Tuesday, May 31, 2016

Overcoming shame

Taxes.

Doing taxes feels like a financial rectal exam. I hate doing taxes. Yeah, I don't like getting rectal exams either.

It's not that I resent paying the government for the fine services they render and the high quality of elected officials we have. It's not the existence of taxes I hate; it's just doing taxes make me feel extremely insecure. Sharing my personal and business finances with my accountant and the government makes me feel like a dope. I feel like I'm stripped naked with all of my flaws exposed.

This is actually ironic because my accountant is a patient of mine. He also, despite my urging, has been slacking on coming to see me. “I just haven't been taking care of myself and feel ashamed,” he told me in an e-mail. “It feels like I'm going to the principal's office.”

I know how that feels. I did go to the principal's office plenty as a kid. So I told him (my accountant, not the principal) that this was exactly how I felt each year during tax season. So we made a pact: I wouldn't make him feel like an idiot, and he'd not make me feel like one. That's easy for both of us, as we are used to seeing other people's financial/physical nakedness.

His feelings about going to the doctor are very common. People often feel insecure and ashamed. Just today, a woman with COPD bowed her head in shame when she confessed she was still smoking. “How stupid is that?” she said, “I have COPD and recently had pneumonia, yet I still can't stop using these things! My kids are always on my case; I just don't know why I can't quit.”

This is true with diabetes, obesity, alcohol consumption, and anything else that seems like it should be easily handled (or at least improved) by lifestyle change. People don't know why they compulsively do bad things or compulsively avoid doing the right thing. This is why I often tell patients is that one of the best things about being a doctor is that I see that everyone else is as screwed up as I am.

This insecurity is the biggest challenge in my practice: getting people to change their behavior. Somehow I have to somehow get people to pay attention to their health when they'd rather ignore it, to be taking medications when they'd rather not, to be exercising when they don't want to, to lose weight when they love cheeseburgers, and to be checking their blood sugars when they'd rather not know how high they are. After trying lots of things over the past 20+ years, the one thing I find almost never works is what is usually done: lecturing the patient.

ACOs and “Meaningful Use” have made lecturing the norm. Here's a clip from the end of a note from a patient's recent visit to the ER: Estimated body mass index is 30.94 kg/(m^2) as calculated from the following: Height as of this encounter: 1.638 m (5’ 4.5”). Weight as of this encounter: 83.008 kg (183 lb). Discussed the acceptable BMI with this 47-year-old female. Her BMI is >25 which is above average for a patent 18-64 years old. BMI management plan: regular exercise and dietary management, education, guidance, and counseling. We discussed the divided plate method.

Great. I am sure this will change her life. She probably loved being lectured by someone she didn't know when she was in the ER for something unrelated to her weight. I'm sure she never realized she was overweight. Her life will be better because of the divided plate method. I sure as heck am delighted to see my patients are lectured about their weight by strangers.

Everyone is lecturing my patients on their weight, smoking, exercise, checking their sugars, taking their medications, and “reducing stress” in their lives. How can you reduce stress when you are surrounded by a bunch of medical busy-bodies? The consequence I see is a bunch of folks who are like my accountant: afraid to get care because they are waiting for a lecture. Many lie to cover up their shame, while others just don't come.

So what to do about this? How can we create a system that promotes honesty and encourages engagement? We can't just ignore these problems. I've had people who used my lack of mentioning their smoking or morbid obesity as me saying they are OK. People need us to be engaged in their struggles in ways that are truly helpful, either helping them overcome these struggles or at least giving them a sympathetic ally in their battles. I want people to come to me for help, not to avoid me or hide the truth because they fear me.

This, of course, brings me back to the idea of patient-centered care. How do we address issues, such as weight, smoking, and non-compliance in a way that is patient-centered? It's harder to answer that question than to answer the opposite: what's the least patient-centered way to address these issues? Checklists that tie reimbursement to lectures.

Checklists force caretakers to ask questions and address topics when they aren't relevant. They are centered on doing the “right” thing for the wrong reason. ACO's and “meaningful use” tie documentation of addressing these issues with reimbursement. So, we either lecture our patients halfheartedly or we simply lie by checking the box. I suspect the majority of times it is the latter. Why, after all, should a urologist lecture a patient about weight loss (other than to get a bigger check from the government, which is the obvious answer)? So patients get buried in an avalanche of lectures and handouts telling them what they are doing wrong.

The solution? I'd be on Dr. Oz right now if I knew an easy way to help people lose weight, quit smoking, or fight their other personal demons. There is no easy way. But it helps a lot to have someone who is fighting with you, not making you feel foolish. I've recently lost 20 pounds by the magic formula of eating less and exercising. It's simple, but it sure as hell hasn't been easy. So the best approach I've found is to sympathize and encourage. I want people to tell me about their struggles and failures, not hide them.

I'm realizing as I get toward the end of this post that I'm not coming to some grand conclusion. This is not magic. It's not a secret trick that can make things easy. Life is a struggle we all face, and it is best faced with good allies. I want people to come to me when they need help, not run from me fearing judgment and lectures. Somehow, despite the checklist culture of our system, we need to keep care away from shame. Yeah, people make bad choices, but that doesn't mean they are bad (or stupid) people. In truth, they're just like their doctors and nurses.

And, it turns out, their accountants.

Medical schools owe their students more

Readers know that I believe that servant leadership should inform leadership and management decisions. We who have the privilege of having leadership positions at medical schools therefore have as a primary responsibility to our students.

Being a medical student, while a reward and a privilege, is nonetheless a stressful experience. The first 2 years at most U.S. medical schools have the students grinding through the basic sciences related to medicine. The volume of material that our students try to absorb is massive. Then they must take a high stakes test (Step 1) and pass it so that they can progress to the clinical years.

The 3rd year of medical school for many students is the reward for the challenging basic science years. The students work hard and grow dramatically. As one who has worked with 3rd year students as a faculty member since 1980, the changes during that year are dramatic. Our students learn the culture of medical care. They experience all social strata of life; they see tragic illnesses; they experience patients dying; they see the diseases of self-abuse. They begin to understand the responsibility of our profession. Unfortunately, too often they have role models who are not great. They too often see cynicism. Too many “role models” do not exemplify the ideal.

As our students go through this experience, and then enter their 4th years, they have the additional stress of The Match. What should we do to help them? How many clinician educators really get to know the students and help them through their stress? While some do, few administrators really get to know the students.

The students pay very high tuitions. We all know how out of proportion tuitions have become. I just calculated the inflation of my tuition in 1971 (~$1,000 per year). According to the adjuster, tuition should be $5,879.80 per year. Yet we all know that almost all schools have tuition of $30,000 per year or greater.

How often do we consider how to give the students appropriate value? One could argue that we can never really provide that value, but others would argue that the return on investment makes this a good one. My stance is that we owe the students more during their medical school years.

What do we owe them? First, we need a great investment in our students. At a national level we really need a fresh look at the structure of medical education. Could we do a better job in the first 2 years? In my opinion we teach so much material, that the students too often do not really learn the most important basics because they have to learn basic science 101, 201, and 301 simultaneously. Too many students do not really learn the 101 basics that will really help them understand diagnosis and treatment.

Second, we need to help them handle the stresses of medical school. We must show our students ultimate respect. We must understand who they are and help them navigate their challenges. Students often thrive when they receive both immediate constructive criticism coupled with immediate praise. They need frequent targeted feedback given with a smile.

Our students need to understand that they have embarked on a difficulty road. They need to understand that we are supporting them, and we do not expect them to know everything. Our job is to help them grow. We can help them by showing them the way.

Most of all, they need to know and feel that they we care. Many leaders in medical schools really do care, but do we transmit those feelings to our students.

I would love to have some comments from medical students about their experiences. So that is my challenge to the students and recent students. What did I get right here, and what is off base?

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.
Friday, May 27, 2016

Risks of probiotics: Who cares?

Earlier this year I read about a medical study that concluded that a diet high in saturated fat won't kill you after all. Moreover, piling on polyunsaturated fat won't save you.

