Friday, December 30, 2016

Developing expertise

Our increased focus on diagnostic errors, while important, needs balance with a spotlight on expertise. Gary Klein in a wonderful book “Seeing What Others Don't“ teaches us that performance improves when we decrease errors AND increase insights.

Many physicians and especially clinician educators have focused on the reasons for diagnostic errors, but we rarely discuss the road towards expertise and insights. This blog post from one of my favorites, Farnam Street, addresses that problem, in “Becoming an Expert: The Elements of Success.”

This article has many important insights. One that I want to emphasize is the value of repetition in recognizing chunks. We have several situations in internal medicine that experts recognize and learners often do not. These concepts seem basic, yet too often we see a lack of understanding.

How do you interpret the vital signs? Seems simple and straightforward, yet learners often do not recognize the patterns. The CBC, the basic metabolic panel, the liver tests, EKGs, Chest X-rays, all of these seem routine and simple, yet experts view these tests in chunks and recognize patterns much more accurately.

As educators we need to first become experts on these fundamentals, and teach them every day. We have to understand the illness scripts for all the common diagnoses and the red flags that warn us that we might not have the seemingly obvious diagnosis.

Actually the mystery cases are not the causes of many errors, because we recruit assistance. When the patient has a complex presentation, we take more time, call more consults, and spend time searching the literature. But sometimes the presentation seems straightforward until we have enough experience to reconsider because something does not make sense. As I quoted recently from the BBC Series Sherlock, “You have a solution that you like, but you are choosing to ignore anything that you see that doesn't comply with it.” Experts have learned to not ignore clues.

It takes time and repetition to develop such expertise. If we want our learners to grow towards expertise, we must be discuss patients and their situations deliberately and completely.

Please read the Farnam Street article and carefully absorb the concepts. These writings are greatly influencing my teaching and learning.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.
Thursday, December 29, 2016

Millennials are really not different

We baby boomers have much in common with our predecessors. Every generation seems to think that the newest generation does not measure up to their great standard. My friend and colleague Goop Dhaliwal wrote a wonderful paper in JAMA, “The Greatest Generation“.

It is possible that in the days of giants, the narrator did unsupervised burr holes as an intern and had mastered the physical examination by the second year of residency. Beware, though, that each time we replay those autobiographical memories about our training, we are prone to make the situation more harrowing or ourselves more dedicated or skillful than the last iteration. These war stories are frequently told with confidence, detail, and emotion, which makes them far more believable—but that doesn't make them any more accurate.

But this is not just Goop's opinion. This wonderful article should shatter that myth: “Boomers Don't Work Any Harder Than Millennials“.

Well, according to a new meta-analysis, there's no real generational difference in work ethic between millennials and baby boomers (or even Gen-Xers!). Published this week in the Journal of Business and Psychology, a research team led by Wayne State University and Ford Motor Company researcher Keith L. Zabel analyzed a whopping 77 studies and some 105 measures of work ethic.

The researchers were evaluating a secularized version of the Protestant work ethic, which states that work is central to life, that if you work hard you'll find success, and that you should delay gratification and rely on yourself. The Protestant work ethic is kind of a big deal to American history.

We have heard multiple talks on how we should treat this generation differently. But my experience suggests that students have not changed over the past 36 years. Medical students and residents generally work hard, and want to become excellent physicians. During medical school and residency we had some slackers back in the 70s. We still have some slackers. But the majority have always the same desire and work ethic.

So we should all avoid this new bias when we work with the newest generation. We should continue to treat students and residents with respect and expect the best. Generally they will impress us with their work ethic and attitude. They are special as were we.

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.

Next to the next-of-kin

There is this whole session we do with the medical students about navigating those sticky moments as doctors. Like, where somebody calls you up and asks you for random antibiotics or to look at the rash on the back of their leg while you're trying to chill during a jazz festival in the park. It involves these role plays on how to shut all that down and, if I recall correctly, this part where you just sort of sit around and talk about it.

“What will you do when the homie asks for some blood pressure pills refills?”

“What's the right answer to the old man at your car wash asking you to hook him up with some of them Viagras?”

Ha.

So yeah. We talk to them about all of that stuff. And, for the most part, it's fine.

Yeah.

But here's the thing--the older I get as a doctor, the more I'm realizing how great of a privilege it is to be next to the next-of-kin. That is, the person who helps a friend or their family navigate scary, lumpy times. I got to do that twice this week. And let me tell you--it did as much for me as it did them.

It did.

