Friday, July 29, 2016

Advice for new third year med students #med3advice

1. You cannot make up the stories patients tell you.
2. You should not share these stories with your non-medical friends.
3. Read about your patients.
4. Keep a notebook (paper or digital) of clinical questions that you see each day.
5. Spend 30-60 minutes reading about those notebook entries each day (reading reinforces the discussion from rounds).
6. Remember that your patients benefit from your caring.
7. Sit down, talk to your patients, touch them in an appropriate manner (I favor wrist pulse). They benefit and you learn more.
8. Ask questions when you do not understand something.
9. Take care of your personal health. Exercise, eat relatively intelligently, sleep enough.
10. Realize that medicine is a team sport. Be a good team member.
11. Discover who you are in medicine.
12. Remember that medicine is all about the patients, not us.

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, July 28, 2016

Appreciating the gifts of life

The value of anything becomes apparent when it is taken away from you. Nothing profound here about one of life's central truths. It is an ongoing challenge not to take life's gifts for granted. I have never known hunger or lived without shelter. I have never been unemployed or suffered a serious illness. I pay my bills. I have 5 children who enjoy excellent health and are forging pathways toward their dreams. I love the people I work with. I have found new love in the 6th decade of life. And, I have ice cream every day of my life.

It would be shameful to have been bestowed so much and then to complain about some of life's trivialities. But, I am human.

Consider the following list of events. Has any of them ever dampened your mood, made you angry or resulted in an outburst of coarse language?
• You find yourself in a traffic jam which delays your arrival to a meeting by 20 minutes.
• Your lengthy and detailed e-mail to a client suddenly disappears.
• The concert of your favorite performer is sold out.
• You have gained 10 lbs.
• The women ahead of you in the cashier's line at the supermarket is digging around in her purse for coins.
• Your cell phone reception disappears.
• The airline informs that you may change your ticket reservation for $200.
• You have a flat tire.
• Your doctor is running an hour behind schedule, again.
• A driver cuts in front of on the road.
• A police officer issues you a ticket for speeding because you were speeding.
• Your dog has made your new Persian rug her toilet.
• Your check bounces higher than a kangaroo in heat.

A man came to my office, accompanied by his wife, for his colonoscopy. He was younger than I. I had never met him before. He was alert and in good spirits. I was pleased that I could inform them both after the procedure that his colon was in excellent health. Sadly, the health of his colon was more robust than his mind was. He had dementia and couldn't recall that he was taking prescription medicines. How sad and unfair that he and his family were losing a gift. After my day was over and I was driving home, how important would a traffic jam really be?

When I am headed out to see a patient in the emergency room at an ungodly hour, I remind myself that the patient has it worse than I. He's the sick person and I will be returning home to sleep in my own bed.

I want to be more grateful and appreciate for all that I have, but I am flawed human specimen. The struggle continues.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Tuesday, July 26, 2016

How salt shakes out

From what I know courtesy of friends and colleagues who work there, it's always busy at the Food and Drug Administration (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 1 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 about70 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 2000 mg per day, and only begins at intake below 3000 mg 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 3000 mg, 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.
Monday, July 25, 2016

Imposing regulations without evidence

“Experts” consistently champion evidence based medicine. Policy wonks opine that we could greatly improve patient care if we more consistently followed the evidence. Evidence has become a major buzzword in health care.

Yet too often regulations impact physicians that have no evidence base. I have argued against the clinical skills exam for many years. Please read this Washington Post article about the exam, “$1,300 to take 1 test? Med students are fed up.

How about the method of note writing that Centers for Medicare and Medicaid Services inspired? Does anyone believe that our notes have improved with the billing requirements?

Do these impositions follow evidence? No! A regulation body imposes something that has face validity to them, but not to us.

As children we often learn the famous saying “What is good for the goose is good for the gander.” If evidence is really important (and why else do we even consider performance measurement), then we should hold the same standard to these regulations. We should not have regulations that impact health care imposed without a strong evidence base.

But then the world does not always act rationally.

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, July 22, 2016

Medical statistics and the art of deception

“There are 3 kinds of lies: lies, damned lies, and statistics.”

There is much truth in this quotation of uncertain provenance. We see this phenomenon regularly in the medical profession. We see it in medical journals when statistics are presented in a manner that exaggerates the benefit of a treatment or a diagnostic test. Massaging numbers is raised to an art form by the pharmaceutical companies who will engage in numerical gymnastics to shine a favorable light on their product. It's massaging, not outright mendacity. The promotional material that pharmaceutical representatives present to doctors is riddled with soft deception.

A favorite from their bag of tricks is to rely upon relative value rather than absolute value. Here's how this works in this hypothetical example.

A drug named Profitsoar is tested to determine if it can reduce the risk of a heart attack. Two thousand patients are participating in the study. Each patients receives either Profitsoar or a placebo at random. Here are the results. Of 1,000 Profitsoar patients, 4 had heart attacks. Of 1,000 placebo patients, 6 had heart attacks.

