself.

Oh, and have a good red lipstick.

Words to live by. Like, literally.


Now playing on my mental iPod …

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

Timing is everything

Quick: Which US state has the highest rate of unintended pregnancy?

I'll reveal below, but I learned the answer and several other surprising facts in an interview with Mark Edwards, the co-founder of Upstream USA, a non-profit advocacy organization that provides technical assistance to health enterprises (medical practices, clinics, public health departments) in the use of long-acting, reversible contraceptives (known in the trade as LARC).

LARC consists of two options: IUDs (intrauterine devices) and implants, which are small, match-sized, plastic rods that deliver a slow, steady dose of hormone to prevent pregnancy. They are planted in the upper arm of women to provide another form of hassle-free contraception.

Both of these methods can be discontinued at any time, at which point fertility returns—faster, I'm told, than in the case of oral contraceptives.

Here's a fact that surprised me about oral contraceptives (aka “The Pill”): Though when taken reliably their ‘success rate’ as a means of preventing unwanted pregnancy is considered to be 99%, over a 10 year use period, due to the challenging nature of remembering to take a daily pill, it's likely that 61% of those taking the pill exclusively for birth control will become pregnant. Most definitely not the intended outcome. (Source: here.)

Big picture: every year in the U.S., there are about 6.6 million pregnancies. Of those, 3.4 million, or slightly more than half, are accidental: either altogether unwanted or “significantly mistimed,” what we in the health care business describe as a pregnancy occurring 2 or more years before desired. The vast majority of these accidental pregnancies occur in women in their 20s (though teen pregnancy is a concern, only 20% of unplanned pregnancies are in teens, and the vast majority of those are in women 18-19 years old. In fact, the teen pregnancy rate has fallen significantly in the last 25 years).

That's why, regardless of your politics, offering LARC to any woman of childbearing age is crucial. At the very first visit. As a primary care doc myself, I know that “family planning” often falls down the list of concerns for patients that I see because there are so many other issues people wish to bring up in our short office visits. Thus, opportunities to provide women with LARC often fall through the cracks.

Upstream USA's methodology includes technical assistance: training staff up to ask every woman that comes in a simple question: “Do you intend to get pregnant in the next year?”

If “yes,” proceed on to other matters. If “no,” offer LARC right then and there. And the provider (doctor, nurse practitioner, or physician assistant) is trained up to put in an IUD or implant on the spot. No waiting until next time.

Why is this so important? Women with unplanned pregnancies are at greater risk for staying or falling into poverty. Their opportunity to advance in their education is diminished. Children should be brought into the world wanted, with parents that are prepared, and with the maturity and resources to succeed.

It's a fundamental choice for a woman to decide if and when she wants to have children. Of course, fewer unplanned pregnancies also means less need for abortion.

So what Upstream USA is offering is win-win-win. It's bipartisan—a rare area that people on all sides of the political spectrum can agree upon. Upstream USA's first big success was in none other than Texas. The organization also has partnerships in a number of other Red and Blue states.

The state with the highest rate of unplanned pregnancy? Surprisingly, Delaware. Upstream USA is there, too. And going big across the whole state.

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.
Thursday, February 18, 2016

Direct patient care time is a moral problem as much as a practical one

I was dining at a friend's house recently after a long day in the hospital. He has just bought a beautiful new home with his rapidly expanding family, and like anyone who has just moved into a new house, his spare time is invariably spent working on getting everything in order and undertaking small upgrades to make the new place as perfect as possible. He's quite DIY-oriented (unlike myself) and was spending a lot of time doing minor construction work. When I asked him why he didn't just hire someone else to do the work, he told me that he'd rather just do it himself and that it was far better and more enjoyable than “just going into the hospital to play around with computers all day.”

I found this a profound statement, and sad on a number of different levels. His hospital had a new computer system installed a few months ago, and like a lot physicians—especially those in generalist specialties—he was now finding himself spending the vast majority of his day staring at a screen, typing and clicking away. He is a physician who really enjoys clinical medicine, values his time with patients, and didn't go to medical school to do a desk job (like all doctors).