Now. I will come right on out and make a confession counter to that last statement: It feels good when I have a very personal connection to the patient or the loved one of the patient. Like, the mother of my sorority sister from my pledge line in college? I want to be the one you call. I want to be next to the next-of-kin.

But.

Your next door neighbor's daughter's boyfriend? I do care. I do. But no. I'd prefer not to be the go to on that one. You? Your mom? That is, if we have a relationship? Yes. Which kind of sucks since by nature as doctors we are supposed to be selfless servants of humankind, you know?

Yeah.

Anyways. I told those students, just listen to your spirit and what feels right. You cannot be the doctor in the family for everyone but it's good to be the doctor in the family for more than just the ones related to you by blood. It's up to you to measure out what that is.

Although the antibiotics and the random Viagras are pretty much a no regardless of our blood relationship.

Ha.

I guess these last few days has me reflecting on how so many aspects of being a doctor can't be taught in a classroom or even on the ward. You have to live it, man. You do.

So tomorrow? I will round on my hospital patients. Then I will round on the couple of people that are on my next to the next-of-kin list. And it is all on my terms and it all feels right. Very right. Nope, I'm not calling doctor shots. Just being there and answering questions. Holding hands and helping making sense out of stuff. And I love it because every time I do that, some piece of me feels like this piece of being a doctor was one of the most important parts of me becoming one at all.

That's all.

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.
Wednesday, December 28, 2016

Suicide, psychiatric care and inadequate resources

An article released today in the JAMA sites evidence that the suicide rate in America has risen by 24% in the last 15 years associated with a significant reduction in the numbers of psychiatric beds available. The US has had a lower capacity for psychiatric patients than comparable countries in Europe for years, but in between 1998 and 2013 that number dropped even further.

Waiting in the ER for days

This trend has resulted in atrocious treatment for people with mental illness. Because it is so difficult to find room in a mental hospital for patients with mental conditions that make it unsafe for them to return home, such as suicidal thoughts or intentions, we sometimes see these people spend days or even weeks in emergency rooms just waiting for something to open up. I never saw this a decade ago, but now it is not uncommon, even in our small critical access hospital, to see a patient in one of the little windowless and noisy cubicles of our ER for days at a time. They can't move upstairs to a more comfortable, if inappropriate, hospital bed because our hospital cannot offer psychiatric hospitalization because we have no psychiatrist on staff. Psychiatrists are rare in small towns.

Many factors led up to this

This situation is a slow motion car wreck, not an all of a sudden sort of thing. Care for people with mental illness has been spotty and often terrible in the US, but has generally had a trajectory that aims toward better care and understanding. Early in the 19th century an approach called “institutionalization” created mental hospitals which were intended to care for people with what was then untreatable mental illness for long periods of time. These institutions fostered dependence, usually did not cure or treat psychiatric disorders, made patients vulnerable to abuse and, to top it all off, were quite expensive. Some of the costs were defrayed by unpaid work required of inmates, but in 1973 a court ruled that they were owed at least minimum wage, making the overcrowded and expensive institutions even less viable. Starting in the 1960's a strong movement, led by mental health pioneers, pushed for deinstitutionalization. It was argued that most mental patients could have their needs met by community mental health centers and could live in sheltered living situations such as halfway houses. Many state mental hospitals were closed in the 1970's and 1980's, with good and bad results. The number of severely mentally ill people who are homeless did increase significantly, putting a higher burden on already stressed acute care hospitals. Drug therapy for depression, bipolar disorder and schizophrenia began to be more effective, though, which meant that some people with these diseases genuinely got better and were able to be successfully independent.

Medical insurance and mental health

There was less capacity for inpatient care of mental patients after deinstitutionalization, but for many of these people any care at all was prohibitively expensive because most insurance plans had little or no coverage for mental health issues. In 1996 the Mental Health Parity Act was passed which required health insurance companies to cover mental health costs up to the same dollar amount as covered for medical or surgical care. Insurance companies quickly circumvented this by restricting numbers of visits and numbers of days in the hospital. In 2008, as the real estate market, banks and stock market were going up in flames, a rider was placed on TARP (Troubled Asset Relief Program--otherwise known as the bank bailout) called the Mental Health Parity and Addiction Equity Act. This was worded in such a way that mental health care is now generally covered by insurance.

It is wonderful that people with depression, schizophrenia, bipolar disorder and other serious mental illness can get help without necessarily bankrupting their families. This can mean that people get treatment for these problems before they get serious enough to require hospitalization. It probably also increases the demand for psychiatrists and psychiatric beds, both of which are in short supply.

