Thursday, June 30, 2016

Naturopaths: fake doctors in white coats?

here is a widely held belief that there is more than 1 kind of medical system. We hear about “mainstream” medicine, traditional Chinese medicine, chiropractic, Ayurvedic, naturopathic medicine. But what is most important to anyone interested in their health is whether or not something works.

The medical system most of us think of when we see our doctors is different from the others in that it is “science-based,” that is it relies on evidence derived from scientific studies for its practices. As a specialist in internal medicine, when I make a recommendation about someone's blood pressure or diabetes, I am relying on decades of scientific studies to guide me in helping my patient.

Sometimes medicine is simple common sense: eat healthy, exercise. Sometimes science turns common sense on its head. A few decades back, patients who had heart attacks were routinely given lidocaine, a drug that prevented the heart rhythm problems seen immediately after the attack. The drug clearly prevented these dangerous rhythms; you could see it right there on the heart monitor. Then someone decided to actually study the practice, and found that patients treated with lidocaine actually fared much worse than those who didn't get the drug. The practice was dropped.

This is the heart of modern medical science: We test out our ideas, and we don't rely only on common sense and things that sound plausible. Most doctors accept that there is no “alternative” medicine; there is only “medicine” and everything else. Any “alternative” medicine that passes scientific muster is adopted and becomes simply “medicine.”

Still, humans are pattern-recognizing machines, always seeking logical explanations for what we observe. For millennia, people have observed what does and does not help us when we are sick. Some of our ancestors found that willow bark helped with pain and fever. Some found that eating peyote cactus gave them visions. Nature is full of medical treasures.

But these treasures, like our lidocaine example, are not just there for the taking. They must be tested, refined, understood and used with caution. Sure, black mamba venom contains a natural painkiller that may be as powerful as morphine. But I'm not about to let 1 bite me when I have a headache.

Which brings us to a popular “system” of alternative medicine: naturopathy. From the headline, you know my bias here: naturopathy is not medicine or science, but more akin to religion. In Colorado and Michigan bills are under consideration to allow naturopaths to have many of the same privileges as doctors. This would be a horrible mistake.

First, we'll see what privileges Michigan wants to give naturopaths, and then why this would be a horrible, dangerous, no-good idea.

Michigan HB 4531 proposes that naturopaths can call themselves “doctor” or “physician” (modified by “naturopathic”), and would allow them to diagnose and treat medical conditions (in other words, be a real doctor).

The bill goes on to list some typical naturopathic procedures that would be allowed in the state, including long-disproved quackery such as homeopathy, hydrotherapy, and electromagnetic therapy (none of which have a consistent definition, but as they are generally understood, make no scientific sense and have been tested and found to be useless or dangerous).

One of my favorite lines from the bill frankly scares me. It would allow naturopaths to:


These fake doctors, without any of the experience or education of real doctors, want the state of Michigan to legally enable them to shove things up your rear end or vagina. That's not good. Equally concerning is their being allowed to prescribe durable medical equipment such as wheelchairs, hospital beds, etc. This is a business neck-deep in fraud, a constant thorn in Medicare's paw. To open it up to more practitioners, especially those without proper training, will needlessly increase costs.

The real problem, though, is that naturopaths are not real doctors. To the extent that they have a coherent belief system (and I'm not conceding that), it is based on outdated ideas about human health. Their official statements try to set them apart from other doctors by claiming to work more “naturally,” whatever that may mean.

The American Association of Naturopathic Physicians describes simply (and damningly) what they are:

Naturopathic medicine is a distinct primary health care profession, emphasizing prevention, treatment, and optimal health through the use of therapeutic methods and substances that encourage individuals' inherent self-healing process. The practice of naturopathic medicine includes modern and traditional, scientific, and empirical methods.

I'm a medical doctor who specializes in internal medicine. That means my work centers on the prevention and treatment of diseases in adults. I use “therapeutic methods and substances that encourage individuals' self-healing,” same as them. Except the way I do it is based on reality and scientific proof. For example, if I prescribe diet and exercise changes to someone at risk for heart disease, and they have a heart attack anyway, 1of the medications I will prescribe them will be an ACEinhibitor. This class of medications helps the heart rebuild and heal itself properly, rather than in a haphazard way that may lead to further damage. Naturopaths can't do that. It's not part of their training.

What naturopathy claims to do is exactly what I am already doing, with 1 exception: what I do is based on over 100 years of science. Their practices are based on imagination. They do not have the proper education or experience to practice anything called “medicine.” In a just world, they wouldn't be licensed but charged with battery.

It would be lovely if we could simply make up medical traditions that somehow magically work and don't have any side effects. We can't. Nature is messy. The only thing that allows us to hold onto the reins at all is science. Remember when you had polio? No? Good. Thank a real scientist and doctor for inventing the vaccine. Does your kid have a tracheotomy scar from epiglottitis? No? Thank a public health official for following the evidence and the science and advising you give your child the Hib vaccine.

Naturopaths are glorified faith-healers trying to put a scientific patina on myth, and worse, legislate trust in their abilities.

They pose no threat to my economic well-being. I'm busy and always will be. But they are a threat to public health. Let's use some sense and not allow them to create more business for me as I clean up the messes they've inflicted on their victims.

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.
Wednesday, June 29, 2016

How the salt story shakes out

From what I know courtesy of friends and colleagues who work there, it's always busy at the FDA. Still, the agency seems to be in the midst of a particular flurry of activity. Even if the activity has not picked up, the profile of it certainly has. In quick succession of late, the FDA has made headlines for updating food labels, revisiting the definition of “healthy,” and now, shaking up the salty status quo.

Specifically, the FDA has issued “draft voluntary targets for reducing sodium in commercially processed and prepared food both in the short-term (2 year) and over the long-term (10 year).” We might constructively pause and reflect on the particulars of that phrasing. First, the current guidance is just a “draft,” and has been put on display to invite public commentary. Thus, nothing yet has been finalized.

Second, the targets, even once they become final and official, are “voluntary.” The FDA in this instance is talking about guidance, not regulation. Players in the food service space still get to decide if they want to play by these rules or not. There is no proposed penalty for opting out, other than the potential rebuke of customers. In effect, FDA guidelines give consumers a standard by which to judge industry practice.

And third, even once final and official, the voluntary targets are delayed and in phases. Nothing happens right away, and when something happens, it happens small. The targets thought suitable for public health don't really kick in for a decade.

All of this to say that objections to the FDA action, of which there are many, are phenomenally out of proportion to the action itself. I side with those celebrating the FDA's announcement, but frankly, the basis for celebration is slim. The basis for protest is slimmer still. There simply isn't any drama here.

As for why I side with the FDA, and not with the protesters, who happen to include some colleagues and even friends, it's all but self-evident with cursory attention to the real world. The FDA is attempting to fix what's broken; the protesters are fretting about a problem that not only doesn't exist, but is far from likely to exist. I'll expound, but first note that this is a position I have mapped out before, more than once, and more than twice.

Until fairly recently, the public health community would likely have been universal in its support of FDA's efforts to constrain the grains of salt populating processed food. While not everyone has agreed with the contention that excess sodium, resulting in high blood pressure, leading in turn to strokes, implicates sodium in 150,000 premature deaths in the U.S. each year, pretty much everyone was comfortable with the idea that we eat too much, and too much is generally bad for us in a variety of ways.

What happened recently is that some studies began to reveal the potential harms of too little sodium ingestion. The most notable paper on this topic was a review in the Lancet that garnered high-profile media attention.