Not so long ago, I wrote a piece about the amount of clinical time that physicians are spending with patients being on life support, primarily because of healthcare information technology. Some studies suggest that medical interns are now spending only around 10% of their day in direct patient care, with the bulk of the rest sitting at a computer terminal. I can well believe that.

In fact, if my own experience is anything to go by, I wouldn't be surprised if during a 12-hour day, patients are lucky if their doctor spends 1-1.5 hours total with them. Think long and hard about that statistic, because it's a disaster for the practice of medicine and for our patients. A typical scenario goes something like this: 5 minutes with you and then 20-25 minutes navigating an inefficient and cumbersome system to document what's just happened! Interacting with a computer during the actual encounter is even worse, and not appreciated by patients when they see their doctor turning around and looking at a screen every few seconds instead of talking to them.

The answer, however, isn't to take the technology away and go back to the ancient days of pen and paper, but rather to design better and more optimal solutions: with a simple acknowledgement that the best IT of the future will be that which is “seen and not heard”. Electronic medical records and physician order entry systems that are quick, super easy to use, and properly reconciled with frontline clinical workflow.

Physicians simply cannot spend 80%-90%-plus of their day sitting down at a computer terminal. It's not what being a doctor is all about. So much of medicine is about communication and yes, much of it is also still an art. The same dismay would result if you turned another profession that views itself as an art upside down and into a screen-staring job (whether it be a sportsperson, a film producer, or a teacher). Whatever we can do to tip the scale back towards patient care, must be done. Although it's unrealistic, and also nonsensical, to think that doctors could ever spend 100% of their day with their patients, there must be a palpable swing towards direct care time. This would not only be good for patients, but also increase productivity and efficiency—as doctors will also be able to see more patients in a meaningful way.

Going back to my friend, who now equates being a physician with going into hospital and “playing around with the computer all day”, the situation is not just an impractical one, but a big moral one too. Moral because it has so many consequences in terms of reducing job satisfaction for a noble, caring and hard-working profession. Moral because it makes every physician forget why they went into medicine in the first place. And most of all, moral because it robs our patients of the care they deserve when their physician is more pre-occupied with documenting the encounter than living it.

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, February 17, 2016

The Value Tension

I spent this past weekend discussing internal medicine's future with colleagues. We spent our time forecasting, predicting and prioritizing. During those discussions the concept of the value tension evolved.

So why is the definition of value so important to internal medicine (and all other medical fields). The MACRA website says, “The MACRA will help us to move more quickly toward our goal of paying for value and better care. It also makes it easier for more health care providers to successfully take part in our quality programs …”

One might assume that value is easy to define. Congress must believe that we can measure value. But many physicians believe that value has different meanings to various stakeholders. Insurance companies (and we should include CMS here) adopt performance measurement as their definition of value. Yesterday's post reflects on the folly of that definition.

Patients do not have one definition. Patients are not homogeneous, rather their desires vary rather widely. Here are some criteria that I have heard from friends:
1. Accessibility
2. Visible evidence of caring (looking at the patient, appropriate touching, listening carefully)
3. Shared decision making
4. Making a correct diagnosis
5. After a correct diagnosis, knowing the most current treatment approaches
6. Clear explanations

Physicians also view value in various ways. Most internists want sufficient time to address all the patient's needs. We want to make correct diagnoses. We want to provide appropriate treatment for the patient who has the disease.

“The good physician treats the disease; the great physician treats the patient who has the disease.”

—William Osler

How do we reconcile these differing viewpoints of value? At least one dictionary has this definition: “relative worth, utility, or importance”.

So if the goal is to pay for value, we need an important thought experiment. Will focusing on one definition have a negative value impact for other definitions? The word value seems straightforward, but it describes a very complex process. Value has multiple dimensions. If we focus on some, but not all the dimensions are we really providing value. Rather are we describing a partial value.

No surprise here—patients say they are usually less satisfied with their doctor's care when computers were used during appointments, according to a recent JAMA Internal Medicine study.

Semantics are not just intellectual games. How we define value really matters. The first step is recognizing and accepting the concept of Value Tension.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.
Tuesday, February 16, 2016

Free Wi-Fi in the doctor's office?

