Monday, October 31, 2016

ICD-10 keeps getting more painful

As I previously discussed, a year ago we transitioned from the disease classification ICD-9 to ICD-10. That has been painful, but they keep making tweaks that require more work.

I guess the powers that be decided that more than 155,000 diagnoses were not enough when they recently changed many diabetes diagnoses (my organization implemented the latest edition). Now it's no longer sufficient to say that someone has Type 2 Diabetes Mellitus with Diabetic Neuropathy [E11.40], for example, but I now have to specify in addition whether it's with or without long term insulin use, or if it's unspecified. That means all my carefully constructed Problem Lists on my patients no longer work. Every diabetic medication I reorder will have to be changed as they are associated with a diagnosis.

Across all my patients I'd estimate that's close to 1,000 changes I will need to make. Assuming it takes me 30 seconds each time (I'm probably a lot faster than most of my colleagues) that's over 8 hours, so a full work day. Multiply that across all the primary care doctors and that's a lot of time, about 1,000 people working years! We have a shortage of primary care physicians and I think there are many better ways to spend our time.

I typed “type 2 diabetes mellitus” into my electronic medical record. I eventually scrolled to the bottom to see a message that there were 3,158 diagnoses loaded, but that the results had been limited due to it being a common phrase! Many of these were synonyms, and 1 can save favorites, but I think it's ludicrous that we have so many codes for just 1 disease. Those who promulgated moving to ICD-10 claimed the higher specificity would lead to all kind of advantages by being more precise, but in reality physicians can't spend all day just to pick a diagnoses and they are going to pick something close that will satisfy the billing system. For many diagnoses you can't even get precise agreement. There are various codes for uncontrolled diabetes, for example, but if you ask different doctors what that means, you'll get different answers.

Patients with diabetes have to suffer from complications of their disease, increased medical costs, and being stuck more often for blood or injections. It's too bad their physicians have to suffer more as well.

Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington. This post originally appeared on his blog, World's Best Site.

When we put our money where our mouths are, what do people eat?

The principal aim of the SNAP program, formerly “food stamps,” is important and simple: to ensure that poor people struggling with food insecurity have enough to eat. The program has always been of great public health importance, but in the aftermath of the great recession, more than one in seven American families found themselves on the SNAP rolls. Enrollment has recently declined, due likely to improving economic conditions. This shows the system works as intended, helping those who truly need it.

But even simple ideas can run into complications. SNAP funds cannot be used for tobacco or alcohol. This makes intuitive sense, since these are not necessary to alleviate the food insecurity SNAP is intended to combat. But it raises a question on a slippery slope: should SNAP funds be used for anything that does more to promote ill health than good? When that question is asked, sugar-sweetened beverages, a.k.a. sodas, come immediately to mind. They are of no nutritional value, and decisively implicated in obesity, diabetes, and other maladies.

Some argue that SNAP funds, which come from taxpayers, should not be used for items like soda that are unnecessary (water is a perfectly adequate, preferable, environmentally friendlier, and less expensive answer to thirst); harmful; and associated with additional costs.

What additional costs?

Well, I have frequently lamented that despite its good intentions, SNAP uses some $80 billion a year in taxpayer revenue to help poor people choose poor food that results in poor health. Then, that poor health requires treatment, much of it covered again by taxpayers through Medicaid, at a cost enormously higher than SNAP itself. Everybody in this scenario loses: the SNAP beneficiaries have something to eat, but also have diabetes, and need coronary bypass; the taxpayers' good money is ill-spent on bad health; and the government has an empty war chest.

There is, in fact, evidence of just this. Colleagues and I found, in a study published in 2014, that diet quality was lower in SNAP participants than in matched, SNAP-eligible non-participants. In other words, the financial support provided through SNAP helped people make their diets, and by extension their health, worse.

There is nothing very surprising about this. We know that in general poverty and food insecurity are associated with poorer quality diets and health, and poorer quality food choices- in part because people facing socioeconomic disadvantage live in communities that conspire against health both by what they do offer (e.g., a particular density of fast food restaurants), and what they don't (e.g., appealing resources for physical activity and recreation; affordable fresh produce, etc.). We know, as well, that the modern food supply has been booby-trapped to induce maximal eating. This effect is greatest in the most highly-processed foods, the very foods that prevail in the fast-food outlets and bodegas that are apt to populate a community where SNAP is in wide use.

That's important, because it indicates clearly that bad choices associated with SNAP support are not the “fault” of the SNAP beneficiaries. There is a perfect storm driving poor people to poor food, and from there, to poor health.

The solution proposed by some is to fix the problem at the source, and limit the use of SNAP foods only to foods deemed suitable. But I trust you see the many problems with that. For starters it is quintessentially paternalistic. In effect, Big Brother gets to decide what you can have for breakfast. For another, it requires universal agreement on what foods are suitable, which in turn means some agreed-open standard for the nutritional quality of all foods. I know from personal experience that challenge can be met, but there is as yet insufficient consensus on the matter to inform food policy.

So we wind up between the proverbial rock and hard place, with an apparent choice between giving out carrots (i.e., no-strings-attached financial aid for food purchases), and wielding a stick (i.e., telling poor people what food they can't buy).

A new paper suggests there is a middle path, and as someone who likes to walk just such roads, I am delighted to see it.

A study in JAMA Internal Medicine compared the effects on diet quality of providing just incentives for uncontroversially ‘healthy’ foods; just restrictions on uncontroversially ‘unhealthy’ foods; both; or neither, in a population of SNAP participants. The best results were seen when incentives and restrictions were combined.

The alternative to outright food restrictions would be financial disincentives, so that foods comfortably catalogued as ‘unhealthy’ came with a penalty. A SNAP-specific application would levy such a penalty within the SNAP system only. A population-wide approach to the same disincentive would be a tax, like the soda tax approved recently in Berkeley, California and Philadelphia.

Whatever approach to financial disincentives is applied, it's easy to view it as the proverbial stick, and contrast it with the carrot of financial rewards for salutary selections. I have mused before in just that direction, as did my friend and colleague, Dr. Marlene Schwartz, editorializing on the new study.

My argument has been that I favor carrots to sticks, both when working to advance public health, and the forward motion of my actual horse. Experience in the saddle, however, makes the case for both- however seldom and gently the stick is wielded. The new study findings say much the same about SNAP.

Why? In the absence of restrictions or disincentives, the addition of incentives to the SNAP program seem prone to increase overall eating. Given the associations between poverty and obesity, and between obesity and chronic disease, an increase in total calories consumed is decidedly counterproductive. The real goal is to reduce intake of ‘bad’ foods, and increase intake of good in their place. Disincentivizing the former, while incentivizing the latter, aptly conforms to just such swaps.

With validated metrics for the overall nutritional quality of foods that enable us to go beyond the narrow categories of ‘uncontestedly good’ or ‘uncontestedly bad’ foods, we might think in terms of more nuanced gradations. We could, if so inclined, disincentivize the least nutritious entries in any food category, while incentivizing every movement up an objective scale. Future studies are required to determine how much greater the impact of this soup-to-nuts approach might be, but evidence to date suggests such comprehensive nutrition guidance is constructive all on its own.

Once we have the best methods worked out, there is no need for this approach to remain relegated to the SNAP program. The private sector would have all the same reasons to replicate the approach, promoting human health while reining in costs.

For now, the evidence we have for getting those reins to work argues for a generous accompaniment of carrots, with strategic, judicious applications of some kind of stick.

