Thursday, September 29, 2016

'Doctor, can the family talk to you?'

Being a doctor is often more about talking to people and communicating than it is about the scientific practice of medicine. This is something that is unfortunately not taught in medical school, and it's left to newly qualified doctors to realize very quickly as they start their careers. Throughout the busy and hectic day of any hospital-based physician—no matter what their specialty—one of the most common requests we hear from nurses is whether patients' family members can also speak with us. Barring few exceptions, these requests will always be diligently met with duty of service. Occasionally however (and this is the absolute minority), I've encountered physicians who shrug their shoulders and wonder, “What does the family want?” or “I spent so much time talking with the patient, why does the family need to speak with me now?” Some of these feelings can be legitimate, especially if the doctor feels rushed and under pressure to move onto the next patient. But it personally makes me internally shudder if I see any doctor who doesn't feel it their duty to talk with their patient's family.

If time is tight, as it invariably always is in a hospital environment, certain techniques can be utilized to make the most of it, such as making sure you establish 1 main point of contact in the family (who can update other family members) and scheduling a particular time of day for the family to be present in the room at the same time you are going to see the patient. Another thing that I personally always do, especially in the elderly, is to call the family from the phone when I'm in the patient room giving my explanation (having them on speakerphone) so that they can also hear from you at the same time and ask any questions.

Here's a simple thought to underscore the importance of doctors always speaking to the family that anybody should be able to relate to. Imagine just for a moment the person you love most in the world is lying in a hospital bed sick and unwell, vulnerable and at a low point in their lives. Imagine this person (and you) have little medical knowledge or any understanding of the internal workings of a hospital. Imagine this person you love has had their happy daily life unexpectedly turned upside down by illness. Imagine feeling intensely their anxiety, concern and stress. Imagine the future they and you had imagined is now up in the air with a potentially life-threatening situation. Imagine how sad and worried you feel entering the hospital, with so many questions that need answering. Who can help you understand what's wrong and what the plan is? Who can help allay your fears and calm you? Who has the authority to reassure you?

That person is you, doctor. It's not the nurse, case manager, or anyone else. It is the part of your day that will be most remembered and appreciated by that anxious person who just wants a few minutes of your time. Not the busywork, the paperwork, the ticking boxes on the computer. But your words of explanation and hope. In nearly all cases, your presence and going back into your patient's room will be met with relief and sincere gratitude. You may be tired, exhausted or hungry to the point that every patient may seem like just another name on your list. But that name is a person. A human being who has a loving, caring and concerned family.

Therefore, when any doctor hears the words; “Doctor, that patient's family wants to speak with you,” see it as your ultimate calling to go and speak with them. Of all the things you do during your day, it can make the most positive difference.
Wednesday, September 28, 2016

The problem of too many consultants

Recently I communicated with a patient's mother in another state. She had great angst when a series of subspecialists gave her different opinions on the ongoing plan for her grown son.

This problem happens too often in 2016. Each subspecialist seems to see the patient solely through the prism of their expertise. We have seen 1 consultant call 3 or 4 other consultants.

Many hospitalists will tell you this story. At many community hospitals the consultants do not just provide an opinion, but rather they write orders. This practice leads to confusion and sometimes conflict amongst the subspecialties.

Several years ago, I watched a video in Canada about this problem. The video discussed a patient with chronic obstructive pulmonary disease, left heart failure and chronic kidney disease. The patient told the story of how each subspecialist gave different opinions on medications. When the patient switched to 1 good internist, his management was much more clear and the patient benefitted.

Having too many consultants without a designated lead physician resembles the sound that you would get from jazz musicians who each want to play their instrument without regard for the other instruments. Great jazz ensembles communicate, and generally have a conductor.

Thirty or so years ago, during the heyday of managed care, internists and family physicians (both specialists in their own right) received the label of gatekeeper. We always hated that term and the implications that it carried.

What we need from outpatient specialists and inpatient specialists (hospitalists generally) is conducting. We are and should be the conductors for our patients. We may ask the pulmonologist for an opinion, but we should make the final decision on that opinion. We have the responsibility to balance multiple recommendations and to limit the number of consultations to just those that are absolutely necessary.

Too many consultants sometimes means that no 1 physician is really in charge. That is not good for patients. Our patients need us to take responsibility for integrating multiple medical problems, polypharmacy and complex social situations. Only when we consider all factors can we develop a logical “game plan” with the patient.

Subspecialists provide value input to patient care, but too many subspecialists seeing the same patient too often create confusion and conflict. All hospitals should require one physician to integrate all the information and make the final decisions about treatment and testing. To do otherwise too often creates cacophony.

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, September 26, 2016

Hearsay

ldquo;Believe half of what you see and none of what you hear.”

A few years back, I was in clinic and went into a room to listen to a patient's heart sounds (*details changed to protect anonymity). A resident physician working with me that day had already seen the patient first. Before I entered the room, he'd described everything about the past medical history including an “easily audible” heart murmur. Even though it was pretty straightforward, I still wanted to listen. And so I did.

“It is an early peaking, systolic murmur,” he said as we walked up the hall, “radiating to the carotids. But super loud.” That description was suggestive of a narrow aortic valve. I figured that a murmur this loud had been assessed with imaging in the past.

“Did she get an echocardiogram?” I asked. The 2-dimensional ultrasound of the heart, or echocardiogram, visualizes the blood flow and the heart valves. Though the physical findings lead us to where we are going in heart disease, actual images tear the roof off of the sucker to confirm things. The clinic was busy. And this was an upper level resident. So I cut to the chase. I wanted the echo results.

“She did,” he replied. “I need to double check the final read but I'm pretty sure it confirmed aortic stenosis.”

“Do you know how severe?”

“No. I'll have to look again when we go back into the room. But I know she doesn't have any symptoms, which is good.”

“Yeah.”

So he went on to tell me a few other things about her before we reached the room. After a quick knock, we entered the clinic room together. Nothing about it was unusual.

“Hi there, ma’am. My name is Dr. Manning and I'm one of the senior doctors in the clinic working with your doctor. We always put our heads together about your health and figure 2 brains are better than 1.” She smiled and I smiled back. After a quick review of her concerns and the plan of care, I reached into my pocket to pull out my stethoscope. “Mind if I listen to your heart?”

“Not at all,” the patient replied. “Guess 4 ears is better than 2, huh?”

I chuckled and nodded while placing the rubber tips of the stethoscope into my ears. And honestly? I wasn't even thinking too hard when I did that. I reached over to her chest and searched the classic listening areas, aortic, pulmonic, tricuspid, and mitral, with the cold diaphragm.

Sure did.

The whole “not thinking too hard” thing wasn't because she didn't matter. It was just that I'd heard the story and exam already, including the echo results. This was mostly a formality, honestly. I even made a comment about the pretty necklace she was wearing as I slid it out of the way to reach her chest. The patient began sharing that she'd splurged on it during on a vacation once and how she hasn't removed it since. I raised my eyebrows and nodded, then lifted one finger to let her know we'd need to hit the pause button for a few moments.

You know. So I could hear the murmur that already had a diagnosis.

And so. I lean in and quickly listen. And just like that, I recognize that what I was hearing isn't at all what had been described to me. I raised my eyebrows. “What did you say this murmur was from?”

“Aortic stenosis.”

I squinted my eye and listened again. “Hmmm. This murmur sounds diastolic to me. Hmmm.”

“She definitely has aortic stenosis. I heard a crescendo-decrescendo murmur. And it was during systole.”