As is evident, only 2 patients were spared a heart attack by the drug. This is a trivial benefit, as only 6 of 1,000 patients in the placebo group suffered a heart attack. This means that taking the drug provides no meaningful protection for an individual patient. However, the drug companies will highlight the results in relative terms to package the results differently. They will claim that Profitsoar reduced heart attack rates by 33%, which would lure many patients and a few doctors to drink the Kool Aid.

Check out this promotional piece below which was recently mailed to me about Uceris, a steroid that I use at times for colitis patients.

See how low the actual remission rates are for the drug. Only 18% of patients responded to the drug, a small minority, and the placebo rate was 6%. No worries. Just brag that Uceris is 3 times more effective than placebo!

Is this a lie? Not exactly. Is it the truth? Technically yes.

Most physicians are tuned into this deception. I know from my own patients that the public is easily seduced by this slick presentation of data. The next time you see a TV ad for a medication, which will be about 5 minutes after you turn on the TV, see if you can spot the illusion. You'll have to watch quickly and repeatedly. Like all skilled magicians, these guys are expert at distraction and sleight of hand. Hint: Whenever you hear the word “percent,” as in “35% of patients responded …,” you should pay particular attention.

When we used to see a woman sawed in half on stage, we knew it was a trick even if we couldn't explain how it was done. I've taken you behind the curtain here. Let's make it a fair fight between us and illusionists.

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, July 21, 2016

Freedom versus control in a private vs. public health care system

This is my 12th year as a physician in the United States. I was born in London, grew up in Berkshire, and decided to become a doctor when I was a teenager. I remember being asked what I thought about the National Health Service (or NHS, the UK's government-run health system) during my medical school interview. That question is almost a rite of passage for anyone applying to medical school in the UK. My answer was an idealistic one, probably identical to what most people in England—if not Europe—would say. Health care is a birthright.

The NHS is a wonderful concept and immensely fair and just. Nobody should ever have to pay for medical care in their hour of need, right? I speak too as someone of Indian heritage, who has seen up close and personal how unexpected illnesses in relatives can completely bankrupt families, causing untold anxiety and stress. Surely nothing could be worse than that free-market extreme with no public system backup?

During medical school, I also worked for a couple of months in Adelaide, Australia, primarily in Accident & Emergency/Trauma in a major tertiary care center. I also did a stint with the Royal Flying Doctor Service going on airborne missions to the outback, mainly rescuing very sick indigenous (Aboriginal) people and bringing them back to the city. The system Down Under is an interesting mix of both public and private health care, but still with a solid government-run backbone for people who really can't afford insurance. However, at that time, even the thought of having to pay for health care at all still seemed very foreign to me as I began my career as a physician.

Before I came to the U.S. back in 2005 to start my medical residency, these were my views on the funding of health care. Fast forward to 2016, and my opinions have shifted rather dramatically in terms of what a health care system should look like and whether people should contribute more themselves. Looking back to when I first moved here, one of the things that first struck me about U.S. medical care was the sheer speed and freedom of it all. Patients appeared free to choose their physicians, were in more control over their care, and didn't have to wait so long to get things done. My jaw dropped when one of my first patients was admitted from the ER, and had already had most of their tests and scans done, including an MRI. They would then be seen by all of the doctors they needed to, including any necessary specialists, within a very short period of their hospitalization. These attending physicians would follow-up with them daily (unlike in the UK, where the vast bulk of the work is left to more junior doctors).

We can get into a debate about fee-for-service and incentives, but it's human nature that people and organizations work harder when they are incentivized to do so. Documentation was also much more thorough than the couple of lines that I was used to seeing scribbled in a patient's chart (True, a lot of this was for billing purposes, but it's still always good to be thorough). Since my very first week working as a medical resident, I've said, and continue to say, that a homeless person presenting with an acute illness such as sepsis or a myocardial infarction in America, will get better and more outstanding care than a rich person almost anywhere else in the world. There's a very common misconception overseas that patients in America are left dying on roads outside the hospital if they cannot afford care! This simply isn't true, and I learned it very fast. Clinical care in the United States is top-notch (albeit at a high cost). As are the central issues of patient dignity, patient rights, and accountability of any hospital or clinic to seriously address any complaints.

Physicians too in America, appeared to have a much better deal than in the system I'd just come from. They were more in control of where and how they worked, weren't restricted in terms of their career progression by the government, and were also compensated a great much more for their hard work (granted however, they also had a much higher debt burden). Despite the problems and changes in U.S. health care over the last decade, it remains the case that doctors here have an unprecedented amount of freedom in how and on what terms they work, compared to almost any other country.