Hee hee. I love this stuff. Established medical dogma back flips every 10 years. Butter in, butter out. Hormone replacement treatment for perimenopausal women is mandatory, until it isn't.

Who knows what to believe when even doctors are confused or just don't know.

We have a medical industrial complex that is a beast that needs to be fed. It fuels itself on our fidelity to medical practices that are labeled as truths. ”Wellness” rules. How many decades did the public and the medical community preach that the prostate-specific antigen blood test saved men's lives? While I believe that urologists were sincere in their mistaken beliefs and practices, there was a whole industry behind the scenes that was fueling the fire. It was good business for hospital operating rooms, medical device companies and radiation therapy suites.

Of course, you could make this same point with respect to my own specialty of gastroenterology, as I often do on this blog, as readers know.

Just because something sounds true, or we want it to be true, doesn't make it true.

Is obesity really a killer on the loose? When a reputable study is published that pulls back from this draconian conclusion, what happens? The study is attacked by those who either truly believe that the study is flawed or by those who are threatened by it. Mammography is a superb example of this phenomenon. It is increasingly recognized that mammography is deeply flawed, problematic and harmful, but try discussing this with a mammography zealot. If you dare to do so, don the Kevlar first.

Probiotics are the rage for maladies spanning digestive disorders to depression to chronic fatigue. Do they work? Does it matter? The science girding most of their claims is porous, deceptive or absent. We should demand that their products be rigorously and independently tested, but this will not happen. Why should these companies tamper with perfection? We're already buying their potions faster than you can say “gluten-free.” Why risk the pesky scientific method that might cast a penumbra of doubt on their healing claims?

Think about the probiotic process. Folks are swallowing billions (that's billions with a ‘b’) of bacteria every day. Of course, these are “good bacteria,” little microscopic elves that will gobble up diseases that are beyond the reach of conventional medicines. First, let's call them what they are: germs. Is there any brave voice out there who is willing to vocalize concern about changing the human flora which took a gazillion years to develop through evolution? Are bifidobacteria really smarter than millions of years of natural selection?

Years from now, when probiotics are off the shelves, folks will nod their heads wondering how millions of us swallowed billions of germs just because we wanted to believe.

Skeptics of the world unite!

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.

Marijuana use may diminish metabolic syndrome

Marijuana is one of the most widely used drugs in the United States, and many states have legalized the medical use of cannabis. Marijuana is legal for recreational use in Colorado, Washington, Alaska, and Oregon. Despite an increasing use of marijuana in different forms, good scientific studies are not often done. A new study on the effects of marijuana on the metabolic syndrome was published in The American Journal of Medicine in February, 2016. This is the first study that examined relationships of marijuana use with the metabolic syndrome across stages of adulthood.

Metabolic syndrome is a dangerous combination of hypertension, obesity, high triglycerides, high glucose and low HDL (good) cholesterol. It is a significant risk factor for cardiac disease and diabetes. Until now we have not understood the effects of tetrahydrocannabinol (THC), the active ingredient in cannabis, on cardiovascular health.

The study analyzed marijuana use in persons 20 to 59 years old, including past and present use and how much marijuana they used. They also looked at race, socioeconomic level, cigarette and other drug use and age. They found that 60% of the subjects used marijuana at some point in their lifetime, 20% used within the last 30 days. The majority (53.2%) of middle-aged adults were past users.

The results showed a lower mean waist circumference (a measure of dangerous obesity) among marijuana users compared to those that never used. Despite the fact that marijuana contains cannabinoids and appetite-stimulating compounds that attach to receptors in the brain and other parts of the body, weight gain was not increased in users. The study also showed higher (good) HDL cholesterol levels in users compared with never users and lower glucose levels in past and current users. The 1 element that differed was systolic blood pressure that was higher in marijuana smokers, compared to non-smokers.

In summary, current and past users of marijuana were associated with a lower prevalence of metabolic syndrome and most of its components, except for systolic blood pressure. Older adults that previously used cannabis had significantly less metabolic syndrome and younger adults who currently used were 54% less likely than never users to have metabolic syndrome.

This study does not answer the big question “Why?”. We need to look at biologic pathways to figure out those relationships. But the more we know about the effects of this commonly used plant on our health, the better decisions can be made about legalization or medical use.

This post originally appeared at Everything Health. Toni Brayer, MD, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.
Thursday, May 26, 2016

Entering the narrative

I was really anxious. My father's legs were getting weaker and his pain was worsening. He had been having pain for quite a while, and that pain was often disabling in its severity, but the weakness was alarming.

Dad went to the neurosurgeon, who was also alarmed at the weakness, but didn't feel that the problem was surgical in nature. When I heard this I broke 1 of my most tightly-held tenets: Don't get involved in my family's care. I wrote a letter explaining the narrative of my dad's condition and why I was immediately concerned. It did the job; he got a study, was seen again by the neurosurgeon, and is now 1 day post-op for the treatment of his severe lumbar stenosis (narrowing of the canal). It's just day 1, so the jury's still out, but he's doing great.

The obvious question arises with this story: why did I see much greater urgency than the neurosurgeon? What did I hear that he did not hear? The answer is that I was a spectator of the whole story as it unfolded. I saw the sudden onset of weakness that was almost immediate after Dad had a procedure on his back (kyphoplasty). There was such a tight temporal correlation that I was sure the kyphoplasty had worsened my dad's condition. This was a mechanical problem that needed fixing.

The problem was, when my father went to the neurosurgeon, he downplayed the importance of this correlation (perhaps not even mentioning it, I'm not sure), so he missed this key fact. It was only a meddling son that raised this point.

This case, which is obviously very close to me, is a clear illustration of yet another important aspect of patient-centered care: the patient narrative. As a writer, I've long loved the idea of narrative in respect to care (and recording that care). The patient has a life story that we enter. They don't walk into the exam room, OR, or radiology suite de novo. They have a narrative that has gone on for their whole lives, and even has extended to previous generations.

We enter the patient's narrative when they need us. They need us for help with their current situation or to make sure their future is not threatened. The come to us with pain, with illness, with disease, wanting us to help them to go back to their non-medical narrative. A person's physical health is part of their life, but not all of it. As a whole, people don't want their health to be the main part of their narrative, although it is obvious that physical health eventually takes over as it ends the person's narrative in death. (I guess that's not completely true, as our legacy is certainly still part of that narrative after we die, but that's not the point of this post).

The underlying question to this series of posts (for my whole blog, really) is this: what is it that we do when we doctor, and why do we do it? The foundation, I believe is simple: to enter the patient's narrative and steer it in a positive direction. We treat and prevent problems so that the person can go on with their non-medical life. This is not the whole of the care we give, but it is the foundation.

That foundation determines the choices we make and the care we give. If we clinicians (as is often the case) believe the doctor-patient interaction narrative is about us, we give worse care. We don't listen to the patient (paying attention to the previous narrative), empathize (current narrative), or educate (future narrative). We see the job as a bunch of check-boxes and tasks we complete so we can pay our mortgage.

I think a lot of health care's problems are due to the corruption of this idea. Care has become about data and check-lists. It has become far too analytical and too little about the narrative. We focus on the office visits, when what really matters is what happens between them. The overwhelming burden of documentation and dealing with the financial side of care has stripped us of the time necessary to engage that narrative. Doctors no longer have time to listen.

Medical records are the most egregious assault on the narrative. Instead of being a written account of the care given to the patient (i.e. Narrative), they are an avalanche of data that buries the narrative. I often wonder what patients would think if they saw their medical records. They'd be confused, as the records are more about what the doctor did in the visit than about the patient. Finding valuable medical information in the chart is, consequently, very difficult. I get 15 pages of computer vomit from the local hospital whenever a patient visits the ER, and am often left guessing what really happened. It's all data and no narrative.

My dad's case illustrates just how critical knowing the narrative is. I don't fault the neurosurgeon's decision-making, as he did what was appropriate for what he thought was going on. The problem was in the incomplete communication of the narrative to him by my father. It just happened that there was a doctor son paying close attention who got freaked out about the symptoms and caused a ruckus. Hopefully, my dad's narrative will continue now in a much better direction (for a long time).