One thing's for sure. When we put literal money where people's mouths are, the intent should be to succor, not sicken. Data, like those newly provided, should help direct us there from here.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
Friday, October 28, 2016

Love is the what

“Any man's death diminishes me, because I am involved in mankind; and therefore never send to know for whom the bell tolls; it tolls for thee.”
—John Donne

It has now happened to me too many times to count. A person comes into the hospital. Our hands touch at that first meeting and our hearts connect. No, not just in some obligatory way that gets outlined in that first year med school lecture about ”BEING EMPATHIC.” But more in a natural way. The kind that happens when you strip down the armor of stoicism and reveal a piece of who you truly are.

Yes. So this happened to me this week. It did.

From our first encounter, I knew. I knew this patient, this person would leave me forever changed. I inwardly chuckled, knowing that it would be one of those weeks of late departures, not because of neediness on her part but my own selfish desire for more. More while I could have it. More because my patient was preparing to leave. She was.

It wasn't obvious at first. So mostly, it was just her quick wit and wisdom that created this giant magnet to which I attracted. Between laughs and reflections, I'd coordinate her care with the residents and speak to consult teams. And for every single day that she was there, I would round on her twice. First, for logistical things like pain control and management. Then, to simply close out my day. I'd drag a chair to her right side, hold her hand, and soak it in. I would and I did.

On Friday she was slowing down. Together we'd agreed upon a master plan for an intervention the following week aimed at making her feel better. But some piece of me was conflicted. “Is this what you want?” I asked her.

“What do you think?” she said.

“I think I don't want you to be uncomfortable.”

“Okay. Let's play it by ear, okay? If I'm not up to it, I think you will know. And I will trust your judgement.”

“I will pay attention, okay?”

“You always do, Dr. Manning.”

And that was the end of that discussion.

When I stepped into her room yesterday, the lights were off. It wasn't pitch dark, but more filled with shadows and only the morning sunlight. The family was at the bedside and another consultant was there, too. My team walked in and the family, with whom I'd also developed a connection, notified us that she wasn't talking. The pain in their faces grabbed me by the neck and punched me in the chest. And that, coupled with those shadows, was telling. It was.

I went to her. Usually, I offer a subtle hello and fall back when a consulting colleague has come first, but on this day I broke the rules. She was my patient. An urgency was swelling inside of me. Something was telling me, screaming to me, “You will not get a ‘2-a-day’ today. You will not.”

She was looking straight ahead, not speaking but appeared totally lucid. Like all of this silence was voluntary, representative of elevated thoughts and reflections. The first thing I did was touch her hand like always and move close to her face. “Hello sunshine,” I murmured.

And just like that, her face erupted into an enormous smile. Relief washed over the family and even the consultant. She was still there. She was. But still. I could feel it. Her hand on this day was ice cold. Yes, her spirit was still warm, but nothing else.

Nope.

I asked her questions about her pain and nausea. She nodded yes and no appropriately and told me how she was. All nonverbal but still fully present. And so. I kept talking to her. And to the family. Fielding questions from them and all the while holding her cold, cold hand.

The consultant slipped out and all that remained was the family, my team, my patient and those shadows. More questions from the family came. Concrete queries that you ask when you love somebody. Love's myopic view doesn't allow for big picture objectivity. Not that kind of love. But what I've learned is that some piece of this love category, that is, the doctor-patient love category, leaves the sliver of insight that gets lost in other kinds of love. And now that I know this, I have to use it. I must.

So, I try. I try to talk but my face. It starts to get boiling hot and those tears. Those pesky tears they pour from my eyes. My voice cracks and I feel her icy hand tighten around mine like a vice grip. She knows. Her clasp stabilizes me. She gives me courage to be honest and transparent. And so I do.

I give her hand an affirming squeeze to let her know I got the marching orders. Then I turn to her daughter. “Tell the family to get here. Get them here. Today. Now. To love on her. Love hard on her like she loved on all of you.” And then I started weeping outright. And because she was holding my hand, I couldn't even wipe the tears fast enough since that would have been a two-hand job.

“Love on her,” her daughter repeated while holding my gaze. “Love on her.”

“Yes. It's all we have. Love is the what.”

There wasn't much more to say after that. Our rapport was good and my patient's response was obvious. I leaned in to tell her good bye and asked once more if she needed anything. She nodded yes to pain medicine and no to nausea medicine. “Okay,” I told her. “I got you.”

And then, just like that, she spoke. “You look so beautiful.” Her voice was clear. Nothing garbled or suggesting confusion. Sure, direct, clear. And those words? They were a gift. Not just to me, but to her family. They needed to know that she was there.

Shortly after that, my team left. Sujin, the third year medical student broke down crying and I consoled her in the hall. And my intern Sonali did the same. “Let it hurt. You want to be affected,” I told them. “And don't let anyone tell you otherwise.” Then, all of us just stood there in quiet awe of the amazing privilege we'd been given as the caregivers to this soul. We sure did.

A nurse saw us walking up the hall afterward. She asked me, “What happened? Did your patient expire?”

I smiled with my red face and snot-filled nose and replied. “No. We are just feeling fortunate to be her doctors. That's what you see.” That is exactly what I said. Because it was true.

My patient passed away yesterday. Only a few hours after that encounter. That family got to her and they were all glad they did. Sonali, the intern caring for her, loved her, too, so returned to the hospital. That sweet intern sure did. And all of it was good. It was.

I'm so glad my boundary issues allow me to feel this way. My chest is heaving as I write this, but in the very best way. We are all connected, I think. Being aware of it and surrendering to it is the issue. That's what I think.

Yeah.

During 1 of our late afternoon handholding sessions, my patient asked me to write about her when she transitioned. I promised her I would. And so today, I honor that promise and also present a piece of her love to you. Because love? Love doesn't expire. And love, my friends, is the what.

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, October 27, 2016

Health care IT: Have we now reached a critical mass?

One of the topics I've written most about on this blog has been our woes with inefficient and cumbersome electronic medical records (EMRs). I started writing about this subject at least 3 years ago, because it's 1 of the issues I feel most passionate about. My own personal frustration in this area then led me to founding HealthITImprove, an organization which is dedicated to improving healthcare IT and decreasing the amount of time that doctors are spending with computers.

I've said it before and will say it again: information technology in its current state in health care, has done more to damage the doctor-patient relationship and the practice of medicine, than any other one single thing. Why is this? I know a lot of people who work in IT, and during my interactions and discussions with them, they unfortunately seem mostly clueless about what's wrong and why doctors (and nurses) are so dissatisfied with the situation.

In their world, it's all about keyboards and screens, and the more time anyone spends with them, the better. If any of these IT folk want to know what's wrong, let me put it quite simply. They take way too much time to use and suck the joy out of medicine. They also dramatically contribute to physician burnout and make doctors quite miserable. Heck, they even make patients miserable too—as one of patients' biggest complaints these days is that their doctor hardly looks at them in the eye any more, and is instead glued to their computer screen.

Now no reasonable person would want to go back to the days of paper charts. But there has to be a happy medium. One that fulfils the requirements of administrators and regulators, while also being good for physicians to use.

A study came out in the Annals of Internal Medicine within the last few weeks that garnered quite a lot of attention. It showed that for every hour doctors spend with patients, they spend 2 hours documenting on the computer (if anything, judging by my own experience, I was surprised that the ratio wasn't even worse). Did you hear that right? Because in no other field would a professional spend double the amount of time recording what they did, rather than actually doing it. That's such a profound statement that I'm going to say it again: in no other field would a professional spend double the amount of time recording what they did, rather than actually doing it.

Most people become doctors and nurses because they have a genuine desire to help and interact with people. If a doctor is spending most of their day on data entry and click box tasks on a computer, it's a travesty to the art of medicine and what it means to be a good physician. This article on KevinMD put it nicely when it said that the public would be shocked with what the typical day of a doctor now involves, and how far it is from the public perception. We have steered the health care ship badly off course over the last decade, and we now find ourselves at a crossroads. Do we allow doctors to become nothing more than “type and click bots,” or do we stay true to the ideals of good and thorough medicine?