Having all these different experiences over the years, if you were to ask me today, I don't believe such a centrally controlled system like the NHS is an ideal system to aspire to. It restricts patients and physicians alike. It is too much at the whim of transient politicians, with no medical knowledge, who can enforce a universal country-wide policy change almost overnight (such as a change in patient rights, physician scheduling, or even banning all doctors from wearing white coats and ties, which is what happened in the UK). Neither does a centralized system foster the best environment for innovation or individualized care. Go to any patient floor in a socialized system, and it often has a Soviet-style aura about it, with rows of patients lined up, little personal space, monolithic designs, and staff wearing the same uniform. The collective American psyche is very different from Europeans, and the consumer-driven mentality here probably wouldn't endear itself to an NHS-type system anyway.

With regards to funding, I don't think it's necessarily a bad thing for patients to contribute themselves for doctor visits and hospital stays, as long it is capped at a very manageable level for the individual, with absolutely no “surprise bills”. There's an argument to be made that if people in England are so willing to spend £30 ($50) for regular restaurant visits, haircuts and other entertainment—why not a small co-pay for a doctor visit? Anything that's completely free can easily foster an increasing culture of entitlement, reduced self-responsibility, and sadly sometimes abuse of the system.

At the other end of the spectrum, is the idea of caring for peoples' health from cradle to grave a noble one? Yes, it is. Should anyone be refused coverage because of a pre-existing condition or go bankrupt and lose sleep because of unforeseen medical bills? No, they shouldn't in any civilized country. Do many of the socialized healthcare systems produce better outcomes than us? Yes, they do. Is the high-cost system we currently have sustainable over the long term? No, it isn't.

Perhaps something in-between the two extremes would be best, like Australia, which gives tax breaks for people who take out private insurance, but still offers a public system as backup to anyone who needs it?

For this debate at least, I'm stuck between a rock and a you-know-what.

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.
Wednesday, July 20, 2016

The argument for time based billing

In 2003 (yes this blog is that old) I wrote this piece, “Billing like lawyers.”

Then, Bob Wachter, MD, tweeted this article, “Time-Based Billing: What Primary Care in the United States Can Learn From Switzerland.”

Time-based billing may offer a simplified payment method that maintains physician autonomy and sense of professionalism. For smaller primary care practices that may not organize into accountable care organizations, time-based claims may offer an alternative means to align payment with meaningful work while simultaneously simplifying documentation and billing. Alternatively, within accountable-care organizations, time-based billing could be used as a physician reimbursement alternative to more common approaches such as volume-based incentives, salary, or pay for performance.

Our current billing processes discourage spending adequate time with each patient. As I have written repeatedly for the past 14 years, patients need us to spend the proper time attending to their needs. Time-based billing has made sense for many years, yet the idea never gains traction in the U.S. Please read the JAMA Internal Medicine article and let us know what you think.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.
Monday, July 18, 2016

Naturopaths (unfortunately) just took a small step toward legitimacy

As I wrote, across the country naturopaths are trying to become licensed as primary care doctors. While we do have a shortage of primary care docs, the solution isn't to license unqualified people. It's like saying there's a commercial pilot shortage and reaching out to BASE jumpers to help fill the gap. Sure, they both deal in altitude, but the similarity stops there.

In Massachusetts last week, the fake doctors scored a victory as the state senate approved a licensing bill.

It's fair to say that most doctors are motivated by the desire to help people, as, I think, are most fake doctors, like naturopaths and others who sell questionable medical services. But being motivated by good isn't the same as actually being good. Given that it's hard to get doctors together to do any real lobbying, how are naturopaths gaining so much ground on the state level?

Luckily, journalists at STAT News are on it.

Doctors (the real kind, like me) don't really have any bodies that represent them politically. Most of us do not belong to the AMA or other lobbying groups. Drug makers certainly don't support legislation to help us out. What reporter Rebecca Robbins found is disturbing. While real doctors rarely sell anything but their own services, naturopaths nearly always sell various supplements. Guess who is supporting legislation to license naturopaths? Vitamin and supplement makers like Emerson Ecologics have poured hundreds of thousands of dollars into naturopaths' battle to get licensed to practice medicine.

Not only are naturopaths not qualified to practice medicine, but their main backers are companies that make supplements of questionable value (at best). If naturopaths are licensed to practice, not only will people be fooled into getting poor medical care, but they will empty their wallets into the pockets of naturopaths and the supplement companies that support them.

This is one of those times you really should contact your state representatives. This link provides the information you will need, including if your state is at risk. Please protect yourself and your neighbors and fight the licensing of fake doctors.

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, July 15, 2016

Can we talk about mental illness?

Mental illness causes great suffering for the afflicted, profoundly affects families and loved ones, and is highly prevalent. As I share stories of my own family, I am routinely struck by how many people have similar stories of their own to tell, really heart-wrenching stories about their children, or their parents, or their siblings, which have shaped their own lives as well as the lives of their loved ones. And yet, we don't much talk about it. It is like a great shared silent burden. Keeping these stories in the shadows compounds the pain of those affected and further stigmatizes mental illness and its sufferers.

