Wednesday, August 31, 2016

Should doctors lie for patients?

Even the most honest among us do not tell the truth all of the time. We are flawed human beings. We covet, we gossip, we steal, we lie and we stand idly by. You don't think you steal? Have you ever “borrowed” someone else's idea and represented it as your own?

A few weeks before I penned this, I was presented with 2 opportunities to lie in order to save a patients a few bucks. The first patient wanted a refill for her heartburn medicine, which she takes once daily. She asked if I would refill the medicine to take twice daily, so she could get double the supply for the same price. The second patient asked me to write a note that he was at risk for Hepatitis B so that he could get the vaccine for free. Writing the note would be easy, but claiming that he faced risk of Hepatitis B infection would require some prevarication.

I'll assume that Whistleblower readers know how I responded to the above 2 issues. However, many patients, and perhaps some physicians, who are so harassed by insurance companies and an uncaring medical bureaucracy are looking for any measure of relief when they can grab it. Many of them have risked rising blood pressures and panic attacks trying to talk common sense with insurance company “customer service” representatives, who have less medical training than hospital housekeepers, about getting their medications approved. I've been down that tortured road more times than I can count, and I feel their pain.

I routinely receive disability forms for patients who are seeking this benefit. I advocate zealously for every patient who has a legitimate claim for any benefit they are entitled to, often making the phone calls with the patient seated beside me. There are occasions; however, where no matter how hard I squint at the patient's chart, I just can't discern any medical evidence of a disability. Sometimes, I haven't seen the patient for years. (Often, disability forms are sent to every physician the patient has seen, so some of these physicians are not appropriate targets.)

Ethical quandaries can be tormenting. Let's say a patient is sent to me to evaluate constipation. A colonoscopy is scheduled. Since the procedure is diagnostic to evaluate his symptom, he will have to pay much more out of pocket than if the procedure is coded as a routine screening colonoscopy. Should I slightly adjust my coding to help the guy out?

It doesn't take much effort to rationalize siphoning a few bucks from insurance companies that many of us think deserve it. Somehow, we don't regard this theft as we would shoplifting or stealing a neighbor's TV.

I could state here that I respect medical insurance companies because of their unwavering devotion to protecting our health and serving the greater good. But, I'd be lying.

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, August 30, 2016

Jeopardy

ˈjepərdē/

noun

danger of loss, harm, or failure.

Two weeks ago, I did something that I have never done in my entire medical career. Had I come close to it before? Yes. And is it something I probably should have done a few times in the past? Definitely.

So, what was it that happened, you ask? Well, I'll tell you. Um, yeah, I'll tell you even though, after 20 full years of not doing this, it's pretty hard to actually confess. I, I, sigh. Okay. I, I, I, whew.

I. Called. In. Sick. *squeezes eyes closed and turns head so you won't look at me*

Yup.

It was the week of our interns' orientation in the hospital. Those first few days had gone just fine and at the end of the hustle-bustle of a particularly crazy afternoon, I popped by a casual eatery to grab a late lunch. And that part was fine, too.

Yep.

It wasn't until about an hour and a half later that I began feeling this cramping sensation in my midsection. My tumbly became rumbly and before I knew it, I was in and out of the restroom doing what the Grady elders (and my daddy) refer to as “running off.” Somehow I managed to get a long enough window to get over to get the kids from their camps but admit that I sprinted from my car to the front door.

Thank goodness I did.

And you know? The running off part I could mostly deal with. I mean, I was hydrating and such and told myself that if there wasn't anything in my gut, the “running off” would eventually “run out.” But then came the nausea. And then came the vomiting.

Uggh.

And so. I pretty much spent the next several hours trying to decide which end of my body to aim at the commode. I tried all those home remedies like ginger ale and the non-home remedies, too, like antiemetics and antidiarrheals. But mostly, this was something that was just going to have to run its course. Literally.

I didn't catch a wink of sleep until about 4:30 that next morning. My alarm went off at 6 a.m. and I just sort of stared at it for a few beats before silencing it. Finally, I sat up on the end of the bed and prepared to treat the day like any other Thursday. I grabbed a t-shirt and a pair of sweats, pulled on some socks and shoes and prepared to walk Willow. And that was fine, too.

Well, I take that back. It actually would have been fine if I wasn't lightheaded from my certain dehydration and on the verge of vomiting the remains of the Canada Dry ginger ale and the electrolyte drink that I'd carefully sipped all night. After only two steps toward the door, I felt my belly churning again. But still, I grabbed the leash (and my tummy at the same time) and took Willow for what I am sure was the least gratifying dog walk ever.

You know? I didn't even think to wake Harry and ask him to take the dog out instead. Even though I knew he would have, I didn't. Then, when I came back inside, I stood staring at the medicine cabinet and trying to decide which concoction would allow me the best chance at not barfing all over a patient. Or passing out on them.

Yeah.

But somewhere in the middle of all of that, I spoke out loud even though no one but me was awake. “I really, really feel like shit.” Which, I am sure, is exactly what I said. Followed by a dry heave.

And right then and there, I had an ah hah moment. I recalled all of the times I've told countless residents that self-care is essential. Even though, particularly when it has come to personal illness, I've never given my health priority over going to work.

Nope.

It dawned on me that if I were advising any of my students or residents, I would tell them to immediately contact a supervisor in order to afford that supervisor as much time as possible to cover the clinical duties. And then I'd tell them to drink, drink, drink fluids like crazy and get in bed under the covers and get some legit rest. And/or seek medical attention if it is even more serious.

But for myself? Chile please.

So with my dog at my feet wagging his tail and me hunched over the kitchen sink on one elbow out of fear of projectile vomit, I made up my mind to do the unthinkable. Yes. I decided to call in sick.

Um, because I was. Sick, that is.

Now. I tried as hard as I could to recall a time ever in my career that I'd done that but came up with nothing. And I think I came up with nothing because that adequately represents how many times I've decided to stay in my household infirmary versus crappily do my job while ill. And how many times I acknowledged that I was too unwell to work.

I blame jeopardy. Confused? Okay. Let me explain.

At nearly every residency training program, there is this back up schedule that is designed precisely for moments such as these. And you know? Nearly every residency training program calls it by the same name: JEOPARDY.

Yup.

So when one is sick, they call the chief resident or schedulers or whomever, and that individual refers to the “jeopardy schedule” and notifies some unlucky soul who, up until that moment, was basking in an awesomely easy assignment. Only to be thrust into the firing line of some essential patient care situation such as the intensive care unit, hospital service, or something else even more hellacious. And yeah, it's exactly as sucky as it sounds when you get called.

Yup.

Similar to, say, jury duty, everyone knows that the jeopardy schedule is everybody's necessary civic duty. That is, in the resident community. But, just like jury duty, it isn't one of those things anybody is particularly pumped up about getting notified about. But physician jeopardy is more complicated than that.

Totally.

When I was a resident, we had this longstanding culture of bravado when it came to toughing it out through illness on the job. And I can't say that it was because our program leadership wasn't supportive of our personal needs. It was just this thing that sort of happened, you know? Most of the time they had no idea.

Nope.

Well, I take that back. They were supportive when a person actually endorsed being ill as a reason to call off. But because they came up in the same system, I can't ever remember anyone insisting that someone leave back then. Go lie down for a few moments? Sure. But full on leave and cause another resident to be called in? Never.

Oh, and before I go further, I will say that there is always this teeny, tiny subset of individuals that call jeopardy 200% more than anyone else in their entire program. Most notable was this girl who had taken 2 Benadryl on accident and called in because she was afraid she'd be drowsy. (Me countering her with the half life of Benadryl, which she'd consumed 4 hours before, didn't seem to make a difference.)

Anyways. The vast majority of my resident colleagues worked when ill. Furthermore, there was this esprit de corps between us that caused us to rally around the sick guy and fill in the gaps. (Forget the fact that everyone was getting exposed to whatever illness the person had.)

Uhhh, yeah.

A few times stand out in particular. One was my junior year when I was taking call in the cardiac care unit (CCU.) I came down with fever, chills and a terrible headache. My neck was tight and I had some nausea and diarrhea, too. It was the summer and I had just come off of the pediatric inpatient service where kids with aseptic meningitis from enteroviruses was rampant. I even had a tell-tale viral exanthem (rash) to go with my constellation of symptoms. And you know? I was 99.9% sure that viral meningitis was exactly what was going on with me.