I personally hate spending so much of my day glued to the screen, and do everything possible to get back to my patients. I hope we are finally reaching a critical mass of like-minded physicians across the country. Healthcare Information Technology: we can't carry on like this anymore.
Wednesday, October 26, 2016

What's wrong with socialized medicine?

The British National Health Service (NHS) was born in 1948, based on legislation passed that year mandating free high quality healthcare for all paid by taxes. In contrast, the U.S. started Medicare in 1966 to provide health care to the elderly and the State Children's Insurance Program (SCHIP) in 1993 to fund health care for children whose parents were unable to afford it. Health care in the UK is still almost entirely funded by the government (through taxes, of course), which it is not in the U.S.

Britain is proud of the NHS, and rightly so. They have it figured out. Or so it would seem. Everyone can get care and nobody goes bankrupt because of huge medical bills. Brits do have to pay for prescriptions but everything costs the same, the equivalent of $11 per month.

So why would the Economist, the global news magazine based in London, call it a mess? This article says that the NHS is in trouble, and needs to learn some new tricks in order to stay effective. It turns out that Britain only spends 7.3% of its gross domestic product (GDP) on health care, which is significantly below average for its peers in the Organization for Economic Cooperation and Development (OECD) countries, and plans to cut that expenditure to 6.6% in the next year. Because their population, like ours, is aging, costs of care are actually rising so already pinched services are being further curtailed. Because of the high costs of caring for patients with complications, some local health commissions will not provide routine surgery to patients who are obese or smoke cigarettes. General practitioners are overworked and can't provide the kind of preventive services that keep patients out of the hospital and nursing homes are unable to house all of the patients who need their beds so those patients stay in the hospital, limiting the beds available for sick people or people needing surgery.

The U.S., in comparison, spends over 17% of its GDP on healthcare, at least 5% more than the next highest OECD country. Most of our problems are not due to stinginess of payers, but rather to distribution of health care dollars, with some people having no access to affordable medical services and others receiving care that is very expensive which they may not need or want. Many of us long for a fully government funded healthcare system like the NHS.

So what has gone wrong with the NHS, then? I'm not entirely sure, but I have some ideas. Since the government is the payer for services, they have the ability to limit funding. Because of the inevitable waste that goes on with the provision of medical services, it could well be that 6.6% of GDP is plenty to provide good health care. It is not enough right now with the system they have. Because the government pays for services regardless of whether the consumers find them to be of good quality, there is no direct incentive to please the patient. Because doctors don't know how much things cost, they are less able to be good stewards of resources. Their health care delivery is therefore inefficient, and reducing funding has not made it better.

We do have similar problems in the U.S., with both lack of knowledge about what things cost and lack of incentive to do things better or more efficiently. Because the government is not the only payer and so cannot put a cap on payment for health care, our system is much more expensive. Our hospitals are prettier and our technology is more snazzy and we probably do more miracle cures per capita. But citizens of the UK have universal access to medical care and nobody goes bankrupt because of medical bills.

Since health care per the NHS is not what we want, but we do want universal access with good quality and lower costs, how shall we do it? Americans have enough mistrust of government, and fiscal conservatives are absolutely allergic to the federal government being the sole provider of health insurance, so we will not get “socialized medicine” anytime soon.

The Affordable Care Act (ACA, also known as Obamacare) has improved our situation considerably. Expanding Medicaid to cover Americans whose income is at or below 138% of the federal poverty line has helped in the 31 states that have adopted that (my state, alas, is not 1 of them.) It is now easier and cheaper for the rest of us to get insurance, which helps avoid catastrophic and crushing medical bills. But even people with health insurance go bankrupt due to their share of health care costs, combined with inability to work. Footing part of our medical costs is supposed to help us make more frugal decisions, which is one of the reasons most health care proposals have included some kind of a deductible (“cost sharing.”) Unfortunately most patients don't have the information they need to make frugal decisions and their doctors don't know enough about costs or other options in many cases to help them do this.

In the JAMA, The Journal of the American Medical Association, an article reported that an intervention to give doctors information on costs of the various aspects of their patients' care as well as a look at their outcomes significantly reduced costs while improving hospitalized patients' health. This seems obvious. Of course knowing what things cost and how a patient fares will make us do a better job and not cost so much. The strange thing is that this is not standard practice. We don't know what the tests and procedures we order actually cost. And most of us don't get a longitudinal view of how a patient's illness or surgery actually turned out.

So if we could have any system at all, what would be best for us here in the U.S.? I'm not sure it actually matters, as long as we get what we need and so long as there is enough shared knowledge about what things cost, how well they work and what are the alternatives. The direction we have gone with private and government funded insurance has led to our present situation. But if the insurance companies paid physicians to take care of patients, and how much we actually made depended on providing the most appropriate care that caused the least unpleasant impact on patients' lives, costs would go down and care would improve. This would require that patients' voices be heard. It would require that doctors knew what was good value and the health care industry was encouraged to create options with better value. A single government payer could do this, but not without built in systems to feedback what patients value and what actually works and innovate actively to improve quality.

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.

Beware how the affect heuristic filters your view of data

The Mr. Spock in us would like to see data as hard, fixed, and totally interpretable. The Dr. McCoy in us understands that data do not have those properties.

Nietzsche once wrote, “There are no facts, only interpretations.” In fact we always interpret “facts” in light of our biases. Our filters come from our preconceived opinions. If we like something, we give great value to “data” that support that belief, while we de-emphasize the negative findings. Vice versa works also.

When you watch the debate, if you like Hilary Clinton, you will cheer her pronouncements and believe them true. If you like Donald Trump, you will dislike her statements.

Few viewers will look at the debate dispassionately. And thus those who claim fact checking are, in fact, not really unbiased either. They develop data that supports their preconceived notions.

We see this in medical debates: screening for prostate cancer, age to screen for breast cancer, whether or not to empirically treat some adolescent/young adult sore throats, the value of palliative care in cancer patients, etc.

A student recently reported a conversation he had with a program director. He asked her if her family medicine residents were exposed to direct primary care practices. She proceeded to scold him and anyone who would even consider such a practice.

In our society we too often disregard Steven Covey's admonition, “Seek first to understand, then to be understood.” We will not see or hear this recommendation modeled in a debate, We rarely see this recommendation followed in medical debates. This recommendation requires civility, and that attribute has become much too rare.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.
Tuesday, October 25, 2016

Is CPAP all it's cracked up to be?

The New England Journal of Medicine has offered tough news for sleep experts lately. First the SERVE-HF trial ruined ASV, now the SAVE trial put a hurt on an even bigger part of their practices, finding that CPAP didn't reduce cardiovascular events in patients with obstructive sleep apnea and pre-existing cardiovascular disease. But based on a panel discussion yesterday, the experts aren't so willing to go along with this one.

They raised a host of objections with the trial--from the population being too old, too male, too undertreated for cardiovascular disease, to not having as many patients as originally intended. Some of the experts eventually conceded that the results do suggest that CPAP doesn't work for the specific population in the trial, one of the important characteristics of which was that they were not sleepy, even before they tried CPAP. Although even on that point, one of the speakers pointed out that people often don't know that they are sleepy, and that quality of life was better in the patients on CPAP.

If I sound suspicious about all this, it might be because the session started with the moderator apparently trying to take down ACP's CPAP guidelines. Of course, after reviewing the evidence, he was forced to concede that "actually maybe the ACP recommendations are correct." Well, duh.