Fortunately, I have seen recent signs that this conspiracy of silence is starting to change. Maybe it is a consequence of the “radical sharing” of the Facebook generation (no, I still don't have an account), and partly a consequence of more effective treatment for serious mental illness. Whatever the cause, people are starting to talk. Here are a couple of examples, just from this last week.

The first was a two-part podcast produced by WNYC as part of the “Only Human” series that explored intergenerational conversations about mental illness. Part 1 focused on immigrant communities, and how children raised in America faced difficult conversations with their parents raised in other cultures. Part 2 was about a medical student who challenged her school and her teachers with an open approach to her own mental illness. Both are well-worth listening to, and may challenge your own thinking.

The other was a video produced by the Washington Post about a young composer, Rachel Griffin, who is developing a musical about mental illness to de-stigmatize her own story. I am proud to say that my daughter, Emily Nash is in the cast, and helping to bring the work to life.

These seem to me to be good signs of progress on a long road. What do you think?

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.
Thursday, July 14, 2016

Is same day colonoscopy right for you?

Like nearly every gastroenterologist, we have an open access endoscopy system. This means that patients can be referred, or refer themselves, directly to our office for a procedure without an office visit in advance.

Why do we do this? We offer it as a convenience so patients do not need to make 2 visits to see us when it is clear that a procedure is necessary. For example, a referring physician doesn't need our consultative advice for his 50-year-old patient with rectal bleeding. He just needs us to do a colonoscopy. We have a strict screening process in place to verify that these patients are appropriate for our 1-stop colonoscopy program. If we have concerns about medical issues or potential informed consent capability, then we arrange for these patients to see us in advance.

However, no screening process is perfect. On occasion, someone shows up whom we might have preferred to see in our office first. How should we handle these situations? We don't automatically cancel the test, particularly after the patient and his driver have taken time off work and the patient has already swallowed the delectable and satisfying colonoscopy prep.

We are meeting many of these folks for the first time, and they are often nervous. We get this. First, they are at a physician's office for an intrusive medical test, always a relaxing activity. The doctor may be a stranger to him, another calming feature of the event. They become victims of intravenous needle assault, always a pleasure even from our ICU nursing veterans. They have been fasting and may have enjoyed the pleasure and delight of our colonoscopy cleansing cocktail. They are naked except for a gown that by design covers about 40% of their body's surface area. Ready to sign up?

Open access endoscopy also raises potential ethical issues. On occasion, a patient arrives for a procedure that we may not feel he truly needs or needs now. Or, the patient is sent for 1 of our procedures, which may not be the best choice to address the patient's symptoms. These are delicate issues and I don't have an idealized response to offer here. In the open access arena, we regard ourselves more as technicians than consultants. This is similar to when a doctor sends a patient for a CAT scan, the study gets done regardless if it is medically appropriate, or the patient has had half a dozen of them over the past year. Radiologists don't question the appropriateness of what we order. While patient care would be better served if radiologists offered their advice in advance, this is not how the game works. Of course, they are happy to have these conversations about our patients, but their default system is open access.

How would you handle this scenario? One of your best referring physicians sends a patient for an open access colonoscopy. We interview him and realize he is 2 years early. He is prepped and took a day off of work. He has a driver with him. Do we tell the patient that he is 2 years early? Do we send the patient home? Do we say nothing? Do we contact the referring physician and point out his error?

As you craft your response to the above hypothetical scenario, remember that this is not an ethics seminar, but is the real world. Real life is not as neat and tidy as we would like.

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.
Wednesday, July 13, 2016

In defense of medical societies, especially ACP

A recent comment attacked medical societies as being impotent on several issues. The commenter clearly expects these societies to work quick visible changes. Here is my take.

My recent leadership role at ACP makes this answer biased, but I believe your expectations of medical societies are harsh. These societies are not impotent, but they are also not potent enough to drive policies. I can speak best for ACP. Let's take your concerns:

Defining quality

Please read ACP's performance measurement evaluations. These evaluations are quite thoughtful and include the reasons that most measures are inadequate. ACP started doing this many years ago, but no one is listening. ACP is trying to influence Medicare Access and CHIP Reauthorization Act, and at least provides information for physicians to pick their own performance measures.

Midlevels and what training is needed to practice medicine

This is a complex issue. ACP's policy on clinical teams does make the point very clearly.

Electronic medical record absurdities

Have you read the ACP's excellent paper on the problems with EMRs?

Meaningful Use

ACP has helped convince the end of meaningful use.

Medical societies cannot be as strident as we can in the blogosphere or the Twitterverse. They must work through the system. They do accomplish a great deal. Often they do not make big news, but I am proud to be a member of ACP. The organization has the best interests of internal medicine and our patients. They plug away at the many problems you cite. They do not throw verbal Molotov cocktails, but ACP does make steady progress.

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, July 12, 2016

Why I love the new NEJM CAUTI study!

Sanjay Saint's group at Michigan published the kingdaddy of CAUTI studies in the New England Journal (free full text here). And yesterday, 1 of the authors guest blogged for us on the study.