But most folks don't have meddling kids with MD after their names. What do they do? How do they get their narratives heard?

Some have read my previous posts as boasting about the superior care I give. I'm sorry if I ever gave that impression. I do think I give better care, but not because I am more caring or competent. I give better care because I no longer have a system that slaps me in the face every time I take time to listen to people. Comparing the care I give now to that which I gave in my old practice, there is little comparison; it is much better now. I have a clear before-and-after snapshot with the same physician to compare, and the care I give now is much more patient-centered, much higher quality, and much more enjoyable to give. The best evidence of the truth of what I say is my own narrative over the past 3 years.

My hope is that somehow we are able to return to care that is patient-centered. People want their narrative to be a good one, and doctors need to be able to enter that narrative and become a positive influence. Our goal needs to push people out of the medical realm and back to living the rest of their narratives with as little contact with the health care system as possible. That's what patient-centered care really is.

It's their story, not ours.

The health care system: What's in a name?

The trail that led me to a career in health promotion is relatively more or less selfish, depending on where we begin it.

The rather more selfish version began at age 13. On little more than a whim, I tried out for the junior high school wrestling team, which, not being a co-ed enterprise, failed to enthrall me. I was there long enough, however, to hear from the coach how many sit-ups and push-ups the worthy among us should have been able to do. Let's just say I was unworthy, and by rather a wide margin.

I had never thought much about exercise before then, despite my father's (a cardiologist) obvious devotion to it. But the margin of my unworthiness grated, so while I did not stick with wrestling, I did go home and do as many sit-ups (not many) and push-ups (even fewer) as I could.

The rest, as they say, is history. I became increasingly fanatical about ever more exercise, and it wasn't long before I began thinking about the fuel, too. So began an early devotion to high nutrition standards that influenced first my family, then my career. I have eaten unusually well, and exercised with great devotion, nearly every day for roughly 40 years.

That's 1 trail. The other, ostensibly less selfish version began around age 27, in the middle of my residency in internal medicine. Residency is that period of medical training that is the stuff of legend and notoriety, and rightly so. Things have improved somewhat since, but in my day, it often meant more than 100 hours of work in the hospital each week, some of it coming in continuous stints of up to almost 40 hours.

Much of the focus was, naturally, on something akin to one's own survival, conjoined to a desperate, continuous effort to avoid killing one's patients through omission, commission, or just general ineptitude. Those were the days!

Despite all that, and through a haze of sleep deprivation, I did what I seem naturally inclined to do: I saw the forest through the trees. Roughly 8 out of 10 hospital beds were clearly filled by miserably sick people that never needed to be so sick in the first place, and that our best efforts, in common with the king's horses and men, would never again make truly whole. Hospitals battled the ravages of disease; we were not in the business of making health. That was beyond our mandate, above our pay grade.

But that didn't seem entirely right, even then. Hospitals were, after all, part of what we have long called our “health care” system. I couldn't swat away the irritating idea that somewhere, among all the catheters and cannulae, and between the raucous resuscitations (successful and otherwise), there was something more to do about actual health. I went on, accordingly, to a second residency in preventive medicine, and have done all I can ever since to keep people out of hospital beds in the first place.

The reality, though, is that a lot of people do wind up in hospital beds; I have been there myself. And along with all of those who are there supine, there are the upright in their diverse multitudes: nurses, doctors, and PAs; technicians, dietitians, and therapists; social workers, chefs, and administrators. There are nearly 6,000 hospitals in the United States, employing more than 5 million of the health care sector's total workforce of some 12.2 million. These are sizable chunks of the U.S. workforce, population, and economy and in a sector that is growing.

As the most visible castles on the most prominent hills of what we call, rightly or wrongly, our “health care” system, hospitals are ineluctably caught up in our notions of what both health and care should mean, and do. There is opportunity here, certainly, but also cause for grave concern, especially if the past portends the future.

Historically, hospitals have been conceived, from their very construction to their by-laws, for the accommodation of providers, not patients. Your medical record, home to all manner of intimacy, has belonged to staff — and not to you. The final hours of potential communion with a loved one in the ICU were subordinate to visiting hour rules often little better than arbitrary.

Not that staff were on a picnic, either. The hours are long; the stress is high; the amenities, questionable. The smells are noxious, the sounds mostly dissonant, and the food generally dubious at best.

So it is these fortresses in the disease wars have done far less than they might to propagate health, and maybe even conspired against it for patients and providers alike. But that can change.

One can imagine kinder, gentler hospitals. One can imagine a lobby like that of a hotel, scented with flowers, not formaldehyde. One can imagine the soothing tones of piano, or guitar. One can imagine an ICU designed with a wrap-around, outer corridor providing families private access to a loved-one's bed, while preserving the unobstructed line of sight and clutter-free workspace the nurses need, thus allowing for visitation any time, day or night.

One can imagine the eviction of fast-food franchises, and junk food vending. One can imagine that these repositories of all the devastation tobacco wreaks would establish smoke-free campuses; sponsor smoking prevention programming; and offer state-of-the are smoking cessation programming as a matter of routine. Tobacco belongs entirely in history's ash tray of dreadful ideas, and hospitals might help speed it on its way.

One can imagine a devotion to actual culinary excellence, so that food, too, is medicine for patients and staff alike. Better still, the hospital cafeteria might showcase family-friendly meals of high nutritional standards, and hand out laminated recipe cards along with encouragement to, by all means, try this at home. Perhaps those cafeterias might extend as well to a take-out service, so that weary staff at the end of a long day or night have recourse to something fresh, and wholesome, and nurturing.

One can imagine, in other words, health promoting hospitals, and ideally, as prominences in a cultural landscape of health promotion. In principle, this is nothing but obvious. In practice, though, and historical context, putting hospitals and health promotion in a common sentence flirts with oxymoron.

There are exceptions, and I am privileged to work in one. Griffin Hospital, in Derby, Connecticut, headquarters for Planetree and the patient-centered care movement, demonstrates much of what's possible. Even here, though, more can be done.

The International Network of Health Promoting Hospitals and Health Services is devoted to narrowing the gap between principle and practice, and to converting the luminous examples of possibility into the industry standards that prevail. They are not new to the fray; they convene their 24th annual conference this June on the Yale University campus. I am honored to be a participant.

Though the most visible landmarks in our health care system, hospitals have historically had little to do with the promotion of health. Deeply caring people around the world are collaborating to change that. There is a bounty of years to add to lives, and a bounty of life to add to years, if we can establish health, and not just the treatment of disease, as the priority of a system that bears the name.

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, May 25, 2016

Tips for clinician educators and aspiring clinicians

Charles Bukowski once said, “Wherever the crowd goes, run in the other direction. They're always wrong.”

How does one become a master? What process do we use to have the highest probability of success? Here are some examples.

Picasso was an extraordinary craftsman, even when measured against the old masters. That he chose to struggle to overcome his visual heritage in order to find a language more responsive to the modern world is an important triumph that has had a vast effect upon our world. (from Picasso's Early Work)

Great musicians practice their scales and learn their chords. They play different time signatures. Only then can they tackle jazz or classical mastery. And yet they continue to practice the fundamentals regularly.

Success doesn't necessarily come from breakthrough innovation but from flawless execution. A great strategy alone won't win a game or a battle; the win comes from basic blocking and tackling, said technology entrepreneur Naveen Jain.

So what is my point? Why have I started this rant with a series of quotes and statements about fundamentals?

Too many students, residents and attending physicians fail to work on mastering the fundamentals. What are the fundamentals? At the risk of being pedantic, this is my personal view.
• Learning to take a careful and complete history of present illness. While this seems straightforward, the art involved takes much practice and much knowledge. Without knowing at least basic differential diagnoses, one will not explore carefully enough. One can only improve this skill through deliberate practice. We also must understand that questions about a patient's history of present illness should not end at the time of admission, but rather continue as we gain more information.
• Learning the fundamentals of the physical exam. While some argue that the physical exam is dead (or dying), I still see patients for whom a physical exam finding focuses our evaluation and sometimes helps make a diagnosis.
• Learning how to interpret all the routine blood tests. We spend money on these tests, and yet too often learners and physicians do not really focus on the lab tests or now what to do with an abnormal result.
• Look at our patients' X-rays and ask about findings that bother us.