Is your doctor out of date?

Years ago, I was having dinner with 2 members of The Cleveland Orchestra, one of the finest orchestras in the world. I asked them, with my kids present, how much time they devoted to their craft. As many parents know, getting kids to commit to practicing a musical instrument is about as easy as splitting the atom in your garage. The musicians told us how much time they practiced, which was mind boggling, as one would expect. Any artist, athlete, Green Beret or similar professional, has to demonstrate extraordinary commitment to maintain a superlative level of excellence and preparedness.

I asked one of the musicians, the violinist, how long he could refrain from playing his instrument before he noted some professional slippage. Guess your answer. At the end of this post, I will relate his reply.

How long can you be away from your job before your performance ebbs? For most of us, we can take weeks or longer on holiday and return back to our positions seamlessly.

A few examples:
• Politicians return to Congress after long breaks and lose not a whit of their capacity for obfuscation and duplicity;
• New York City cab drivers return from vacation and can still take you on a ride of terror to any destination;
• An airline customer service representative a few continents away maintains state-of-the-art client service even after a month away from her cubicle.

What about doctors? What about gastroenterologists?

Yes, I do take vacations, but most of them are long weekends. It's rare that I take even a week off. Perhaps, the reason why I maintain such a keen colonoscopic edge is because my absences are brief. If I took a sabbatical for 6 months, would I be rusty when I approached my first rectum on my return?

Now, manipulating a colonoscopy when I bringing light into a dark world is not exactly the same as playing violin in the Cleveland orchestra. I'll leave it to the reader to contemplate which of these activities demands more skill.

Seriously, do physicians lose their cognitive and procedural skills after an absence? I'm not sure this has been tested, but I believe the question is a reasonable one for patients to consider. Hospitals will track volume of surgeries from specific surgeons, but a busy surgeon could meet the yearly threshold, and still take several months off. Should a patient who is to undergo a cardiac bypass or a colonoscopy after the physician has been away for a few months be concerned?

Is medicine like riding a bicycle that one can do well after a hiatus of years or more? Or should doctors who have been off the bike for a while put some training wheels back on.

Consider this the next time you are hearing music from a master musician in a concert hall. One thing is for certain. He hasn't been loafing on the beach. My musician friend told me that if he is separated from his instrument for 3 days, he can hear the difference even if we couldn't.

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, October 24, 2016

Is adaptive servo ventilation still good for anything?

It wasn't much of a debate at the pro/con session at CHEST 2016 (which I'm in LA covering this week). Both speakers agreed that last year's SERVE-HF trial, published in the New England Journal of Medicine, was the end of adaptive servo ventilation (ASV) as a treatment for heart failure patients who have Cheyne-Stokes breathing. The treatment not only failed to improve patients' survival, it appeared to decrease it, leading the manufacturer to issue a field safety notice. The only question left is whether ASV might be useful for other purposes. Najib Ayas, MD, made the argument that patients with opioid-related central apnea and patients with complex apnea might still benefit from ASV. Especially among patients who are already on ASV, it can make sense to still use it (as long as they have normal ejection fraction), he argued. His debate opponent Harry Yaggi, MD, countered that treating the underlying causes of the apnea is really the way to go, and that there's not good data to support the use of ASV in these patients. You'll be totally shocked by the conclusion they agreed on--more research is needed to determine the best course of treatment!

Bullets and the burden of innuendo

One of the favored arguments of the guns-for-all campaign is that the best response to a gun in the hand of a bad guy is a gun in the hand of a good guy.

Don't worry; I have no intention of taking us into any of the usual quagmires. I am not going to talk about rights, tyranny, the Constitution, or the meaning of a militia, let alone the placement of a comma. Rather, I want to confront something that should reside safely on common ground: the difference between a good guy, and a bad guy.

We obviously can't throw around those terms and not require them to mean something. If they do mean anything, we should be able to say what it is. Of course, it's possible that good guy and bad guy, in common with pornography and junk food, are easier to spot than to define. But let's try just the same.

I think one readily agreed upon distinction, as it pertains to the guns in hand with which we began, is that a bad guy cares a lot less about who s/he shoots than a good guy does. A bad good with a gun is, in order to be a bad guy, presumably willing to shoot a good guy. A bad guy with a gun is obviously willing to shoot another bad guy who isn't on the same team.

A good guy with a gun, in contrast, is obligated to care about who s/he shoots with it. I trust we can all agree that not caring who you shoot surrenders your right to be 1 of the good guys. That should be an easy one.

But now we have a potential problem with that original proposition. A bad guy has a gun, and is quite willing to use it and find out after, if ever, the particulars of the chap at the receiving end. A good guy with the very same gun, in order to be a good guy, has to verify those particulars quite carefully before pulling the trigger.

All other things being equal, it's pretty clear who is likely to win this shootout. But as I hinted at the start, this isn't about guns—it's about good and bad—so let's move on.

What's true of bullets is almost identically true of innuendo. A bad guy wielding verbal abuse and propaganda against an adversary doesn't have to check facts; they can just fire away. A good guy, whether seeking retaliation, or self-defense, or even a preemptive assault can't get away with that. If they try, they no longer qualify as a good guy. By definition, a good guy can't use the methods that make a bad guy bad. They can't just make stuff up.

This gets ominous for good guys pretty fast. Imagine that a bad guy, in service to their bad ways, finds bad things to say about a good guy they oppose. Imagine that what they say is distorted, and out of context, and more false than true, but with just a bit of truth for good measure. The good guy, though basically good, is nonetheless human and imperfect, of course.

The good guy, being good, feels obligated to address that bit of truth, however disproportionately small it may be, and whatever it may represent from human imperfection, to a loss of patience, to a slip of the tongue, to a lapse in judgment. As soon as they do, the bad guy, being bad, is at liberty to pounce, and shout: See! I told you so. His/her friends shout along, too, generally using social media as a megaphone, and amplifying the distortion.

But put the shoe on the other foot. Any given good guy may at times spin a tale in a direction they favor, or exaggerate. In general, though, they stick far closer to the objective truth than the bad guy because, again, if they didn't, they wouldn't be good in the first place.

So the good guy criticizes the bad guy with an argument that is mostly true. The bad guy's response? Deny it, and disparage it. Bad guys have a weapon in their arsenal that good guy's simply can't use: bad guys can lie about lying. They can lie about having lied about lying. Once you're good with being bad, there are no rules. It's a position that makes you practically bulletproof.

A good guy can't do this, because if ever they do, they are no longer good. This is all implied by Edmund Burke's famous admonition regarding evil in the world, but was consigned to the fine print.

My point, obviously, is that a hail of innuendo, like a hail of bullets, is apt to favor those who fire without compunction. Compunction is clearly part of what differentiates good guys from bad guys in the first place, in any definition worth considering.

If you've discerned that I might be writing from personal experience and proprietary passion, you are quite right. I am far from an exception to the rule about human imperfection, but I try very hard to be a good guy, and to do good in the world. When I want to know if I am trying hard enough, I look into the eyes of my wife and my children. I have fought the very fight I am describing- and despite the burdens of innuendo, have every intention of fighting on. But I do concede that at times, the burdens of innuendo are heavy.

Lately, I have had cause to think such burdens put me in some rather rarefied company. I'm not the only one to reflect in that direction.

Whatever else they may be, presidential candidates are humans, and thus subject to these same exigencies. But presidential candidates don't live normal routines. Their every gesture is scrutinized, and when opportune either to garnish or tarnish, amplified ad infinitum. It's as if some tiny epidermal blemish were blown up a thousand times and posted as your profile picture. Saying it was you wouldn't be false, exactly, but no one who knows you would recognize you.