I have always been irked when a hotel charges me for Wi-Fi use. This pick-pocketing is resented by hotel guests across the fruited plain. This money grab is taken right out of the airlines' playbook, who now charge us for carry-on bags, an aisle seat, a candy bar, a working flotation device “in the unlikely event of a water landing” or a functioning oxygen mask. Need to change your reservation? Easily done for $150. On what basis can this fee be deemed reasonable? It constitutes consumer abuse of the first order. Although airline profits are soaring, and fuel costs have tanked, there has been no trickle-down effect to travelers, who are left with little recourse except to pen cranky blog posts.

Hotels know that Wi-Fi is like oxygen. Since we can't live without it, why not extort a few dollars for it. A paradox in this exploitative practice is that cheap hotels give their guests free Wi-Fi, while top tier hotels might charge $15 a day for the privilege of using a service that costs the hotel nothing. There will usually be some inconvenient location where it is free for all, knowing that most of us want the service in our hotel rooms.

“We have a free Wi-Fi area on the other side of the parking lot. Since it's raining, we do have umbrellas available, for a small fee …”

Guests are pushing back. Hotels are taking notice and backing off. We have an expectation that some goods and services should be free according to natural law.

Here are some items that I never want to pay for.
• water at restaurant
• bread at a restaurant
• Wi-Fi
• customer service from a living, breathing human being regarding a product i have purchased.
• an extended warrantee.
• plastic or paper bags at a supermarket.
• parking lot fee at a theater.
• shipping and handling fees.

The medical profession is always on the lookout for revenue enhancement. Perhaps, we should also adopt an a la carte fee approach. Here are some items we might start charging for in our gastroenterology practice.
• pre-visit handwash.
• restroom use.
• toilet paper in the restroom.
• working light in the restroom.
• clean colonoscopy equipment.
• waiting room magazines less than 6 months old.
• waiting room chair use. This would be coin operated. Once the 15 minutes expires, the patient would have 2 minutes to insert additional coins in order to avoid a very gentle series of electric shocks.

Why should we physicians leave money on the table? If you want to change your appointment, we can do this for a mere $150.

Perhaps, our practice should establish a Rewards Program, where patients can accrue points after each office visit. 100 points might give you a preferred parking place. 250 points might guarantee you an on time appointment. 500 points might entitle you to extra anesthesia during your procedure. And, 750 points might grant you a half hour access to our Wi-Fi.

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.

Great idea

Occasionally, I come across something that is so profound that it illuminates how I think about a whole host of other things. The emerging science around the gut microbiome is an example. It seems like everywhere I turn there is more evidence that the variety and interactions of the bacteria in our intestines can affect everything from our mood to our risk of heart disease. It has re-ordered my thinking about health and wellness.

More recently, I read a book that has re-ordered my thinking about a lot of things, including health and wellness. The book is Connected by Nicholas Christakis and James Fowler. The central observation of the book is that we exist as social beings. We are all part of different networks of connected people, and the nature of those networks, and the people connected to us through them, have profound effects on each of us. You may have heard about some of the work that is summarized in the book, like the finding that if friends of our friends gain weight, we are more likely to do so as well, even if we don't know those friends of friends, but that doesn't begin to tell the story. Read the book. Or at least watch the TED talk which, when I checked, had been viewed over 1.1 million times.

Like the song sometimes gets stuck in one's head, I now find it hard to avoid seeing “network” effects in all sorts of places. The one that prompted this post was a recent article in the New York Times about rising mortality associated with drug overdose. Specifically, it was this paragraph: “In fact, graphs of the drug overdose deaths look like those of deaths from a new infectious disease, said Jonathan Skinner, a Dartmouth economist. ‘It is like an infection model, diffusing out and catching more and more people,’ he said.”

In fact, in all likelihood, the resemblance is not coincidental. Instead, the spread is evidence of the strong influence of the underlying social networks to which these victims belong.

Being cognizant of these network effects has created, for me, a new lens through which to view such apparently disparate things as smoking cessation and presidential election politics. Even baseball! The bottom line is that each of us lives in a web of overlapping, interacting, profoundly important connections, and the nature of those connections, and the people to whom we are linked through them, shape our lives.