Many newly minted attending physicians either do not really know the fundamentals, or do not understand that their learners need the fundamentals more than they need to learn the esoteric. Too often residents choose weird patient presentations for morning reports, when they really need to dissect carefully the common.

As attending physicians we often erroneously assume that residents have mastered the fundamentals. But while some have, many have not. We rarely go wrong when we discuss physiology, pharmacology or anatomy that relates to the patient's problem. Even the best residents benefit from a careful discussion of why the serum sodium is high or low, why the bicarbonate level is abnormal, or why the patient has few lymphocytes. Even the best residents benefit from discussing bedside manner, history taking or demonstrating a physical finding.

So my advice is to work constantly to master the fundamentals, even when you exploring the more esoteric. We can only explore new insights accurately when they are based on these fundamentals.

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, May 24, 2016

A doctor that every patient would want

The practice of medicine has changed dramatically over the last couple of decades, with many of the changes unfortunately not so good for patients. It's a well-known feeling among health care professionals, that among all the new elements of bureaucracy and information technology requirements and mandates, the one person who is often completely forgotten about is the patient.

As someone who has worked up and down the east coast in every type of hospital over the last several years, I am witness to that unfortunate truth. We always tend to forget the patient. With that in mind, I have gotten a real sense of what patients value and desire from their physician. Here is what I suspect those “dream doctor” traits would be, and what a letter from a patient would look like:

Dear Healthcare Organizations & All Physicians,

Based on my interactions with doctors, here is a list of the things I'd really like mine to be like. I find that most doctors are technically excellent and very competent, and the major issues simply relate to communication. If you are serious about raising the quality of care and improving the health care experience, you may want to take some of these points on board:
Speak to me respectfully and take time to listen to me. Empathy and compassion go a long way, and sometimes just a caring ear can count for an awful lot. Sit down and explain everything clearly to me (and my family if they are also present). Give me a chance to ask questions too.
Following on from the above, please make sure you are on the same page as any other doctors I'm seeing. It really gives me great heart to know you are all talking to each other!
When you are with me, please maintain eye contact. I am really bothered if you keep turning around to your screen to type furiously on your keyboard and click boxes. I am a real person with a story to tell.
Familiarize yourself with my chart and past history before you see me for the first time. Again, this is very heartening and reassuring to me.
Be accessible. If I have a question or concern, it's great to know that I can get in touch with you. I know you are super busy, but even if it's your office staff or a colleague, it should be relatively straightforward for me to relay a concern.
Please make sure that when I leave your care, whether in a hospital or in your office, that my followup instructions are clear and unambiguous. I don't understand technical medical terms. Last time I left the hospital I got a printout of computer gabble that looked similar to the paper I got after my car was serviced—that meant nothing to me and I couldn't understand.
Keep in mind that you are seeing me at one of the lowest points in my life. Those few minutes you spend with me are really important and I'm hanging on every word you say.
Smile more and remember that each patient you see is a real person and not just another name on your list! I have a life and just want to feel well again so that I can back to it.

Many Thanks for the great work you do every day,

Patient

Based on the above, here is how a “dream doctor” would communicate (in a hospital):
• You walk into the room and greet me with a handshake and warm smile
• You pull up a chair, sit down and get talking, asking openended questions
• You already know a lot about me (assuming we are meeting for the first time)
• You speak slowly and clearly, avoiding excessive medical jargon
• You maintain eye contact and don't keep turning around to start clicking and typing
• You give me and my family a chance to ask questions
• You summarize everything to me
• You say goodbye and tell me when you will next be seeing me or how I can follow-up

These requests could come from anywhere in America, or indeed the world. The question however, from the physicians' side, is how do we get to a health care environment where these (relatively simple) demands can be met? If physicians simply don't have the time to do these things because for every 5-minute patient encounter there's 20-25 minutes of bureaucracy and IT click boxes, we clearly can't fulfill our patients' wishes and needs.

That's why we need to get back to the drawing board. The doctor-patient interaction is sacred and those precious few minutes transcend everything else and should be every doctor's “zone”. That is something that no mandate, administrator or information technology can ever touch. They are what the patients and families will remember and judge you on. Patients simply cannot just be an afterthought in a real health care system.

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.
Monday, May 23, 2016

How bedside ultrasound was awesome last week

I sometimes do locum tenens assignments as a hospitalist in rural hospitals. It is a good way to find out how other systems work, or don't work, and meet new people and interact with new communities. It's great to be home and also good to go away and come back later. Besides the usual trappings of doctoring, including stethoscope, otoscope, and white coat, I wouldn't be caught dead without my pocket ultrasound.

I just got back from a week of 12-hour shifts in a 48-bed hospital and once again was very happy to have the ultrasound. They do have ultrasonography in the radiology department at this hospital, but echocardiography (ultrasound of the heart) is only available on weekdays from about 8 to 5, and it needs to be scheduled in advance. Also, the ultrasonographers don't necessarily look at the things I find interesting, and can't combine imaging with physical exam findings and what the patient tells me in real time. Patients also really enjoy seeing what's going on inside when we both look at the pictures together. Ultrasound has been part of my usual practice for 4 years now, and you might think it would get old or boring, but it hasn't.

These are a few of the cases in which it made a huge difference to a patient that I had access to ultrasound at the bedside as part of the physical exam:
1. A man came in with a history of heart valve surgery and swelling of the legs. It was not clear how well he took his medication at home, but he was known to have congestive heart failure. He had had a large pericardial effusion with tamponade (fluid surrounding the heart causing it to fail) a few months before I saw him. The bedside ultrasound ruled out tamponade and showed that his heart failure was in pretty good control. He improved impressively with just staying on his regular medication and keeping his feet up. Without the reassurance of the ultrasound I might have given him extra diuretic medication and perhaps caused kidney failure. I also might have had to send him to another hospital for a full scale echocardiogram to rule out tamponade, which would have required an emergency intervention.
2. A person with a long history of alcohol abuse came in feeling generally terrible. After treatment for alcohol withdrawal, he developed very low blood pressure and high heart rate with a low grade fever. Ultrasound of the left lung showed a definite pneumonia, though the chest X-ray visualized that area poorly, missing the pneumonia completely. Having this diagnosis helped considerably in diagnosing sepsis and choosing the right antibiotic as well as ruling out a heart problem as the cause of the vital sign abnormalities.
3. A very old man came in from home with a recent history of bleeding from his urinary catheter due to pulling on it. The family was worried about blood clots obstructing the catheter. A very quick ultrasound reassured them that all was working as it should have been. The patient was saved having the catheter unnecessarily removed and replaced.
4. After a motorcycle wreck which caused rib fractures and a pneumothorax (popped lung) a patient had persistently low blood oxygen levels. She was also a smoker so the differential diagnosis included worsening pneumothorax or simply not breathing deeply due to pain. The little ultrasound detected no pneumothorax so treatment was aimed at improving breathing rather than considering placement of a chest tube. There are many other imaging procedures that could have made this determination, but none of them were instantly at hand when I needed the answer.

Bedside ultrasound is gaining popularity as a tool for internal medicine physicians and hospitalists, but is nowhere near being universally or even commonly a part of our practice. It does take training, practice and the little machine in the pocket or easily available on a cart in the clinic or hospital floor. Truly, these are obstacles, but totally worth tackling.

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.

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.

Zika virus, birth control and abortion

“CDC's Emergency Operations Center (EOC) was activated January 22, 2016, and moved to a level 1 activation—the highest level–on February 8, 2016. The EOC is the command center for monitoring and coordinating the emergency response to Zika, bringing together CDC scientists with expertise in arboviruses like Zika, reproductive health, birth defects and developmental disabilities, and travel health.”
—U.S. Centers for Disease Control and Prevention

“How many people have fallen in the city of Philadelphia by the pestilential infection is unknown to the Author–and he believes to the inhabitants of the same place, for the accounts are very different, as some mention four, others five, six, and even more than seven thousand: and the latter has been supposed to be not too large. Some have given the disorder one name, and others another, etc. It has been called a ‘genuine plague’; a ‘putrid malignant fever’, a ‘Yellow fever …’”
—Stearns, Samuel. An Account of the Terrible Effects of the Pestilential Infection in the City of Philadelphia; … [1793?]. From the Harvard U. Open Collections Program.