The relevance? Not all “lies” are created equal. Finding some tendency to dissimulate in all concerned does not a draw make.

Consider the implications as the spirit moves you. As for me, I will be rooting for the good guys to win in the end, in spite of it all; doing my utmost to remain on the right team- and hoping no one gets shot.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
Friday, October 21, 2016

Rose-colored heart

My patient took off her glasses and said, “I can't keep looking through these rose-colored glasses. I just can't.”

I was holding her hand and both of us had tears in our eyes. Her body was sick and she knew it. I felt sad because there wasn't any other treatment to offer.

Then, all of a sudden, she looked at me and smirked. “You know what? I just noticed that these ol’ glasses of mine really are rose-colored!” She threw her head back and laughed so hard that I did, too.

After that, we just sat in silence. Holding hands, looking out the window, and wishing on invisible stars.

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, October 20, 2016

The awesome human factor

Recently I watched the movie Sully. It was the first time I'd ever watched a movie on its actual release date. Knowing what a legendary actor Tom Hanks is, and what a fascinating and near-tragic story unfolded on Jan. 15, 2009, I felt confident that my choice to venture out to the cinema on a beautiful Boston September evening, would be a good one. The movie sure didn't disappoint. Brilliantly directed and acted, the viewer learns about the series of events that unfolded after US Airways flight 1549 encountered a flock of Canada geese 3 minutes into the flight, causing catastrophic bilateral engine failure. Captain Chesley Sullenberger, who had a lifetime of aviation experience (and a keen interest in airline safety) heroically guided the stricken plane into the Hudson. Miraculously, everyone survived—and the rest is history.

The movie guides us in detail through the subsequent events, when the National Transportation Safety Board (NTSB) investigates what happened and whether Captain Sullenberger could have made it back to the airport safely instead of landing in the freezing Hudson River. I have read conflicting reports about whether the NTSB was as harsh in their initial assessment as the movie makes out, but as the story unfolded, the viewer was left with the feeling that it was the hero Captain Sully versus an uncompromising and mean-spirited safety review panel.

The aviation industry is rightly seen as a role model of extremely lofty safety standards, and many leaders in other industries have attempted to emulate their success. I have written previously about how lots of prominent health care leaders have also sought to do this, and how despite some good intentions, the comparison is a flimsy one.

One theme that comes up a lot in Sully, and is passionately defended by Captain Sullenberger, is the “human factor.” Hindsight is always 20-20, and everyone is always the wiser afterwards. This does not mean that we shouldn't investigate and analyze, but the problem with the so-called experts' initial analysis of Flight 1549, was that an engine-failure so soon after take-off was completely unprecedented, and nobody could confidently say how a human being would respond.

It turns out that the computer simulations that were used by the NTSB were incorrectly stating that a pilot could have made it back safely to a runway. In actuality however, only after a large number of attempts, did any simulator pilot make it back safely (and that was using the assumption that they knew immediately what had happened and what to do). Captain Sullenberger's defense of his own actions turned out to be right, and it was in fact only the human factor i.e. Captain Sully's actions, that saved the lives of all 155 people on board. Turns out no computer would have done that.

As the term “human factor” kept coming up in the movie, it got me thinking again about the health care comparison, and how it's really only that which puts the “care” into health care. In my capacity as a doctor, and all the other work I do in the entrepreneurial, writing and consulting realms—I meet so many people who are involved at the peripheries of healthcare. Technologists, start-up folk, “Big Data” people and yes, regulators and administrators—and there's 1 common theme that unites all of them. When you talk to most of them (and again, I hate to generalize, but for most of them it's true), they appear to have little understanding of the frontlines of medicine and the heroic work that goes on day in and day out. To them, medicine is all about numbers, outcomes and population health. The whole agenda appears to do everything possible to completely take out the “uncontrollable human factor.”

The problem with this perspective is that health care is different from any other industry, and this “helicopter view” doesn't quite make the cut. Caring for people is not like running a factory assembly line or operating a large automated machine. Whether we are talking about individual doctor-patient (or even nurse-patient) everyday interactions, or life and death situations such as a patient coding in the hospital—you cannot separate out the science from the human factor in an arena that is so full of very real human emotions. That's why anybody who takes an armchair general or Monday morning quarterback approach is doing the wrong thing. By all means investigate, be thorough, seek to improve, and hold to account any deviation from normal protocol, but never forget the very human side of medicine. The general standards of health care in the United States are already exceptionally high when compared to almost any other country, and the reality is that everyone is so highly trained that really serious mistakes are thankfully rare.

What everyone does in health care is heroic. Doctors, nurses, or any other professional who shows compassion and cares for the sick when they need help, are doing a noble thing. Using your skills to get people better may seem like “just a job” after a bit, but you are having your own Captain Sully moment every time you selflessly dedicate yourself to your patients' wellbeing.

Sitting talking to an elderly patient reminiscing about his Second World War experiences, spending an extra 5 minutes with a family who has had their whole world turned upside down, holding the hand of a dying grandmother who is expressing her biggest regret in life, or calmly facing the parents of a child who has been diagnosed with terminal illness. In health care, the human factor is everything.

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, October 19, 2016

Why I oppose home strep testing

Recently I read this tweet, “home strep test likely to reduce inconvenience, cost, strep complications, unneeded antibiotic and antibiotic resistance #medx”

I disagree, but the reasons are fairly complex.

In order to understand this problem, we have to define the possible test, its use, the likely misuse and both the intended and unintended consequences of such a test.

What makes a good home test? Users should have no difficulty collecting the test sample. The test performance must be straightforward and simple. The test should answer a question that has a dichotomous implication.

Clearly, even health care professionals receive criticism in obtaining tonsillar swabs. So that would make our current tests difficult to perform for many at home. Possibly one could use a spit test—again difficult to perform.

One could possibly develop a test that is almost foolproof to run. That does represent another challenge.

But the real problem is the rationale for the test. The underlying assumption of the strep test does not pass muster. Advocates would argue that patients either have group A strep pharyngitis (and thus deserve antibiotics) or not (and thus do not deserve antibiotics). This assumption has flaws on both positive tests and negative tests.

All guidelines recommend not testing patients for group A strep unless they have a Centor score of 2 or greater. Currently many urgent care centers, emergency departments and retail clinics test everyone, regardless of the score. One would expect many to run a home test for any sore throat, therefore leading to continued overtesting. Most experts believe that treating the zeros and ones means that we are giving antibiotics to carriers.

The next false assumption is that the test is highly reliable. Our meta-analysis (as well as other expert estimations) shows that the sensitivity in practice settings is only around 80-85%. Thus, as high as 20% of patients with strep throat are missed with a rapid test.

But the biggest problem is that rapid strep tests oversimplify our approach to sore throats. In pre-adolescents we really do primarily worry about group A strep, but acute sore throats in adolescents and young adults have a wider differential diagnosis that group A strep only.

A home strep test would not diagnose group C Streptococcus or Fusobacterium necrophorum pharyngitis. It would not help diagnosis infectious mononucleosis. A home strep test could give a false sense of not having a dangerous diagnosis. Acute pharyngitis can turn into worsening pharyngitis.

Admittedly, many physicians do not consider the entire differential diagnosis of acute sore throats or even understand when the patient does not have an acute sore throat. Will patients know when to seek medical care if they have a negative strep test?

Many patients and physicians seem to embrace the phrase “just a sore throat”. I fear that a home strep test would reinforce that phrase.

I have written before about long tail problems. Most sore throats are self-limited, but sore throats can portend great morbidity and even mortality. I fear dumbing down sore throat presentations. We need physicians who understand the complete differential diagnosis of sore throats. We need physicians who understand the “red flags” that alert us that it is not “just a sore throat” but rather something more complicated. (infectious mono, early HIV, peritonsillar abscess, Lemierre syndrome, Still's disease, leukemia, etc.)