Maybe even surer than that.

I called one of my classmates (who was also on call) and asked him to come examine me in the nurses station which he did. “Dude. You probably got viral meninge. You gonna go to the ER and let a second month intern do a spinal tap on you?” He bit into the room temperature honey bun he was eating and laughed at his own joke.

“No way, dude. Did you see my rash?” I asked while pulling up my sleeve.

“Cool,” he replied. “So what are you gonna do?”

“I think if I take some Motrin, I can make it through the night.”

“Yeah, probably so.”

And I am not kidding you. This is what happened. I took the call, fever, stiff neck and all.

Super stupid. Especially since it could have been something far more serious.

That same friend called me the following year (when we were both on call again) to check him out in a call room. He'd developed some shaking chills and a nasty, rattly cough rather suddenly. When I got there, he was breathing super-fast. “Dude! Holy shit. You look like you're about to code.”

“I feel like I'm about to code.”

I listened to his lungs. “Yikes. You've got signs of consolidation. This looks like a bad pneumonia. And that history, man! You might have pneumococcus, I think.”

“Hmmm. Cool. Think I can tough it out?”

“You're breathing pretty fast, bud. Let's go to the PICU nurses station and pop a pulse oximiter on you to see if you're hypoxic.” Which is exactly what we did.

Guess what his oxygen saturation was? 82% (96-100% is normal.) Craziness.

Let me tell you. This guy? He looked sick-sick. It was NOT a soft call. At all. That said, I am convinced that were it not for the whole needing oxygen thing, he would have slugged it out through that call with his pneumonia.

Yup.

Would you believe that he got admitted to the hospital that very night? And you know? We were so entrenched in that culture that I can remember like yesterday cracking jokes in his room about him spreading TB to the interns and telling him that I was totally going to present him in morning report the next day.

Which he found funny, too. That is, when he wasn't nearly about to code.

Uh, yeah.

I blame this word “jeopardy.” The actual definition means “danger of loss, harm or failure.” I can't think of anyone who has ever wanted to be the one responsible for putting someone in that situation--that is, one involving jeopardy. Especially another overtired resident who finally, finally, finally is on a lighter work assignment.

But see, that word just underscores the culture. It sounds heinous, punitive even. And to tap into it literally puts another person in peril, if you follow the definition. And I think that's a part of the problem, frankly.

The one time I called jeopardy as a resident was when my father had a massive heart attack requiring emergency surgery. And you know what? I actually took call all night before taking a flight out, now that I think about it. We also have a jeopardy schedule (also called “jeopardy”) in my current faculty position and you know what? The one time I called jeopardy with this group then was on November 15, 2012--the night my sister Deanna passed away.

Yup.

So yeah. I am reflecting on all of this and realizing that doctors who neglect themselves really aren't the best physicians at all. Coming to work while truly ill puts patients in danger, can make things worse and it probably increases the chance of an error happening.

Now. Do I think folks should be calling off for sniffles or allergies? No. Do I think taking two benadryl should allow a rain delay at best but not a full on call off? Damn right. But do I believe that a vomiting, diarrhea-ing, teeth-chattering person should have another able physician working in their place? Definitely.

If you ask me (though no one did) the first step is changing the name. Instead of calling it “JEOPARDY” it might be better to refer to it as “FAMLY EMERGENCY/ILLNESS PATIENT CARE BACK UP.” This way, those who need it will understand when it is to be called. And those who get called will feel okay with being called in.

We could even call it “FEIBU” (pronouced FAY-BOO?) for short. As a reminder that this is for FAMILY EMERGENCIES and ILLNESS when back up is needed. And that FAMILY EMERGENCIES and ILLNESS happen and aren't a sign of weakness at all.

Mmmm hmmmm.

Oh, and the times that folks get pulled in because of human scheduling glitches NOT due to the needs of a colleague dealing with a FAMILY EMERGENCY or ILLNESS? Well. Keep right on calling those times ”jeopardy.”

Ha.

So yeah. I acknowledged that I was ill and called off the other day. My colleague Stacie S. was great and made sure I didn't have to feel guilty. And my other colleague Alanna S. was super kind about picking up my slack in the resident clinic that morning. And you know? I think if my patients knew of my decision, they would have appreciated my choice to call off, too.

And so. I drank fluids and rested in my bed all day. That photo is proof that I was exactly where I was supposed to be, too. I went through a whole lot of hand sanitizer and considered going to get a bolus of IV fluids at one point. But the next morning, I felt a thousand percent better which taught me a mighty lesson.

And you know the best part? Not a single patient was harmed or put in jeopardy, thanks to my decision to first put the oxygen on myself.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.
Monday, August 29, 2016

The yearly physical

“I'm going to the doctor next week for my yearly physical.”

So normal. Of course you are. Everyone should do that.

But the concept of a yearly examination of one's whole body to see if everything checks out fine is a relatively new invention and whether or not it is necessary is a very controversial question.

I just read an article by Abraham Verghese, an internist and champion of physical diagnosis, professor at Stanford University, and inspired writer, about the history of the physical exam. The idea that physicians could know more about a person than he or she could know about him or herself has only gained traction in the last century and comes partly from the invention of gadgets such as the stethoscope, the reflex hammer and the blood pressure cuff which reveal truths only to those of us skilled in their use. Enthusiasm for these has waned a bit as we have become enamored of our ability to see the shadows made by bones and such during an onslaught of electrons (X-rays), or the ability to check the levels of molecules and minerals in the fluids of our bodies, among other technological miracles. This evolution which takes us away from the bedside has also made us less confident in and also less dependent on the information we get by physically examining our patients.

We love what we can measure and correlate, and the physical exam is part of that process. If we can feel an enlarged spleen or liver, that is correlated with certain disease states, but certainly not always. If we can feel lumps in the breasts, testicles or thyroid, there may be something life threatening going on. Or not.

As doctors, we are trained in the nuances of the physical exam. I learned how to examine every orifice and surface, looking for specific abnormalities, and then developed skills over many years in understanding the wide variation in normal people. My physical exam is a conversation with my patient's body which happens simultaneously with a verbal conversation, which in itself is a kind of physical examination. How a person speaks, what interests them, how they follow the conversation are part of the neurological and psychiatric examination. As the physical exam unfolds, my understanding of a patient and my relationship with him or her deepens.

Does a physical exam save lives? I'm not sure. The definitive study will never be done. Only a small subset of what we do at the time of a physical exam has been rigorously studied and found to be of benefit. What a physical exam should entail has never been adequately worked out and there is no consensus. A pelvic and rectal exam, synonymous for some people with a “complete physical” have not been shown to have value in a patient with no symptoms in those areas. These and other parts of a “routine physical” may lead to overdiagnosis: finding something wrong that leads to more testing or treatment that does not improve or lengthen life. Nevertheless, it seems likely that a physical exam, done well and mindfully, is substantially valuable.

If it is valuable, shouldn't we all be getting one, yearly at least? Not necessarily. Plenty of people are healthy and will remain healthy without a doctor doing anything at all to them. “Health checks” were studied by the Cochrane Collaboration and found not to improve morbidity or mortality. There are a few things that would be good to check if you are feeling healthy, just to make sure all is well, though. It would be good to measure blood pressure or screen for HIV or hepatitis C for people at risk. If a patient somehow hasn't heard that it is unhealthy to smoke and be inactive and morbidly obese, ride a motorcycle without a helmet or drink and drive, it may make sense to impart this wisdom.

Medicare does not cover a general physical in the sense that most people think of it. What it does cover is a “Welcome to Medicare Physical” right after becoming insured under Medicare, which involves some screening that is important for determining risks and needs, and a yearly “Wellness Visit” which involves only vital signs and some screening tests along with advice on what is presently being recommended, stuff like mammograms, pap smears and colonoscopies. Patients are often put off by this because they don't like scripted interactions with their doctors, and doctors are put off by it because we have usually not memorized the script and some of us are not sure we agree with it.