Tens of thousands of North Americans died of yellow fever during the first few hundred years of European colonization. The virus, spread by mosquitoes, was probably imported by African slavers: the wages of sin, one might say. In 1878, about 10% of the population of Memphis, Tenn., died of the disease, despite half the population having fled the city.

Even in 18th-century Philadelphia, physicians had recognized that the disease was related to shipping and that it only appeared in warm weather. It would be more than a hundred years until the link with mosquitoes was clear.

Aedes aegypti, the mosquito responsible for spreading the disease, also transmits other nasty viral infections such as dengue fever, chikungunya, and Zika virus.

Yellow fever probably made its Western Hemisphere debut in the Caribbean in the 17th century. Zika is a more recent import, appearing in Colombia and Brazil in 2015.

Mosquito-borne diseases are nothing new in the tropics, but in late 2015 an unusual birth defect was showing up in unprecedented numbers in the same areas as the Zika outbreak. Infants born with microcephaly are immediately recognizable, with misshapen heads and often brain damage.

Since the association was noticed, it has become increasingly likely that Zika infection during pregnancy can cause microcephaly. We're also learning more about the virus and its transmission; for example, that men can transmit it to women sexually.

But mosquito bites will likely continue to be the main way people become infected. For most people, the infection is either mild or not noticed at all. But the implications for pregnancy are enormous. And Zika is probably heading our way.

Take a look at the map in the New York Times article linked above. Then take a look at these from FiveThirtyEight. The areas most at risk if Zika hits the U.S. have some of the most restrictive abortion laws in the country. Given that Americans are still fighting for basic access to birth control, things are likely to get messy.

I've already seen dozens of patients with questions about Zika virus and travel (I counsel them per CDC recommendations to avoid pregnancy when traveling to affected areas). What happens when it becomes less academic?

Women who contract Zika while pregnant may wish to have abortions. How many would choose this is of course unknown, but we have some serious work to do, and quickly. We need to focus on mosquito control now, as the season is upon us. We need to make sure that women in areas likely to be affected by Zika have information about the disease and access to birth control, and, if desired, abortion.

We like to think that tropical diseases are gone from the U.S., but as West Nile Virus and other outbreaks have taught us, we are 1 shipment of old tires away from an outbreak. We need to prepare for the public health, medical and societal problems that the latest mosquito-borne disease brings with it.

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog at Forbes. His blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.
Friday, May 20, 2016

Weight loss breakthrough melts pounds off!

What's all this chatter I hear about how hard it is to lose weight? Relax. Obesity has finally been conquered. Those stubborn extra pounds that you've been stuck with will soon melt faster than a Popsicle on a steamy summer day. Although I am a practicing gastroenterologist who deals with nutritional issues routinely, I did not learn of this breakthrough in my medical journals or from experts in the field. I learned it just by listening to the radio.

I'm in the car several times a day, so I get my share of radio time. Not a day passes that I don't hear an ad for some kind of fat-busting pill or potion. The products are different but the pitch is always the same.
• Rapid weight loss
• No excercise
• No work or effort. Pound magically disappear

This seductive pitch is followed by testimonials from smiling “customers” posing on the beach who corroborate the amazing result. Their script usually includes: ‘I've tried everything and nothing works. When I heard about (insert product name), I was skeptical, but I've dropped 20 pounds and I'm eating more than ever!’

Then, viewers will see the before and after photos. The “before” shot is a grainy black and white photo with bad hair and a scowling expression. You know what the “after” shot looks like.

Then the announcer returns and cautions viewers that this product should only be taken for serious weight loss because it is “extremely potent.” Then, we will hear the incredibly clever tag line, “The only thing you have to lose is weight!”

As the ad concludes, a disclaimer is read at a speed faster than the human ear can process. I can barely pick out the phrase, “Results may vary.” I think we all know what that means.

Losing weight is tough work, as folks who have been battling against their bathroom scales can attest. The weight loss journey should be regarded as a slow marathon jog, not a high speed sprint. If losing weight were easy, then we'd all be thin.

But, it can be done. We all know people who cracked the code against obesity and trimmed down. How did they do it? What are their secrets?

Here are some of the lessons I have learned from them after a quarter century of medical practice.
• Losing weight is a mental and psychological process. Don't try to lose an ounce until you have made a strong mental commitment to the effort.
• Understand why you eat excessively. It's usually not from hunger. Understanding “why” will help you plan an effective strategy. For example, if you reach for food when you are stressed, then exploring stress reduction options will be a key component of your plan.
• Avoid gimmicks. They don't work. There's no quick fix here.
• Set modest weight loss goals and try to achieve them. If you intend to lose 2 lbs. per month, keep to this level. Don't overshoot; stay at a steady pace.
• Make dietary changes that you can live with forever. This is why gimmicks fail and nearly these folks regain the weight after experiencing initial rapid weight loss.
• Have a friend or family member to serve as your coach and cheerleader.
• You're not perfect. Don't hold yourself up to an infallible standard. Backsliding is not failure, it's human.

Physicians can help here, but we can't do the work for you. We can share with you the secrets of successful patients and we will do our best to make you one of them. Talk to your doctor. You have nothing to lose except …

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, May 19, 2016

Noncompliant patient-centeredness

I was talking with a few friends not long ago. Our conversation somehow got to the issue of authority, and what exactly respect for authority looks like. One of them, trying to make a point, turned to me and asked: “So you surely deal with people who don't listen to what you have to say. What do you do when your patients don't take the medications you prescribe?”

I think he was expecting me to be like the movie superhero character Mr. Furious and lash out against the patients who don't give proper respect for my authority. Most people have heard how irritated many doctors get when patients are non-compliant.

“Well,” I said, hesitating, “I guess I just ask them why they aren't taking them. There's got to be a reason for it, and I try to figure out why. It could be that the prescription costs too much; it could be that they are afraid of side effects; it could be that they heard something bad, or have some other bias against the medication for a reason I don't know; or it could be that they just don't understand why I think they should be on it in the first place.”

I totally wrecked his point, which made me glad because I didn't agree with it anyhow.

Since I am in the midst of a series of posts on patient-centeredness in health care, I need to take a quick (1,200-ish word) detour to an important related question: What happens when the patient doesn't cooperate? What does patient-centered care look like with non-compliant patients?

If you look up the word “compliance” in a thesaurus, the first synonym (at least in my thesaurus) is “obedience to.” This implies that non-compliant patients are, at least to some degree, equivalent to disobedient patients. This is borne out by the reaction many patients seem to expect of me when they “confess” they haven't taken prescribed medications: they look guilty, like they are expecting to be scolded. I guess scolding is what they've had in the past. Certainly hearing my colleagues complain about “those non-compliant patients,” I am not shocked that they scold their patients. It's as if the patient is not taking their medication with the express intent of irritating their doctor.

But this is a very doctor-centered view of things, not patient-centered. It assumes the doctor is the one who should be in control, and the patient's job is to “obey” what they've been told. It is a “prescriptive” type of healthcare, telling people what they should do. Doctors, after all, give “orders” for things, and the Rx on our prescriptions translates to “take thou.” We are the captains of the HMS Health Care, aren't we?

Perhaps this was the case when we held on to our “special knowledge” that others had little access to. Before the Internet, doctors were often the only source of medical information. People could go to the library and look things up, but most didn't take the time to do so, and there was still an air of awe given to doctors, who should never be questioned. Things have changed. Now all of the information I've got and knowledge I gained in my training and during my practice is available to everyone any time. Sure, people lack the context in which to use much of that information, but they can (and usually do) check their medical questions with Dr. Google.