The literature suggesting potential harms of overzealous sodium reduction has spawned a secondary literature warning against efforts to reduce sodium intake at all. In at least one case, the argument was made that attention to sodium would divert attention from sugar. With regard to that last one, I certainly differ. I think attention to any one nutrient at a time has diverted attention from the overall wholesomeness of foods, and the quality of the diet, and that's where the action really is. But that's no reason to ignore the relevant effects of any given nutrient for favor of another, but rather a mandate to address both, along with all the others, holistically.

In any event, there is now a large volume of noise arguing against sodium reduction, and many in that chorus are now protesting the FDA action. The Lancet paper is among those invoked to justify this position, but that pushes the envelope to the tearing point. Here is the conclusion the authors of that paper reached: “lowering sodium intake is best targeted at populations with hypertension who consume high sodium diets.”

Well, pretty much all Americans consume high-sodium diets. And, there are about 70 million hypertensives in the United States now. That's a figure that bears repeating: 70 million.

But that's just now. A study recently told us that half the population of California is prediabetic. Why California? Not because the problem is worse there than elsewhere, but because the data are better. This is the situation throughout the U.S. There are many liabilities attached to prediabetes, and hypertension is frequently in that mix.

So, while “only” a third of adults in the U.S. are hypertensive now, we have portents of that rising to half. We also, by the way, have ever more prehypertension and hypertension, and prediabetes and diabetes, for that matter, in children.

OK, but since not EVERYONE is hypertensive, shouldn't sodium reduction efforts just be directed to the tens of millions who are? Maybe, except that doesn't work. Given the copious quantities of sodium in most commercially prepared food,experts have long concluded that the only effective strategy for meaningful sodium reduction is to change the food supply.

But won't the FDA efforts to do just that impose the risk of too little sodium on the other half of the population? Hardly. Leaving aside the improbability of an action catalogued as draft, voluntary, and delayed having the impact to hurt anyone, the crux of the matter here is dose.

While there has long been concern about the potential harms of too little sodium (no, it's not new), and rebuttal to that concern for just as long, that concern is most acute for sodium intake well below 2000mg per day, and only begins at intake below 3000mg per day. The average intake in the U.S. among adults is 3400mg per day. Stated differently, Americans would have to reduce mean sodium intake by about 12% before hitting even the top end of the range where even a small minority of researchers see even the start of any basis for concern.

For what it's worth, I find it highly implausible that harms would result from sodium reduction well below 3000mg, and not because of clinical trials. Rather, we already know that many populations around the world, including some of the healthiest, routinely consume dramatically less sodium than we do, simply because they don't eat processed foods. We also know, from the best papers by the best experts, that our native, Paleolithic intake was even more dramatically lower than the current norm. The likelihood of being harmed by a sodium intake commensurate with our native adaptations would be hard to explain.

And lastly, there is always recourse to a salt shaker. Tepid as it is, the FDA statement says nothing at all about obligating anyone to reduce their sodium intake. Rather, this is an attempt to remove the virtual obligation we have now to over-consume sodium. In a world where commercially prepared food is routinely lower in salt than it is now, there is at least the chance of getting down to reasonable intake levels. Those concerned about getting too little on the basis of idle anxiety, or their medical status and physician advice, can shake it on as the spirit moves them.

That, then, is how this all shakes out for me. Sodium reduction to reasonable levels is uncontroversially good for those with hypertension, and that is already a third of U.S. adults, and rising. It is probably good for everyone else, too, since current intake is far above reasonable. The risks of too little sodium in the context of the horribly sorry, typical American diet are both theoretical, and rather far-fetched. The risks of too much are clear, and all but omnipresent.

You are no more obligated to wait for the FDA's draft, voluntary, and deferred guidance to kick in than you are to reduce your personal sodium intake if disinclined. Eat less processed, more wholesome foods right now- and fix your sodium intake by looking right past salt to the character of your diet. We have long had abundant evidence that people who do just that move from health risk, not into it.

Risks of too little sodium are a valid concern only at levels massively below mean intake in the U.S., while the harms of excess are with us right now. The priority, obviously, is fixing what's broken. Kudos to the FDA. Their action on salt does not yet have traction in the real world, but it does pertain to 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 LinkedIn page.
Tuesday, June 28, 2016

Medical error--the third leading cause of death, or not nearly so simple?

Splashed over news feeds this last week is a reference to an article published last week in BMJ (formerly known as the British Medical Journal) that states that “medical error [is] the third leading cause of death in the United States.”

What is this article actually about?

The new article refers to research done over the last 2 decades, and most recently an article by NASA toxicologist and patient safety advocate John T. James PhD in the Journal of Patient Safety in 2013. Dr. James evaluated 4 previous studies and estimated that 400,000 people, approximately, die yearly in the U.S. of conditions that were either caused by or, more often, made worse by medical error.

That article, too, was met by outrage and was widely quoted and misinterpreted. I think hardly anybody actually read the article. Headlines read “Deaths by Medical Mistakes Claim the Lives of 400,000 People Each Year.”

No new data, but a new way to think about it:

As far as I can tell from reading this most recent article, in BMJ, there is no new data. There is just the realization that if this many people are dying of medical error, it should be showing up somehow as a major cause of death, just like heart disease or cancer. The reason that it is not is because the questions that are asked on death certificates do not include anything about whether medical error had occurred. The article, quite correctly, states that this should be documented. Documenting this is the first step toward making major changes that will keep patients safer.

So what did the original article actually say?

When Dr. James' article came out in 2013, I read it and wrote a blog commenting on the study, its methods and what medical error looks like from my experience. Dr. James kindly responded in a comment, “Thank you for putting my JPS study in an appropriate perspective. Some folks like to sensationalize the results as if these patients die only because of a medical error, and that is not what I wrote or intended.”

The blog from 2013 was actually pretty good and completely relevant to the recent news release. You may want to read it. It does put the data into perspective.

Patient safety is very, very important!

I am glad that this recent article has grabbed international attention for patient safety. What we read in USA Today and the rest of the popular press is not an accurate depiction of the problem, but the problem remains very real. Medical error is contributing to the deaths of hundreds of thousands of patients yearly. We, as physicians and health care providers, are trusted with the lives of vulnerable people, and it is up to us to build processes that allow our good intentions to be translated into good care.

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.
Monday, June 27, 2016

Measuring physician quality: bully or just plain bull

Patients are amazing creatures. The current breed is hyperinformed on medical information and has an ever expanding reservoir of physician data to trove through. I'm not just referring to physician reviews on Angie's list. Soon, the public will be encouraged to review our success and failure rates with respect to medical treatments, how much cash the drug companies grease us with, all disciplinary actions, comparison with peers, complication rates, medical malpractice entanglements and how much Medicare reimbursement we have received.

There will be published quality benchmarks on physicians so that the public can see how their physicians scored on these various quality measurements. I have opined throughout this blog that I feel that these measurements are tantamount to taurine excrement. Sadly, reimbursement will be tied to these results with physicians who don't rate high enough having some of their income confiscated. Physicians who don't make the grade may game the system to achieve higher grades, which has nothing to do with true medical quality. Is that what our patients want and deserve?

I was poised to begin a colonoscopy on an informed woman who asked me what my ADR was. I will presume that readers are not aware of what this means. Most physicians are likely also ignorant of what these letters stand for. In fact, I'll bet a decent percentage of gastroenterologists are clueless here as well. The ADR refers to the Adenoma Detection Rate, which is one of the silly statistics that “experts” feel separate skilled colonoscopists from pretenders. Adenomas are polyps which are precursors to colon cancer and are the target lesion for screening colonoscopies. When you consent to undergo a colonic delight at age 50, your gastroenterologist is seeking out adenomas, removing them before they can morph into a cancerous condition.