“Okay.” I carefully listened again. I then felt the patient's pulse and listened some more while timing it out with the rhythm of the heart. And still what I heard sounded like the flow of turbulent blood during the relaxation phase of the heart cycle. I listened some more. And then once more. “Aortic stenosis, huh? Okay. I guess my hearing is off today.” And that was that.

I conceded since I knew that the imaging supported his assessment. But honestly? That murmur sounded nothing like what he was saying to me. The whole thing made me uncomfortable, especially feeling so off on something like this, a bread and butter physical finding.

“Yup. Stenosis. But let me just confirm how severe, okay?” He pecked into the computer and clicked a few screens. And while he did, the patient asked a few questions.

“Is my heart okay?”

“Have you been told about your heart murmur?”

“Yes'm.”

“We're just talking about your heart murmur. That's just the flow of blood rushing over your heart valves. Have you been lightheaded or dizzy?”

“Naw. Never that.”

“Okay. We're just checking to see how narrow your heart valve is but it sounds like this is an old issue, okay?”

“Oh alright then.”

She asked a few questions about aortic stenosis and what that meant while he moved through screens to confirm for me the final reading on the echocardiogram images. Since I was less occupied, I pitched in and explained. Even though my ears were telling me of a different diagnosis.

Yeah.

So as we discussed all of that, suddenly I notice a funny look on the resident's face. “Oh must've misread that,” he mumbled to himself. “Um, Dr. M? It's actually moderate to severe aortic regurgitation.”

He said that right after I'd finished my soliloquy on aortic STENOSIS and right after I'd finally talked myself out of what I knew to be true based upon what I'd heard with my own ears.

Shit.

And no. It didn't turn into a big thing with the patient at all. I apologized and told her that I'd misspoken and that her heart murmur was more of the kind you get form a leaky heart valve instead of a narrow one. My face felt like it was a million degrees. She laughed and said, “I was wondering. I been told before my valve was leaky. I ain't never heard of it being stiff and narrow before so that was news to me.”

Sigh.

So here's my point of telling you all of this:

The things that happen to me at Grady are simply metaphors for life. Trust your gut and what you know. Listen with your own ears and then listen again. Believe your ears, especially when they've heard a lot of things. Same goes for your eyes. But especially believe yourself even when odds stack against what you think. That is, when you feel sure.

I doubted myself. And honestly? It wasn't even a soft call. I felt embarrassed for my initial instinct to doubt the echo report when I shouldn't have. I shouldn't have at all. Plus, I hadn't seen that echo result with my own eyes. That's a lesson, too.

And no. I am not always sure. But this time I was. And I'm still mad at myself for not laying down my nickel and betting on me. I recognize it's okay to be wrong. But I think my “ah hah” moment is in that I need to be just as okay with being right.

Does this even make sense?

As for my resident, I gave him some feedback. I'm pretty sure he, too, convinced himself of what he heard based on what he thought the images showed or could have just been so junior that he misjudged what he heard altogether. So yeah, I gave him feedback right away. But as I did, I showed my own clay feet and revealed what I'd done wrong as well. I'm senior to him yet I needed him to understand that even after 20 years of being a doctor, we are still works in progress. I let him know that being scared of looking silly isn't a good reason to not push when you feel pretty sure. And mostly, I was sure, even though I was being told otherwise. I was just two seconds away from saying, “Well, I don't know what that echo is saying, but this murmur isn't consistent with aortic stenosis at all.” But I didn't. After all, the echo said it was aortic stenosis.

That is, until it didn't.

Yeah.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.
Thursday, September 22, 2016

A message to all of those eager young medical students and residents who want to 'transform health care'

Living in the fine city of Boston, I am fortunate enough to be located right in the middle of a medical hub. A place that's full of exciting new research, developments and ideas. Working at the frontline of hospital care, also with a keen interest in quality improvement, patient experience, and technology, I frequently attend social and professional healthcare networking events around the city. While doing this, I've gotten to meet a lot of interesting, diverse and ambitious people. But there's a trend I've noticed among many students and resident physicians who are interested in health care policy and technology in particular. It's the phenomenon of a young starry-eyed future doctor who has barely even started their career yet (typically still in medical school), who expresses their desire to “completely transform health care.”

Yet when you speak a little bit more to these well-intentioned folk, you realize that they want to do it from as far away as possible from the front lines of clinical medicine! From my experience, Boston has hundreds of these types of people floating around. Whenever I meet them (and don't get me wrong, they seem sincere and pleasant enough), I'm amazed by how brazen they are in their assertions about what's wrong with health care and what we need to do to “change things”. They are also the most enthusiastic about how great the proliferation of information technology, through Meaningful Use, has been for health care and how the last decade has really improved things for patients (go figure). My advice for them is always the same:
• Sure, it's awesome to have high and lofty ambitions. But if you're still in medical school, focus on becoming a good and competent doctor first and foremost.
• Never lose touch with the front lines, no matter where you intend to be 1 day.
• Remember that without doctors (and nurses) on board, “change” in health care is meaningless. Listen to them, because their perspective—along with of course our patients—is paramount.
• There is a reason why health care (in almost every country) has very big problems that need to be addressed. It's a complex beast. No overnight or easy solutions exist.
• Wherever you go, your best and most meaningful career moments and highest job satisfaction will likely come from those special moments when you are just being a good doctor. This can't be recreated in many other jobs, so never look towards the bigger picture so much that you fail to see how much difference you can make in the trenches of everyday medical care. Medicine is a uniquely personal and emotional arena, with humanity, compassion, and empathy at its core.

In short, don't try to save the world from afar! I always remember a quote by Dag Hammarskjöld, the Swedish economist and author who is widely considered to be the epitome of a true global diplomat. If you don't know very much about Mr. Hammarskjöld, his life story makes fascinating reading. He was a man of great integrity who worked tirelessly on several peace projects after World War II. He served as the Secretary-General of the United Nations, but sadly died during his term in a plane crash in 1961. He was posthumously awarded the Nobel Peace Prize and John F. Kennedy called him “the greatest statesman of our century.” Considering the turbulence of the first half of the last century, that's quite an accolade. Many wise and thoughtful quotations are attributed to him, some of which are actually very relevant to medicine and health. One of them is about how “constant attention by a good nurse may be just as important as a major operation by a surgeon”.

Hammarskjöld was a man who understood the nature of humans and the complexities of our world. This particular piece of advice applies to any doctor who is wondering what's the most essential and worthwhile thing to be doing. He said: ”It is more noble to give yourself completely to 1 individual than to labor diligently for the salvation of the masses.”

If there's ever any question about what the higher cause is—striving to save the world or just being a good doctor—the answer is right there. It is always selflessly dedicating yourself to your patients.

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, September 21, 2016

Palliative care is our responsibility to patients

This week we had an all too common clinical situation. A patient with severe chronic obstructive pulmonary disease (COPD) developed pneumonia. His prognosis because of his underlying disease is relatively poor.

Fortunately, the patient and his wife had previously discussed resuscitation and intubation. He does not want to go down that road. Because of this conversation we quickly went down the road to palliative care.

As we explained to the patient and his wife, we will treat his pneumonia with appropriate antibiotics, but we will also treat him. Sometimes in medicine we forget the patient. We focus on the disease or the prevention of a disease. But patients want us to treat them. They care about how they feel and that they are suffering.

The palliative care movement reminds us daily that we must focus on the patient at least as much as we focus on the disease. But often the patient's needs trump the recommended treatment of the disease.

Palliative care is truly patient-centered. It is family-centered. Palliative care brings humanity to medicine, a humanity that we risk forgetting. When we start medical school, most medical students come wanting to focus on that humanity. As we go through school and residency, and even in practice, we can become enamored with the science and treatments. Palliative care reminds us to maintain a balance between the science and the humanity.