This changes the whole dynamic of the relationship between doctor and patient. Many would say this is for the worse, but I disagree. My father has recently (as I've documented) been going through significant problems with his back. While it's my normal practice to avoid being a meddler in the care my family gets, I've had significant cause over the past six months to worry over that care in respect to Dad's back. By my urging, my parents (who grew up in the age of the high priesthood of doctors) have asked far more questions and have gotten better care as a consequence. “Yeah, but you're a doctor,” some might argue. So then are only doctors able to question care they (or their loved ones) are getting?

No, we should welcome questions from our patients, as they may just point us in a direction we hadn't considered. Since I've been more engaged with my patients in this practice, I have seen them open up to me much more about things because they perceive that what they say matters to me. I respect what they have to say about things, so they talk to me and don't hold back on their fears or concerns. This means that people are much less scared to talk to me about things, much more likely to confess their alcoholism, their depression, or their concerns about medications they are taking. All of these things allow me to give better care.

So what does patient-centered care look like in a world where the patient is a participant? Here are the rules I follow:
• The patient always deserves my respect, and should always perceive that respect. It's not enough to respect them, I've got to show that I do.
• It's their body, not mine. I can think it makes sense to get a surgery or take a medication, but they are the ones who have to get cut on or put the foreign substance in their body. I have to approach them with this in mind, asking about their fears and concerns, and not assuming the fact that I prescribe or recommend something that they will not question it.
• I may know more about medicine than they do, but they know more about their own bodies. There is an old saying in medicine, “the patient will always tell you what is wrong with them.” In other words, it is our job to listen, to ask questions, and to discuss things with them so that we can know what is going on. Many docs are far too quick to disbelieve symptoms the patient reports, and so many patients are afraid to tell of symptoms that “don't make sense.” This can lead to misdiagnosis.
• It's more important to get it right than to be right. If the patient comes up with the diagnosis then hooray. I don't care how we come up with it. Who cares if they looked it up on Google. I look up my non-medical problems on Google. Should plumbers, electricians, or geologists be mad at me when I look up information in their areas? I could care less. It's my pipes, my wires, and my … rocks.
• I want my patients taking responsibility for their health. As I said before, what happens between appointments is far more important than what happens in them. This means that my job is now one of teacher, interpreter, and encourager. If I can't explain why they need a medication, they shouldn't take it. If they have questions, fears, or concerns, I want to hear about them. Most of all, I don't want people worrying about being scolded when they come to my office. I'm not their mom.
• In the end, it's their choice. If after explaining, listening, educating, and even warning, people don't follow my instructions, I'm OK with that. My job is to let them know the risk of their choices. Once I've done my part, I don't lose any sleep about their choices.

As it stands, I feel my patients are quite compliant with what I recommend. They comply as long as I've done my side of the agreement, and they tell me if they don't do as I recommend. I wish other docs would lighten up and stop thinking we are in the Marcus Welby world of prescriptive medicine.

We aren't, thank goodness.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

Evidence and clinical judgment should complement each other

The term evidence-based medicine (EBM) provokes strong feelings from its proponents and its skeptics. I spent a full day recently in discussions about EBM. As the day proceeded I understood that evidence is wonderful when it fits the clinical question, but that too often the clinical question does not, and probably will not, have adequate evidence.

We have great evidence for some clinical questions. We all know that angiotension-converting enzyme inhibitors decrease mortality in patients having systolic dysfunction. We know that antibiotics help a variety of documented infections. We know which biologically active disease-modifying anti-rheumatic drugs improve the course of rheumatoid arthritis. We know that home oxygen decreases mortality in chronic hypoxic patients.

But how many clinical questions lack such specificity. My recent clinical passion, Lemierre syndrome, has no evidence for prevention or treatment. Yet we must make decisions about empiric antibiotics for severe sore throats in adolescents and young adults, and we must choose antibiotics in a patient diagnosed with the syndrome. We do not have, and likely will not have any randomized, controlled trials to guide our management. Rather we must use clinical judgment.

Believing in EBM does not and should not eschew faith in clinical judgment. Many clinical situations do require judgment.

Even if one believes in EBM, controversies among guidelines must give one pause. These likely occur because differing guideline committees have differing priorities and values. Data are not hard cold facts that we can always apply to our patients. Rather we must filter data through a screen of patient preferences, co-morbidities and social concerns (including money).

Medicine is a challenging career, because we must always meld our scientific knowledge with our art. Yes, the art of medicine and the science of medicine are not, and should not be considered separate entities. Every clinical decision must relate to the patient's context. When we have performance measures that do not consider those contexts, then the measurement developers are actually impacting our decision making, and often in a negative manner.

Clinical medicine is difficult. We oversimplify medicine when we think that rules can always substitute for judgment. This is our conundrum. When the evidence and the patient conflict we physicians have unease, especially when someone is judging our decision making without understand the underlying patient context.

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.
Wednesday, May 18, 2016

Calling the doctor after hours

Of course, patients are entitled to medical care around the clock. You would not expect to show up at 2:00 a.m. at an emergency room to find a “Closed” sign. If you are having chest pain on a weekend, and you call your doctor's office, you should expect a prompt response from a living and breathing medical doctor. Patients are aware that when they call the doctor at night, that they are unlikely to reach their own doctor. Similarly, when a patient is admitted to the hospital, they will likely be attended to by a hospitalist, not the primary care physician. Such is the reality of medical practice today.

Here are 3 types of after hour calls that merit mentioning.
1. One of my partner's patients calls me because the diarrhea is still not better and it's been more than 3 months. While I completely understand the frustrated patient's rationale for calling, there's not much I can do in these circumstances. It is generally not helpful to call a doctor at night to discuss chronic medical complaints, as you will likely not reach your own physician. For example, if you have been having nausea for months, and have had several diagnostic tests and tried different medications, it is doubtful that a covering physician on the phone at night who does not know you will crack the case.
2. The radiology department calls me at night to give a reading. Here's how this works when one of my partner's patients undergoes an evening radiologic test. ”Dr. Kirsch. a patient you have never heard of who left the hospital a half hour ago had a CAT scan of the abdomen. The radiologist suspects mild diverticulitis. Good luck, doctor and have a nice evening!” What this means, of course, is that the radiology department has “checked off a box” that I have been notified and is now in the clear. It is now my responsibility at 11:00 p.m. to sort through this. When I call the patient and can't reach him, how well do you think I sleep that night? I don't have a solution here, but clearly, this is not ideal medical care.
3. A hospital nurse calls me at night to approve a patient's discharge. This is always a killer. It's generally 1 of my partner's patients whom I have never seen. He may have had a complicated hospital course that involved multiple consultants. There is an extensive medication list. The patient still has stomach pain, which the medical team can't explain. If I give the nurse the green light on sending the patient home, then I am accepting full responsibility for this decision even though I have never laid a hand on him. How you would suggest I respond to the nurse in this situation?

Yes, our practice is available to our patients at every hour. But, some hours are more equal than others. It's challenging enough to take care of patients we know well. How can we take care of patients we have never seen?

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.

Diet, deafness, and the drums of war

A commentary just out in JAMA says many reasonable things about diet and health. The author notes that the overall low quality of the prevailing American diet is an anchor on life expectancy itself. Amen to that. No, multicolored marshmallows are NOT part of a (sane) complete breakfast. Really.

The commentary begins with, and was apparently provoked by, new Centers for Disease Control and Prevention data suggesting that age-adjusted mortality rates for major diet and lifestyle-related diseases ticked up in 2015. The author and I agree: This is ominous.

To be clear, we have known for a long time that lifestyle practices in our culture militate against the full measure of both longevity, and vitality. We heard about the “actual causes of death in the United States,” also in JAMA, all the way back in 1993. We've had plenty of time, every opportunity, and ample reason to do more than count the cost.

We have known as well, and also for years, that reversing the lifestyle practices that conspire against lifespan and health span alike, tobacco, poor diet, lack of physical activity to name only the top 3, works just as hoped. Eating well and being active is reliably, if imperfectly, associated with lasting weight control, and when those 4 factors are combined, not smoking, eating well, being active, and maintaining a healthy weight, they dial down the risk for all major chronic disease by a stunning 80%.