Is a physical exam a good idea then? And should it be performed yearly on everyone? I, personally, would prefer that I have a chance to have unstructured time to physically examine and interview my patients yearly, in other words to do a physical. I would like them also to get information about what the evidence says about various screening tests and I would like that to be easily accessible in the medical record, but I don't necessarily feel strongly about being the person to offer that information. Perhaps a nurse or a health educator could do that better. I recognize that insurance companies may not cover a complete exam for a person who is healthy. For this reason, a physical exam may need to be scheduled as a prolonged visit to discuss multiple health issues. Taken as a whole, and not because it is based in scientific evidence, I favor the physical exam. I also would completely forgive anyone who preferred to skip it.

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

Who decides if medical marijuana is safe and effective?

Medical marijuana is a smokin’ hot issue in Ohio. Marijuana enthusiasts targeted our state constitution again this year with another amendment attempt, which failed. Instead, our legislature passed House Bill 523, which will legalize medical marijuana use.

As a physician, with some training and experience in prescribing medicines to patients, these marijuana machinations are medical madness. Is this how we want to bring new medicines to market?

I think it is absurd that a specific medical treatment—or any medical treatment—should become a constitutional issue. Do we want to establish a constitutional right to a specific medicine? Why stop at marijuana? Why not start circulating petitions for constitutional amendments for screening colonoscopies, mammographies, and MRIs for back pain? Patients with chronic lumbar disk issues have rights too!

The Ohio bill specifies an array of medical conditions that could be treated with marijuana, including AIDS, hepatitis C, inflammatory bowel disease, Parkinson's disease, post-traumatic stress disorder, and many other illnesses. Is it the legislature's responsibility to decide that a medicine should be approved for a medical illness? Do legislators have medical expertise? Do we want the state's Senate or House weighing in on approving a new chemotherapy agent or artificial hip?

Might I suggest with just a tincture of cynicism that medical marijuana mania has become a mite politicized? Do we want folks who stand to make money or enhance their political power from a new medicine and who have no medical expertise to be the ones with a major role in approving its use? Are cannabis con artists using a political pathway because they fear that the medical avenue will less hospitable to their objective?

Once marijuana becomes a legal product, an inevitable outcome, will enthusiasts for its medical use support vigorous testing of its therapeutic value?

I am deeply skeptical that the medical claims of medical marijuana adherents are supported by persuasive medical evidence. I remain open, however, to submitting marijuana to the same Food and Drug Administration (FDA) testing that all new medicines are subjected to. Let the scientific method with appropriate clinical studies and peer review judge the product for safety and efficacy. If approved, then the public and the medical profession can be confident that the approval was on the basis of science and not smoke. Shouldn't those who champion medical marijuana use demand this level of independent scrutiny? If not, then why not?

Yes, I have heard powerful individual vignettes describing great benefits of medical marijuana. Every physician has similar anecdotes of patients who have achieved significant benefits from unconventional and unapproved medical treatments. But, anecdotes are not science. If medical marijuana is the healing elixir its proponents promise, then prove it.

Let our politicians do what they do well, whatever that is, and leave medicine to the professionals.

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.

Pseudoconfusion about saturated fat: 5 reasons for 1 hot mess

I know, you keep hearing conflicting reports about saturated fat and health outcomes. So do I.

A colleague circulated this study, purportedly showing no association between saturated fat intake and heart disease in a cohort of Dutch adults. Except, the study also reported, rather as an afterthought, that half of all the saturated fat in question was palmitic acid, a saturated fatty acid found in palm oil, dairy and meat; and that variation in palmitic acid did predict variation in heart disease rates. Honestly, I had trouble making sense of this 1, and that's my job.

It's also hard to reconcile the gist of this new paper with a recent, rather mammoth study out of Harvard, showing rather decisively that higher intake of saturated fat leads to increased risk of early death, while increased intake of polyunsaturated and/or monounsaturated fat reduces mortality.

Since all of this has something to do with what we all choose to eat every day, and since diet is long, even anciently, established as the veritable cornerstone of health, then “hard to reconcile” and “trouble making sense” are not a good place to get stuck! We really do need to know the truth, and frankly, I think we do.

We are not actually confused, neither about the basic care and feeding of Homo sapiens in general, nor about the role of saturated fat from the usual sources (i.e., meat, dairy, certain cooking oils, and the parade of processed products incorporating and adulterating these) in our health. What is being propagated is pseudoconfusion, and I have identified 5 common reasons for it.

1) Inattention to: instead of what?

Most of the academic discourse, and attendant pop-culture chatter over recent years about the potentially unfair indictment of saturated fat for crimes against humanity traces its origins to two widely cited meta-analyses, one published in 2010, the other in 2014. They share a very important blind spot. Both looked at variation in saturated fat intake and variation in cardiovascular disease and mortality, finding no meaningful association. Oddly, though, the first of these papers, four years before the second, noted its blind spot: it had not asked or examined the “instead of what?” question. In other words, the study was completely inattentive to the foods being eaten more often when pepperoni pizza was being eaten less often, or vice versa. It noted that future studies on this topic should certainly ask and answer the critical “instead of what?” question, particularly in a society so prone to move from 1 kind of junk food to another. For reasons I've never entirely understood, the 2014 paper did not do so, again looking at variation in dietary fat and health outcomes, but not at change in overall diet pattern or diet quality.

Fortunately, a still more recent study did just that, asking when people eat less saturated fat, or more, what do they eat more (or less) of instead, and how does that affect health outcomes? The answer this time was concordant with both the weight of evidence, and just plain sense. When saturated fat calories were replaced by trans fat calories, things went from bad to worse (i.e., heart disease and mortality rates went up). When they were replaced by sugar and refined starch, as has happened so often when people “cut fat” by eating Snackwells, rates of chronic disease and premature death remained comparably high both times. But when saturated fat calories from meat and dairy were displaced by either whole grain calories, or unsaturated fat calories from nuts, seeds, olive oil, avocado, and fish, rates of cardiovascular disease and mortality went down significantly.

The bottom line: we cannot understand the implications of more or less X as a percent of our total calories, without attention to the Y that replaces it.

2) Disregard for the role of ranges

Major studies cited to show that saturated fat is “fine” now because its variation does not lead to variation in heart disease suffer from another rather flagrant limitation. They are often conducted within a given country or culture, be it the U.S. or the Netherlands or wherever else, and the range of variation in saturated fat intake is quite narrow. If you are comparing, for instance, the top and bottom quintiles of saturated fat intake here in the U.S., and the vast majority of us consume some version of the typical American diet (and we do, which is why it is “typical”!) ― then the extremes of that range are not very far apart. Yes, you can find exceptionally high and extraordinarily low intake levels here, but those disappear into rounding errors when conducting a population-level study.

How does this matter? Well, consider a study to determine if parachutes can save the lives of people who fall out of planes. Now, imagine 1 study compares parachutes that are 1 square inch in total surface area to parachutes that are 1.25 square inches in area. Would you expect to see any difference in survival rates? Of course not. But now imagine the headlines: “parachutes useless; size does not matter …”

Conversely, in a comparison of parachutes of 350 square feet (a realistic surface area) vs. 348 squqre feet, other things being equal, would you expect to see a survival difference? Again, almost certainly not. Now the headline is: “parachutes work every time, no matter how small …”

The bottom line: if variation in X is being examined to explain variation in Y, then it matters whether or not X varies much in the first place.

3) Dietary tunnel vision

Let's imagine we hear that saturated fat from, say, butter, may help protect us against type 2 diabetes, at least a bit. But, unfortunately, we also hear it appears to increase the risk of both heart disease and mortality a bit as well. In fact, we recently heard exactly that.

Yes, but, the headlines tell us: butter fat protects against type 2 diabetes! And that story goes round and round. Relative to Coca Cola and donuts, it's probably true. What's missing?

Any mention of all the foods long known to protect against diabetes and against heart disease and premature mortality overall! What foods do that? All the good sources of soluble fiber, like beans, lentils, whole grains, berries, apples, and so on. All the good sources of monounsaturated fat, like nuts, seeds, olives, and avocado.