“Experts” advise that competent gastroenterologists should have an ADR of 25% in males and 15% in females who are undergoing screening colonoscopies. Lower rates, they claim, suggest sloppy or rushed examinations. Now, some colonoscopists are removing every pimple they find to make sure they will surpass these thresholds. Does this sound like good medicine?

Remember, colon polyps are surrogate markers. The true objective of colonoscopy is to prevent cancer, not finding small benign polyps. A patient should be more interested to know if their gastroenterologist prevents colon cancer, which is not that easy to measure. In contrast, measuring the ADR is simple, so it is used as a substitute for colon cancer prevention because it is so easy to do. Similarly, the statin drug companies boast about their cholesterol lowering properties, which is easy to measure. Cholesterol levels are also surrogate markers for what we should really care about, heart attacks and strokes, events that can't be studied and measured as easily as simple blood test results. A surrogate marker “benefit” may not lead to the desired medical outcome, despite claims that it will.

My nurse assured the inquisitive woman on the gurney that my ADR was above threshold. Am I a high quality gastroenterologist? I must be. I've got ADR mojo. Let's give a shout out to the government and the insurance companies for adopting the ADR standard. Can we agree that it's Another Dumb Regulation?

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.

The 28-year-old MBA telling an experienced physician where to round first

The last couple of decades have seen a dramatic shift of power and clout away from individual physicians and towards administrators and the business side of health care. In many ways, physicians have nobody but themselves to blame collectively—because for any large and respected group of people to surrender so much autonomy so quickly, a lack of strong leadership must always be a factor.

So many different reasons for this sea change can be discussed, but the consequences are very palpable. To name but a few, we've seen the relentless push towards consolidation and mass employment of physicians, a rise in mandates and bureaucratic requirements, and a general explosion in the number of administrative folk while the number of physicians appears to be shrinking! Then there's the more subtle changes that the medical profession has also allowed to happen right under their noses, such as the refusal of many in the hierarchy to even call doctors by their true job title any more—instead labeling them only as “providers” (a subject I've written about including in this article and an open letter to the AMA and all State Medical Boards).

Speaking as someone who maintains a large network of physician friends and colleagues across the country, some of the stories I've heard about what happens nowadays are astonishing. Fortunately, after a few bad experiences, I'm now part of an organization where the relationship between physicians and administrators is probably as good as it can be. But from what I see, this is a rarity.

I relate 1 recent story in particular. I have a very close friend in the Midwest who is quite a brilliant doctor. He went to a top U.S. medical school and got stellar USMLE scores. I've known him for years and am proud to have trained with him. He is sub-specialty board certified, but decided to practice hospital medicine. He told me that his group, which is essentially run by non-clinicians, is completely (and unsurprisingly) focused on the bottom line only. Administrators aggressively monitor their physicians' whereabouts and try to review all of their patient interactions (mostly how it pertains to billing).

Anyway, to cut a long story short, he told me that the administration for some reason or another wanted him to round first on a particular floor. He didn't think it was the right thing to do for patient care (apparently another floor frequently had patients who required closer and more immediate attention), and it culminated in him basically being scolded by a 28-year-old MBA who informed him that he had to round on that particular floor first—like it or not. Needless to say, he didn't take too kindly to this interaction and that particular experience persuaded him that the time was right to move on.

This story bothered me on multiple different levels, as I'm sure it would any self-respecting physician. First and foremost, how did the medical profession surrender so much to the business of medicine that a situation like this could happen? I wonder what our more esteemed colleagues in perhaps their 50s and 60s would have done twenty years ago if a 28-year-old MBA had dared tell them where to round first? Secondly, how did that young man feel so empowered to scold a highly qualified physician and feel so convinced that “he was the boss”? And thirdly, perhaps most worryingly, is this the future of medicine in the United States? If so, is there any way that physicians can wrestle back a bit of control over their own profession to avoid situations like this becoming the norm? Because if we can't, and the practice of medicine is no longer led by doctors, it's not only the doctors who lose. Patients will too.

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.
Thursday, June 23, 2016

Medical blogger attacks respected cancer doctor

When it comes to explaining medical science and exposing dangerous medical scams and practices, the Science-Based Medicine blog is tops (full disclosure: I was one of the early bloggers at the site and I'm personally a fan). The team of bloggers are well-recognized doctors, researchers and communicators, many from top institutions. Dr. David Gorski, the managing editor, is a highly respected breast cancer surgeon and researcher at Karmanos Cancer Center, a nationally recognized NIH Comprehensive Cancer Center. Steve Novella, the founder of the blog, is a Yale neurologist, well-known for helping educate the public and other doctors about science and medicine.

Naturally, this puts these folks in the crosshairs from time to time. I'm not nearly as prolific as either of them, and I receive a respectable volume of hate mail. I've had critics try to pad online doctor rating sites with negative reviews. But I'm busy, I'm well-respected, and I'm good at what I do. And, importantly, I'm in private practice, which gives me a great deal of freedom to say what I want.

While I've had some pretty unpleasant run-ins with some pretty crazy people, nothing compares to what Dr. David Gorski appears to be going through. One of Gorski's frequent targets of criticism is a guy named Mike Adams who fancies himself some sort of “Health Ranger.” I don't know what that means, exactly, but his website Natural News, which calls itself “the world's top news source on natural health,” is a cesspit of conspiracy theories and very bad health advice. Beyond the fact that it promotes unproven and often dangerous medical practices, Adams's tone is so paranoid and abrasive, he makes Ted Cruz seem like a teddy bear.

I hate the site. I don't know the guy behind the site, but I'm beginning to take on a strong dislike of him as well, not just because he promotes dangerous and frankly idiotic medical ideas, but because he takes on his critics with vicious personal attacks, threatening their livelihoods, their feeling of safety and their careers.

Just this week, Adams published a piece titled, ”Karmanos cancer surgeon Dr. David Gorski linked to “skeptics” kingpin James Randi caught on tape soliciting bl*w job from young man—source.” The really scary thing here is that the headline is the least inflammatory part of the article.

Let's put aside the fact that the headline seems to imply that Gorski was the one doing the soliciting. Further reading shows that he simply knows the man who Adams is accusing of sexual improprieties. That sort of cowardly, defamatory garbage is just the lede. The real attacks come in the body of the blog. Here's the point-by-point breakdown of Adams's lies, dishonest allegations and defamatory (at least in my lay opinion) accusations.

First, there is a non-existent FBI investigation: Dr. David Gorski—already the subject of a Natural News investigation that has submitted numerous allegations to the Federal Bureau of Investigation …

If you read carefully and follow the links, you see that Dr. Gorski is not the subject of any investigation but the 1 in Mike Adams's own head. Adams's writes that he himself has pestered the FBI to look into Dr. Gorski for … “reasons”? Making it seem as if a well-respected surgeon is the subject of a federal investigation is a dangerous road to go down.

Next, is alleged “racketeering”: Dr. David Gorski … is the mentally deranged leader of an online hate group calling themselves “skeptics.” An ongoing Natural News investigation has revealed that Gorski is just one of several co-conspirators who engage in online racketeering, identity deceptions and alleged cyber crimes to commit scientific fraud while destroying their targeted enemies in the holistic health realm.