Although it's not a randomized controlled trial, it's just about everything else you'd want to see in a CAUTI intervention study:
• large and multicenter (over 900 units in 603 hospitals across 32 states),
• well designed,
• well executed,
• conceptually similar to the CLABSI Keystone study, arguably the most important study in our field since Semmelweiss, which demonstrated a huge (2/3) reduction in CLABSI, and
• bundled interventions, including daily assessment of catheter necessity, catheter avoidance, aseptic insertion, proper catheter maintenance, feedback on CAUTI rates, and multifaceted training via in-person or virtual training, monthly content calls, and monthly coaching calls.

Now, the results:
• Overall, there was a statistically significant reduction in CAUTIs of 14% after the intervention;
• Absolute rate reduction was 0.35 CAUTI/1,000 catheter days; and
• When hospital units were stratified (ICU vs non-ICU), all of the reduction was found to be in non-ICUs. There was no significant change in CAUTI rates in ICUs.

So let's bring this study a little closer to home. We'll assume that a 700-bed hospital has 35,000 catheter days yearly. If they implemented this intervention with the same results, the number of avoided infections would be 12.2 annually. If 1% of CAUTI patients become bacteremic (see here and here), they would avoid 0.12 secondary BSIs per year. And if 11% of bacteremic UTIs result in death, they would avoid 0.01 deaths per year. Expressed another way, this comprehensive, bundled intervention would result in saving 1 life every 100 years. Saving any life is a noble goal. But context is key. CLABSIs have an attributable mortality of 25%. In other words, CLABSIs kill people relatively commonly. CAUTIs rarely do. And there are many other nosocomial events that kill more than 1 person every 100 years.

The take home message is that a superb study designed by the world's CAUTI experts didn't yield much impact. This is no fault of the investigators. It's due to two reasons: (1) the attributable morbidity and mortality of CAUTI are relatively small; and (2) CAUTIs have low preventability (at least in 2016).

Dan Livorsi and Eli Perencevich summed it all up in their ICHE editorial last year when they questioned whether an NHSN-defined CAUTI is an episode of preventable harm. Is the work we do on surveillance and prevention of CAUTI an opportunity or an opportunity cost? I think the answer is clear.

Lastly, 1 point made in the guest post yesterday really bothers me: ”How a hospital addresses CAUTI likely says much about how such a facility attacks other endemic and mundane harms such as falls, delirium and pressure sores.” This is a specious argument. As the Chief Quality Officer of an academic medical center, I spend a great deal of time deciding where to best utilize our resources to prevent both infectious and non-infectious adverse outcomes. In fact, the hospital's leadership team actively engages in setting our quality and safety targets. As a utilitarian, I'm duty bound to attempt to have the greatest impact for our patients. And the reason why I love this study so much is that it makes the decision to focus on issues other than CAUTI even easier.

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.
Monday, July 11, 2016

Invincible food, vulnerable father and son

One of the regional supermarket chains in my part of the world, in fact the very one my family shops most often, routinely markets pizza in their TV commercials. The very point of TV commercials for a retail supermarket is to get people into the store, and this strategy must work for them, or the commercials would stop running. TV time is expensive, and businesses that spend their cash on things that don't earn back more than they cost don't tend to last very long.

So marketing this pizza must work, presumably both to sell the pizza itself, and to get people into the store, where they buy other things, too. Soda, for instance, to wash the pizza down.

This particular pizza, and the marketing campaign in which it figures, are both noteworthy in a variety of deeply disturbing ways for anyone who has heard the rumors about the state of either public health (i.e., epidemic obesity, epidemic diabetes, etc.), or the planet (i.e., climate change, water shortages, habitat destruction, etc.). You see, it is not just any pizza.

The pizza in question is called the In-Vince-Ible pizza, presumably both because it is just too “good” to be beaten by any other pizza, and because it is fronted by Vince Wilfork, a NFL defensive tackle currently with the Houston Texans, but known and loved here in Connecticut for his 11-year-run with the New England Patriots. This pizza is the younger sibling in the franchise, expanding the brand established with the In-Vince-Ible sandwich.

The sandwich features a pound of meat, comprising ham, pepperoni, hard salami, and capicola ham. The pedigree of the meats in question is not provided, but given the prevailing norms, one presumes that both cattle and pigs were harmed in the making of this meal. The on-line ad campaign acknowledges that customers might want to share this mega-meal, but more or less taunts them to eat it alone. I could not find the nutrition details for the sandwich anywhere, but since the meat represents some 700 calories, and then there's the whole loaf of Italian bread, the cheese, the mayo and the rest. It is clearly more than a full day's supply of food for many in the target audience.

The pizza has a similar profile, representing carnage in the service of carnivorous palates. It, too, features ham, pepperoni, hard salami, and capicola ham, and differs from the sandwich perhaps mostly in its geometry, and by placing a somewhat greater emphasis on cheese.