The problem here is talking about one food or nutrient at a time, as if the rest of the diet, the rest of the food supply, and other options didn't exist. If you are at high risk for type 2 diabetes and hear enough times that dairy fat may help protect you, at the cost of other risks, you may feel as if you have no choice, and have to take your chances. Looking at diet and health outside the tunnel of that one study, however, shows choices very clearly. There are dietary patterns, foods, and food combinations repeatedly, and decisively linked not just to less diabetes risk, but better health overall. There is a pretty big difference between “this may help you in some ways and is just as likely to hurt you in others” and “this is almost certain to help you in every way.” But with any given study and any given news cycle, that critical part of understanding routinely fails to make the cut.

The bottom line: the best ways to the best outcomes routinely reside with foods and diets outside the tunnel vision of a study with a single nutrient focus.

4) Conflating lack of harm with good

This item is the cousin of #3 above. Let's say the evidence showing harms from saturated fat really is much less damning than we thought at the height of the “just cut fat” craze. It is.

The next obvious question, and one routinely neglected, is: does relative lack of overt harm define a “good” food? It hardly pays to dignify so silly a question with an answer, but let's: hell no! Food is our fuel, construction material and sustenance. It is supposed to be good for us! Lack of harm, let alone relative lack of harm, is an absurdly low place to set the bar.

So, what is the evidence that dietary patterns high in saturated fat from the prevailing sources, baked goods, processed dairy products, processed meats, and so on, produce the health outcome that matters most, longevity combined with vitality, anywhere in the world? There is none. The longest-lived, healthiest populations vary widely in their total fat intake, but they all consume diets of mostly wholesome plant foods, which tend to be low in saturated fat. In North Karelia, Finland, heart disease rates were reduced 82% and life expectancy increased by 10 years with a shift from higher intake of animal foods and saturated fat to a higher intake of plant foods and a significant reduction in saturated fat.

The bottom line: good food should be held to a much higher standard than “maybe not quite as harmful as we once thought…”

5) Neglecting the link between planet and plate

Finally, and emphatically, the day has come and gone when any of us can think about diet for health without factoring in the fate of the planet. There are no healthy people without a viable planet to live on, and prevailing dietary patterns are an even more obvious threat to the world around us than to the biological world within each of us.

My friend and colleague, S. Boyd Eaton, is one of the founding fathers of our modern understanding of the Paleo diet. Anyone who claims to know anything about that diet is effectively obligated to cite the scholarly contributions of Dr. Eaton and his associates. I defer to him on this topic.

Prof. Eaton states emphatically that we need to eat less meat, for 2 reasons, one minor, the other major. The minor reason is that most of the meat most modern people eat is nothing at all like the pure meat of wild game that was the only option in the Paleolithic. There was, as I have noted before, no Paleolithic pastrami, or bacon, for that matter.

The second, major reason, and again, this is Prof. Eaton talking, not me, is that we were isolated, scattered bands in a vast, empty world of seemingly limitless resources during the Stone Age. We are a global, marauding, devouring horde of over 8 billion now. We cannot be hunter-gatherers, and we cannot be substantially carnivorous without annihilating the very biodiversity that sustains us. Dr. Eaton thinks we can learn something from our Stone Age intake of protein, but need to translate it into plant sources, no matter how much we might like meat.

The bottom line: Dorothy, we aren't in the Stone Age anymore!

If the status quo were harmless, I could look on passively as pseudoconfusion propagates it. But the status quo is anything but. Each new lap we take to nowhere leads to a few fewer intact ecosystems; a few fewer intact fisheries; a few fewer species enriching the biodiversity of this planet; a few fewer glaciers; a few more inches of sea level; a few more days over 90 degrees; a few more droughts, and few more floods. What is threatened, ultimately, is that our home will simply become inhospitable to our kind. We are all just part of the same, single, planetary game of survival, and will win or lose collectively.

In other words, every lap to nowhere makes the mess down here a bit messier. And yes, of course; hotter, too. The risk is that we relinquish control of the menu entirely until there is just 1 featured dish: our cooked goose.

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.
Thursday, August 25, 2016

The evolution of hospitals

Once upon a time, a hospital was a place you went if you were sick. Doctors would (ideally) figure out what was wrong, offer treatment, and you would convalesce.

The longer you stayed in a hospital, the more the hospital could charge you (your insurance, really, if you had it).

This all changed in 1983, with the advent of the DRG system (it stands for Diagnosis-Related Group). Almost overnight, the incentives for hospitals changed. With DRG payment, the hospital would get 1 bundled payment for the whole hospitalization based on the patient's diagnosis. Average length of stay for hospitalized patients went from 30 days (imagine: a month(!) in a hospital). Hospital executives saw the need to minimize length of stay. Depending on the payment for each diagnosis, there would be an inflection point when a patient staying beyond a certain number of days would result in financial loss.

“Throughput” became the term of art. (Like widgets on an assembly line.)

Now the average time someone spends in a hospital is a little more than 4 days. (Of course, for mothers with normal births, this is even less, about 2 days. Many surgeries that used to necessitate several days in the hospital are now done on an outpatient basis. Length of stay in those situations: zero.)

A recent essay on this topic in the New York Times by Dr. Abigail Zuger brought back memories for me. I once had a teacher tell me, “No one should ever need to be in a hospital. Except for some cardiac conditions that require immediate care, the only people winding up in hospitals are frail elders, and those with social problems and no place to go: the mentally ill, the destitute, the homeless.” I remember feeling a bit shocked by this, but as I reflected on it, I realized he had a point. I should start with the assumption, he told me, “that almost no one really needs to be there and they're better off at home.”

The modern condition leads us to keep people in hospitals for as short a duration as possible. But something is clearly lost. As Dr. Zuger writes:”Hospitals were where you stayed when you were too sick to survive at home; now you go home anyway, cobbling together your own nursing services from friends, relatives, and drop-in professionals.”

Patients often go home feeling brutalized by all the blood draws, hospital food, and lack of sleep. Rare is the patient who says, “I feel better now. Can I go home?” Often we send them home before they feel ready.

It sounds a bit cruel, and like there's a perverse incentive at play. But keeping people in the hospital is also inherently risky. Hospitalization can cause infections, loss of muscle and coordination (especially in older folks), falls, and delirium. So getting people out as quickly as possible is in many ways the right thing to do.

The truth, however, probably lies somewhere in the middle.

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.
Wednesday, August 24, 2016

Love of my life

For as long as he could remember, she was there. From those early days sitting criss-cross applesauce on the porch shelling peas with grandmama, right along with the unmistakable scent of red Georgia clay was the hint of her presence wafting by with every humid breeze.

“I can't remember a time without that being a part of my life,” he said. And when he said it, he looked down at his hands and sighed. “I just can't.”

There was a sadness about him. This heavy cloak of melancholy that pushed against the agenda I'd planned before entering the room. See, this was supposed to be a congratulatory conversation. Me applauding his triumphant separation from alcohol.

Yep.

But as soon as I came into that room and laid eyes on him, I could feel it. Yes, this was a good thing he'd done for his health. And definitely, abstaining from Jack Daniels for 16 full months after nearly a lifetime of being his best friend is no minor feat. So, yeah. I had all these lofty plans of shaking his hand hard and telling him how great it was. Reaching out with both hands and staring deep into his eyes to let him know that I meant it.

Because I did.

But. None of that felt right once I actually sat down. His shoulders were curled inward and his expression was lonely. Like some middle school kid chosen last in the kickball lineup, the kind you immediately want to hug and defend. Yes, Mr. Caldwell had crossed the 1- year hurdle with AA and had the improvements in his health to show for it. But still. He didn't seem happy.

Nope.

I guess I'd sized him up with this assumption of what he'd be like and where his mind should be, you know? Imagining some gum chewing chap with a bunch of AA key fobs proudly telling it on the mountain that he's just taking it 1 day at a time. I was expecting a testimony of how now even the smell of alcohol makes his stomach turn a little, especially now that he's broken free of that stronghold. But that isn't what I found.

At all.

“You seem sad,” I finally said. “What you've done for yourself is so amazing. And you're doing so great, too. But you seem … I don't know … sad.”

Mr. Caldwell just stared at me for few moments without speaking. Then, instead of saying something in response, he just sighed and shrugged. His lips moved and I think he said, “Yeah,” but it wasn't audible.

“Is everything okay at home? Did something happen?”