We are fortunate to have palliative care physicians to remind us. We should not need that reminder, but we do. So we should all thank those dedicated physicians for helping us maintain our moral compass.

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, September 20, 2016

Are doctors paid too much?

Years ago on Cape Cod, my kids and I stumbled across a man who had spent the day creating a sand sculpture of a mermaid. It was an impressive piece of art. “How long did it take you to make it?” we asked. While I can't recall his precise words, the response was something like “25 years and 7 hours”. I'm sure my astute readers will get his point.

We become transfixed watching Olympic athletes as they performed in Rio. So much depended upon their brief routines, which can last seconds to a few minutes. While a diver's acrobatic plunge may take 2 seconds, it would not be fair to leave aside the years of work and training that prepared the athlete for this moment.

The same point can be made for anyone who has worked and trained hard to reach a point where the action performed seems easy to a spectator or a customer. If an attorney prepares estate documents, we can assume that the fee for this reflects the prior training and research that the lawyer has done on this issue, as it should. If an appliance repairman, by virtue of his expertise, fixed our ailing washing machine in 5 minutes and charged us $100, should we balk at this price gouging? If a less skilled competitor spent 2 hours before finding and correcting the glitch, would we feel better about handing over $100? Is this fair? A musician doesn't just wake up 1 morning and hop onto a stage to give a concert. When we pay to listen to an artist perform for 2 hours, we are likely listening to the product of years of grinding work, disappointment, innovation and discovery.

I believe that this same principle applies to my own profession. Over the years I have heard patients complain about various medical charges and fees. While we all know that there have been excesses, many of their gripes are misplaced, in my view. It's not fair to equate the medical fee with the time that the physician expended on providing your care. A cardiac bypass operation takes just a few hours. A colonoscopy takes 10 minutes. Treating a patient in an emergency room with a drug overdose may take just a few hours. A psychiatrist might guide a suicidal patient to choose another path in half an hour. A spine injection to relieve chronic pain takes only a few minutes. A dermatologist recognizes a suspicious lesion in a few seconds. A seasoned surgeon tells an anxious patient after a 20 minute consultation that surgery is not necessary.

Often, folks who make us all look easy are fooling us. If we think it's as easy as it looks, then we're the fools.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Monday, September 19, 2016

'Juneteenth'

You didn't quit smoking. Nope. Not even after that big, long, drawn out discussion we'd had about you setting the perfect quit day. ”Juneteenth!” you announced with a big, loud laugh. You banged your hand on the desk and clapped your hands after. I typed it right into the chart when you did:

QUIT DATE: JUNE 19, 2016

Then you added, “Perfect, ain't it? The day of emancipation, right?” And I nodded my head in acknowledgement, loving the idea of you being freed of the nicotine stronghold on the very day that our people came up from under the dark cloud of slavery.

“That day sounds perfect,” I replied. And I said that because it was true.

But sadly that day came and went. And you didn't quit. Nope.

Your blood pressure was high today, too. You promised that you'd take your blood pressure pills but when I looked into the pharmacy history, you hadn't picked up a refill for two full months.

Nope.

342. That was your blood sugar reading on the finger stick today. Which meant that you probably weren't taking you insulin either. (Even though you'd promised you would.)

And last was your weight. Your chief concern at the last visit was losing weight and quitting smoking. We'd talked and talked and talked all about it and you sounded so ready. So ready. Together we identified some simple tweaks that could be made to help you shed pounds and, I have to admit, I was just as excited as you.

Sure was.

But that didn't work out either. Instead of dropping a few pounds, you gained nearly 10. 9.73 to be exact. Which didn't fit the gameplan we'd discussed. At all.

So yeah. Essentially none of what was supposed to happen happened. And honestly, I'd be lying if I said that some piece of it wasn't frustrating because it was.

Yeah, it was.

And so. I creaked open the clinic room door to come see you. The undeniable scent of cigarette smoke wafted into my nostrils the very moment I stepped inside; it had found a crevice of every part of that room. I coached myself to not be disappointed in you. To not feel like you'd hoodwinked and bamboozled me into believing that this visit would be some celebratory party where I fist bumped you for your big emancipation from cigarettes and unhealthy foods. Yeah.

“Good morning,” I started. I took the seat across from you and smiled. Trying my best to not sound condescending, I added, “It's good to see you.”

I was kind of tired that morning. Isaiah had forgotten to tell me about a homework assignment he had until the very last minute which forced a late night/early morning kitchen table science combination. Zachary couldn't find his shoe and seemed hell bent on wearing only the pair that had the missing mate. Our dog decided he'd tear up a throw pillow overnight. And I'd run out of creamer that morning so had to drink black coffee which I did but did not enjoy 1 bit.

So yeah. I'd hoped for some good news from you.

“I didn't quit, you know.”

I sighed and leaned my face into my hand. “Yeah. I know.”

“I gained some weight, too. Even though I ain't had much of a appetite. I just ain't been doing so good.” Your mouth twisted when you said that and I could have sworn I saw tears glistening in the corners of your eyes.

“What do you mean by that? By ’ain't doing so good?’”

That's when those tears became undeniable, spilling over your lashes and onto your cheeks. You offered a lopsided shrug in response. And this? This was different for you. Normally you were chipper and full of happy spunk. And even though I was not so thrilled about your failure to clear the hurdles we'd pinky sworn upon, at minimum, I'd expected some funny one-liner about why it didn't happen. But not this. Not tears.

And so. I just waited. I touched your forearm and waited.

“Remember my grandson? The one who was staying with me?”

I thought for a moment and then remembered him from a visit once. He'd driven his grandmother to the clinic one day and seemed rather unhappy about having to sit in on a discussion of antihypertensives and insulin. “I do.”

“Well, he … he … “ You couldn't finish. Instead you just dropped you head into your hands and wept hard. Your ample bosom shook rhythmically along with your fleshy arms.

“Oh my goodness, did he get hurt? Is he, is he alive?” My hands covered my mouth immediately after I said that. I hated to be so direct but I'd worked at Grady Hospital long enough to know that it was a fair question. Your home address was in a rough part of town and that grandson was in your custody after drugs left his mother unfindable and incapable of raising him. The same streets that took his mama, though, preyed upon him, too. And you knew that. You'd lamented about your concerns of him selling drugs on corners and getting mixed up with the wrong crowds. So yeah. That question wasn't unreasonable.

“He got locked up. Caught a murder charge. He gone, Miss Manning. He might as well be dead. He gone for his whole life. And he ain't but nineteen.”

I felt my eyes throbbing with tears. I puckered my lips outward and swallowed hard to try to keep myself from crying, too. It didn't work. “I'm sorry,” I whispered. The tears splashed disappeared under my chin before I could wipe them away.

“Me, too,” you murmured back.

And that was it. We didn't utter another word about you blood pressure or your smoking or your blood sugars or your weight. We just sort of sat there and felt the enormity of how hard this life can be sometimes and pushed all of the rest of it to the back burner. And yes. Your blood pressure and weight and blood sugar are important. But your emotional well-being is, too. You'd lost your baby boy after losing the baby girl who made him. Your aging soul didn't deserve this pain. The streets were winning 2-0, which meant you were 0 for 2.

Later that day I thought of you. Thought of your grandson and the significance of his age--19--and that date you'd so cheerfully chosen for your quit date, June 19 or, as you said it, ”Juneteenth.” That number was supposed to be a happy one, representing freedom and a brand new day. Instead, it turned out to be symbolic of pain.

I hated that.