We have seen this verified by the diverse yet kindred cultures of the Blue Zones, and the blessings of longevity and vitality they confer. We have seen this demonstrated in population-wide interventions across a generational expanse. We have seen this demonstrated in randomized controlled trials. A repetitive drumbeat of publications in the peer-reviewed literature has rapped out this message for years with remarkable, nearly metronomic consistency.

These are, or should be, drums of war. The enemy, a culture that willfully places profit ahead of the life expectancy of your daughter, and my son, is inside the gates. If such a clear and omnipresent menace does not inspire our passions, and unity of purpose, it's hard to imagine what would. The skin in this game is that of the people we love most in the world. What are we waiting for?

The commentary author and I, as best I can tell, agree about all this. But we do seem to disagree about what will help us, at long last, overcome our apparent deafness to the invitation of those drums.

My answer is: stop arguing long enough to hear them. We have missed the common invitation of the drums for decades in the persistent noise of our perpetual discord.

I can't help but think in terms of an analogy. We might imagine we are actual soldiers, and I am from New York, say, and you are from Chicago. We argue over which of the two is the greater city, and miss the warning hiss of artillery, incoming. We might instead be Americans together, acknowledge the greatness of both cities, and take the next hill.

In the world of diet, details are the stuff of such dangerous diversion. There is a veritable cottage industry these days in pointing out the relative advantages of diets higher in total fat. Such arguments, like the case for Chicago over New York or vice versa, are invariably selective, reliably omitting any study that shows an advantage in the other direction. The real-world evidence implies that macronutrient levels are effectively irrelevant. When cultures eat wholesome foods in sensible combinations, they do just fine whether their fat intake is high, or low.

Similarly, endless debate about the esoterica involved in the burning of calories tends to play out by the light of fires burning arguments of straw. Allegedly, those of us who maintain that calories do, in fact, count are oblivious to consideration of the quality of food choice. The JAMA commentary even implies that the 2015 Dietary Guidelines Advisory Committee went awry by noting the relevance of calories to weight, despite the explicit emphasis of their report on wholesome foods, not calorie counting, as the essential means to desired ends.

There is so far as I know no law obligating a choice between the importance of calorie quantity, and quality. To the contrary, we have abundant reason and have had such reason for longer than many may realize to respect the indelible links between the 2. One of the defining virtues of high “quality” food is that it tends to fill us up on fewer calories. One of the defining features of “junk” food, and intentionally so, is that … nobody can eat just 1.

Simple, wholesome, minimally processed or unprocessed foods tend to have many virtues, satiety among them. There is no need to make a choice between the quantity and quality of calories; eat high quality foods, and quantity tends to take care of itself, with at times astonishing benefit. Nor is there a need here to line up behind the banner of one macronutrient or another. People readily over-consume calories from high-sugar, fat-free sodas; we also readily over-consume French fries, which get their calories almost equally from fat and carbohydrate, or, for that matter, honey-roasted almonds, which get almost 75% of their calories from fat. What these items have in common is not macronutrient distribution, but processing in the service of … certainly not health.

In contrast, plain, unprocessed, high-fat nuts are very satiating. So are high-carb beans, and lentils, and apples for that matter. So are baked potatoes, naked and unadorned. Simplicity is the common theme here.

There's no need to choose this nutrient or that, quantity or quality and there's certainly no value in endless argument that forestalls collective action. Discord lends comfort only to the enemy. Ancel Keys no more meant, “eat Snackwells,” than Robert Atkins meant, “eat low-carb brownies.” Having seen both such variants on the follies of history, and others besides, the only question now is: do we learn from them and move on, or just keep repeating them?

There are, and there will long be, many unanswered questions about the particulars of nutrition. Good will surely come of plugging those gaps in our knowledge, but not from plugging our ears to all but the opinions we already own. Not if we squander the opportunities in what we already know between now and then. I am sure there are many interesting metrics as yet untallied that would allow for refined comparisons among the great cities in America. We don't need them to know that all such cities are on the common ground of this country.

John Donne warned us centuries ago about the common implications of the bell. It rings true today, and of drums as well.

The threat to life expectancy is present and more than sufficiently clear to give us common cause. The lives in question are those of our children, and grandchildren, establishing our common interest. We certainly have questions left to answer, but have enough answers already to protect our loved ones robustly.

But we do need to stop arguing long enough to hear, and heed that percussive taunt and rally to the common battle, in defense of our common ground.
Tuesday, May 17, 2016

What's up with people who are in the hospital a very long time?

I just finished reading a very delightful “A Piece of My Mind” essay in JAMA, The Journal of the American Medical Association. JAMA is primarily a research journal, filled with new scientific or semi-scientific studies and comments on those, plus reviews of the literature and editorials on science or politics. There are also letters and announcements and educational sections for doctors or patients, even poems, but the part I like to read all the way through is called “A Piece of My Mind.” These essays are almost always stories about something that has made a profound impression on the writer.

The most recent title was “A Place to Stay,” written by Benjamin Clark, an internist at the Yale New Haven Medical Center. He describes a patient who is stuck in the hospital probably for the rest of his life due to a medical condition whose treatment requires management that can't be done anywhere else. It's lovely, and true (even if the details are not, and I'm guessing they aren't) and I won't describe it more fully because it is available in full at the link.

It made me think about the vast diversity of patients I've known who have stayed in the hospital for way too long.

The “Piece of My Mind” story was about a well-educated and deeply lovable person with a bad disease that was in no way his fault. Most of the patients we end up taking care of for very long stretches are not this way. This sometimes makes them less appealing. Still, all of them are people with whom we become intimately familiar, knowing their families and their prospects as well as their everyday quirks, preferences and routines. We fuss and connive about how we might move them out of our hospitals and eventually, for most of them, this happens. They don't usually die with us.

During their stays we feel frustration and experience dread as we repeatedly fail to do our job as hospitalists, which is to get them better and get them out. As the days pass we adjust medication and perform diagnostic tests, consider and try new approaches and eventually manage expectations.

We feel that these cases are failures because we can't get the patient well as fast as we think we should. This is partly because of the ways hospitals are paid to take care of people. For decades we have been urged to reduce the number of days patients stay in the hospital. This started decades ago when healthcare costs were first starting to be alarming to payers, especially Medicare. Patients who remained in the hospital for many days often were getting complications, pneumonia, other hospital acquired infections, confusion, and these extra days were costing insurance companies and the government lots of money. Payment models were changed and we were paid flat amounts for a given diagnosis. Because of this, our hospital made more money if a patient was cured more quickly than expected. This can be good all around. Patients don't usually want to be in hospitals and often get sicker if they stay, and hospitals don't want to foot bills that are made larger by more days and more tests and treatments. This method of payment gave us financial incentives to cure patients rapidly. They also left us no room in our hearts or minds for the outliers who take a long time to be ready to leave.

Beside the patient in the “A Piece of My Mind” story, who are these patients?

We just discharged a patient who had been in our hospital for over a month. She had been heavy all of her life, but after having children her situation became dire. She had a gastric bypass and lost 100 pounds, which brought her down to a manageable 300 pounds. Job changes resulted in gaining most of that weight back, and then a divorce made her even less active as she turned to alcohol for comfort. She finally sought help when she was 600 pounds, couldn't get out of bed and was so swollen that half of her skin was oozing, some of it covered with infected wounds.

When she got to our emergency department it was difficult to maintain her oxygen level. She could barely breathe and was so heavy and weak that she could only just move her arms. Her chronically low oxygen levels had led to severe pulmonary hypertension and so much of her weight was retained fluid. We began the process of giving her diuretics to remove extra fluid, cleaning and dressing her wounds, using mechanical lifts to be able to lift the skirt of fat and fluid to care for the skin underneath.

She was horribly malnourished, since her diet was terrible and her gastric bypass made her unable to absorb nutrients well. She was depressed, with horrible self-esteem, and was surprised to learn that we thought this was a problem. Over the course of 5 weeks she was able to lose nearly 200 pounds of primarily water weight, with daily attention to replacement of rapidly depleted electrolytes. Physical therapy worked with her daily and by the time of discharge she could climb stairs and walk the halls alone. She will get further rehabilitation which should allow her to cook and bathe and even drive independently. During the 5 weeks we all got to know her well and discussing her success became a high point of all of our day. There was no point during those 5 weeks that she could have successfully left the hospital.