“No, ma’am. Everything fine with my people, Miss Manning. My kids so happy I don't drink no more.” When he said that, the corner of the left side of his mouth turned up a bit.

“That's great, Mr. Caldwell!” I did my best to ramp up the enthusiasm to counter his somber mood. It didn't work.

“I'm okay,” he finally said. Then, to make sure I knew he meant it, he repeated himself, this time a little more firmly. “I'm okay.”

I leaned into my palm with my chin and squinted my eyes a bit. “You know? You don't seem so okay, Mr. Caldwell.”

And something about that—my body language and that last statement—unlocked something. I could tell. His eyes focused on mine some more and I could tell he was trying to decide whether or not to tell me something.

“Tell me,” I pressed. “Tell me what is making you so sad.”

Mr. Caldwell took a big drag of air through his nostrils, closed his eyes and then shook his head slowly. Then he just froze for a beat with his eyes still closed before parting his lips respond. “I … I just … “ He sighed once more and went on. “I just miss it is all.”

“Miss what? You mean drinking, sir?”

“Yeah. Like, I keep waiting for that point where I lose the taste for it but it ain't never happened. So when I see it or smell it or see folks drinking, I guess it just make me feel sad.”

“Hmmm.”

“Like, you know how when you was little how your main memories are tied to how stuff smell or the sounds you hear? See, that's how it is with me and drinking. Like, I come from a long family of alcoholics. But not fall down drunk and cuss you out alcoholics. Happy, domino and card playing drinkers. Shit talking and laughing. Having fun. But drinking the whole time. Even with kids around.”

The image he'd painted was so vivid that I was at a loss for words. He kept going.

“My grandmama and my granddaddy drank a lot. I was raised around them and both my parents died from problems related to drinking. So I know that it's bad for my health which is what got me to quit, you know? That time they kept me in the hospital, I knew I had to quit so I did. But I guess as time go by I'm realizing that just about every memory I have involve either me drinking or being with somebody who was drinking. Going all the way back.”

“You know what, Mr. Caldwell? I never thought of it that way.” I said that because it was true. “For you, alcohol is like an old friend.”

“Naaah. It's even more than that. Alcohol for me? She family. As much a part of my family as anything. Even when I was a kid.”

“You started drinking as a child?”

“Naw, not at all. But my auntie’nem used to sit us on the porch and braid our hair down in cornrows. My mama didn't like cutting out hair so us boys always had braids. I'd be sitting right on the step between her legs. Every so often she'd fuss at me or my cousins saying, ‘You bet’ not knock over my damn drink!’” That made him laugh. But it was fleeting. “It's funny ‘cause whenever I smell some gin, I want to cry for missing my auntie so much. That mixed with Newport menthols. And then along with the smell of some collard greens cooking with ham hocks and the sound of somebody cranking a ice cream maker.”

And that? That made my eyes sting. Partly because I finally understood what he meant. But also because I knew there wasn't really anything I could do about it. I started to counter him with some canned commentary on the health benefits of no longer drinking but none of it felt right. Instead I just twisted my mouth and nodded. Because I got it.

I put my hand on his and squeezed it. “Thank you for giving me a new perspective, Mr. Caldwell. I get it.”

Finally, he let out an unexpected chuckle. “Sometimes seem like the ones you can't get enough of don't love you back, do they? I love her but she don't love me.”

“Yeah, she's funny like that.”

“But I miss her. Every single day. Even though I shouldn't, I do. And all the people I loved though the years that's associated with her. My whole world different. My whole life different.”

“In a good way?”

“I'm alive, which is good. I ain't getting DUI charges, which is good. But just imagine if whatever it is that connect you to all your favorite people, favorite memories and favorite things, you can't do no more. Or if you couldn't be around none of it no more. It's hard.”

“That sounds super hard.”

After that we just sat in silence. Him looking directly at me, face washed over with this complicated grief, and me squeezing down on his hand with mine. I kept wanting to say something or feeling like I should but nothing was feeling authentic enough. I stayed quiet.

Finally, Mr. Caldwell sighed and gently pulled his hand back. “I appreciate your concern, Miss Manning. I do.” He began sliding his papers and medications back into his little knapsack and then pulled the drawstring closed. Patting the bag, he said for closure, “Yeah. So I guess I'm sad ‘cause it's the end of a love affair. But not just any love affair—like the love of my life.”

“Wow,” I whispered.

“Sound crazy, don't I?”

“No, sir. You sound honest.”

Yeah.

In the 20 years that I have been a physician, I have asked the same question of countless patients struggling with alcohol use disorders: “Did you grow up with any drinkers?” To date, I have never once heard a response that included anything other than the affirmative.

Nope.

This? Mr. Caldwell's story? It opened my eyes. He taught me a new layer of why it's so hard for people to let go of alcohol. And you know what else? Thanks to Mr. Caldwell, I will never look at alcohol abstention the same way again.

Ever.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.
Tuesday, August 23, 2016

How to make medicine safer

I have 2 very inquisitive sisters, and they've raised 4 inquisitive children. I give them full credit for this, although my parents must have had something to do with it, as in 7th-grade math I won an award for my “unique ability to question the trivial.”

Of course, trivial is in the eye of the beholder. Sometimes the trivial questions are the hardest, like: “What is 0?”

One of my sisters asked me a not-so-trivial question a few years ago:

“So, as a doctor, are you ever worried that you'll make mistakes?”

“No,” I answered, “I know I'm going to make mistakes.”

This is something other industries such as airlines have understood for decades. Medicine is only starting to learn what this means. Throughout our training, we are taught over and over to double- and triple-check our work. We devote hours and hours to memorizing drugs and their interactions. But we aren't taught how mistakes really happen, or even that they do. We are taught that mistakes are not inevitable, are a sign of personal failure and that only our own actions can prevent them.

This is very, very wrong.

Several years ago, a professor from Johns Hopkins, Dr. Peter Pronovost, realized that individuals make errors, and came up with an idea to improve systems so that the imperfections of individuals will matter less.

The Keystone project is simple and made immediate, measurable improvements in patient care. For example, the rate of infections of IV lines in ICUs dropped to essentially 0 soon after implementing Keystone.

And what was this enormously successful intervention?

A checklist. In brief, in non-emergent placement of IV lines, nurses are given the authority to make sure doctors follow a brief, simple checklist, and to stop the procedure if it isn't followed. The program also educates clinicians on the basics of preventing line infections and makes sure the need for an IV line is reassessed daily so that they will not be left in unnecessarily.

These relatively simple system changes have been made successfully in other hospital settings, but are not yet truly a part of medical culture.

In the U.S., medical care is fragmented. My patients often ask me why I don't have access to their electronic records. The answer is simple: Different doctors and hospitals use different systems, and these systems don't talk to each other. The technology exists, but our culture hasn't realized the importance of it.

If I were able to look up any patient of mine and see every test done, every medication prescribed, their care would be safer. But this simply isn't done, and the reason is cultural. In the U.S. we are afraid of anything that smells of “socialized medicine” and anything that might violate our medical privacy. These aren't trivial concerns, but they ignore the fact that as healthcare becomes better, it also becomes more dangerous. Detractors love to cite statistics about how many deaths in the U.S. are attributable to the health care system, but this distracts from the real problem. Modern medicine improves lives. And people in hospitals are very, very ill compared to the past.

Even when we get to the point where Keystone-like systems are the norm and sharing of medical information is automatic, people will be injured and die in hospitals because that's where we go when we're sick. People don't die at Wrigley Field because they don't go there for their cancer or heart disease.

“Have you washed your hands?” seems a trivial question, but it turns out to be life-saving. Individuals easily forget, but a system designed to ensure your compliance saves lives.

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.
Monday, August 22, 2016

Preventing cervical cancer in Tanzania

I visited Tanzania again this summer, once again helping a group of amazing University of California, Irvine medical students with their summer not-a-vacation trip to teach bedside ultrasound and do other research projects.