Here's what you taught me, though. That sometimes even when there is some pressing shit to discuss, something else more pressing should take precedent. And that sometimes the reasons that people don't follow through on things is because they physically and emotionally cannot. That slowing down and paying attention to souls matters more than slapping wrists for missing marks.

This lesson is one I need in all aspects of my life. So thank you, my friend. And know that this morning I am quietly weeping into my coffee and holding your hand. Feeling sad that nineteen hurts for you and wishing there was something I could do to fix it all. Like offer you some kind of Juneteenth to rescue you, your baby boy and his mama from the shackles of your reality.

“Let's talk about all of that other stuff next time, okay?”

“I'd appreciate that,” you replied.

I realize now that I appreciated it, too.

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.
Friday, September 16, 2016

Diets, doubts, and doughnuts: are we truly clueless?

No, we are not, absolutely not, emphatically not clueless about the basic care and feeding of Homo sapiens. The fundamental lifestyle formula, including diet, conducive to the addition of years to our lives, and life to our years, is reliably clear and a product of science, sense, and global consensus. Really. You can be confused about it if you want to be, but I advise against it. You will be procrastinating, and missing out- because healthy people have more fun.

In the New York Times this past week, Gina Kolata made the case that almost all studies about diet, exercise, and health are suspect in 1 way or another, and that therefore we are confused about lifestyle practices for health, and justifiably so. The first point is valid; the second is utter nonsense. Let's take them in turn.

The contention that all research addressing lifestyle practices for health is limited in some way is certainly true, to the point of being both trivial and trite. All research is limited in some way; the perfect study has never been conceived, let alone executed. But we have nonetheless used research to produce very tangible results that prove the utility of our imperfect methods. We have put footprints on the moon; eradicated smallpox; put a spaceship in orbit around Jupiter; and routinely shoot perfectly clear messages to one another by jiggling electrons in cyberspace. Anyone exploiting the tools of modern living is a living illustration that research, though ineluctably flawed, works pretty darn well.

There is, moreover, a case to make that research addressing lifestyle practices may be especially prone to important limitations. If we consider that the pinnacle of evidence in human research is, generally, the randomized, double-blind, placebo-controlled trial, the challenges are immediately clear. How do you pair exercise, or an optimal diet, with some “placebo control,” while keeping your study participants blind to their treatment assignment? How can we have some people exercise, and others not, without them picking up on it? We cannot.

But that's just the start of our tribulations with such trials. Consider an effort to determine if, say, an optimal Mediterranean diet is better or worse for human health than an optimal vegan diet, or an optimal Paleo diet. The ultimate outcome of interest, healthy survival, is a product of both longevity and vitality. To address longevity, we need very long trials. Years won't do; we are talking decades.

Now, we must allow for the fact that lifestyle influences health throughout the lifespan. If we want to know what diet is best for health, we should therefore look across the entire lifespan. That means starting young. In fact, even young isn't early enough, because dietary effects begin in utero. There is even a case for them beginning with our grandparents, but we will let that epigenetic influence go for the sake of pragmatism.

Still, to study the lifelong effects of diet on health, we would need to randomize a very large cohort of pregnant women to different dietary patterns. The women would need to be alike in all ways but diet. They would need to adhere to their dietary assignment throughout pregnancy, then proceed to breast feeding, and adhere then as well. After that, as the large crop of infants is weaned from breast milk, those neonates would become the study participants, and it would be their turn to adhere to the dietary assignment- forever. After some span of decades, and the expenditure of a staggering sum, we would be able to look at differences in health outcomes, and perhaps attribute them to our intervention if too many other things were not now different between our groups.

I trust you understand why such a trial has not been conducted, and why you shouldn't hold your breath waiting for it. That leaves us with the lesser standards of research against which Ms. Kolata has chosen to inveigh.

But that does not leave us clueless, any more than the lack of a randomized comparison of treatment versus benign neglect is required to know that bullet holes through peoples' chests warrant emergency surgery. We have no randomized trials telling us that water puts out most fires, and yet our firefighters carry on as if they know what they are doing. We had no perfectly unassailable proof that we could put a spaceship into orbit around Jupiter, until we went ahead and based on imperfect science, did exactly that.

What we have done in all areas where science has proven its inimitable utility is look at the weight of evidence, and apply sense. That formula is vastly more powerful, useful, and nearly perfect than any one study has ever been.

In the case of lifestyle for health, the formula works perfectly well despite the research imperfections that trouble Ms. Kolata. She is quite right to recommend a raised eyebrow about any 1 study, and in particular, the hyperbolic headlines it is likely to engender. But look instead at the weight of evidence, encompassing randomized trials, mechanistic studies, observational epidemiology, and real-world experience at the level of whole populations- and you generate a rather emphatic mandate to keep that restless eyebrow at its low-altitude ease.

Consider the implications for yourself, and for that matter Ms. Kolata, if the lack of “perfect” research really made us clueless about diet. We would have no idea whether lentils or lollipops were a better source of sustenance. We could not judge the differential merits of dates, and jelly doughnuts. We would not know whether oatmeal and walnuts, or Doritos and Coca Cola made a better breakfast.

I very much doubt that Ms. Kolata has any difficulty judging the relative merits of kale and cheese doodles. But once we are in for that penny, we are in for a pound. If we know, despite our research imperfections, that broccoli is generally a terrific choice, and baloney not so much, then we clearly have a basis to understand something in spite of it all. There is no reason for that understanding to end with baloney, and indeed it does not. We, and Ms. Kolata, all make confident choices every day, informed by science, guided by sense.

No single study, about diet or anything else, is perfect. If that gets you exercised, go ahead and exercise your derisive eyebrow as Ms. Kolata advises. But on the other hand, the massive weight of evidence in the aggregate tips clearly and decisively. A global consensus of expert judgment concurs. Sense, applied a bit too seldom to be called “common,” alas, aligns. Routine physical activity and a diet of mostly minimally processed vegetables, fruits, whole grains, beans, lentils, nuts, seeds and water when thirsty redounds consistently to the advantage of human health. It offers benefits to the planet as well.

I recommend that you leave your eyebrow just where it is, and lift instead your feet, and your fork, accordingly.

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, September 15, 2016

The often murky and insincere world of physician recruiters

The last several years since I graduated from residency have been a deliberate adventure for me, as I sought to gain experience in a variety of different hospital environments. During this time, I've worked in every type of hospital up and down the East Coast, ranging from large urban academic medical centers, to more rural community outposts. How I've gone about finding these jobs has also varied enormously, from personal recommendations, to going through traditional physician recruiters.

At this particular point in time, with the ageing population and shortage of physicians, most generalist specialties find themselves in enormous demand. The physician recruitment industry has therefore gone into overdrive as well. And even though I've used physician recruiters myself, my negative experiences with many of them (and the jobs that result) have led me to question a lot of what goes on in this industry and the tactics employed. With pay-offs for recruiters ranging from a hefty 10-30% of a physician's yearly salary for a single placement, the aggressiveness of many recruiters is going through the roof.