I think this is pretty cool stuff. What do you think?
Monday, February 15, 2016

Annoying acronyms and miserable mnemonics: AIDET and the H's and T's

Mnemonics can be incredibly cool. When I was in medical school there was just too much stuff to remember and memory aids were so very helpful. Most specifically I refer to the vile and inappropriate 1 that helped me remember the cranial nerves which I remember to this day and will not share in print. In ancient times orators used memory palaces to memorize long speeches or poems, associating words with familiar and sometimes bizarre images. All this is to say that I have nothing against a good mnemonic. Lately though, as I have struggled to memorize a new acronym which is supposed to be good for me, I've been thinking about what makes a mnemonic good and what makes one annoyingly terrible.

The most irritating mnemonic in recent experience is probably the “H's and T's” from advanced cardiac life support (ACLS). When a person's heart has ceased to be able to sustain life or blood pressure, we use a memorized sequence of interventions to resuscitate them, the ACLS protocol. Ideally, we would all be fast enough and coolly competent and use our diagnostic skills and knowledge of treatment to rapidly and effectively help the patient recover in short order. The fact is that, for most of us, a cardiac arrest occurs rather infrequently and is associated with enough anxiety that, without a good solid script, shared with a treating team, we might just stand around and flap our hands and mumble. With the script we sometimes are able to restore a functional cardiac rhythm in time to keep from irrevocably damaging the brain. But if we try the usual maneuvers and nothing works, we are encouraged to think of the H's and T's. I have studied this for years and still I find that these letters do not help me much at all. That is because humans are not good at thinking of many things that start with the same letter. That's why the game Scattergories is actually challenging. A mnemonic has to be really good to work in a life and death situation.

In order to help me maybe remember the H's and T's again, here they are. If a person persists in being dead despite your best efforts they may have: hypoxia, hypovolemia, high hydrogen ion (acidosis), hypothermia, thrombosis of the coronary or pulmonary circulation, tamponade, tension pneumothorax, or toxins (poisoning.) And don't you forget it!

The other annoying acronym is AIDET, a communication tool introduced by health care consultants the Studer group to help improve patient satisfaction. The Studer Group arose out of the experience of Quint Studer in using a business model to improve patient and employee satisfaction in a failing hospital. Many hospitals could use help and Studer techniques have become very well accepted by management in hospitals, though somewhat less enthusiastically by clinical staff, who right or wrong do not feel like they need a script in order to communicate. AIDET stands for Acknowledge, Introduce, Duration, Explanation, and Thank You. As a grammar police person I resent the fact that these are different parts of speech. Two are verbs, 2 are nouns and the last 1 is 2 words that make up a sentence. If one does by some chance memorize the words the problem may reasonably arise that they don't actually tell 1 what to do. After attending a workshop one might learn that one is supposed to say, “Good morning, Mr. Qwerty. My name is Jkl;. I'll be working with you today in what I hope is your most awesome and joyful health care experience ever. In 15 minutes your anesthesiologist, Dr. Asdf will be in to assess you for your surgery scheduled for 2 p.m. today. You will not be able to eat prior to surgery but we will be happy to get you a late tray when you return. Thank you for allowing us to work with you today. We know you have many choices and we are happy you chose X hospital.”

AIDET is not entirely bad. Maybe it's not mostly bad. But it is also not great. First the acronym/mnemonic. It doesn't work. That's 1 reason why hospitals have to get their employees to attend practice sessions to absorb it. And they do. I have failed to attend a practice session myself and, once I get back from Africa, I will likely need to do remedial work. A good mnemonic is ABC for airway, breathing, circulation, the recently replaced beginning of cardiopulmonary resuscitation (now CAB.) Or “righty tighty, lefty loosey” for opening a valve. Using AIDET to remember to recognize a patient, introduce oneself, explain what will happen and when and express gratitude of some sort is like grabbing for a cement life preserver. Maybe “who, what, when, where, why and hurray for you” or something goofy like that could work. The AIDET acronym is actually copyright protected so maybe that's why they push it. If you use it you have to pay Studer Group. Also the content and the concept is less than great. I accept that doctors and nurses often need to slow down and introduce themselves and explain what's going to happen, also to affirm the worth and dignity of the patient. But we need to do it in our own way, otherwise we lose our own dignity and will fail to notice what this patient needs at this particular moment. Patients will also start to notice that we are talking strangely.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

2015 Dietary Guidelines are a plate full of politics

I won't mince words: In my opinion, the 2015 Dietary Guidelines for Americans, are a national embarrassment. They are a betrayal of the diligent work of nutrition scientists, and a willful sacrifice of public health on the altar of profit for well-organized special interests. This is a sad day for nutrition policy in America. It is a sad day for public health. It is a day of shame.