My concerns here are the obvious ones; let's start with epidemiology. We do, indeed, live in a world of rampant obesity and chronic disease, both fueled by dietary misdirects and excesses of just this sort. Despite the cottage industries in propagating doubt about the fundamentals of diet and health, or the links between a typical American diet and all manner of adverse outcomes, there is no legitimate doubt.

You remember the arguments that cigarettes couldn't really, reliably be implicated in lung cancer, don't you? Those arguments were made by the companies selling tobacco, and scientists they hired to prevaricate on their behalf. You've heard of the Merchants of Doubt, right? I trust you realize that no industry has an exclusive contract with the mercenaries of pseudo-science. They stand ready, apparently, to help obscure the truth about any given field.

Where the likes of this pizza and sandwich, and soda and donuts and French fries are introduced, health is devastated, and in short order. Where just this sort of fare is removed to make way for more vegetables, fruits, beans, lentils, whole grains, nuts, seeds, and water when thirsty, the improvements in health are stunning. Where this sort of dietary debauchery was avoided in the first place, if only by cultural happenstance rather than foresight, longevity and vitality tend to be rather enviable.

As disturbing as the epidemiologic implications of a pound of processed meat for lunch are, a more intimate view of this matter is in some ways even more so. According to his official “specs,” Vince is 6’2” tall, and 325 lbs. That gives him a BMI of almost 42. I have no doubt Vince is monstrously strong and has a lot more muscle than the rest of us, but it does not require a metabolic chamber to ascertain his severe obesity even now, as he continues to play the game. Studies show that the “eyeball test” differentiates fat from muscle nearly as well as fancy measures of body composition. Meaning no disrespect whatever to Vince, an especially perspicacious eyeball is not required to see that his health is in peril. There are plenty of images on-line; search them and see for yourself.

So, do we not care that Vince is severely obese even during his career as a professional athlete, to say nothing of what will become of him when he stops playing? The movie Concussion, and other high-profile attention to CTE has us all concerned, and rightly so, with the blows football players take to the head in service to their craft, and our entertainment. The obesity and metabolic mayhem to which they are subject in retirement may exact a greater toll, yet be too mundane in our culture to garner much concern, let alone figure in a feature film. Thankfully some insiders are attending to it, notably former NFL player Jamie Dukes.

I'll just go ahead and say it: I am worried about Vince. He seems like a nice guy. I very much suspect his health is a ticking bomb, and retirement will markedly trim the fuse.

As a father, preventive medicine specialist, and the founding editor-in-chief of the peer-reviewed journal, Childhood Obesity, I confess to even greater concern about Vince's young son, who also figures in the ad campaign. We look on as Vince encourages his son to eat like a man. Alas, this young boy is learning to eat in a manner that threatens to give his generation a shorter life expectancy than ours, and to situate him in a population where nearly one in two adults is diabetic, and he likely among them.

And yet, we are all, apparently, OK with this. Such is the influence of culture. If our culture tells us it's fine to market even to children the very products most certain to steal years from their lives and life from their years, a population of decent, loving parents and grandparents manages to look on and feel no outrage. The case for a collective trance is not far-fetched.

And all of this says nothing about the environmental costs of that pizza and sandwich. Although, inevitably, there is some pushback from scientists with direct ties to the industries affected, the consensus among experts the world over is that the implications of meat-centric diets for everything from climate change, to water consumption, to biodiversity is nothing less than calamitous. Even one of the founding fathers of our Paleo diet understanding asserts, and forcefully, that nearly8 billion Homo sapiens simply cannot be substantially carnivorous and expect to stick around.

James Cameron has aptly noted that a society subordinating public and planetary health alike to profits from the customary practices is sleepwalking off a cliff. But maybe we are awake after all, and passing the pizza under the pigskin's good-time halo, too bemused to notice the precipice, and our looming doom.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
Friday, July 8, 2016

Hippocrates and the Internet

The Hofstra Northwell School of Medicine recently graduated its second class. The commencement was a wonderful “feel-good” event, complete with beautiful weather, happy graduates and proud families. The ceremony closed with the newly minted physicians rising to their feet and reciting the oath of the physician. In a nice touch, the other physicians in the audience were invited to renew their commitment to the profession by joining in. I found the whole thing joyous, and the opportunity to publically take the oath again was a moving reminder of what doctoring is all about.

Coincidentally, I also had the opportunity this week to lead one of the sessions in Northwell's Physician Leadership Development Program, part of a half-day session withSven Gierlinger, our organization's Chief Experience Officer, and Jill Kalman, the Medical Director of Lenox Hill Hospital, devoted to the voice of the patient. My bit was about our “transparency project“ to publish our physicians' patient experience scores on our public website. I used the story of how and why we did that as a case study that tied together the themes of physicians driving change and of improving the care we provide to patients and their families.

It was only after the fact that it occurred to me that there was a profound connection between the 2 events.