The American psychiatrist: an endangered species

Psychiatry is not a very popular specialty. Out of about 30,000 residency positions each year, only 211 were for psychiatry in 2014-15. That would translate to 211 new psychiatrists for the whole US the year they complete training, assuming all of those candidates finish the program and choose to practice in the field. Many psychiatrists are aging and retiring and there is already a critical shortage of psychiatrists to meet our present needs. Psychiatry is one of the lower paid medical specialties and is a difficult row to hoe. Successful treatment of patients is very dependent on variables over which a psychiatrist has no control, such as community support, housing and job programs.

Prisons: our new insane asylums

Prisons now house a tremendous number of people with mental illness. In 2007 the Department of Justice reported that 24% of jail inmates had symptoms of psychosis, about a quarter of people in jails and prisons had a history of mental illness and a higher percentage had symptoms of mania and depression. The total number of patients in state mental hospitals is about 35,000 and the number or mentally ill people in prison is over 10 times that number. It is very difficult for people dealing with mental problems to tolerate the stresses of incarceration, leading to high rates of injury in fights and attempted suicide.

But people with mental disorders who are at risk for injuring others or breaking the law are more likely to get a bed in a psychiatric facility than people who are simply miserable or increasingly psychotic and have not broken the law, who could really benefit from a stay in a psychiatric hospital to stabilize their medication and give them intensive treatment. It is those miserable, suicidal and psychotic to the point of inability to care for themselves people who end up in emergency rooms for days awaiting a bed.

What would it be like...

I can only imagine how it feels to be seriously mentally ill in some of these situations. Picture being seriously depressed or anxious and being in prison, where kind words are mostly non-existent and there is nowhere to take comfort. Or schizophrenic, hearing voices that break you down, surrounded by nobody who cares. I can hardly allow myself to conceive of depression, anxiety or psychosis while homeless, exposed to the rain and the cold and vulnerable to assault. Closer to home are the patients who wait in the emergency rooms, with nothing to do, no chance to go outside, take a walk, lying on a 30 inch wide gurney covered with rumpled sheets, contemplating suicide while having no idea what is happening and when.

If we were to fix this, what steps would we need to take?

Clearly we need more psychiatrists. We also need more psychologists and they need more authority to treat, including with medications. This is a different conversation, with intrigue that I don't really understand. But we do need psychiatrists, MD trained, motivated, excellent at what they do, and we need to pay them in accordance with how vital their work is. There are already incentive programs to train as a psychiatrist and work in underserved areas, but we need more incentives.

We need more capacity to take care of patients in hospitals, for those times when things get too intense for them to survive independently.

We need systems to help take care of people with mental illness who need jobs and housing and treatment for substance abuse. We need to strengthen social networks in neighborhoods and communities. This is vitally important for keeping patients out of psychiatric hospitals and out of prison.

We need to shift people with mental illness out of the prisons, which are overcrowded, overused and dysfunctional. This will involve better and more capable staffing and better oversight along with more capacity to take care of them in psychiatric hospitals and community mental health facilities.

We need to support the families of these patients because they are often the only stable thing in their lives. Patients with mental illnesses often burn out their families which is a tragedy in so many ways. Programs to support families, including caregivers and assistants to help support patients' independence should be strengthened.

All of this will cost money, but I suspect not more money than we are presently spending on our dysfunctional systems. Shifting money towards appropriate care for people with mental health problems will not only reduce costs that go to warehousing many of them in the prison system and the cost of acute medical care for the homeless and those plagued with addiction, it might also decrease the overall national burden of misery, hopelessness and isolation.

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.
Tuesday, December 27, 2016

Declines in dementia, of hearts and minds

In this season when we are meant to be thankful, but when so many of us have had so many reasons to be otherwise, we have received a timely, welcome bit of universally good news. Rates of dementia in the United States appear to be declining.

This news reaches us courtesy of a study published recently in JAMA Internal Medicine. The investigators used standard, validated measures of cognitive function and dementia in two groups of more than 10,000 people in the U.S. with an average age of roughly 75 in the year 2000, and again in 2012. The overall rate of dementia declined over that span from 11.6% to 8.8%.

Taking this news at face value, it is extremely encouraging. There have been rather dire projections that with the population in the U.S. and other developed countries aging, rates of dementia would rise in tandem. Alzheimer's and related conditions are devastating, obviously, so the human cost of such a rise- imposed on victims of the condition and their caregivers alike- is the principal concern. But these projections also pertain to the financial devastation wrought by a tidal wave of dementia-related healthcare costs crashing into a system already drowning in the costs of chronic disease.