One of the projects this year sprung out of a request by a doctor we have worked with on Ukerewe Island. The island he serves is rural, primarily supported by fishing, and has a high rate of sexually transmitted diseases due to fishermen visiting prostitutes on the mainland and bringing home infections to their wives and girlfriends. This translates to high rates of HIV infection, pelvic inflammatory disease and the spectrum of disease caused by human papillomavirus (HPV). HPV can cause genital warts, which are only mildly distressing, but it can also set in motion cellular changes of the cervix that can lead to cervical cancer. Tanzania has a distressingly high incidence and death rate from cervical cancer and this Tanzanian physician asked one of the students if we could do a project that would help reduce cervical cancer.

The high mortality and incidence of cervical cancer in sub-Saharan Africa can be (and has been) addressed in many ways. Primary prevention would involve using condoms or maintaining celibacy or reliable monogamy. We have a vaccine now that can prevent persistent infection, but it is still very expensive and not used much in resource poor countries like Tanzania. Pap testing is the method we use in the U.S. to prevent cervical cancer, and its use is widespread and effective here. It involves taking a sample of the cells of the cervix during a speculum exam, sending this to a pathologist for evaluation, and repeating that test at regular intervals. Abnormal pap tests are reported to the patient who is notified to return for further testing and eventually removal of the infected tissue if it persists. The abnormal tissue is visualized by applying acetic acid to the skin of the cervix, then using a cervical microscope or colposcope to either biopsy, cut or freeze away abnormal tissue. In most of Africa this is not even vaguely practical since women go to the doctor infrequently and speculum exams are not often performed. It is not always practical to contact people by phone, and they often come from far enough away that returning for multiple visits to deal with an abnormal pap is not likely to happen. In addition, were physicians to start performing regular pap testing, there are not enough pathologists to process the specimens.

About 10 years ago I read an article in one of the large medical journals which described an abbreviated screening test for HPV infection in which vinegar (acetic acid) was applied to the cervix, abnormal areas that looked HPV infected were identified with the naked eye and those areas were simply frozen, destroying the infected and precancerous tissue. This sounded amazing. Since then this procedure has become well accepted, though certainly not universally available, to people living in many African countries. The World Health Organization has studied it and pronounced it to be practical and recommends it for resource poor settings.

The students heard about an organization, CureCervicalCancer, which teaches healthcare workers visual inspection with acetic acid (VIA) and supplies a gun which can deliver compressed carbon dioxide (available in poor countries because it is used to make soda pop) to the infected tissue of the cervix, to freeze it off.

This year several people affiliated with Cure Cervical Cancer came to Tanzania with us, trained Tanzanian MD and non-MD healthcare workers to perform visual inspection and cryotherapy and gave them supplies they would need to make the service ongoing.

The idea of being able to provide that kind of immediate and practical service was very exciting. I just thought it wouldn't work. Doctors and nurses in Tanzania are so overworked that I doubted they would come for a few days to learn a new technique. I also thought that a pelvic exam using a speculum would be a VERY hard sell for women who have never had a pelvic exam, especially since they would be feeling fine. I thought that the doctors wouldn't have time to continue to do these exams after we left. It turns out I was wrong: health care workers were enthusiastic and attended the trainings and women lined up for testing.

The first day we had fewer patients than the leaders felt was acceptable, about 60 patients total I think. So the students who knew Tanzania from previous trips made flyers which they handed out, used their large word of mouth network and finally hired guy in a truck with a loud speaker to drive around the streets advertising the free clinic. The next two days doubled or even tripled the number of patients screened! Several cases of HPV infection were seen and treated and a few early cervical cancers were identified and referred for likely surgery.

This project may persist. They were able to train people from the city of Mwanza as well as Ukerewe Island and they promise to continue to do screening after we leave, free of charge. We shall see. There is some kind of audit planned for 6 months out. Clearly more nurses and doctors need to be trained to do this. This is clearly the right kind of screening to do in this setting and may reduce the burden of cervical cancer. In our screening clinic the host hospital also offered free HIV screening which was fantastic since treatment of HIV in Tanzania is free. Cervical cancer is more common and more aggressive in HIV infected women, so combining the screenings is really powerful.

I think this will help. I do have some reservations, though. In the US, 80% of people will be infected with HPV during their lifetimes, and the vast majority will kick it and have no ill effect. At any one time, I've read, 10% of women will have HPV infections. Only a fraction of the types of HPV that are out there are able to cause cervical cancer. The point here is that all HPV infection does not necessarily need treatment. We don't have evidence yet that VIA with cryotherapy saves lives, though it seems likely that it will and there have been mathematical models that evaluate this. VIA is, though, a sustainable method to treat HPV infection early and thus to prevent late sequelae including cancer Clearly real prevention of infection would be the most valuable intervention in prevention of cervical cancer. This could be by vaccination, if the vaccine were affordable, or use of condoms to prevent transmission of infection. More important even than that would be changes that allow women to have more control of what happens to them sexually. This will require improved education and economic opportunities so that women have value in the society outside of their roles as mates and mothers.

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.

Do new medical interns in July threaten patients?

Would you have elective surgery in the nearby major teaching institution on July 4? Why not, you wonder?

Prowling around the hospital wards every July are the fresh faced interns wearing starched white coats, with stethoscopes draped across their shoulders, with pockets stuffed with reflex hammers, K-Y jelly, and various cheat sheets to rescue ailing patients.

These guys know nothing. How do I know this? I was one of them. Luckily, I knew that I was clueless and never pretended that I could treat athlete's foot or even a splinter.

Imagine you are in a hospital bed in early summer complaining of chest discomfort. Your nurse summons the intern who speeds into your room peppering you with questions. Before you finish your answer to a question, another question erupts. This physician is barely out of his shrink wrap and is understandably anxious that he is witnessing an impending cardiac catastrophe. With his spanking new stethoscope, he establishes that there is a beating heart nestled inside your chest. Your heart rate is high, most likely as a result of anxiety from witnessing the intern's state of near panic. I'm sure you will calm down when he whips out his Tips for Chest Pain Cheat Sheet which he will use to treat you.

Teaching hospitals have an important teaching mission. This is the venue where physicians learn their trade—on real patients. New interns start in July and they know nothing. Sure, there are multiple levels of supervision over them, but these many layers can cause gaps and vulnerabilities in patient care. The supervising medical resident, himself with only a year or 2 of experience, has several interns he is responsible for. He can't be with every intern every minute. Sure, the intern can always call for help, but what if he doesn't know that he needs help?

Patients at teaching hospitals enjoy many advantages. There is often state of the art equipment and a renowned faculty. They claim that with so many physicians of different hierarchical levels seeing patients, that this built-in redundancy catches errors and oversights. This may be true, but as I have expressed, it is also a cause for miscommunications, excessive medical diagnostic testing, errors, exploding costs, and gaps and lapses in care.

Imagine you are admitted by your internist and a cardiologist and a gastroenterologist are both consulted, a very common scenario. Each of these 3 physicians has his own team of fellows, residents and interns. You could be seen by 10 physicians in a day. Communication lapses are expected as it is not possible for all of these physicians to know what all colleagues on the case are thinking and planning.

Contrast this with the situation in a community hospital, such as the ones I practice in. There are no interns, residents or fellows. I perform my own history and physical examination and take ownership of the patient. I communicate with the nurses and other physicians on the case personally. While this system is not perfect, there is much greater accountability to the patient. There is no one I delegate to. There aren't layers of doctors pushing their own agenda to the extent there is in a teaching hospital.

Our mission in the community hospital setting is patient care, not physician training. In my experience, having been in both types of institutions, I think community hospitals have an intrinsic quality advantage. Teaching hospitals would argue this point. I don't think it can be argued, however, that there are conflicts of interest in teaching institutions as patients are exposed to excessive medical care in order to provide education and training to young physicians. This is undeniable.

If a July 4 hospitalization is in your future, you can choose your local community hospital or the Medical Mecca downtown. If you choose the latter, get ready for some fireworks.

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.
Friday, August 19, 2016

The insincerity of customer service without the personal relationships

Customer service is all the rage these days in most facets of our lives. America leads the world in this area (however much the public here may take it for granted). I've traveled all over the world, and the concept of customer service in many other parts of the globe, including highly advanced and prosperous other Western nations, still leaves a lot to be desired. It's always reassuring to know in the United States that if you have genuine concerns or complaints, these will be taken very seriously by the appropriate authorities. Consumer protection laws and regulations also exist and are enforced to protect the public from unscrupulous and unethical business folk.