First, the oath specifically references the value of a therapeutic relationship between the physician and the patient, stating that “there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.” Our efforts to elevate the importance of our patients' experiences, and to encourage our physicians to improve them, is built on this. It is not “just” about providing a better experience; it is that a better experience is integral to healing. On the other hand, that part was not new. I had always known that Hippocratic Oath contained language of this sort.

It was really the next line of the oath that revealed another connection that I hadn't appreciated before:

“I will not be ashamed to say ‘I know not,’ nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.”

Translated to a contemporary context, I take this to mean that we owe it to our patients to honestly report our personal limitations. Put another way, our professional oath as physicians demands that we be transparent about our performance, even if that means that we are called upon to share information that is not flattering. That is exactly the approach we have taken in sharing our patients' ratings and comments—warts and all— for everyone to see.

I suspect that our new graduates, all of whom grew up in a world connected by the Internet, saw these connections before I did.

What do you think?

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.
Thursday, July 7, 2016

Good personal service versus the cookie-cutter approach

A couple of weeks ago I visited the island of Cyprus with family. Having seen a lot of mainland Europe over the last several years, I was keen for something a bit off the beaten track and away from a major city. We thought about a few possible destinations, but opted in the end for Cyprus (partly because of the desperate need for some warmer weather).

Booking the trip quite rapidly, as the Internet now enables one to do, I initially booked with a tried and tested hotel chain, albeit a pretty well-respected one (no names mentioned). However, upon our arrival to Paphos, the capital, we realized that the hotel we booked was not in the location we thought it was. After a slight panic and flurry of activity on my smartphone at the airport, we instead settled on a lesser-known hotel with some help from the information booth. This hotel would be much more convenient, and the old hotel was kind enough to allow us to cancel without incurring any penalty fee. I was a bit nervous about not going with a brand name hotel, especially with it being Cyprus, away from mainland Europe. However, the new hotel appeared to have some good reviews—although was not quite in the same class as the one we had previously booked.

I quickly realized that any fears I had were totally unfounded. Upon our arrival, we were immediately greeted by the friendliest of doormen. He seemed pleasant, sincere and eager to please. The front desk reception staff were equally welcoming, and despite us finalizing the booking only an hour before, they gave us some complimentary refreshing lemonade as soon as we checked-in, encouraging us to sit down and relax for a couple of minutes in their spacious lobby. We were then showed to our room by the doorman, who went above and beyond in talking to us, seeing if we needed help, and getting us set up with everything in our room (he fully deserved the generous tip we gave him).

The room was excellent, and the stay exceeded all my expectations. Throughout it, little personal touches were added like delivering fresh fruit to our rooms, offering additional help when we needed it, and advising us on what to do and where to go during our stay. All, I should add, at a much cheaper price than the hotel we had originally booked!

The main lesson I drew from this experience—and I do want to bring this back to primarily being a health care blog—is that there's absolutely no substitute for personalized, genuine and unique service. As someone who travels a lot, I usually always tend to default to the bigger hotel chains (perhaps that's my bad for not being adventurous enough). But never have I received service such as in Cyprus, from a hotel that was and not bogged down by being a brand name and having the “cookie-cutter” mentality that pervades most of the corporate world. As good as those bigger-name hotels may be, they just aren't unique and personalized in the same way.

As the worlds of business and medicine increasingly interlock, it's worth remembering that healthcare in particular is an arena where a cookie-cutter approach will actually tend to produce the worst service and experience for our patients. It may work for certain protocol-driven practices, but insofar as humans are concerned, and how we perceive our experiences—it does not. The reason is quite simple and healthcare administrators should take note: Human beings are not cookies, who can be defined by a 1-size-fits-all approach. We value personal interactions and individualized care. And that's what any health care system also has to promote.

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.
Wednesday, July 6, 2016

Incentives without forethought

“In life, as in chess, forethought wins.”
—Charles Buxton

Long time readers know that I worry greatly about the incentives in our health care system. “Every system is perfectly designed to get the results it gets.” But here is the problem. Few managers and leaders think through the implications of their incentives, explicit or implicit.

Farnam Street Blog has a brilliant post on incentives, titled, “Incentives Gone Wrong: Cobras, Severed Hands, and Shea Butter.”

As you read this post, you will quickly recognize that the incentives get created without including any forethought about what could go wrong. Gary Klein's pre-mortem exam process can potentially help us design systems.

We have many examples of forethought deficiency in medicine. The Resource-Based Relative Value Scale and the Relative Value Scale Update Committee represent a classic example. This system is harming medical care through incorrect incentives. The current implementation of electronic health records represent another great example. Performance measures have significant unintended consequences. Richard Byyny has a wonderful piece about these problems in The Pharos, “Time matters in caring for patients.”

Thinking ahead is difficult. Wrong decisions occur because the decision makers think through problems in a shallow fashion. Politicians provide the classic example of shallow thinking. The Centers for Medicare and Medicaid Services looks for quick fixes to complex issues. Their solutions look good to the politicians, but they rarely have the results that they predict implicitly.