Most physicians have had experiences of being approached by recruiters, and most will tell you how some of them come across as nothing more than glorified car salesmen, with little in-depth knowledge of the medical profession and tacky 1-liners about how “awesome” and “amazing” their job opportunity is. Give your contact number to any agency, and expect a barrage of phone calls and emails for the next several months or years. Sometimes physicians inadvertently do it during medical conferences, unaware of what will happen next. I've done the same, and have been totally unprepared for the amount of soliciting that has resulted. Despite blocking countless numbers from my cell phone (an easy thing to do on an iPhone), I still receive at least 2 or 3 messages on most days asking me if I'm interested in additional opportunities. Now don't get me wrong, it's nice to be in demand, but not if it gets to the point of being bothersome and almost bordering on absurd at times. A few stories to tell of the unscrupulous tactics being used:
1. If you receive a call that's from 1 particular number, and you know it's a recruiting company and block the number, frequently another extension will call you back within minutes. When you do the same with that extension, sure enough, yet another extension immediately starts calling! Do these people just sit at their phones all day playing this game?!
2. Some messages left by both email and phone are rather comical, from recruiters who appear to be imploring me in a pleading voice to “PLEASE” call them back “AS SOON AS POSSIBLE” to hear about all their opportunities.
3. I have a colleague who is in private practice, and was recently called by a recruiter telling him that there was “wonderful local opportunity” that he couldn't miss. When he asked for more details, he realized that this was his main competitor across the street! He then berated the recruiter for not doing his research before calling him.
4. As well as phone calls, many physicians find their e-mail inboxes full of messages on a daily basis from recruiters, as well as a deluge of handouts and flyers in the regular mail. The same recruiter will often leave multiple messages a week, despite no response from the recipient.
5. The incident that took the biscuit for me actually happened a couple of weeks back. I was busy seeing patients in the hospital and was pulled out of a patient room because there was an announcement that I had an urgent phone call. Rushing out of the patient's room, and picking up the phone, instead of it being an urgent medical issue like I expected, I was met by a recruiter who claimed that he knew some great jobs that I should learn more about. When I asked how he knew where I was, he casually admitted that he found which hospital I was working in through an online search. It takes a lot to get me angry, but I told him that it was unacceptable to ever be calling me when I was working in the hospital. He was then evasive when I asked for his name and who exactly he was working for.

As for the 2 or 3 positions that I've found through a recruiter, as I look back, these have unfortunately been my worst and unhappiest jobs. I have been very underwhelmed as well with the sincerity of those I've worked with, and it's become evident to me that most of them view their clients just as dollar signs. Case in point, one recruiter who I worked with for several weeks in order to find a job in my town of choice, appeared to be all about frequent communication and contacting me all the time. After I secured the position and had signed the contract, I was concerned about something and attempted to contact him. I left a couple of messages, but no call back. The question then answered itself, and everything was taken care of. I was genuinely excited by the job, and sent him an e-mail to say thanks for his help. I also left a phone message saying the same. Can you guess what happened? Not 1 reply. Not one message of good luck or saying that it was his pleasure working with me for the last couple of months. Everything went stone cold after he presumably got his payment. That was the last time I ever worked with a recruiter.

So here's 3 pieces of advice for any (especially new) physician who is contemplating their next career move:
1. Avoid physician recruiters completely if you can. Go directly to the hospital, clinic or group that you want to work with and do your own networking. Browse direct advertisements in medical journals and online. It's easy to find contact information yourself nowadays. You've reached this far and are by far the best person to sell yourself and negotiate what you want.
2. In-house direct recruiters are completely fine to work with (recruiters who work for the organization you want to join). In contrast to what I describe above, they have only ever been excellent. It's the third party recruiters who typically work for big companies, charging high fees to the institution for their services, who are the ones to avoid.
3. When trying to find the right job, nothing beats a personal professional recommendation from someone who already works there. Their opinion trumps any non-medically trained recruiter who is trying to sell you the “best job since sliced bread.”

I suppose I should also finish by leaving some advice for recruiters. I don't think you are all bad people by any means, and I'm sure many of you believe yourself to be very genuine individuals who are just doing your job to the best of your abilities. Remember that doctors are intelligent people, and tacky salesman-like tactics won't work in the medical profession. Treat us with respect, don't harass us, and be sincere. Gain an intricate understanding of what doctors do, and what we are looking for. Finally, when you've successfully found a position for your “client,” they shouldn't just cease to exist in your mind. Wish them good luck and stay in touch with them. Who knows, if you develop long-term relationships based on trust and understanding, you will probably gain more business and success than you could ever imagine.

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, September 14, 2016

Teaching the history of present illness

Students (and interns and residents) provide important insights into their skills and understanding with their oral presentation of the history of present illness (HPI). The history of present illness provides the key to diagnosis in a great majority of patients. A recitation of the history of present illness shows us how the learner has thought through the patient's problem and their skill at asking the best follow-up questions.

Several years ago I heard this great description of the process of reporting the HPI. The first paragraph recounts the patient's story in depth. This includes the patient's chief complaint, as well as the answers to questions that the interviewer has asked. The first paragraph often contains relevant past medical history and medications.

The second paragraph includes the answers to questions that flesh out the differential diagnosis. The second paragraph anticipates the questions that the listener might ask.

That framework starts our conversation. As attending physicians we can use the HPI presentation to teach history taking, differential diagnosis, and the cognitive process.

A common trope in medical education suggests that we should not interrupt the presenter. Here I will agree and disagree. At the end of the HPI we should stop the presentation and teach. We have the opportunity to provide feedback and show provide that feedback immediately. Delayed feedback does not work as well. We should provide positive as well as constructive feedback.

I focus my teaching on the HPI. Each presentation led to the following question: ”What did the HPI not include?” Potential examples:
1. Stating that the patient has diarrhea and not describing the diarrhea.
2. The patient complains of chest pain, but the HPI does not systematically go through a thorough description of the pain, inciting and relieving features, previous chest pain history, associated symptoms, etc.
3. Present medical history includes type 2 diabetes mellitus, but does not report duration and complications.

I could continue, but you likely get the point.

We have a wonderful opportunity to teach our learners how to think through the HPI. We know that the best physicians obtain very complete histories. As we ask these questions of our learners, and as we retake the history at the bedside and get more information, our learners grow, especially when we discuss the rationale for the information.

Recently we had a patient admitted to our service for dyspnea. The patient had a history of chronic obstructive pulmonary disease (COPD) and already used home oxygen. The presenting learner gave a complete history of the COPD and when the oxygen requirement increased. So I had the opportunity to provide very positive feedback.

The referring physician had prescribed antibiotics and steroids but the learner gave a clear history that the patient did not have acute bronchitis. This history allowed us to discuss the differential of worsening dyspnea in a COPD patient. Again the learners did an excellent job.

Routine labs revealed severe anemia, and thus the presenter gave a history of melena.

The HPI did not include a complete history of dyspepsia. At the bedside the patient gave a history of early satiety for the past month or two. The patient had started taking a PPI.

Because the COPD “exacerbation” occurred secondary to acute anemia (Hgb<6), the dyspepsia history belonged in the HPI.

Spending time on presenting can greatly help our learners. So let the learner complete the HPI, but then discuss the HPI prior to hearing the rest of the data. Doing so can help the learners refine their HPI. Doing so allows us to give the feedback necessary for deliberate practice.

Focus on the HPI and our learners will benefit.

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, September 13, 2016

Overtreatment and unnecessary medical testing? You make the call!

Ok, readers. I know how many of you fantasize about being part of the high drama and glamour of the medical profession. Believe me, it's even more exciting than the medical TV shows that have been part of pop culture for generations. Remember Ben Casey? Marcus Welby? Dr. Kildare? Dr. Seuss? Rescuing folks hovering over the Grim Reaper was just another day at work for these guys.

Here's your chance to play doctor for the duration of this post.

A patient wants a colonoscopy, but it is not medically necessary. Assuming he cannot be convinced to withdraw the request, should you perform it?

A physician wants you to perform colonoscopy on his patient, but it is not medically necessary. Assuming the physician cannot be convinced to withdraw the request, should you perform it?