But as great as good customer service always feels, is there a time when we go too far to the point of becoming ungenuine, insincere and somewhat annoying?

This is particularly something to be on the guard about in health care, where administrators all across the country are banging their heads together trying to “improve the hospital experience” and “raise patient satisfaction”, without realizing that health care is very different from all other industry sectors. That's because medicine is all about personal relationships and trust. It's a uniquely emotional arena, where compassion, empathy and a caring ear are all that most people ask for. No creative handout, iPhone app or bumper sticker solution can change this, and health care administrators need to understand this.

Recently my car had an unexpected problem and wouldn't start. It ended up being towed to the nearest dealership, to fix quite an electrical ignition issue. I usually avoid dealerships if I can at all help it. In addition to always being more expensive, I don't like the “corporate” and “herd feeling” that I get from them, as opposed to “Sam's Auto Shop” around the corner. However, on this occasion I had no choice but for my car to be taken straight to the dealership.

Over the next few days, I received telephone calls from the dealership, trying to keep me updated with what was happening. As earnest as these calls were, unfortunately they appeared mixed up sometimes with what the problem was, and I wasn't entirely convinced of their thoroughness. Anyway, a couple of days and an expensive rental car charge later, I picked up my car again, fixed and ready to go. The following day, I received another message on my phone from the dealership. It was someone from the customer service department. The message was one of the most cheesiest and insincere messages I've ever heard and went something like this: “Hello Suneel Dhand … thanks for getting your car fixed by us … and we just want to call and make sure we gave you outstaaanding service!” (the outstanding was duly exaggerated in a strong salesman-like tone).

This type of message summarizes exactly what customer service gets wrong. It was from someone I've never talked to before and who likely had no idea of what was wrong with my car. It typifies the corporate way of speaking and addressing customers, rather than the good old-fashioned way of providing one-on-one service which emphasizes strong personal relationships. I see the same phenomenon in health care now, especially with the rush towards consolidation and mergers. There's no room for personal relationships any more, which is exactly what our patients (or indeed anyone) desire the most.

In previous places I've lived, including in Baltimore during my medical residency, I found great local mechanics whom I trusted and always gave me good service. They were sincere and genuine. I could call them at any time and they would always follow up with me. I remember towards the end of my medical residency when I thought a piece of jewelry had got lost in my car and fallen deep under the seat. My mechanic spent a good couple of hours trying to locate it, removing the seat and searching diligently. After he was done, I wanted to pay him, but he insisted he wouldn't charge me for it because I'd been such a loyal customer over the years. I was touched. Here was someone who had worked in baking hot Baltimore summer weather for a significant amount of time and taken the inside of my car apart, but refused to charge me. These are exactly the types of acts of personal goodwill that don't exist in corporations, who will be sure to nickel and dime you for every little thing.

While corporations may work very well in lots of parts of our economy, such as with technology (Apple) and other mass-consumer goods, there's just something that doesn't quite work with the service industry and immediately takes on an impersonal feel. Whether it's Sam's Auto Shop around the corner, your hairdresser, school teacher, and yes—even your physician—customer service is all about that personal relationship and how close and trusting you feel towards that person.

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, August 18, 2016

A living wage and paid sick leave are infection control issues

We've written often about presenteeism, workers staying on the job while they are sick, and have mentioned paid sick leave as a mechanism for keeping sick health care workers at home. A few years ago, New York City mandated a minimum of 5 days paid sick leave for all companies with over 20 workers, yet few other cities or states have similar regulations. While most presenteeism discussions focus on workers in specific workplaces, little attention has been paid to home health care providers. These individuals face significant time and financial pressures to work while sick, as evidenced by a recent Guardian article examining issues facing working mothers in Denver.

In the first of an election year series of discussion groups, The Guardian asked 5 working mothers, including 3 home health care workers, about the many barriers they face caring and providing for their families. Several quotes from the article are particularly relevant to discussions of presenteeism and infection prevention:
• “As the women discussed, they're paid less than male colleagues, they often struggle to find reliable childcare, they lack medical leave and they rarely even get paid time off”
• “I mean, I cannot miss a day of work, because I have to pay rent.”
• “They [home health care companies] don't give you benefits, they don't give gas [money], they don't pay for my mileage, and you take care of all these sick people in their homes. And then when you get home with this low paycheck, again, you're struggling. The money's not enough for us to take care of our family. No vacation, no sick pay, no benefits.”
• “All the women who were home health care aides lacked paid medical leave, which can leave both them and their clients vulnerable.”
• “When I go into people's homes, I need to be well. I take care of people with AIDS, I take care of people with cancer. They don't need to get pneumonia from me. So it's not just about me as a home care worker, it's about raising the standard of home care not only for myself, but for the people I take care of.”
• “I was sick last year with Type A flu virus. I couldn't take 1 day, and they told me to wear a mask on my face to go to my client. She's 84.”

Much attention has been paid to social determinants of health and how social and economics factors are associated with poor individual and community health. What is clear from this discussion group is that social determinants of health impact infection control through presenteeism and that no one, not even the wealthy, are protected from infections (e.g. influenza) transmitted in the community by home healthcare workers who have to work while sick to provide for their families. A living wage and paid sick leave for all workers are critically needed for infection prevention and for many other reasons, as outlined in this excellent, well-timed, discussion group.

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.
Wednesday, August 17, 2016

Dealing with obstacles

Over the past several months, I have been slowly reading The Obstacle is the Way: The Timeless Art of Turning Trials into Triumph.

Here are some quotes:

“We forget: In life, it doesn't matter what happens to you or where you came from. It matters what you do with what happens and what you've been given.”

“The only guarantee, ever, is that things will go wrong. The only thing we can use to mitigate this is anticipation. Because the only variable we control completely is ourselves.”

“It's okay to be discouraged. It's not okay to quit. To know you want to quit but to plant your feet and keep inching closer until you take the impenetrable fortress you've decided to lay siege to in your own life—that's persistence.”

“The obstacle in the path becomes the path. Never forget, within every obstacle is an opportunity to improve our condition.”

“All great victories, be they in politics, business, art, or seduction, involved resolving vexing problems with a potent cocktail of creativity, focus, and daring. When you have a goal, obstacles are actually teaching you how to get where you want to go—carving you a path. “The things which hurt,” Benjamin Franklin wrote, “instruct.”

This book follows a stoic philosophy.

“What matters most is not what these obstacles are but how we see them, how we react to them, and whether we keep our composure.”

As I read this philosophy, our challenge involves accepting obstacles and then using those obstacles to continue on our path. The book reminds us to anticipate obstacles and anticipate how we will handle them.

As I consider my career and our profession, this advice and philosophy resonates. Perhaps this explains why the Hindu god Ganesh has such universal appeal.

Ganesh, also known as Ganapati, is immediately recognizable as the elephant-headed god. He is the god of wisdom and learning, as well as the remover of obstacles, and consequently the sign of auspiciousness.

Life is never totally smooth. We all face obstacles. Our patients face many obstacles.

We help our patients through the process of removing obstacles. We do that through wisdom and learning. We fail when we let obstacles overwhelm us. Thus, the title of Ryan Holiday's book. We succeed when we accept the obstacles and turn them into growth.

This quote embodies the philosophy, “People think Stoicism is about not having emotions… [but] Stoicism as a philosophy is a series of exercises and reminders that men and women have practiced throughout history that are designed to help them deal with loss, pain, fear, our own mortality, temptation. It's about living an ordered, rational disciplined life so you're not being jerked around by success or failure.”

Thanks to Farnam Street for recommending this book.

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, August 16, 2016

Candor and thoughtfulness

In a first for an occupant of the White House, President Barack Obama has authored a lengthy appraisal of health care reform efforts in the United States in a top-notch medical journal, JAMA. The essay looks in detail at the effects of the Affordable Care Act (“ObamaCare”) thus far on access to health coverage and the trends in health care spending.

Beside the historic first of a sitting President publishing a significant health care think-piece, what's notable is the candor with which Obama appraises the ACA, both its successes and failures. He offers a roadmap going forward for how we can further expand coverage and continue to diminish the portion of our spending devoted to health care (both as a government and as individuals, i.e. what we pay out-of-pocket).