Much of this is simply deranged opinion, but to state as fact that someone is “mentally deranged” and “leader of an online hate group” is dangerously close to making harmful, knowingly false statements about someone. And to state as fact that someone is engaged in a racketeering scheme seems to go well beyond “opinion.”

Third, is guilt by association: David Gorski's colleague was just convicted of massive medical fraud and sentenced to 45 years in federal prison

This is as far as I can read without actually vomiting. Here in the Detroit area, a cancer doctor named Farid Fata was sentenced to prison for crimes that, for doctors like David Gorski and me, are so horrific as to be nearly indescribable. Dr. Fata told people they had cancer and gave them chemotherapy even when they were perfectly healthy. He did this at great profit. He violated the most important trust, that your doctor is in this for you, the patient, and that he would rather give up his career than harm a single person.

Dr. Fata and Dr. Gorski were “colleagues” in about the same way as me and Josef Mengele: Yeah, we're both doctors, so “colleagues,” I guess, except 1 of us was a pathological torturer and murderer (hint: not me). Dr. Fata was affiliated with an institution which was affiliated with an institution that Dr. Gorski is part of. So, yeah, they were colleagues maybe in some sort of twisted definition. The only conceivable reason to write this is to imply that Dr. Gorski is guilty of the same horrific crimes by association.

Nothing could be further from the truth. David, who I am proud to call a friend and colleague, has spoken out against Fata and other dangerous doctors for years. He has made it a mission to help reveal to the world how quacks do what they do, and how to watch out for them. In addition to fighting cancer in the lab and in the operating room, he fights with the written word against dangerous and deceptive medical practices.

Dr. David Gorski is a quiet medical hero. OK, he's not quiet online, but he's a soft-spoken, gentle, brilliant guy. I can live with the accusations that imply that he is involved in online “racketeering” or is friends with someone who may have asked someone for a BJ (and really, is that all that rare?) but to associate him with a criminal of the worst sort, a doctor who intentionally harms patients for profit, is the worst sort of attack.

I'm a good doctor, but I'm no lawyer. I have no idea whether Mike Adams has crossed the defamation line, and even if he has, whether Dr. Gorski would dignify Adams's idiocy with any sort of legal response. But let's hope that those of us who benefit from Dr. Gorski's work (which is just about everyone who wants to improve the quality of medical care) will not let some nut job tossing around hateful allegations silence people like Dave.

Mike Adams has opinions that are distasteful and dangerous. That is my opinion. He also has every right to state them, as long as he doesn't harm others in a way our legal system recognizes. Dr. Gorski's employers, funding sources and colleagues, if they bother to notice Adams at all, should thank David for being willing to stand on the front line, defending what we all care about most–helping others.

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.
Wednesday, June 22, 2016

How expertise dies: of character, credentials, and crap

Perhaps no topic better illustrates the enormous gap between knowledge and ignorance, and its profound importance to the ambient understanding of all humanity vital to advancement at the most basic level, than evolution. The story of evolution by natural selection is, effectively, written, in vivid detail, in the language of molecular genetics. If you can read this language, the tale it tells is clear, decisive, and irrefutable; the facts presented about as prone to denial as sunrise.

Nor need you be literate in molecular genetics per se, any more than you need learn Russian to read Crime and Punishment. There are highly proficient translators in both cases. A bounty of books on evolutionary biology have been written by the unassailably erudite for the decidedly less so among us. Complex science has been translated into the lingua franca.

What, then, is the basis for denial in all its shades of gray, from intelligent design, to young earth creationism? In a word, ignorance. But not ignorance of the traditional “I really wish I knew, but alas, I don't” variety. Rather, this is generally ignorance of the “my eyes are covered and my ears are plugged, so you must be wrong” variety.

The only way to dispute the evidence for evolution is never to look at it in the first place. The fossil record is itself almost astonishingly replete, given what is required to preserve the faint impressions of fleeting life in dust and mud over millions of years. But the fossil record is all but irrelevant, mere icing on the cake. The cake is baked of our DNA, which provides an encyclopedic account of life's recipe.

So, permit me to reiterate: the only way to dispute so incontrovertible a case is to ignore it. Now, of course, you cannot ignore the content of an entire domain and achieve any recognition by peers, credentials, expertise, or even rudimentary understanding. Ignoring leads only to ignorance. Actual experts can and do, of course, disagree in their interpretations. But those interpretations require knowledge and understanding. Knowing is prerequisite to interpreting. Disagreements born of expertise are interesting, and resolving such tensions is in the service of progress.

Not so the dissent of non-experts. Asserting the deficiencies of a field one has never mastered is tantamount to the claim that any language you don't speak is just gibberish.

The problem is indeed acute for evolutionary biology, but by no means unique to it. In every field, from evolutionary biology, to biomedicine, to political science, the cries of non-experts populate cyberspace: listen to us, too! We've only ever read what we already decided to believe—if we've read anything at all—but listen to us just the same.

The long-standing tendency to repudiate understanding not on the basis of alternative understanding, but on utter lack of understanding and, for that matter, never attempting to learn, is massively amplified by the Internet, the ultimate leveler. Nobel laureates, and consummate nincompoops, have recourse to the same megaphone. This is where expertise goes to die.

But how does it die? There is famous concern about ending with a whimper rather than a bang. Sadly, we are well into the realm of a demise more tiresome still.

Non-experts routinely assert their opinions to refute the views of experts they simply don't like (this may refer to the views, the experts, or both). If challenged for want of expertise, they label it an attempt at character assassination. They allege that their legitimate, alternative view is being suppressed. In other words, they whine, 140 characters at a time.

But credentials are not character; that's a load of crap. Credentials, whether formal or informal, are the price of entry into any legitimate debate. Expert debate actually requires expertise on both sides. Two literary scholars might differ in their interpretations of Crime and Punishment, or War and Peace, and an interested audience might benefit from the exchange. But the audience is forgiven for restricting its interest to debaters who have actually read the works in question. Participation in the vein of, “I never read it, but I know it stinks,” would be reliably less illuminating.

Confront the pretenders for what they are, and you find yourself in the morass where credentials are conflated with character. They may also charge at you under an anti-elitist banner, implying that expertise is really just prissy privilege in disguise. But that campaign reeks of hypocrisy. Find me the anti-elitist willing to let any untrained, highly opinionated stooge perform neurosurgery on their child, and I will give up my day job for hula dancing.

So, yes, our culture seems tolerant to the substitution of fatuous hearsay for genuine knowledge, earned the hard way (is there any other?). Yes, our culture is implicated in the death of expertise.

It dies neither with a bang, nor a whimper. It dies silently, drowned in the endless echoes of incessant cyberspatial whining by those conspiring, ignorantly, to kill 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.
Tuesday, June 21, 2016

Is there a pill to make you live longer? The HOPE-3 trial and the hype that will surely follow

Today in the New England Journal of Medicine an article has appeared reporting the results of the Heart Outcomes Prevention Evaluation-3 (HOPE-3)trial. Exciting simplifications are sure to follow in the news. If you would like to stop reading now, the answer to the question posed in the title is probably no.

The question:
For many years researchers have discussed the possibility of a creating a pill that might contain several kinds of medication that would reduce people's risk of dying of cardiovascular disease. It is an attractive thought. Since cardiovascular disease is the major cause of death globally, reducing that risk has the potential to vastly reduce death and disability. Originally we thought that a suitable “polypill” might contain something to lower the blood pressure, something to lower cholesterol and something to reduce the risk of blood clots. Many studies have looked at the mortality benefits of various blood pressure pills, cholesterol lowering strategies and anti-clotting drugs and we have found that some of them help some people to some extent and some cause some people problems. Drat. So complex.