Medical care is very complex. Too many systems (political, insurers and researchers) want to measure our care and rate physicians or organizations. They often suffer from shallow thinking.

Incentives must work – and paradoxically they do. However they often do not give the imagined result. Clearly, we need more careful thinking as we develop rules that impact how we practice medicine.

This problem has no easy solution. While he was a despicable person, H.L. Mencken does have an important quote here, “For every complex problem there is an answer that is clear, simple, and wrong.”

We have to make this argument widely. If we understand the complexity herein, we have a responsibility to make these concepts well known. Any redesign of health care systems must include very careful forethought. Unfortunately, forethought is rare.

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, July 5, 2016

Even with the Hawthorne Effect, hand hygiene compliance still hideous

A recurring theme has emerged in hand hygiene science: When you really look, compliance is very, very low. A study 5 years ago reported that compliance was below 10% when hidden video monitoring was utilized. Our group has quantified the impact of the Hawthorne Effect, improved behavior when subjects know they're being observed, on hand hygiene compliance. In a multicenter study, we found that both measured exit and entry compliance increased the longer direct observers remained on the unit.

There is a report of a new APIC abstract in ABC-News that further quantifies that impact of the Hawthorne Effect and highlights the lack of investment in hand hygiene programs. Investigators from Santa Clara, California compared compliance measured by well-recognized Infection Prevention nurses, to observations collected by unknown high-school and college-aged volunteers who were trained to use the same surveillance methods. Here are their findings:

The investigators found that hand hygiene compliance rate observed by IP nurses was about 57%, while hospital volunteers, who tended to blend in and not be recognized as hygiene auditors, recorded rates of about 22%. While this phenomenon has been noted before, the team at SCVMC was surprised by the stark gap, and they have launched a series of interventions to try and drive their compliance rates higher and higher.

So, what do I make of these findings? First, even 57% is too low. Second, hospitals and health care systems continue to throw hand hygiene programs under the rug. We are much happier to report compliance rates of 100% collected by nurse managers on the floor (or compliance of 57% by recognized IPs) and ignore the problem than spend time and money detecting compliance rates of 22%, which would then require additional investments in proven hand hygiene interventions.

Any administrator who thinks compliance in their hospital is higher than 70% or 90% won't invest in hand hygiene programs. Since hospitals are happier to report compliance of 90% to the Joint Commission, we also won't invest in technological and socio-adaptive interventions that will finally improve the safety of our hospitals. We must work to create a safety culture where it is better to report hand hygiene compliance of 20% than falsely high compliance rates of 90%.

Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands). This post originally appeared at the blog Controversies in Hospital Infection Prevention.
Friday, July 1, 2016

Sound familiar?

I am reading a really interesting book entitled Team of Teams written by (naturally) a team, which includes retired United States Army General Stanley McChrystal. McChrystal, you may recall, was the commander of U.S. and coalition forces in Afghanistan before he got sacked for comments he and his staff made to a reporter for Rolling Stone. Prior to taking command, he served as the head of U.S. Special Forces in Iraq during the Sunni insurgency, and this book is about how he and his deputies restructured that “Task Force” to meet the unprecedented challenge they faced.

Early in the book, he discusses the rise of “efficiency” as an organizing principle for industry and, by extension, other forms of human endeavor. He tells the story of Frederick W. Taylor who, late in the 19th century, introduced the idea of organizing activities in a factory so that the workers could produce “more, faster, with less.” Taylor also popularized the means of doing so by standardizing processes to reduce wasted time and effort and by optimizing each element of production. He was, one could say, the Lean production maven of his day. Here's the passage from McChrystal's book that really caught my attention, describing Taylor's experience in a factory in 1874:

Taylor became fascinated by the contrast between the scientific precision of the machines in the shop and the remarkably unscientific processes that connected the humans to those beautiful contraptions. Although the industrial revolution has ushered in a new era of technology, the management structures that held everything in place had not changed since the days of artisans, small shops, and guilds: knowledge was largely rule of thumb, acquired through tips and tricks that would trickle down to aspiring craftsmen over the course of a long apprenticeship.

That transformation from artisanal workshop to organized enterprise, and from “tips and tricks” learned through apprenticeship to standardized work that can be specified and taught, sounds to me exactly like what medicine is going through today. In fact, the changes in medical practice that have been advocated as the pathway to better, less expensive care have been described using the very same language.

McChrystal's book goes on to document how the “efficient” model of military organization had to be reconsidered and redesigned to successfully confront and defeat an enemy operating in an unprecedented, technology-enabled, networked way. In doing so, it is a cautionary tale about the utility of the factory model in a changing world.

I think we should be similarly cautious about the slavish devotion to efficiency, standardization and optimization in our own complex, rapidly changing, technology-enabled, networked world of medicine.

What do you think?

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