Expecting dementia rates to rise and seeing them fall is simply good news. But inevitably, the whole story is not quite so simple.

For one thing, projections about a rise in dementia rates do relate directly to aging of the population, while this study matched its cohorts for average age. In fact, the mean age of the 2012 cohort was slightly less than the earlier group, although from a statistical perspective that were nearly equivalent. Still, the 2012 cohort certainly was not older- and it is the increase in numbers of ever-older people that was predicted to drive an increase in dementia rates. So, what if we compared a cohort of 10,000 people now with a mean age of 80, to a cohort from a decade ago with a mean age of 75?

The new study does not answer this question. The more recent study cohort did have more people over age 85 than the earlier cohort, even though the average age of the group was trivially lower, not higher. The study methods did include adjustment for age, and the decline in dementia over time remained significant. So, the good news here appears to be fairly robust- but not robust enough to preclude the feared increase in the prevalence of dementia as the mean age of the population ascends.

The basic finding of this study begs the obvious question: why? The only obvious explanation the study itself contributes is education. The more recent study cohort had significantly more educational attainment than their predecessors from a decade ago. Because this is an observational study, and not an intervention designed to establish cause and effect, it can only tell us that more years of education appear to be associated with less risk of dementia in older age.

This association is certainly plausible. Much prior research suggests that the brain, like the body, is subject to the “use it or lose it” adage. Education is brain exercise, and plausibly defends against what we might call “cognitive atrophy.” That much more so if more education in turn leads to more intellectually demanding work. The study suggests that is likely, as average income and socioeconomic status were significantly higher in the more recent study group. Whatever the direct benefits of education, the indirect benefits over time of more opportunity, more security, and more mental stimulation on the job and perhaps off as well, are apt to be greater.

This finding is promising, since education in our population is something we have the capacity to modify. The advantages to raising population-wide, average educational attainment are diverse and compelling, but that much more so if reducing the lifetime risk of dementia is in the mix. But, this finding is concerning as well. A shift in social priorities away from investments in education and the reduction in disparities that prevail in that area could certainly threaten to reverse the favorable trend.

The paper notes other associations of interest, if not of entirely obvious meaning. Rates of diabetes, heart disease, and obesity were higher, not lower, in the more recent cohort; rates of dementia were lower despite these liabilities, as was the rate of impaired daily function. This might be testimony to the power of modern medical treatment. Newer, better drugs and procedures do very little to prevent cardiometabolic risk factors or the diseases associated with them, but do defend robustly against their dire complications, such as heart attack, stroke, premature death, and perhaps- dementia.

Ironically, this paper is almost entirely silent on the topic long known to have the greatest potential to prevent dementia, namely, lifestyle. The word itself does not appear in the paper at all. Exactly one line in the discussion refers to diet and physical activity, in parentheses, when the authors note that: “Higher levels of educational attainment are also associated with health behaviors (e.g., physical activity, diet, and smoking) … which may play a role in decreasing lifetime dementia risk.”

Dementia of the Alzheimer's type, and related vascular dementia, are generally regarded as close cousins to cardiovascular disease, and/or type 2 diabetes. Such dementia has even been called “type 3 diabetes,” referring to preferential, adverse effects of insulin resistance on the brain. Both heart disease and type 2 diabetes are overwhelmingly preventable with lifestyle. This is established by a vast aggregation of diverse research; is reflected in the health status of the world's Blue Zone populations; and is further validated by the results of intervention at the level of a whole population over a span of decades.

The new study leaves us, as research so often does, with more questions than answers. But we may gratefully imbibe the dose of good news, even as we work to know just where it came from, and how we might go from a cup half full, to one full to the brim.

For now, though, we do know that risk factors for dementia are much the same as those for type 2 diabetes and heart disease, which in turn we know how to prevent with lifestyle. We could do a world of good for bodies and minds alike by persuading hearts and minds around the world to put to full use at long last knowledge we have long had about the primacy of lifestyle.

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, December 23, 2016

Sepsis bundles and why sensitivity and specificity matter

Graham Walker(@grahamwalker) tweeted this in response to a blog post:

“Agree w @medrants on Abx usage. Sepsis guidelines mandating Abx for anything that COULD be sepsis is the problem”

I responded that his example is brilliant. Let's dissect the problem.

Sepsis is a severe problem that responds better to early aggressive treatment.