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, October 18, 2016

Nursing staffing levels threaten patient care

On the day that I penned this post, I rounded at our community hospital. My first patient was in the step-down unit, which houses patients who are too ill for the regular hospital floor. I spoke to the nurse in order to be briefed on my patient's status. I learned that this nurse was assigned 6 patients to care for, an absurd patient volume for a step-down unit. “Why so many patients?” I asked. She explained that some nurses called off work and the patients had to be spread around among the existing nurses.

This occurs every day in every hospital in the country. Nurses are routinely required to care for more patients than they should because there is a nursing shortage on a particular day. Why do hospital administrators allow this to happen? If any are reading this post, I invite your response. Enlighten us. When a nurse is overburdened, how do you think this affects quality of care and nursing morale?

I suppose it saves a few bucks on payroll, but this strikes me as very short term gain that risks medical and financial consequences. Providing high quality medical care can't be a rushed effort. If a nurse's job description increases by 30%, do you think the quality of care and patient/family satisfaction won't decline? Don't administrators fear the risk of medical errors from overworked nurses? Would any of them like to be patients under these circumstances?

Nurses have confided to me for years how demoralized they are that no one speaks for them. Instead of watching their backs, they often feel that they are stabbed in the back.

I do not have warm feelings for labor unions and I support right to work initiatives. But, when I see what nurses endure and the lack of support that they receive, I would support them if they moved to organize.

If a third grade teacher is ill, we expect a substitute teacher to be called in. The third graders are not simply herded into another classroom expecting 1 teacher to handle a double load.

Many of us today are asked to do more with less. Teachers, law enforcement, businessmen and government program administrators know this well. At some point, you aren't cutting fat anymore, but are slicing into bone. We are not taking proper care of those who have dedicated their lives to care for us. Who will heal the healers?

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.

Goodbye triclosan and triclocarban

Back when I was an infectious disease fellow, I completed a national survey (along with Anthony Harris) of the availability of tricolsan and triclocarban containing antibacterial soaps. At the time, the industry wouldn't release the use or sales data we needed to estimate a population risk from these chemicals. We found that 76% of liquid soaps and 29% of bar soaps sold to consumers contained these agents. Fifteen years ago we concluded: “with limited documented benefits and experimental laboratory evidence suggesting possible adverse effects on the emergence of antimicrobial resistance, consumer antibacterial use of this magnitude should be questioned.”

Well, patience is a virtue. Today, the FDA issued a rule banning triclosan, triclocarban and 17 other agents in hand soaps and body washes. The ban does not apply to antibacterial soaps used in health care settings. In a press release, the FDA stated:

“there isn't enough science to show that over-the-counter (OTC) antibacterial soaps are better at preventing illness than washing with plain soap and water. To date, the benefits of using antibacterial hand soap haven't been proven. In addition, the wide use of these products over a long time has raised the question of potential negative effects on your health.”

It's nice to see positive change happen in your lifetime. It's also nice not to have to read a soap's ingredients before washing our hands.

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.
Monday, October 17, 2016

Humanity's fishy origins

I am just back from a sequence of speaking engagements at scientific conferences in and around Cape Town, South Africa and, as fate would have it, a quick and illuminating trip to the Stone Age.

That unexpected detour came courtesy of Professor Frits Muskiet of the University of Groningen, The Netherlands. Prof. Muskiet, a clinical chemist extensively published in the area of fatty acid metabolism, was among the plenary speakers at the ISSFAL (International Society for the Study of Fatty Acids and Lipids) 2016 Congress, as, indeed, I was honored to be. He took advantage of the occasion to deliver a talk in equal measure erudite and entertaining in the area of evolutionary medicine, and human adaptations to particularly patterns of dietary fat intake.

The question with which Prof. Muskiet especially wrestled was this: why should humans, with alleged origins in the savannas of Africa, have adapted a need foromega-3 fats? If the question sounds at all odd to you, it should not. Creatures adapt to need what their environment provides, or they make a hasty retreat from living at all. It is not happenstance, for example, that all of the vitamins and minerals we discover to be essential in some way to human metabolism are found on this planet. The same may be said of the gases we breathe.

Stated differently, if we have evolved a dependence on omega-3 fatty acids in our diets- a fact indicated by the categorization of these among others as “essential” fatty acids- then omega-3 fats must have been part of the nutritional habitat in which humans evolved. Where, then, were these fats now routinely called “fish oil” coming from on African savannas?

My answer has long been from the flesh of wild game that is to the flesh of grain-fed, domestic cattle as saber-tooth is to tabby. This is by no means an argument of my own devising. Rather, just this is suggested by the seminal, peer-reviewed papers on Paleolithic nutrition, now spanning several decades.

Among others, Boyd Eaton, whose work and insights I have gratefully acknowledged before, and colleagues have suggested stark differences between the meat that prevails in modern societies, and the meat consumed by our hunter-gatherer forebears. In brief, well over 30% of the calories in modern beef come routinely from fat, much of it saturated, and effectively none of it omega-3. In contrast, the flesh of antelope, thought roughly approximate to that of favored Stone Age game, derives as little as 7% of total calories from fat, little if any of it saturated, and a meaningful portion of it omega-3.

The simple conclusion is that what we now call fish oil- the long-chain omega-3 fatty acids, EPA and DHA- has been domesticated out of terrestrial animals by adulterating the composition of their diets. As other presentations at the ISSFAL conference suggested, we are at risk of doing the same to fish by altering their diets in aquaculture.

Prof. Muskiet allowed for this when I asked him about it, but he made a compelling, parallel case. Citing the work of various paleoanthropologists and archaeologists, and tracing findings through the stages of human ancestry, his argument was that humanity has long favored life at a land/water interface. Much of this involved lakes and rivers, and sourcing shellfish from tidal flats. Quite ancient archeological sites indicate human, and even pre-human, consumption of mussels and other mollusks. Fishing hooks many thousands of years old suggest that even fish from the sea figured in the human diet long before the dawn of agriculture.

We may, and indeed must, allow for substantial uncertainty regarding our habitual dietary intake tens of thousands of years ago. Most of us struggle to recall what we ate yesterday with any degree of fidelity. But we must also accommodate the truism that what we now require in our diets is what we adapted to eat. Omega-3 is an essential dietary requirement, and that requirement came from our long, pre-agricultural evolutionary history. Argument one is that it came by land, and argument two is that it came by sea. Let's take the easy way out and allow for either, or both, and continue from there.

There are two important implications of our omega-3 requirement. The first is that popular expressions of the Paleo fantasy that emphasize the fatty meats of land animals are woefully misguided. Seldom does one see ardent proponents of Stone Age dietary patterns emphasize fish, let alone mussels, to say nothing of the arduous daily exertions and estimated 100 grams of daily fiber that were also thought to figure in it. Rather, the Paleo “brand” has been corrupted into pop-culture nonsense, and an invitation to eat more bacon.

The second, of course, is that we all need omega-3 in our diets, and many of us need more- for optimal balance, if not to avoid overt deficiency- than we routinely get. How best to address that?

We have 3 options. The first is to get our omega-3s from plant sources, such as flax, walnuts, and seaweed. This, however, provides mostly for ALA, a short-chain omega-3 we convert into EPA and DHA with variable efficiency. ALA is good for us in its own right, but it is somewhat unreliable as a source of the long-chain omega-3s so important to our vitality in various ways.