An elderly patient's son wants a colonoscopy performed on his father, but it is not medically necessary. The patient is ambivalent and delegates the decision to his son. Assuming the son cannot be convinced to withdraw the request, should you perform it?

A nursing home requests that a feeding tube be placed on an elderly resident. While the tube would be much more convenient for the staff with regard to administering food and medication, the tube could be avoided if a staff member had sufficient time to assist the patient with meals and medicines. Should you place the feeding tube?

An anxious mom (please forgive the sexism here) demands an antibiotic for her child's sore throat, which is not medically necessary. Assuming she cannot be dissuaded from her request, reinforced by prior physicians who prescribed antibiotics under similar circumstances, should you acquiesce?

A man is critically ill in the intensive care unit and is nearing the afterlife. The consensus among the treating physicians is that additional care would be medically futile. There is no advanced directive or medical power of attorney. The next of kin insists that the patient be placed on life support. He is not persuaded to withdraw his demand and suggests that there would be consequences if his relative is simply allowed to die. What would you do here?

So, “doctors”, any thoughts?

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Monday, September 12, 2016

No way out

Perhaps you have heard the rather grim joke about how doctors don't know when to stop treating patients who no longer benefit. It goes something like this: The oncologist goes to the cemetery to find (and treat) Mrs. Jones, since she hasn't “seen” the latest chemo-cocktail for her recently fatal malignancy. When he asks the grave-digger why she isn't in her assigned plot, he is told that she is off getting dialysis. Bah dum bump. OK, so it is crude, but everybody gets it, because it is just an exaggeration of the kind of aggressive, low-utility care that we often see (or provide) at the end of life.

Readers of this blog know that I believe that we, as physicians, often fail our patients by doing more than we would want done for ourselves. I have generally considered this a distinctly American issue, fueled in part by unreasonable expectations of the utility of medical interventions, the entrepreneurial nature of a lot of U.S. health care, and the prevalent American sentiment that death is somehow optional, or at least to be opposed vigorously at all times regardless of the circumstances.

A recent paper in Heart provided a little international—and, alas, cardiology—flavor.

In it, researchers from the UK, Israel, and France reported on their experience performing primary percutaneous coronary interventions (PCI) for acute ST-segment elevation myocardial infarctions (STEMI) in nonagenarians. It was a retrospective analysis of a series of 145 patients with no control group, which almost certainly means that there was a strong selection bias toward treating only “the best” nonagenarians. The principal finding was a 24% in-hospital mortality, with a 6 month mortality of 39% and 1 year mortality of 47%. No data on post-infarct functional status or quality of life were presented.

They concluded: “These results should encourage primary PCI to be offered to selected nonagenarians with acute myocardial infarction.” Really?

Leaving aside the fact that there was way too little information provided to support that conclusion, I just can't get past the idea of doing these procedures in the first place. It is not “age discrimination” to point out that everyone dies of something, and that employing aggressive interventions in the extreme elderly is, at best, a choice to take a different path to the same certain destination; a path that itself often encounters its own pain and suffering.

Kids, if you are reading this, please don't let them do this to me if I make it to my 90s. Make me comfortable and draw the curtain.

What do you think?
Friday, September 9, 2016

Politics, propaganda, and perspective: how preventive medicine pertains

In any political campaign season, fidelity to facts is often sacrificed for the persuasiveness of propaganda. In this campaign season of roiling discontent, that is only all the more so. In particular, the identification of every act of terrorism or violence as a systemic failure of the current power structure is as specious as it is seductive. Preventive medicine can lend some very relevant perspective.

As a board certified preventive medicine specialist, I know full well the major liability of my field. No one gets much credit for what doesn't happen.

There are no tears of gratitude from family members because father or mother, sister, or brother did not have a heart attack. There are no cards on your office wall expressing abiding thanks for the stroke that never occurred. No crayon drawings of adulation from children who grow up without type 2 diabetes because of some policy or program. There are no philanthropists eager to support you in any way you ask because you saved their life, or the life of someone they love. Perhaps you did just that, but if you did, they certainly don't know it happened, and you may not even know it yourself.

Such is the thanklessness of prevention, but it's a price well worth paying. The field of preventive medicine has brought us cancer screening programs that save thousands upon thousands of lives, and immunizations that save millions. Luminaries in this field are why we need no longer fear such one-time ubiquitous perils as smallpox, and polio. And, of course, in the modern era the relevant efforts continue to address immunization and infectious disease, cancer screening and interdiction, while shifting ever more to an emphasis on lifestyle as medicine in the prevention of cardiometabolic and other chronic, degenerative diseases.

There is a direct analogy between such efforts and their often-unrecognized utility, and the work of homeland security, with all of its reverberations into the current, noisome political campaigns.

Let's revisit immunization. You have surely heard the false contention that vaccines cause autism, and have likely been tempted to believe it. You have doubtless heard the true indictments of the 1976 swine flu vaccine, one tainted batch of which caused cases of Guillain-Barre syndrome. But can you say how many lives have been saved with the MMR vaccine, or the flu vaccine? Can you even hazard at a guess at the ratio of infections prevented, or lives saved, over a given recent decade, to unintended adverse effects?

I am guessing you can't, because I can't, and it's my purview. I could look up the figures, but I don't know them off hand. What I do know is that those ratios are enormously favorable. They are likely in the general domain of millions to one, and reliably well into the many tens-of-thousands to one.

And yet, it's the “one” that makes headlines, and grabs our attention. The number of cases of measles prevented by that vaccine does not make news. The discredited claim that the MMR vaccine causes autism makes news again, and again, and again.

Similarly, we are unlikely to have any idea about most threats of terrorism that never come to fruition. Every now and then we hear about such a threat, interdicted when near to full maturity. But given the nature of prevention, most such crises are surely averted at earlier stages, entirely unconducive to drama. There is no drama, there are no headlines, and we are none the wiser.

We are, of course, unlikely to live in a world where no acts of terrorism take place, now that there are sizable entities with considerable resources dedicated to the perpetration of just such acts. It might be possible to achieve perfect interdiction in a fully militarized state, but the loss of liberty would be far too high a price to pay.

Similarly, we are unlikely to live in a world where civil liberties and privacy are fully unfettered. There are real dangers to contend with here. Were we to renounce all security for the sake of unmitigated liberty for all, we would be taking our lives in our hands at every gathering we attend.

In health and security alike, we are seeking the sweet spot. We are aiming at a ratio of effective prevention to occasional lapse that rightly balances the advantages of interdiction with the costs, sacrifices, and inconveniences with which we are willing to purchase them.

But ratios and balance and realistic compromises are not the stuff of campaign bravado. Nor are they the stuff of headlines, and there are papers to sell and air time to fill every day. Failure of preventive efforts unfailingly gets the spotlight; success is consigned to the shadows.

Consequently, we will certainly know about every act of violence and terrorism that makes it through the existing filters, just as we will know about every screening test or vaccine gone awry. How easy, then, for anyone inclined to demagoguery to point an accusing finger at any evidence of current failure, blame it on those currently in charge, and promise us a world free of it- although invariably without any cogent explanation as to how.

In politics, this is how we tend to roll, and everyone seems to accept it. No doubt far too many are actually persuaded by the captivating combination of misdirected blame, and unsubstantiated promises.

But imagine for a moment if medicine worked this way. With every case of colon cancer, there would be an argument to abandon colon cancer screening altogether since, obviously, it had failed! The occurrence of breast cancer would propagate arguments to abandon mammography, rather than efforts to improve it. Opposing medical factions would blame bad outcomes on one another, and make vague promises about alternative approaches that would provide perfect results. We, the people, would favor first one group, then another, only to be disappointed by each in turn.