The history:
The original HOPE trial looked at a blood pressure pill (ramipril) which was added to whatever other medication a group of people at high risk of cardiovascular disease were taking. It lowered the risk of heart attack, stroke and death significantly enough that the study was stopped early and drugs in the ramipril class (ACE inhibitors) were aggressively prescribed, especially for patients with diabetes, probably to good effect.

The HOPE-2 trial looked at using vitamins to reduce homocysteine levels, which appeared to be a significant risk factor for heart attack and stroke. The studied doses of vitamin B6, B12 and folate did not reduce any of the outcomes they looked at. HOPE-2 was dashed.

In 2007 HOPE-3 began, looking at a combination of blood pressure medication and cholesterol medication, specifically to reduce death from heart attack or stroke, new heart failure, cardiac arrest or non-fatal heart attack or angina. The study was performed in academic medical centers all over the world, including the U.S., Europe, China and India, South Africa and Southeast Asia. Over 14,000 patients were enrolled, limited to men 55 and over and women 65 and over with intermediate cardiovascular risk (calculated at about 1% per year). Women 60-65 years of age were eligible if they had one of several specific risk factors, including glucose intolerance, smoking and high waist to hip ratios. These were people who had never had heart problems or strokes.

Drug company involvement:
Astra Zeneca helped fund this study along with the Canadian Institutes of Health Research. The cholesterol and blood pressure medication used in the study was on patent and sold by Astra Zeneca. The cholesterol pill was rosuvastatin (Crestor) and the blood pressure medication was candesartan/hydrochlorothiazide (Atacand/HCT). There were many drugs to choose from in the categories of effective blood pressure reducers and statin cholesterol medication, some of which would have been cheap and generic. The drugs they did choose are now generic but not yet cheap. I suspect Astra Zeneca hoped the study would have ended in time for them to reap financial benefits as their particular drug proved miraculously effective, or that the combination of the drugs could be made into a new formulation that would extend their market share.

So what happened? Getting to the point.
First there was a run-in phase. The 14,000+ patients were given the study drugs and about 2000 of them dropped out because they didn't tolerate them or didn't want to participate anymore. 12,000 patients were left. Of these about 3000 took placebo pills, 3000 took the blood pressure pills only, 3000 took the cholesterol pill only and 3000 took both blood pressure and cholesterol medication. After about 5.5 years, the patients taking blood pressure medication did not have a significantly lower risk of death, heart attack or stroke or the other cardiovascular outcomes. The patients taking cholesterol medication did have a reduced risk of death and cardiovascular outcomes. Taking both blood pressure medication and cholesterol medication was no better than just taking the cholesterol medication.

How big was the effect and how much does this cost?
The article quotes a hazard ratio of 0.71 for patients taking the combination medication, meaning that the medicated patient has 7 tenths the risk of a bad outcome of the unmedicated patient. The raw numbers are way more interesting. After about five and a half years of taking the combination of drugs or placebo, 163 patients in the active drug group had died and 178 of the placebo group had died, a difference of 15. At the present cost of these drugs, about $280 per month, it would cost about $3.7 million per life saved, which is pretty steep. Just taking the cholesterol medication, which is really the only one that had a positive effect, would cost about $2.6 million per life saved. If there were drugs on a $4 a month plan that did the same thing we might get down to a very reasonable cost of $53,000, assuming no other associated costs like doctor visits or lab testing (which is not a fair assumption.) Death is not the only thing we care about, of course, but other differences, such as numbers of hospitalizations, were not much more impressive when I reviewed the supplemental data.

How about side effects?
To begin with, 2,000 of 14,000 patients did not like or tolerate the study drugs, so some of them probably had intolerable side effects. During the study, however, there weren't many important side effects except a bit more dizziness in the patients on blood pressure medication, which apparently didn't do them much good anyway. There was some muscle pain, but patients on placebo also had that. The dose of the cholesterol pill was very low, which might have explained the pretty awesome side effect profile. Also the patients most bothered by side effects probably dropped out in the run-in period. By the end of the study only about 70% of patients were still taking the prescribed drugs, so there may have been intolerance that was not reported. There was no excess of development of diabetes, perhaps because of the very low statin dose. Good studies have shown more development of diabetes in statin users, but doses are often significantly higher.

Other interesting findings from the supplemental data:
I was very pleased that the NEJM published a well written summary of data that didn't get discussed in the article. There were some really weird things that showed up.
1. South Asians and to some extent Chinese subjects did not have near as much benefit from the study drugs as did subjects of European descent.
2. Stroke risk was actually higher for patients with borderline high blood pressure when they were treated with the blood pressure lowering drugs, though reduced for patients with higher and lower blood pressures.
3. Patients with the highest cholesterol levels (LDL greater than 141, mean of 166) did not benefit from treatment with cholesterol lowering drugs. That's really strange and counterintuitive.

Bottom line?
We have not discovered a pill yet that will make everyone live longer. Taking a statin drug which lowers cholesterol (who knows if that's the important effect) may lower your risk of cardiovascular disease or death, but you need to take it a long time to make a small difference and we aren't sure which one is most effective. Most people who take statin drugs (Lipitor, Crestor/rosuvastatin etc.) for primary prevention (meaning they haven't had heart attacks or strokes) will not benefit from them. Low doses of Crestor/rosuvastatin usually have a low risk of side effects. Treating normal or slightly high blood pressure with low dose candesartan/HCTZ doesn't reduce the risk of heart attacks, strokes or cardiovascular death. Navigating the pros and cons of all of these pills and potions is neither obvious nor simple and is best done with a doctor who you know and trust.

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.

What is shingles?

Thanks to my patient for allowing me to use her photo to talk about a common condition known as shingles. The medical name is herpes zoster and it is caused by the re-activation of the chickenpox virus (varicella zoster). This crazy virus lays dormant in the nerves and something causes it to flare up years or decades later.

This patient noticed a small rash behind her right ear and thought it was insect bites after a camping trip. She had some tingling (a common sign) and swollen and tender lymph nodes. Two days later when I saw her, the rash had spread down her neck and shoulder and she definitely had lymph node swelling at the neck and above the clavicle (nuchal and supraclavicular nodes). She had no fever but felt a little down.

Most shingles occurs in older people but it is not uncommon in younger folks too, like this patient. The rash takes about a week to develop and can last about 2 weeks with varying degrees of pain and annoying tingling. Some patients have pain that lasts in the nerves long after the rash has resolved.

We treat shingles with antiviral medication (valcyclovir ) and pain control. People over the age of 60 are recommended to get Zostavax vaccine to help prevent an outbreak. It reduces the chances of shingles by 51% and even higher reduction of post-herpetic neuralgia pain.

No special tests are needed to make the diagnosis. This is another reason everyone should have a primary care physician who can make the diagnosis and get the patient started on treatment.

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, June 20, 2016

Medical insurance companies: heroes or villains?

Physicians are expected to be hostile to insurance companies. Indeed, a prior Whistleblower post directed arrows in their direction. They are an easy target, often vilified for their greed and perceived indifference toward those they insure. Ask most of us if we think insurance companies favor profits over patients, and most of us will respond that profits prevail.

Insurance companies are businesses, not charitable undertakings. Sure, we all like free stuff. Or, if it's not free, we prefer that someone else pays for it. We are outraged at the costs of chemotherapy, hepatitis C treatment and biologic treatments such as Humira and Remicade, leaving aside the zillions of dollars it takes to research, develop, manufacture, market and monitor innovative new drugs.