Another patient arrived with high fevers and back pain. He had been in recovery from heroin abuse but had relapsed. He had Staphylococcus aureus growing on 1 of his heart valves, and it had been throwing little infected blobs to his spine, his spleen and his kidneys. He was treated with the proper antibiotics, but ended up with abscesses in his brain, which made him confused and difficult to handle. He had a long-term central intravenous catheter (PICC line) that we placed in hopes that he might be able to get antibiotics as an outpatient, but his parade of misfortunes made it impossible for him to survive outside of an actual hospital and the temptation to inject heroin into his pristine PICC if he were on the outside made it unwise once he stabilized. Nursing homes do not like young drug addicts because they assume that they won't play well with their primarily ancient clientele. He needed at least 6 weeks of intravenous antibiotics. He was ours. No other options. After he stopped being a complete pain in the rear he was like a family member.

Who pays for all of these hospital days? It varies. In actual fact, we all do. Hospitals eat some of the costs and pass them on to other payers if they are to remain solvent. All of us who work, pay taxes, buy insurance or use medical services pay in some way.

So what do we do about patients like this, ones who can't go home? We struggle. We stew. We blame ourselves and them. Discharge planners shake their heads and make more telephone calls. We dread our daily visits in which there is nothing much to say that we haven't all said before. At our best we finally come to peace with the fact that these patients and their epic hospitalizations are part of what is real about our job and not just inconvenient outliers.

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.

Best practices, and when your doctor says no

The American College of Physicians and the Centers for Disease Control and Prevention give guidelines (known as high-value care advice) to physicians based on the best current scientific evidence. Physicians try to treat patients based on those guidelines even when patients want a different treatment. Here are three that create the most problems when physicians try to do the right thing.
No antibiotics for acute bronchitis. Acute bronchial bronchitis can last up to 6 weeks with a purulent or dry cough. It is one of the most common out-patient diagnoses we see. More than 15 excellent scientific studies show no benefit in treating with antibiotics and a trend toward adverse complications when antibiotics were used. All primary care physicians and emergency department physicians experience the constant request for Z-Pac throughout the winter. “It helped my friend, family, kid.” “It's the only thing that works for me.” It is hard to see a suffering patient who wants to be helped and resist the request. That is why 70% of patients with acute bronchial bronchitis get an antibiotic.
No antibiotics for pharyngitis unless testing positive for strep. Only 15% of acute sore throats are caused by bacterial infections. The remainder are viruses that do not respond to antibiotics.
No antibiotics for acute rhinosinusitis, aka sinusitis. More than 4.3 million adults are diagnosed with sinusitis annually and 80% receive antibiotics despite the fact that it is usually a self-limited illness caused by a virus, allergy, or irritant that causes inflammation in the tissue in the nose and sinus cavity. A bacterial cause usually lasts longer than 10 days and is associated with fever.

Doctors are often put between a rock and a hard place if they follow evidence-based guidelines. We want to please patient and help them, and when we don't, patient satisfaction scores go down. But some studies are showing that doctors who offer symptomatic relief and take the extra time to explain why antibiotics are not needed can still get good survey scores.

According to the Annals of Internal Medicine, reducing inappropriate antibiotic use will improve quality of care, decrease health care costs and preserve the effectiveness of antibiotics.

This post originally appeared at Everything Health. Toni Brayer, MD, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.
Monday, May 16, 2016

The dog in the fight

I came on as the attending on a Monday. An unexpected scheduling need had shifted my assignment from the outpatient clinic to the inpatient hospital service. By the time I joined the team, the month was nearly over and plans were mostly gelled. Consultants were following and things were rolling along as they often do. And during this week, the census was full and the patients were sick. Very sick.

Okay, so I come onto the scene as the Monday morning quarterback, literally. A new set of eyes who is looking at every case from the 30,000-foot view, first seeing the big picture and then trying to serially zoom in on the little picture parts. And this, this approach when I come into something where the ball is already in motion, is generally my approach. I observe and ask some questions. I make up my mind to be a skeptic and to not just go with what's already happening. Even though, most of the time, I am completely in agreement with the current plan.

Yup.

But sometimes when stepping in something happens. You realize that everyone involved has been so zoomed in that they've lost sight of that big picture. So you come strolling up and start firing off all your queries. They seem like obvious questions, actually. I know this because I've been there. The one who has been slugging it out for weeks on a sick patient only to have someone ask 1 or 2 things that make me wonder what the hell I've been doing all this time. That, or they point some very clear observation out that makes you inwardly cringe because it's the kind of thing you should have asked yourself a full week before.

Anyways. On Monday, that's where I was. And there was this one patient in particular that didn't seem to make perfect sense to me. I mean, it wasn't because the last attending wasn't awesome. It was more one of those things where the Monday morning quarterback had the advantage, you know?

So yeah. I look and I ask and I probe. And finally I resolve that we needed to shake up the game plan some. And by shake it up, I mostly meant that we needed to go harder as advocates.

Yes, that. Advocates.

So what does that mean? Well. To me, it's simple. What I do is close my eyes and picture myself as the very concerned mama-sister-wife-daughter-granddaughter-partner at the bedside. I push myself to let the patient matter to me as it would to that person. I pop in my mouth piece and shadow box in the corner. And then I go as hard as I can, as if that person's loved one is strapped on my back pleading with me to help.

Does that sound crazy? I know it probably does.

Okay, so let me explain what was going on without giving too much detail. Essentially, a lot of doctors were seeing this patient and weren't in full agreement. One said to do 1 thing which would require another one to do a procedure. But the procedure-doing doctor didn't feel so much like that was needed. Then, another consultant was somewhere in the middle. Maybe a procedure, maybe just more antibiotics. But see, for me? The main thing I saw was a patient who, despite all that, was still sick as stink. Which meant somebody somewhere was going to have to do something different than what we'd been doing.

Yeah.

And so. I strapped them to my back. The patient and the ones who love my patient the most. I fought with the zeal of a mama bear protecting her cubs. Called and spoke to attendings directly and asked some uncomfortable questions. Pushed my colleagues to be decisive and to also feel the sweet burden of caring like it is their loved one, too. And what I've found is that I work with some good, good people. These good, good people are very busy and often spread thin. But since they are good, good they are usually willing to slow down long enough to stick a foot in the way of the clinical inertia ball.

We all talked. And thought. Together. Someone pulled papers from the literature and others modified recommendations. The senior radiologists did more than just read the images; they re-read them with their experience in mind and the clinical context considered. And all of it felt right and good.

So what happened? Well. Slowly but surely, the patient started improving. But mostly, it felt more like we were on the same team, you know? Instead of just a bunch of stakeholders with our own prideful opinions, we were one big, bad team. Fighting the hell out of that disease and telling it that we weren't the ones to be effed with. Knowing that not only do we have a dog in the fight, we ARE the dog in the fight.

Yes. That.

And you know? It's not guaranteed that any of this will work. The patient could remain ill regardless of our earnest attempts and reroutes. But I like to remember 1 of Harry's quotes about losing a fight:

“I might not have won, but he knew I was there and I'm pretty sure he'd never want to fight me again.”

Ha.

Let me be clear: I am just as guilty as anyone else when it comes to all of this. I fall in love with a diagnosis or plan of care that I developed and can't see the forest for the trees. I also forget that my fifteen years at Grady has afforded me a voice that someone might listen to and entertain if I ask questions. I'm guilty of sometimes letting my exhaustion dampen my enthusiasm. Totally.

But then, like clockwork, in comes a Monday morning quarterback. A good, good colleague nudges me to do the right thing. To reexamine things with fresh eyes and to fight like my loved one depends upon it.

Does any of this even make sense? Probably not.

My point is this: There is a lot of stuff that just can't be learned in books. And this? This little shift in how we see ourselves as patient advocates is just one of them. I'm still learning. But 1 thing I can say for sure is this: I'm still trying, too.

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.