Whether in defense of the human body, or of our collective security, the best we can do is the best we can do. It involves tradeoffs between protection of life and limb, and protection of comfort, convenience, and civil liberties.

If inclined to think that someone else should be in charge because those who have been haven't prevented everything bad, ask yourself what you actually know about how much bad stuff has been prevented. The answer, inevitably for those of us without high-level security clearance, is: we don't know much. We might well be living in a world of six-sigma security, yet only know about the 1 failure in a million.

In my field, news not made by things that haven't happened tends to be what matters most of all. In a troubled, complicated world of terrorist organizations, much the same is apt to be true of our security.

Preventive medicine invites us to consider the importance of what does not happen, along with that of what does. In so doing, it might help us see past the distortions of political propaganda and false promises of perfect success, to a balanced perspective about balancing priorities, and the best we can do with that reality.

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, September 8, 2016

A silent epidemic affecting our hospitals

There's a huge problem we have right now affecting our nations' hospitals. It's not a disease you've ever heard of before, or something that cutting edge research or treatments are going to solve. It's a seemingly simple issue that has been lacking in every single hospital I've ever worked in, whether it be a large academic teaching hospital or a small rural medical center. It's rarely talked about, but endemic nevertheless. I'm hereby going to assign it a name:

“Sinking in bed syndrome”

What on earth is it you may ask? Well, the scenario goes something like this. A patient, usually elderly, is admitted to hospital with an acute medical illness. During the first few days of treatment, they are basically lying in bed while receiving all their treatments. They get more and more sunk into their bed, becoming weaker and weaker at the same time (even though their actual illness is improving). As they recover, they find it more difficult to get up out of bed and start walking again. The longer they are in bed, the more difficult it will be. Muscles have become tense and joints are stiffer. Because of this deconditioned state, recovery will be prolonged and patients will spend longer getting back to their baseline state.

All hospital-based doctors see this type of scenario unfold on a weekly basis. Sadly, lots of these patients actually report having quite reasonable and independent function prior to their admission. Of course, they have been unwell, and their illness itself will set them back. But having seen how we leave patients “sinking” in their bed for days at a time, I'm of the firm belief that keeping them in this state really sets them back even more.

In short, we just need to get them up much sooner. Unfortunately, it's not in our systemic culture to do that, and in almost all places I've worked, I sometimes need to plead just to get our patients up out of bed to the chair simply to make sure they are not lying down flat all the time. Sometimes sadly, it's family members who are the ones voicing their concern to me that their loved ones have become weak and need to sit up and walk more. It's a shame too that many health care institutions only think of getting physical therapy involved when discharging from the hospital is imminent, when actually it should be done much sooner.

Only a few decades ago, the culture was to keep patients who were sick in the hospital on complete bed rest for an extraordinarily long amount of time. Patients having heart attacks would be kept in and observed for several weeks. We now know that such a prolonged hospitalization is not only unnecessary, but also very bad for our patients.

So why do we not get our patients up sooner? I believe it's not a question of laziness or lack of resources. Nurses and nurses' aides are the most hardworking people I've ever encountered, and most nurses are aware that it's good to get patients up and moving. However, in the haze and hustle of a hospital admission, with intravenous lines, telemetry monitors, strong medications and constant tests, we lose sight of the simple little things that can make an enormous difference. In my experience, patients even just look so much better sitting up in a chair as opposed to lying in the bed.

So here's what the world of health care should really push for: A National Ambulate the Patient Week. This should involve:

 Education for all healthcare professionals about the importance of ambulation. Physicians should be encouraged to write “OUT OF BED TO CHAIR AT LEAST 3 TIMES DAILY” as an order for nearly all hospitalized patients as soon as they can, usually from hospital day 2. With that order should be assumption to “ENCOURAGE AMBULATION”, either with or without assistance depending on the circumstance,

 Invest in more physical therapy services and also dedicated PT-aides, also known as “walkers or mobility aides,” to get people up and moving early,

 Administrative oversight from charge nurses and unit supervisors to raise a red flag when they see a patient who potentially has “sinking in bed syndrome”,

 Posters around hospitals encouraging early ambulation and walks around the hospital floor,

 More comfortable chairs! This may sound rudimentary, but a common complaint I hear everywhere is that hospital chairs are very uncomfortable. However much they are purportedly designed for hospitalized patients, just glancing at them and testing them out myself, I'm very skeptical about how comfortable patients can feel sitting in them. I get the same feedback from relatives who test them out. If healthy people don't feel comfortable in any given place, how on earth do we expect sick people to?

There are certain departments that are actually already very good at mobilizing their patients. One such example is orthopedics, where surgeons are almost obsessive about getting people up as early as possible after hip or knee surgery. If they can do it, so can everyone else.

Richard Asher, the British endocrinologist and forward-thinker from the early part of the 20th Century, once said: ”Look at the patient lying long in bed. What a pathetic picture he makes! The blood clotting in his veins, the lime draining from his bones, the scybala stacking up in his colon, the flesh rotting from his seat, the urine leaking from his distended bladder and the spirit evaporating from his soul.”

That quote was from 1947. I will leave it to your imagination to think what scybala is!

Seventy years later, while we are not as bad as we were in the 1930s and 1940s, we can still do a lot better. So let's make it a national priority get all our hospitalized patients up and moving earlier. Starting from today.

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, September 7, 2016

How internal medicine attendings can incorporate basic sciences

When we understand how things work and how they function in an impaired fashion, then we better remember testing and treatment. In internal medicine, when we understand the physiology and pathophysiology, then we often make better decisions.

Teaching from a physiologic viewpoint can challenge many attending physicians. We believe that investing in this approach has great worth.

Hyponatremia provides an excellent example. When we discuss hyponatremia, we must first understand that it represents a water problem: for some reason we are not excreting enough water. Then we understand how the kidney excretes water. This reasoning leads us to understand the appropriate and inappropriate secretion of ADH. At a higher level, we should understand the stimuli for ADH that can dominate protecting the serum osmolality (stress, pain, volume contraction). Then we should discuss the solute requirement for water excretion and how inadequate solute with fluid ingestion can lead to hyponatremia (beer potomania and tea & toast). Finally, we need to understand the limits of water excretion to understand primary polydipsia. Once we understand the physiology, we understand what tests to order and the principles of treatment.

Then we need to understand the physiology of brain cells and why they swell. This likely explains the risks of correcting the sodium too quickly.

Finally, the physiology helps us understand who has the greatest risk of too rapid correction. Understanding hyponatremia greatly improves when we frame the conversation with basic science.

We can develop a series of such problems. Normal gap acidosis understanding requires a review of physiology. Diuretic pharmacology and use depends on understanding where and how the diuretics work.

Systolic heart failure, home oxygen, the serum ascites albumin gradient, lactic acidosis and the use of biventricular pacing all benefit from a basic science understanding.

We believe that great attending physicians help learners when they explain concepts rather than provide cookbook recipes. Please suggest other examples in the comment section!

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, September 6, 2016

We need to implement shoe decontamination interventions

“You pass through places and places pass through you
But you carry them with you on the soles of your traveler's shoes”
— “The Littlest Birds“ by The Be Good Tanyas

I know we really shouldn't be looking for other interventions to reduce pathogen transmission in hospitals since we're too busy eliminating contact precautions at the moment. But I can't resist highlighting this recent systematic review on contamination of shoe soles from Tasnuva Rashid and colleagues published in the Journal of Applied Microbiology.