We want to drive a Cadillac, but only pay for a Chevy.

No person, business or organization is wrong all of the time. Consider the following practices. Who's side are you on here?

A patient has chronic back pain and ran out of his pain medications on the weekend. He calls the doctor and is connected to a weekend covering physician, who declines to refill the medicine. The patient then proceeds to an emergency room, where he is evaluated and given the desired prescription. Who should pay for the ER care?

A patient is seen in the office and prescribed a 2-week course of antibiotics for diverticulitis. The medicine nauseates him and he stops them in 3 days. He does not contact his physician. Ten days later, he develops severe abdominal pain and fever and needs to be hospitalized for severe diverticulitis. He is in the hospital for 5 days and is seen by numerous medical specialists. Who should pay the costs of this hospitalization?

A 55-year-old individual has never had a colonoscopy performed. His primary care physician advises him to proceed, but the patient declines. A decade later he is discovered to have colon cancer and needs to be hospitalized for surgery and evaluation by an oncologist. Who should pay for the costs of his care?

If a patient with high blood pressure, skips appointments and his medications, and a complication develops …

I'm not carrying water for the insurance companies. I am pointing out, however, that we often expect them to pay for medical care that is either inappropriate or should not have been necessary. That's not reasonable or fair. Don't we have a responsibility to be personally responsible?

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.

Why I don't subscribe to the notion that Medicare and CMS are a 'big evil empire'

With all the changes happening in health care and the increasing weight of federal mandates and requirements, it's easy to view Centers for Medicare & Medicaid Services (CMS) as the big, bad enemy. After all, if they just left all physicians and healthcare institutions on their own, everything would be okay wouldn't it? It's an occasional line of thinking I've heard from many esteemed colleagues and also appears to be a prevailing theme online too. To be fair, this is the easy and default viewpoint for any physician or health care organization to take, as they feel crushed by bureaucracy and other relatively newer requirements such as Meaningful Use. It's a classic “us” versus “them” mindset, that I must admit I occasionally feel as well.

Last week, I was reading the comments section of a healthcare article, and was struck by one particular comment about how Medicare simply doesn't have enough funds to sustain the current model. The particular viewpoint was as follows. It's all very well for physicians to pine for the good old days of the 1960s to 1980s (or even more recent), but back in the mid-twentieth century there were something like 7 working people for every Medicare recipient. In a decade, that figure is going to be closer to 2.5. Do the Math. Some figures even suggest that if current Medicare growth continues, it would account for over 30 percent of the entire nation's wealth in just over 50 years, with total health care expenditures accounting for 99 percent of GDP! How can such a model possibly be sustained?

This doesn't mean that physicians (and nurses) shouldn't lobby and push hard for what they believe is the right way forward. I wrote a piece a few weeks back about the craziness of the Observation versus Inpatient distinction, and how I believe that when you add up all the additional resources, manpower, and spin-off industries that have come with this, I'd be surprised if it even saved the country a dime. Similarly, Meaningful Use may have had some noble intentions at its core (i.e. making the U.S. health care system fully electronic and computerized), but the way it was rapidly rolled out with immature and cumbersome IT systems that were not ready for prime time, has caused something of a disaster at the frontlines of medicine.

Physicians who complain and moan without getting together and pushing for positive change, are not taking the correct course of action. Cynicism and negativity are not signs of learned wisdom, but of laziness. As part of my work with the Society of Hospital Medicine, I have twice had the honor of going to Capitol Hill to meet congressional leaders and advocate on behalf of issues important to hospital physicians. While any change requires a monumental effort to take effect, I don't think most physicians (or even the general public for that matter) realize how open and accessible our great democracy is, and if you have the time, power and energy—you really can meet some high level people and draw attention to your cause.

Medicare is overall a good system for our elderly, especially in a country that does not have socialized medicine. There are plenty of areas that CMS can improve, and these need to be highlighted by the professionals at the coalface. I've encountered many people high in the healthcare bureaucracy, and on the surface they are perfectly decent and normal people, doing their day job to the best of their abilities. They just may not be doing what we'd like all the time. But to simply expect that Medicare can exist like it has up till now, without some acknowledgement that it needs to contain costs, tighten its belt and change a few things, is simply unrealistic.

There's an old popular saying that I grew up with, used in England a lot, that's something of an eternal truth when it comes to those who hold the purse strings. He who pays the piper calls the tune. It happens in any arena in life, and even when any of us ourselves are paying people for their services—be it a building contractor, hairdresser or an event coordinator. We pay you, therefore we decide what you do for us and what resources you work with. As long as that's the system, that's the way things will be. The best one can do is try to influence that tune in any way they can.
Friday, June 17, 2016

The sad corruption of the performance measurement movement

This rant reflects conversations with experts, but it does not qualify as good reporting. I will take some liberties, and have not done careful checking of information. Nonetheless I believe everything that I am typing.

Too many decision makers in the performance measurement field ignore the evidence. While the initial impetus for performance measurement came from the belief that with measurement we could improve adherence to evidence based treatments or testing. If one truly believes in evidence based medicine, then the evidence should be indisputable and we should even have evidence that measuring performance actually helps patients.

But too many who have influence in the decision making for performance measures do so without understanding evidence, the concept of unintended consequences, or even the clinical situations involved. Too often groups lobby for their favorite goals, without really understanding what adopting a performance measure means.

For the near future we are stuck with performance measures and payments influenced by our performance. Hospitals already influence patient care so that their payments do not suffer.

Those who do this are often practicing medicine without a license. While they likely do not really understand that concept, that is the case de facto.

The famous 4-hour pneumonia rule, now rescinded, unfortunately still influences practice. Too many patients get labeled as having community acquired pneumonia on the basis of incomplete data and problem representations that do not match the illness script. This tendency started because hospitals received payments based on how quickly pneumonia patients received antibiotics (first within 4 hours, and later within 6 hours). Thus they “encouraged” the emergency department to start antibiotics presumptively if the patient might have CAP.

Anyone who has studied test characteristics understands the problem that ensued. When you increase sensitivity (and that was what emergency departments under the urging of hospital administrators did), you must decrease specificity. You could not avoid overuse of antibiotics.

Performance measurement decisions too often result from political influences (not from professional politicians but rather from health care organizations ranging from subspecialty societies to hospital organization). As a physician who tries to make patient centered decisions, the more that I hear about how performance measures are actually chosen, the sadder and more disgusted I become.

Perhaps we should always remember that the road to hell is paved with good intentions. Perhaps I am being a bit melodramatic, but I really do believe that unless we transform the performance measurement movement, we will continue to harm rather than benefit patient care.

We need prospective evaluations of careful considered performance measures. These evaluations should resemble phase 3 drug trials, looking for benefits and harms. To do less is a shame.

We should remember that the famous Deming quote is almost always misquoted:

The problem is that Deming actually wrote, “It is wrong to suppose that if you can't measure it, you can't manage it—a costly myth” (my emphasis added)—the exact opposite. Deming consistently cautioned against requiring measurement to guide management decisions, observing that the most important data needed to manage often are unknown and unknowable.

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

The delusion continues (part 3)

In response to my last post a reader emailed me the following: Very easy to sit at a keyboard and throw blog bombs … I would be thrilled to hear your constructive suggestions for a solution(s).