The 2 most impressive achievements of the ACA are the drop in numbers of uninsured Americans (from 16% to 9% of the population) and the slowing of health care inflation. The article is a bit wonky, so here is a key portion of the argument about how the ACA has slowed health care spending: “From 2010 through 2014, mean annual growth in real per-enrollee Medicare spending has actually been negative, down from a mean of 4.7% per year from 2000 through 2005 and 2.4% per year from 2006 to 2010 … Similarly, mean real per-enrollee growth in private insurance spending has been 1.1% per year since 2010, compared with a mean of 6.5% from 2000 through 2005 and 3.4% from 2005 to 2010 …

“As a result, health care spending is likely to be far lower than expected. For example, relative to the projections the Congressional Budget Office (CBO) issued just before I took office, CBO now projects Medicare to spend 20%, or about $160 billion, less in 2019 alone.”

What I also find interesting is the ancillary material: Like all JAMA authors, President Obama was required to submit a financial disclosure form to demonstrate no apparent financial conflicts of interest in his presentation of data and policy recommendations. As an attachment to the article, the White House included the President's annual financial public disclosure statement. A couple of take homes for me: Index Funds. The President sensibly has retirement investments in Vanguard index funds. There's even information about the mortgage on his Chicago home. If interest rates stay the way they are, he should definitely think about refinancing soon.

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.
Monday, August 15, 2016

My thyroid nodule

About 4 years ago I was examining my neck and discovered a nodule in the right side of my thyroid gland. I was examining my neck because I very rarely see a doctor and figured that I should at least cursorily examine myself to see if I could find anything of interest. My heart sounded fine, my lungs were excellent, weight was just right, pulse was nice and low, liver and spleen were fine, skin was slightly sun damaged but basically OK, blood pressure was a tad high and there was a small but definite lump in the right side of my neck.

Since I have a portable ultrasound, I looked at my thyroid nodule and found it to be about 1.8 cm, with some internal calcifications and a bright capsule. It was slightly darker than the surrounding thyroid tissue and had a few visible blood vessels.

I read about thyroid nodules and found that:
1. They are being noticed much more frequently because of increased use of CT scanning and ultrasound imaging.
2. They are very common. Nearly half of people will have significant, greater than 1 cm, thyroid nodules at autopsy.
3. About 5% of thyroid nodules are cancer, and cancer is more common in younger people, people with a family history of thyroid cancer, history of radiation to the head and neck, rapid growth of a nodule and larger nodules.
4. Experts generally recommend biopsy (taking a thin needle sample) of nodules over 1 cm in size.
5. Thyroid cancer is being overdiagnosed due to biopsies, because a needle can pick up a little bitty thyroid cancer which would never have been any problem over a person's life.
6. Some thyroid cancers will kill people. Most will not. It's hard to tell which will do what even after evaluating the tissue taken at a biopsy.

So I decided that if mine were a cancer which would cause trouble, it would almost certainly grow. I decided to follow it on ultrasound, measuring its size and watching what it looked like, and maybe get a biopsy if it grew.

It didn't seem to grow, at least not much. I was aware that it existed. I could feel it, though it didn't hurt. I was happy with my decision. Then I went to a talk about thyroid cancer at a major medical meeting. The speaker said that some thyroid cancers could grow very slowly over years and could still metastasize (spread to other areas.) Shucks. What if I got metastatic thyroid cancer? I could just imagine my family's displeasure. “It's a fool who has herself for a doctor.” Also the expense, the plans forsaken. I decided to have it biopsied.

I went to a radiologist friend who said she had done many and assured me it would be painless. I scheduled it a week after my decision. I found that I needed a preoperative physical exam, which was a problem because I didn't have a doctor and hesitated to fill out my own paperwork because I figured I couldn't get away with it. So I had a physical exam which wasn't bad at all. I shuttled the paper copy to the radiology department. They still lost it, but eventually found it, and all was as it should be.

The radiology department is very familiar to me. I knew the smell and sound and paint color of the room in which I donned my hospital gown. The radiology technician gooped my neck with ultrasound gel and took about a million pictures of my nodule, measuring its length, width, height, observing its color Doppler signal, looking for other nodules that might have hidden from my examining hand. My radiologist friend came in. We discussed things we agreed upon. We argued about the utility of mammography. That was probably not a good move, since she would then stick my neck with a variety of needles.

She numbed the left side of my neck with a lidocaine injection. I asked her if she knew that the nodule was on the opposite side and she reassured me that she hadn't been born yesterday and had performed this procedure before and knew exactly where my nodule was. She introduced a long needle from the wrong side of my neck into the nodule on the other side so as to avoid poking my carotid artery which was really quite close to my nodule. The bright shiny capsule turned out to be incredibly tough, requiring rather vigorous stabbing to get a sample. She then informed me that she recommended we do a core biopsy as well, since the pathologist appreciated a larger piece for evaluation. This was done through a type of coaxial cable. The core was taken with a gun which made a disconcerting thump as it removed tiny pieces of my thyroid. She showed me the little bottles with chunks of tissue it them. The hardware came out of my neck. Blood was mopped up.

It didn't hurt very much. Maybe a little like being strangled without the “can't breathe” part. Maybe not that bad, since I've never actually been strangled and wouldn't know. There isn't much numbing, just at the place where the needle goes into the skin because the thyroid itself has only dull pressure sensation. Swallowing is rather sore for a few days, however, because the thyroid moves up and down with every swallow.

Weeks later the bills began to arrive. I have medical insurance these days, through the hospital where I work. The total charges were $2,361. About half of this was for the ultrasound, about $300 was for the pathologist to read the slides. Another approximately $300 was to the radiologist, with free update on the utility of 3-D mammography and $500 was for supplies such as needles and coaxial cable. “Adjustments” due to using the hospital, which provides the insurance, for the whole procedure reduced the cost by a bit over $1,000. So insurance paid $820 and I paid about $500.

The results came back “non-diagnostic.” There was not enough thyroid tissue to be sure it's not cancer. Up to 20% of thyroid biopsies are non-diagnostic.

My initial reaction was that I was looking for cancer cells and they didn't find cancer cells and so I'm fine. It turns out that this is about right. There is a study from 2014 in which patients with non-diagnostic results on fine needle aspirate had a repeat biopsy (which I would not do because ouch, in so many ways). These patients almost never had cancer diagnosed, and almost all of those who did have abnormal repeat biopsies turned out to have false positive results. This means that they had a significant surgery removing a part of the thyroid and there was no cancer.

What I learned from my thyroid biopsy:
1. They are very expensive and the cost to even a well insured consumer is not small.
2. A thyroid biopsy is not painless. It is also not horribly painful. I do not want another one.

In the big picture, there is not a lot of value in routinely evaluating thyroid nodules with biopsy. There are 240 million adults in the U.S. About half of them probably have thyroid nodules greater than 1 cm. Performing an uncomplicated biopsy on all of them would cost about 240 billion dollars, assuming no repeat biopsies, diagnosing 6 million of them with cancer. Thyroidectomy and further treatment and follow-up of these diagnosed patients could easily cost that much again, adding up to nearly half of the US's yearly healthcare spending. A not insignificant number of people would suffer damage to their recurrent laryngeal nerve, limiting their ability to speak and sing, or lose the function of their parathyroid glands which regulate calcium balance. Of the cancers discovered, quite a few (hard to know the number) would never cause harm if untreated. Only about 1,900 people die of thyroid cancer each year in the U.S. and some of these are due to very aggressive cancers that will be fatal regardless of when or whether surgery is done. Despite an increase in detection and surgery for thyroid cancer in the last decade, there has been no change in death rates for this disease.

In the smaller picture, specifically the picture of an individual person with a lump in the thyroid, it is difficult to know what to do. Thyroid cancers can metastasize and kill a person. They just don't do that very often. Reassurance is valuable. Being diagnosed with cancer that would have caused no harm could be devastating. Being diagnosed early and avoiding death is priceless but extremely unlikely. As a doctor my practical approach should probably be to avoid searching for thyroid lumps in patients with no symptoms and to try to help those patients whose lumps come to light navigate the dangerous waters of further medical evaluation.

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.