The second is to eat fish and seafood routinely. There are many good arguments for this approach, but an important one against it: 8 billion hungry Homo sapiens are decimating the world's fisheries. We go this route with sustainability always in mind, or we go there at our peril.

The third is to take supplements, for which the sustainability of sourcing, be it fish, or krill, or mussels, is again a salient concern.

These options are, of course, not mutually exclusive. They can be combined in various ways, and for whatever it's worth, I rely personally on all three.

As for sustainability, there are excellent resources to guide our selections, and industry is under increasing pressure to make this a priority. With increasing attention to the matter on the part of both demand and supply, we have hope of getting our omega-3, and keeping fish in the sea, too.

But the main point here is simply that a realistic understanding of our Paleolithic proclivities leads us toward omega-3s in the first place. Almost paradoxically, those of us who find ourselves most routinely in argument with the ardent proponents of contrived distortions of the Paleo diet are often ardent proponents of the relevance of the real Paleo diet. I certainly am, having closely followed the literature on this topic for nearly three decades. If native diet and adaptations to it are relevant to the basic care and feeding of every other species on the planet, as they clearly are, what preposterous hubris to think them irrelevant to us. Efforts to probe, and honestly portray, our own primal diet are accordingly of immanent value.

The sad reality, though, is that prevailing pop-culture expressions of Paleo devotion are much about salesmanship, and not at all about scholarship. Mussels and mammoth are Paleo; bacon, baloney and lard- are not. Whatever the temptations of telling people what they want to hear, you simply can't make a polyester purse from a woolly mammoth's ear.

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

Words of affirmation

Today I received an email from a former Emory student/resident that was, quite possibly, the single, most moving thing I've ever had written to me or about me in my entire career. I'm busy right now. Just got back on the hospital service. Have been mad at myself about missing personal deadlines on completing a manuscript I need to finish. And dreading the over 15 “strong” letters of recommendation that students are depending upon me to write for their residency applications. This work can be so grueling sometimes. And sometimes thankless, too.

I started out this day feeling frazzled. I rushed the kids all around the house this morning and still got both of them to school just after the bell. (Fail.) After that, I drove to work coaching myself like a good girlfriend, saying things like, “Girl, stop tripping! You are a great mom” and “Oh, come on. You're an awesome doctor.” Because, you know? It was just one of those days. I was so turned around at 1 point that I thought it was Friday. Except it was Thursday.

But then I checked my email. While sitting in my minivan waiting for my son to come out of ultimate Frisbee practice and feeling flustered about the things I still had to do once I got home. A simple tap of my thumb and there it was. Waiting on my iPhone like a balm for my soul. On a day that I truly needed it.

As a clinician educator, I have won some really great awards—I'm talking career-defining ones that parents and family fly in to witness. I've also done some cool stuff, from talking to Anderson Cooper on CNN to publishing in JAMA and Annals of Internal Medicine in the same month to even getting a medical blog nod in the doggone Oprah Magazine. But nothing—and I do mean nothing—compares to 1 individual learner's affirmation that you've had a real, true impact on his or her life and career. It supersedes any trophy, plaque or media attention. My fellow clinician educators (and educators in general) know what I mean.

You know what? I feel like going on.

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, October 13, 2016

Why fee-for-service isn't always necessarily a bad thing

One of the biggest shifts in American health care over the last several years (and we've only just seen the tip of the iceberg so far) is the shift of the system away from the traditional fee-for-service model, and towards a system based more on quality, outcomes, and yes, a degree of rationing. By all measures, we know that the pure fee-for-service model—at least mostly funded by Medicare—is unsustainable. Some estimates even suggest health care spending could approach close to 50% of the entire nation's GDP in the next 50 years!

Put simply, if the brakes are not put on in some way or another, the current system will completely bankrupt the nation very soon. So, as a solution, policymakers are doing everything possible to halt the exponential growth in spending. Moving away from fee-for-service has understandably ruffled a lot of feathers, because it not only requires changes in how we go about funding healthcare, but also the whole philosophy of how we work and think about the practice of medicine.

In its purest form, fee-for-service always is a dubious way to administer health care. That's because the more we investigate, test and intervene—the more financial rewards potentially exist. If there's no thought about whether or not certain things are actually really needed—and everything is just reimbursed regardless—that's really not a healthy thing (no pun intended). It also doesn't put the right amount of focus on preventive medicine and wellness.

I've seen situations exist in certain Third World countries I've visited, where everything is completely paid out-of-pocket, and doctors are a bit ruthless with getting as much as they can. An unacceptable situation. If that's human nature at 1 end of the spectrum, I'd like to focus on human nature at the other end of the spectrum. I grew up and went to medical school in the United Kingdom, which probably has the most centralized and regulated health care system in the world. The National Health Service, NHS, is a national treasure across the pond—widely respected and admired. But there's an aspect of that system which really didn't sit well with me, and made me all the more appreciative of the United States.

You see, in the UK, within the entirely government-run and funded health care system, you have the complete opposite mentality of fee-for-service. Over there, the mantra is to not treat and avoid intervention as much as possible. I remember when I worked in NHS hospitals, the pushback general practitioners would get (often disrespectfully) if they ever wanted to admit a patient to hospital. I remember how hard it was to get specialists to see our patients in the hospital and how much we had to justify (almost to the point of getting onto our knees!) to the radiologist, if we ever wanted to get a CT or MRI scan.

Now I don't mean to knock the amazing work that doctors in England do on a daily basis and how hard-working they are (many of my friends are still there). But it's only human nature that when you get paid the same to see 5 patients a day, or 25 patients a day, the work ethic on a human psychological level is always going to be different. When I first came to America, it was a pleasure to be able to order tests at will (not frivolously), but at least not get so much resistance every time I felt my patient needed something done. It was also great to call specialists up and have them “thank me for the consult” and see the patient in quick time. A total customer service mentality, with the underlying philosophy that the harder you work and more productive you are, the more you will get paid and reimbursed.

America, be very wary of moving towards a rationed and “quality” based health care system that doesn't have the right rewards and incentives in place. The American public may be very disappointed with what we end up with.

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, October 12, 2016

My week in ultrasound

After 5 years of doing bedside ultrasound, I'm still excited about it. Bedside, or point-of-care, ultrasound is using an ultrasound machine during the physical examination of a patient in order to make a diagnosis. I use a pretty tiny machine that fits in my pocket. As an internist who works in the hospital and in rural clinic outpatient settings, I get to use my ultrasound all the time, and it's still lots of fun. (For more on adventures in ultrasound see this or this or this.) Those of you who have read this blog for a while can skip the intro and go to the cool cases.

When I talk about it, most people who haven't already heard me wax eloquent say, “You mean you look at babies?” Ultrasound has been used as a bedside tool for looking at pregnant wombs for a very long time. It is extremely useful for that, since you can see if the baby is alive, about how old it is, whether there are 2, what position it is in, and a number of other useful things. I would never give up the chance to look at a baby if my patient were pregnant and willing, because they are so cute, but since I am not an obstetrician, I look mostly at other things. I can see whether the heart is failing, whether there is extra fluid in the lungs or belly, whether the kidneys are blocked, whether the bladder empties. I can see pneumonia and broken bones, tell whether a swelling is full of fluid and whether a lump is solid or a cyst. I can see disease in blood vessels and stones in gallbladders. Combined with talking to a patient and doing my usual physical exam, I can determine whether a patient is dehydrated or the opposite and can often be more accurate about diagnosing blood clots or sepsis. It's cool. Yes indeedy it is.