I know, I should tell you what I really think. Maybe next time.

I want to make clear that the scientific report on which these new Dietary Guidelines for Americans (DGs) were allegedly to be based was outstanding. Perhaps not perfect—What ever is?—but truly outstanding.

That's a position I have asserted before, many times, encompassing the report's very appropriate inclusion of sustainability. I raise it again now for two reasons.

First, I want to make unmistakably clear that my criticism here is of the political adulterations of the excellent work of scientists, and not one iota about the work of those scientists. Second, the 2015 Dietary Guidelines Advisory Committee (DGAC) Report has been subject to unprecedented abuse since the day it was released. Many in the vanguard of those assaults have pretended it was an effort to challenge, and thus improve, the quality of the science. It was not. It was foreplay for this. It was softening up support for the work of true public health scientists so that politicians could stick it to the American people and line the pockets of their influential friends.

There will be—indeed, it has already begun—a Tsunami of ink (well, electrons, mostly) allocated to this topic, today and after. It will be parsed in its every particular. I myself may weigh in again, and get more specific. For now, a rather high-level critique will suffice.

Where the DGs are good, and there aren't many places in the lengthy document, it's where they preserved key components of the DGAC report. For example, they respected recommendations about key nutrient thresholds, such as limiting saturated fat intake, not limiting total fat intake, and perhaps most importantly, limiting added sugar. They also preserved the idea, if not a sensible representation of it, of healthy dietary patterns, and provided examples to show that these are variations on a theme. I can give this very little bit of credit where so little credit is due.

Otherwise, as compared to the DGAC Report, the DGs represent a disgraceful replacement of specific guidance with the vaguest possible language. A term that recurs often, clearly intended to sound like something while saying next to nothing, is “nutrient dense foods.” That replaces reference to specific foods that populate the original document. It might mean broccoli, it might mean Total Cereal. I guess it might even mean pepperoni. We can't tell, and that is clearly by design.

There is an astonishing effort to shoehorn in advice to keep consuming “all food groups.” When is the last time we have even heard that term? Not only is this document a display of complete submission to special interests, it is a submission to special interests stuck in 1950! Seriously, eat from all “food groups”?

There is a disgraceful backtracking on clear recommendations to eat less meat and more plants. The report advises particular age groups of men and boys to cut back somewhat on meat intake, but all this does is highlight the abandonment of the recommendation in the DGAC Report that “less” meat was advisable to the general population for the sake of people and planet alike.

There is overt hypocrisy on display as well. The DGs explicitly, even in the Executive Summary, emphasize the importance of physical activity. I am entirely in support of this recommendation, make no mistake. But how is this a “dietary” guideline? Congress decided, some months ago, that sustainability would NOT be included in these guidelines because it was beyond the mandate of the DGAC. Really? The ability to keep supplying the food recommended is not considered relevant enough, but a topic that isn't about food at all is? I really don't think you even need to be able to spell hypocrisy to smell it here.

While the report talks about foods being emphasized over nutrients, recommendations about what NOT to eat (or, even, what to limit) are entirely cast in terms of nutrients. We are advised to limit our intake of saturated fat, for instance, but there is virtually no language, and none featured prominently, indicating what foods to avoid to achieve that. Much the same is true of added sugar. Clearly advice about eating less of anything conflicts with the interests of some big industry sector the federal agencies and their bosses in Congress don't want to upset. So, somehow, we are left to cut back on our intake of saturated fat and sugar while washing down our corned beef with Coca-Cola. Good luck, folks.