Fair enough. I'll address that. But it's important, I think, to first say a few words about this blog, which is now in its eighth year. From the beginning, we wanted to make controversial issues a focal point, and the issue of the infectious disease (ID) workforce (or lack thereof) is controversial and a topic of great interest to readers. In addition, we welcome comments and guest blog posts to offer alternative viewpoints. Eli Perencevich, MD, ACP Member, Dan Diekema, MD, FACP, and I don't always agree with each other (as is evident in our posts). The only comments that are censored are those advertising black market erectile dysfunction drugs and other products. And all requests for guest posts have been honored unless the author has conflicts of interest with industry. So readers, please feel free to respond to our posts.

My comments on the workforce/compensation issue and IDSA's response are made in the context of my experience with these issues. In my former job as an infectious diseases division chief in an academic medical center, I had firsthand experience with the difficulties of recruiting fellows and faculty, the inequities that resulted from a purely relative value unit-based compensation plan, and the toll this took on teaching and morale.

At the same time, I was observing a private health system across town crank through a multitude of infectious diseases doctors, each of whom left practice once their guaranteed salary expired and they one by one came to the realization that they couldn't generate enough RVUs to maintain their salaries. Several of these physicians became hospitalists.

In my current position, I see my division chief struggling with trying to balance his budget, offer salaries that can compete with other hospitals and medical schools, deal with ever increasing consultation volumes and expectations for rapid responses to consult requests, while trying to minimize the stress all of this has on his fellows and faculty members. We now have starting salaries for brand new nurse practitioners that are within a few thousand dollars of junior ID faculty salaries.

I'll be the first to admit that my experience may not be the same as others. In the IDSA compensation survey, 1 respondent reported a salary of $1.45 million, so obviously his situation is quite different than mine and his views on these issues probably are as well.

I did a little more research on salaries by looking at the Association of American Medical Colleges data. The median salary for an infectious disease assistant professor is $152,000, while the median for a hospitalist assistant professor is $207,000. For a third year internal medicine resident, that's a huge difference. At the associate and full professor levels, hospitalists still earn more money than infectious diseases specialists. Moreover, hospitalists salaries are rising yearly at a higher percentage than ID's, so the difference continues to expand.

Another interesting finding is that of salaries for chairs of Departments of Internal Medicine. Unfortunately, if you're an infectious diseases doctor you'll earn significantly less than your chair peer who's an invasive cardiologist, a difference of about $350,000. And what do cardiologists learn in their fellowship about being a department chair that would explain that difference? I hate to sound like Donald Trump, but it's a rigged system. And it follows you throughout your career.

As for constructive suggestions for solutions, I've written about this in older posts, but here are a few:
• Focus on the parity with hospitalists, since that's our biggest threat with regards to recruitment of residents into infectious diseases. Until ID salaries are at least as good as hospitalists', there's little reason to think that we will turn this around.
• Consider shortening the ID fellowship to positively affect the cost-benefit calculus of additional training. Do trainees who plan to enter private practice really need hands-on training in research or scholarly activities?
• Develop hybrid models of training to lessen the economic impact on trainees (for example, integrate ID training with hospitalist practice). Various models could be envisioned—such as one month hospitalist attending, alternating with one month ID fellowship. This would increase the fellow's salary, and even if the total duration of training were extended, may entice more residents to consider ID training. Some would probably continue this model beyond training into employment.
• If IDSA is working hard to address these issues, it's not apparent from their website or communications with its members. Most importantly, in my view, IDSA needs to own the workforce issue and honestly deal with it. And that begins by calling it what it is–a crisis. A crisis, magnified by the many problems that are in the news every day, like Zika virus and antimicrobial resistance. I'm not a communications specialist, but it seems to me that these issues could be highlighted to help our cause.

Unfortunately, the two articles and editorial published this week in IDSA's journals spin an unrealistic view of the problem. I doubt that the your-salary's-not-as-bad-as-you-think-it-is campaign will have much impact. Time will tell. In December, we'll see the results of the next Match.

Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on improving the quality and safety of health care, and sees patients in the inpatient and outpatient settings. This post originally appeared at the blog Controversies in Hospital Infection Prevention.
Wednesday, June 15, 2016

The fountain of youth, where no one drinks

I was greatly privileged this past weekend to deliver a keynote address at the American Academy of Anti-Aging Medicine (A4M) World Congress in Hollywood, Florida. I have spoken before at the Academy's conference in Las Vegas, and will have the opportunity to do so at their sister organization's meeting in Melbourne, Australia this summer (their winter). The conferences are a big draw to health professionals and scientists interested in exploring the latest advances in anti-aging, from basic science to clinical application.

But I didn't really address any advances, latest or otherwise. Rather, I pointed out how late we all already were to our own party.

I began by telling the thousand or so health professionals in the audience about a National Institutes of Health trial, just profiled in the New York Times, examining the anti-aging potential of the drug, rapamycin, in dogs. Effects have already been shown in rodent models, and dogs are next in line.

Given the nature of the conference, and audience, many assembled likely knew more about this particular trial than I do. But that was fine, and rather by design. For me, the dogs in the trial were really just a segue to the neglected elephants in the room.

We already know the anti-aging secret.

After all, what would “anti-aging” mean in practical terms, if not more years in life, and more life in years? We surely don't mean actually stopping the clock, fixing the sun in the heavens and halting the calendar, as Joshua allegedly did. Leaving aside the rather dire, cosmic ramifications of heavenly bodies that stop dancing, I simply note no reference to any such methods in the otherwise quite comprehensive A4M subject matter.

So anti-aging has to mean preserving the good qualities of relative youth, even as the clock hands turn, the planets revolve, and the calendar turns. We must mean, simply: longevity, plus vitality. More years in life, more life in years. And if that is what we mean, we know how. We have long known how.

So I told my audience, delivering a version of a tale I have told innumerable times over the course of my career, from podiums around the world, and in print again, and again, and again. The repetition, alas, seems both necessary and insufficient, as the world is disinclined to heed.

We have known for decades the modifiable, root causes of premature death and chronic disease. These factors are not just modifiable now, with knowledge born of latest advances; they have been modifiable for as long as we've known about them, with knowledge accessible then. Knowledge in this case has been nothing like power, since we have so consistently failed to use what we know.

We have known for years not just the root causes of premature death and chronic disease around the globe, but what happens when we do modify them. Chronic diseases that would have occurred, don't, at least 8 times in 10. People live longer, and better.

We know, too, what happens in cultures where entire populations are beneficiaries of lifestyle as medicine, where they eat well, exercise routinely, avoid toxins like tobacco, sleep soundly, limit the toll of stress, and cultivate their strong connections to one another. In those places we call Blue Zones, people routinely live to a vital 100, and then some time after that, die peacefully in their sleep. If there is a greater prize to which mortals might aspire in this sphere than longevity, vitality, and a gentle exit into that good night at the timely end, I've not found it. If this is not the very quintessence of “anti-aging,” I haven't a clue what would be.

And we know, as well, that these very blessings may be imparted to an entire population in the span of one generation by translating what we have long known about healthful living into a concerted, collective action. In North Karelia, Finland, a dedication to lifestyle as medicine for all has slashed heart disease rates by over 80%, and added fully ten years to life expectancy. An additional ten years of living is an anti-aging achievement worthy of a Nobel Prize if ever there was one, but there are no Nobel Prizes in science for using what we have long known.

Perhaps that's the problem. The unknown always beckons. The new and exotic tantalizes. We are all eager to hear about Nobel Prizes attached to the promise of great, potential advances, even as we fail to keep the promises of the tried and true. We are drawn to the sources of power in distant shadow, even as the amazing might of elephants in the room is put to no good use for the simple fact that they are already in the room, and thus, mundane.