This week I worked as an outpatient doctor in clinic and also in the hospital, admitting and taking care of sick patients. I use the ultrasound nearly every time I examine a patient and it always helps, but there were some cases in which it was more spectacularly useful than in others.
1. A patient in clinic had pain in her head and cheek and teeth on the right side 3 weeks after getting a cold. She had a long history of allergies and sometimes used a nose spray or an antihistamine, but this was worse than usual. On exam there were polyps in the nose and maybe a little bit of tenderness in the right side of her face. It is possible to use the ultrasound on the sinus bones behind the cheek to see if there is fluid, because fluid transmits ultrasound and you can see the back wall of the sinus only if there is fluid in it. I could see the back wall on the right, the side with symptoms and not on the left. I diagnosed a sinus infection. She will try nasal steroid spray and washes to see if things can open up and drain, and if that doesn't work, she has a “pocket prescription” for an antibiotic which she can fill and take. I also looked at the teeth on the right with the ultrasound and found no evidence of an abscess, which was reassuring.
2. Another patient in clinic had stubbed his toe pretty hard. It had swollen and then swollen some more and he was concerned about an infection. The clinic does not have an X-ray machine and is a pretty long drive to the closest one. Beside the cost, it takes an hour of a patient's time to wait, fill out papers and then have an X-ray done, plus I will usually then wait another hour for results and the patient will then be difficult to contact. I was able to ultrasound the toe, find a non-displaced fracture at the point where he was tender and give an explanation plus an appropriate set of recommendations.
3. At the hospital I had a patient who had been admitted with low blood pressure and likely pneumonia along with blood enzyme tests suggesting a possible heart attack. He responded well to antibiotics and fluids and, due to having lots of chronic medical problems, wanted to avoid being transferred to a larger hospital to see a cardiologist. I knew from previous visits what his heart looked like with ultrasound and could tell him that it looked no worse, which meant that an emergent visit to the cardiologist was not necessary. I was able to use the ultrasound of the heart at the time of our conversation to help guide our shared decision-making about whether to get in a helicopter and head far away from family and friends.
4. Another patient had severe pancreatitis, an inflammation of one of the nastiest and most caustic organs in the digestive system. He was 80 years old and drank too much whiskey on a daily basis, which caused the pancreas to become angry. After a day or so he developed an acute alcohol withdrawal syndrome, trying to crawl out of bed, anxious and with an elevated heart rate. We treated him for the alcohol withdrawal, but his heart rate remained elevated. Was he dehydrated? None of the other labs gave me the information I needed, but ultrasound of the inferior vena cava showed that he had been adequately hydrated and that, as expected in severe pancreatitis, there was some fluid in the belly and at the base of the lungs, so more fluid would make things worse rather than better. I was able to repeat the ultrasound daily to determine how much intravenous fluid to give.
5. A young man with a history of longstanding intestinal inflammation and several operations in the past presented with abdominal pain. X-ray was pretty normal, but can be hugely misleading. A CT scan would have been helpful, but is associated with a high radiation dose. He had undergone many CT scans in his life and the possibility of his developing cancer on the basis of his radiation exposure was already significant. I was able to look for fluid in the belly or fluid filled loops of bowel which would suggest obstruction and feel pretty confident that a non-surgical approach to his problem was safe.

It was a good week. Nobody died. I felt competent. Patients were happy. Bedside ultrasound was terrific.

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.

Physicians versus computers--the wrong question!

I now have a better understanding of artificial intelligence after listening to a Freakonomics podcast, The Future (Probably) Isn't as Scary as You Think. It states, “And in general, what's happened in the past couple of years is the best chess player on this planet is not an AI. And it's not a human. It's the team that he calls centaurs; it's the team of humans and AI. Because they're complementary. Because AIs think differently than humans. And the same of the world's best medical diagnostician is not Watson, it's not a human doctor. It's the team of Watson plus doctor.”

In this Knowledge Project podcast, the same examples and conclusions develop, Pedro Domingos on Artificial Intelligence.

As I listened to these discussions, an important concept crystallized. Computers and especially AI will provide us the best “peripheral brain”, but they really cannot replace us. Humans have strengths that computers likely will have great difficulty duplicating. Computers do not really think, but their algorithms can reveal connections that we humans do not recognize. So working with algorithms we can do a better job at diagnosis and treatment.

Recently we had a wonderful gentleman in his 70s admitted for chest pain. Chest pain occurs for many different reasons. Our human skills are put to a major test in sorting out a precise history. This intelligent, verbal patient kept talking about his heartburn. He pointed to his sternum and described the discomfort as burning. He had a difficult time defining relieving or inducing activities. He had no major risk factors for CAD other than his gender and age.

While talking the history, we asked him if he still worked. He told us that he had to stop working as a janitor because of the chest discomfort. He further stated that he had slowed down at first, because his regular pace brought on the pain.

We got this history despite having asked him previously what brought on the pain. A different approach clarified the pain in our minds.

His nuclear medicine stress test showed an approximately 10-15% perfusion/reperfusion defect in the right coronary artery region.

We called cardiology, who took the history and believed that the patient really had reflux.

One week later when reflux medications and CAD treatment (including beta blocker, statin and ASA) did not relieve the pain, and it actually worsened, a cardiac catheterization showed an isolated 95% right coronary artery lesion. A stent totally relieved his discomfort (which was even occurring at rest).

AI would only work here if it received a proper history. But taking the history required some skill and some intuition. Human diagnosis would only work if we paid attention to the technology. We need to combine an atypical history with other findings. AI would work if a human could interpret a history that was not linear in any way.

So the real question is how do we partner with artificial intelligence? We already partner with Dr. Google and Dr. Uptodate. Partnering with AI in selected cases can help us do our jobs better. Together our patients 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, October 11, 2016

Why I'm against medical marijuana

I have already opined on my disapproval of a medical marijuana law recently passed in Ohio. Once of my points in that piece is that I did not want legislators making medical decisions for us. They can't even do their own jobs.

I am not against medical marijuana; I am for science. The currency of determining the safety and efficacy of a medicine should be medical evidence, not faith, hope, or belief.

Marijuana is a Drug Enforcement Agency (DEA) Schedule 1 drug, alongside heroin, LSD, and ecstasy. I realize this seems odd since most of us do not believe that marijuana has the health or addictive risks of the other agents on the list. It doesn't. But, danger is not the only criteria used in determining which category a drug belongs in, a point often misunderstood or ignored by medical marijuana enthusiasts. An important criterion of Schedule 1 drugs is that they are deemed to have no proven medical use.

The federal government recently affirmed marijuana's Schedule 1 status, which disappointed those who argue that this agent is the panacea, or at least an effective treatment, for dozens of ailments. The government disagreed. It reviewed several hundred medical studies and only identified 11 of them that were of sufficient scientific quality worthy of consideration. None of them demonstrated a salutary effect of marijuana.

An advocate of medical marijuana use was railing against this decision and stated that 80% of Americans believed marijuana had medical value. His point demonstrates the vacuousness of his argument. He might support letting polling determine if a drug is safe and effective; but I trust the FDA and hard science to make these determinations.

I am sure that if we polled the public on the medical benefits of probiotics, gluten restriction, GMO foods, organic foods, radiated foods, colonic detoxification, yoga, veganism and meditation that we might find that the public's belief in these practices doesn't have firm scientific support. I do not argue that these dietary and lifestyle practices do not have health benefits or enhance life in other ways, only that they are either unproven or disproven. There are still folks out there who believe that the measles vaccine causes autism, even though this theory has been thoroughly debunked. In my view, releasing a medicine to market requires firm scientific support. Anecdotes and low quality “studies” should be afforded the weight they deserve.

Should we open up the gates to all kinds of potions and elixirs that are unproven for the public? We do! They are called dietary supplements. These agents are considered safe until they are proven to be dangerous. Is this the standard we want for prescription drugs?

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.