The DG document is not even internally consistent. There is a specific recommendation FOR eating meat and poultry, as well as fish, ostensibly in the service of achieving a “variety” of protein sources, and eating from all food groups. Nonetheless, the DG does offer a vegetarian pattern as an example of healthy eating. This made perfect sense in the context of the DGAC Report, which made it clear that less meat was a good idea. It looks like lip service and gobbledygook in the context of a document specifically recommending meat intake. The DG, shockingly, even carves out space to say it is “okay” to eat “processed meats and poultry” provided that nutrient thresholds are respected. This is absurd in the aftermath of a WHO report identifying processed meat as carcinogenic, in addition to its many other established liabilities. It is also another example of hypocrisy in these guidelines, since we are told the emphasis will be on foods rather than nutrients, but then told it's fine to eat bad foods as long as certain nutrient levels are vaguely … good.

The 2015 Dietary Guidelines for Americans is, alas, a virtuoso display of linguistic contortionism to remove from the nation's official nutrition policy document the actionable clarity of the DGAC at every opportunity. Specific advice about what to eat more of, and especially what to eat less of, has been replaced with the vaguest possible language about food groups, nutrient dense foods, and the idea that everything is OK provided a few nutrient thresholds are minded. The DGs include the topic of “shifts,” allegedly how to trade up by replacing foods in our diets with better choices, but here, remarkably, the language itself “shifts” again from food to nutrients, so we have no hope of knowing what we shouldn't eat. Perish the thought, that would be money out of someone's pocket. We are left with a very clear, and genuinely helpful notion that we can probably just eat whatever the hell we want, and all will be well.

Except it won't. We are awash in preventable chronic disease. We are eating away our own health. We are eating our children's health, and their food, and drinking up their water. We are, into the bargain, devouring our very planet. Yet we are told here to keep on keeping on. That's what you get when it is politics, rather than science, on the plate. Bon appétit.

The good news—and there isn't much this day—is that we don't have to swallow this. Having chewed on it, and choked on it, we can just spit it out (Aim carefully, please; there are nice shoes out there).

I call on you to do just that. The 2015 DGAC Report is in the public domain. Our hypocrisy, thank goodness, has not yet advanced to the level of expunging the work of true scientists entirely. So, ignore the DGs, and turn to the DGAC Report for guidance instead. It is accessible to you, and it is about you, not the wealth of Congressional cronies.

I call upon my colleagues in public health and science, as indeed I have done, to band together and express our views directly, and in a common voice, cutting out the political middleman. We have the capacity to do that, and the public has the opportunity to decide whom to trust.

The bad news is that our Dietary Guidelines are pretty awful. The good news is that guidance isn't guidance if no one follows, and we don't have to follow where this national embarrassment leads. We have been betrayed; but we don't have to eat it.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
Friday, February 12, 2016

Medical education snaps into 'BST' mode

We have an amazing culture of teaching at Emory. The best part, though, is that not only do the faculty get really into it, we also pour an incredible amount of time and energy into building the most junior of our learners into teachers, too.

This photo was snapped during our resident conference yesterday. This particular session is a unique monthly lecture series where resident physicians are coached by faculty members to deliver high level, evidence-based lectures--but here's the kicker: They can only be 8 minutes long. We started doing this last year and it was an immediate hit. I think part of it has to do with young people just enjoying the inspiration of being taught by their peers. But also there's something to be said about somebody only talking for 8 minutes and that's it.

Of course, I had to come up with a witty title for the conference. We call it “BST Mode” (pronounced BEAST MODE), short for “Bite-sized Teaching.” My diabolical plot, of which BST Mode is a part, is to get us to a point where nobody ever lectures to anyone for more than 20 minutes. Okay, 30 minutes tops.

*insert wicked laughter*

The 4 residents were answering questions from the audience when I took this snap. It got me thinking about how critical of a skill the question and answer period is after a lecture. I've found that it can really make or break someone's merit at the end of a great talk. This fab 4 did great with theirs. That said, the nerdy teacher in me sees this as a great opportunity for some future focused teaching-learning-growing exercises. I like to think of it as “The Art of I Don't Know, But Here's What I Do Know.”


I love my job. And this is one of the main reasons that, even if I had won the Powerball, I'd be right here at Grady. (That is, after being dropped off by my personal Uber driver.)

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.