So I told my audience, assuring them I meant no disrespect to the last batch of Nobel laureates, nor to the next. I like Nobel Prizes as much as the next guy. I just wonder why we can't award them to those who learn the things we never knew we never knew, even as we use the things we long have.

We focus on dogs in trials, I contended, while missing elephants in the rooms with us. We chase birds in the bushes, and overlook the bird in hand. We strive to slow the aging of adults, but look on passively as we willfully accelerating the senescence of our children for profit. What lesser charge is deserved by a society that laments the unnecessary propagation of type 2 diabetes among children, even as it peddles sugar-sweetened beverages for every thirst, and the likes of multi-colored marshmallows for every breakfast?

We know what to eat to foster longevity and vitality for people and planet alike, but hardly anyone is willing to swallow it.

Scientists are irresistibly drawn to the glamour, glories, and allure of the unknown. You'll get no objection to that from me; we are all the beneficiaries of that endless quest. But it does seem to invite periodic exhortations on elephants in rooms, reality checks about knowledge and power. Such was my mission in Hollywood.

As for the population at large, and our culture in general, the problem runs rather deeper. We have been preoccupied with anti-aging perhaps since the very dawn of self-awareness, and the implications of mortality it unveiled. We have, ever since, tethered our fears to faith and fantasy, tangled our aspirations up in fable, about fountains of youth in particular.

The reality is, we have long since found just such a fountain, but hardly anyone drinks from it.

Why? Presumably because the fountain dispenses only water, and the line forms elsewhere. There is a concession stand nearby where, inevitably, they are selling Coca Cola.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
Tuesday, June 14, 2016

Thinking beyond hospice

I recently attended the death of a friend at his home. He had a disease that was terminal and untreatable and he and his wife had finally decided on no further medical treatments that would require hospitalization. He was not very old and had been cared for by his children and wife during the previous 4 months that he couldn't care for himself. Time had become short and valuable and he had become weak, so he didn't amend his POST (Physician's Order for Scope of Treatment) to indicate that he wanted no resuscitation, though his wife and family knew his preferences. He had not entered hospice because his needs were adequately fulfilled by his family, friends, his physicians, and home health.

When his wife noticed his breathing had changed, she called me, a friend of the family. I had offered to be available to come over for any medical situation in which they might need a rapid house call. I arrived about 15 minutes later and he had just died. I confirmed the situation with my medical gadgets. We were all sad and tearful and we talked and hugged and talked some more. I called the police, reported the death and the fact that it was expected. A kind and respectful sheriff's deputy came out and took a picture and a couple of statements. I called the local funeral home and a couple of guys who were on call came over with their stretcher and bag and quilt to collect him. About 90 minutes after I got the first call, his body was on its way to the funeral home and thence the earth and eventually the far corners of the universe. We sat and talked as the sun went down.

It was a good death, as much as a death of a vital and gifted person with plans can be good. It was a hospice-free home death, surrounded by family and friends. Such a thing is becoming vanishingly rare, and it made me think. Maybe we could make this easier. Maybe our community could reclaim the wisdom that it takes to facilitate better deaths, with or without hospice, nuanced to our needs and resources.

Hospice care is intended to be a holistic approach to providing support to dying patients during their last 6 months of life. The concept of hospice dates back to medieval times. Wikipedia says that in 1090 there is evidence that places existed which were devoted to care of the incurably ill, staffed by crusaders. There have been institutions for treatment of people who are dying since then, likely because of the clear need for dedicated care for people who are vulnerable and in pain and unable to advocate for themselves. Hospice at home was encouraged by Elizabeth Kubler-Ross (author of the book On Death and Dying), arguing that we shouldn't institutionalize people who are going through a universal life process. Legislation to pay for hospice care passed in the early 1980s in America. Hospice care has increased in popularity, more than doubling the number of patients utilizing the service and the amount of money spent in the last 10 years. This year an industry report predicts that the U.S. will spend over $25 billion on hospice care. (It will also save several times this amount of money by providing appropriate care for the dying rather than futile procedures in a hospital setting.)

Hospice is extremely valuable in our culture which has lost the habit and skills of taking care of the dying at home. They provide a consulting nurse who keeps in touch with both the patient and his or her doctor, providing adjustment of medication to ease suffering and equipment such as hospital beds or shower chairs that may become necessary. They provide 24 hour phone advice and expertise regarding the dying process. They organize volunteers who will spell a caregiver to go out for a walk or shopping and aides who can help with bathing.

Besides being valuable, hospice is also extremely expensive (mostly paid for by insurance including Medicare) and often feels like a one-size-fits-all solution. Hospice is difficult for introverts and people who treasure their privacy. “Going on hospice” can be demoralizing. Hospice is mostly not available to people who are still undergoing life-prolonging treatments such as chemotherapy. The use of pain and anxiety medication often seems heavy handed. I have ranted about some of these issues in the past. All this aside, I am truly grateful for the existence of hospice services and devoted hospice workers who make dying at home and in peace easier.

But I think we can do more and maybe better. My friend who died, and his family, needed his wise friends and his multidisciplinary team organized by his specialist, his flexible and understanding primary care physician and, in the end, me to smooth the difficulties of his passing. It turned out that he needed a bare minimum of medication and remained intelligent and interactive up until nearly his final breath. He didn't need hospice, but he did need help. I think there is support that a community can provide that is beyond what a hospice organization does.

What we need is a network of people in our community who are good for different things, to share with each other and with people somewhere on the dying spectrum what they know. Emergency medical technicians know what needs to be done when somebody dies at home of a terminal disease and so do I, but families of dying people should know too. It would be reassuring. Lawyers know about what is needed to have a valid will. Priests, nuns and other clergy people are skilled in helping people find meaning in the process of dying. There are people in my community who always seem to be there when someone is very sick and they are comfortable with some of the worldly aspects of the end of life. There are people who have special relationships with animals who could give comfort by visiting with a cuddly creature. There are musicians of all description and artists who can brighten a dreary space. People who have recently gone through the death of a loved one might be glad to sit down for a cup of coffee or come along for a doctor's appointment to take notes or ask the right questions. They may know how to make the funeral process less expensive. There are social workers who would be founts of good advice. Some people know about helping write a life history. Some people can do guided imagery or hypnosis for symptoms control. There are needs and solutions I haven't thought of, and somebody in my community knows about them.

When I was pregnant with my second child, we hired a doula. She was a woman who had lots of experience with birth and who helped me with questions I didn't want to ask an obstetrician. She encouraged me, shared stories and sat with me the entire time I was in labor, which was a long time. Because of her confidence I didn't feel frightened and I didn't need labor anesthesia. There are also doulas for the end of life. There are none in my community, but I think there are people with the basic wisdom and experience to be a companion for a patient and family during the dying process. Death can be frightening but it doesn't need to be.

This network of people would not displace traditional hospice, at least not in most cases. It would be a volunteer organization and, with the possible exception of doulas, there would be no requirement to be “on-call.” This would create new connections within our community. There would be unexpected and probably positive consequences. Each person who volunteered would know that, although they are giving now, they will be receiving at some point because death is going to happen to all of us.

The hospice movement that gained steam in the 1980s was very important. It helped move death out of the hospital and the intensive care unit and back home, where we can be surrounded familiar things that bring us comfort. I think we are ready to take the next step. We may be ready to use our collective wisdom to find the meaning in life's end, beyond the mistaken concept that death is a failure of medical technology. Life is valuable in part because we know we will die. Like birth, we only get to do it once. Maybe we can be intentional about it and help each other out by sharing what we do well.

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.