The authors reviewed the published literature from 1946 through 2015 to identify studies evaluating (1) shoes as vectors for infectious pathogens and (2) evidence on possible decontamination strategies. Their extensive review identified 13 studies (10 cross-sectional and 3 longitudinal) for inclusion. Three studies were completed in hospitals. One study found methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci on 56% of physicians' shoes before rounds and 65% after rounds. Two additional studies found significant contamination of operating theater shoes with pathogens including staphylococcus, streptococcus and bacillus species. It doesn't get any better when looking at shoes worn in the community with significant contamination by Clostridium difficile (40%), Listeria species, Salmonella species, and Escherichia coli. I won't even mention the contamination found on the shoes of folks that work with animals.

Possible interventions evaluated include placing chemical filled mats in operating rooms and ward entry points, and shoe covers. While the reviewed studies suggest possible benefits for these interventions, more studies are needed. Of course, you know where I'm heading based on my intro paragraph. We need to implement shoe covers and chemical mats immediately in all hospitals. The data is clearly just as compelling as eliminating contact precautions based on single center studies. Oh, and we can fund these new shoe-targeted interventions using the savings generated through the elimination of contact precautions. Awesome!

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, September 2, 2016

The skullcap feud

There's a feud brewing between 2 professional societies on appropriate attire in the operating room. Earlier this year, AORN (the Association of periOperative Registered Nurses) issued updated guidelines on OR attire. The guideline forbids the wearing of skullcaps because the head covering should cover the head, hair, ears, facial hair, and nape of neck when personnel enter the semi-restricted and restricted areas of the OR. This didn't sit well with some surgeons, and the American College of Surgeons (ACS) issued their own statement on OR attire earlier this month.

With regards to the skullcap, they state, ”the skullcap is symbolic of the surgical profession. The skullcap can be worn when close to the totality of hair is covered by it and only a limited amount of hair on the nape of the neck or a modest sideburn remains uncovered. Like OR scrubs, cloth skull caps should be cleaned and changed daily. Paper skull caps should be disposed of daily and following every dirty or contaminated case.”

From AORN's perspective, the issue with skullcaps is the exposed ears and exposed hair at the base of the head, from which pathogens may contaminate the surgical field as hair and skin squames are shed. The counterargument, of course, is that there is no evidence to suggest that skullcaps have been associated with surgical site infections. And now we find ourselves in essentially the same quagmire as with white coats.

This week, AORN shot back, and they punched the good old boys right in the gonads. Says AORN, ”Head coverings based on symbolism and a personal attachment to historical norms have no place in the patient benefits analysis expected of guidelines developers.” AORN rightly took the moral high ground and called out the ACS for using a professionalism argument to justify their stance.

As I have argued before with regards to the white coat, professionalism exists to protect the profession, not the patient. So while the surgeons' argument with regards to lack of evidence has validity, the professionalism argument does not. And my thinking about the skullcap is the same as for the white coat: the biologic plausibility for causing infection should lead to a suggestion to avoid the skullcap but not a mandate. While AORN may argue that their recommendations are guidelines, the reality is that the Joint Commission enforces them as mandates.

I'm not a surgeon, but if I were, I'd give up my skullcap, just in case bacteria were falling off my earlobes. And I think these issues are much easier to resolve if we simply follow the dictum, the patient comes first in everything that we do.

While I'm on my moral high horse, and since I'm an equal opportunity critic, I'd be remiss if I didn't point out an issue with the AORN. You may have noticed that there is no link to the AORN attire guideline in this post, and that's because AORN sells their guidelines for $225. It seems to me that when any professional society has something so important to say that it is written into a guideline, they have a moral imperative to make the guideline accessible free of charge to everyone, particularly when the guideline impacts patient safety. This is but another example of the ugly side of professionalism, a decrepit concept that continues to haunt us.

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.
Thursday, September 1, 2016

Mylan defends EpiPen price hike

Why do smart people often do dumb things? Would you plagiarize a speech that you know is going to be carefully scrutinized? Would you respond to a robocall that congratulates you on winning a free cruise? Would you keep eating sushi that didn't smell right?

I'm certainly not judging anyone here. I've had plenty of my own misadventures and I periodically add to the list.

Our presidential candidates fall prey to human error and misjudgments surprisingly often. Aren't these folks supposed to be pros or at least managed by honed handlers? Why would Donald Trump have insulted nearly every constituency and rival during the primary election process knowing that this might render him unelectable in the general election? Why would Hillary Clinton demand unconscionable speaking fees from special interest groups when she knew that she would pursue the presidency and her payoffs would be publicized?

I'll leave it to readers to ponder their own responses to the above inquiries.

Last year, I posted on a drug company that raised the price of a pill from $13.50 to $750. Even if such a practice is legal, or is justified by market forces, it is very, very dumb. It is guaranteed to provoke outrage and will surely result in scrutiny that will go much wider and deeper than the initial offense. It did. For more details, just click here.

One would think that rival pharmaceutical companies would be more cautious before enacting similar price gouging. Guess again. Mylan, who makes EpiPen, raised the price of this product about 500% over the past years, bringing the price to $608 for a 2-pack. The company stands by the new pricing. Sure, they have offered a few discount coupons, but they are leading from way behind. They are not likely to prevail, even if they have a potent economic argument.

This stuff is ripe grist for politicians, who can rail against the pharmaceutical barons, in order to distract the public from their own abysmal performance. And, angry parents will use social media and other methods to publicize their outrage. The fact that many patients who rely upon EpiPens are young children doesn't make the company's case any easier.

If Mylan's CEO Heather Bresch is called to testify, how will the optics be when she states that her compensation last year was about $19 million?

Why are so many pharmaceutical folks so allergic to good judgment? Perhaps, they should carry around an EpiPen, if they can afford it.

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.

It's a start

There is a deadly explosion of opioid addiction in the United States. While it is clear that nothing this complex or widespread can have a single cause, it is also clear that American prescribing habits have been a significant contributing factor.

According to the Department of Health and Human Services more than 240 million prescriptions for opioids were written in 2014, and it is well established that prescription oral analgesics are the principal gateway for heroin and other injection narcotics.

It is also true that use of narcotic analgesics is much higher in the United States than in other countries. Here again, the difference between the U.S. and the rest of the world probably has multiple causes, including pharmaceutical marketing, and the easy availability of drugs. Recently, the Centers for Medicare and Medicaid Services implicitly acknowledged another cause: the creation of patient expectations around pain control, and the subsequent pressure that has had on U.S. physicians' prescribing habits.

Starting with the Joint Commission establishing pain as “the fifth vital sign” (after blood pressure, heart rate, temperature, and respiratory rate) an entire generation of U.S. physicians was trained to eradicate pain aggressively. I recall being taught that aggressive pain management was an essential element of good patient care, and that it had a low likelihood of leading to addiction or abuse.

CMS got into the act by including questions about pain management on the mandatory (Hospital Consumer Assessment of Healthcare Providers and Systems) HCAHPS hospital patient experience survey. Since HCAHPS scores are tied to hospital reimbursement, institutions nationally were incentivized to implement intensive pain assessment and treatment protocols, nearly all of which relied heavily on the use of opioid analgesics.

Reacting to the epidemic and to the perception that its policies may be counterproductive, CMS announced recently that: “Although CMS is not aware of any scientific studies that support an association between scores on the pain management dimension questions and opioid prescribing practices, we are proposing to remove the pain management dimension of the HCAHPS survey for purposes of the Hospital VBP [value based purchasing] Program in an abundance of caution.”

It won't change the landscape of opioid abuse overnight, but it seems to me like an important step in the right direction.

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.