Those invested in diagnosing sepsis desire bundles that have a high sensitivity. In case you forgot the definition of sensitivity, it is the true positive rate. Sensitivity here represents the percentage of sepsis patients that you treat promptly. Sounds good; we do not want to miss any patients with sepsis.

But wait! All tests or bundles have both false negatives and false positives. We want to minimize our false negatives, but we cannot do that without increasing the false positives. Since specificity equals 1, the false positive rate, we have a tautology. Increasing sensitivity means decreasing specificity.

Anyone who spends some time considering this problem will understand that a sepsis bundle that errs on the side of diagnosing sepsis will have the expected consequence of giving antibiotics to a significant number of patients who do not have sepsis, but rather other reasons for matching the criteria in the sepsis bundle.

We love antibiotics when appropriately used, but antibiotics are not benign. Patients who received broad spectrum antibiotics suffer the risk of antibiotic associated diarrhea, allergic reactions and other side effects. Broad spectrum antibiotics increase the emergence of antibiotic resistance.

The problem that Dr. Walker describes (and again I quote one of his tweets):

“Lact 2-3.9 and admitting them for their GI bleed? You'd better give them abx, and quickly!”

As he implies, we need physicians to understand the patient's context. Simple guidelines that include a check box will treat many patients appropriately, but still too many patients inappropriately.

Any premortem examination of these bundles would quickly identify this problem, yet most hospitalists have had these bundles enacted without considering the patient's context.

Now the good news:

The Centers for Medicare & Medicaid Services (CMS) updated the Severe Sepsis and Septic Shock: Management Bundle (SEP-1) measure specifications several times in response to newly published evidence. As a result, CMS will not score the SEP-1 measure validation for Hospital Inpatient Quality Reporting (IQR) Fiscal Year (FY) 2018. CMS is also postponing the public reporting of the SEP-1 measure on Hospital Compare until it is confident that it has valid data that reflects hospitals' performance.

But I doubt that hospitals will reconsider these bundles. CMS discontinued the 4 and then 6 hour pneumonia rule, but still too many patients get antibiotics and are labeled community acquired pneumonia in most emergency departments. While CMS will not be reporting, the sepsis boulder will keep rolling downhill and gaining speed.

And then we will wonder about overuse of antibiotics and emerging antibiotic resistance.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.
Thursday, December 22, 2016

With diagnosis, the adjectives are just as important as the nouns

You present a patient with a past medical history of chronic kidney disease, heart failure and type 2 diabetes. I hear 3 nouns, but I really do not know much about the past medical history.

Cardiologists and coders demand that we further define the heart failure: left or right, if left systolic dysfunction or preserved ejection fraction. Is there valvular disease, or restrictive cardiomyopathy. The nouns do not tell the story.

With type 2 diabetes we need to know how long and what complications. With chronic obstructive pulmonary disease we should know how severe the obstruction and whether they need home oxygen. Is it mostly emphysema or chronic bronchitis?

This article The CKD Classification System in the Precision Medicine Era from the Clinical Journal of the American Society of Nephrology speaks loudly to this problem:

“Chronic diseases of the kidney range from rare inherited disorders, such as Fabry disease, to more common acquired entities, such as diabetic kidney disease. Despite the myriad clinical phenotypes and histopathologic subtypes, even within, for example, diabetic kidney disease, this diverse collective is viewed similarly when estimates of glomerular filtration align. Contrast this approach with that of multiple myeloma, a diagnosis that prompts routine cytogenetic studies, such as fluorescent in situ hybridization, to guide additional diagnostics, therapeutics, and research. Classifying kidney diseases on the basis of eGFR further ignores the complexities of renal function.”

We should demand more precision in our history taking and reporting. Understanding the adjectives helps us better address the patient's complaints and diagnosis. We should not simplify our diagnosis list.

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, December 20, 2016

Bad information for a social disease

I rather doubt ignorance is genuine bliss. It's just a holding pattern; the proverbial calm that anticipates a storm. While the arc of the moral universe is long and bends toward justice, the arc of understanding is long and bends toward truth. It finds us all, eventually. The most ignorant are simply the last to get the memo. Ignorance is delay.

To be clear, ignorance is not a term of disparagement, not a character flaw. It's a state into which we are all born; babies are ignorant. Children are only nominally less so. Time conjoined to information is the remedy. The condition is preserved when information is inaccessible, through no necessary fault of those left uninformed.

Ignorance provides no active resistance against truth, for nature abhors a vacuum. Good information can readily populate the vacant spaces ignorance provides.

Ignorance is bad medicine, of course, relative to knowledge. To whatever extent knowledge reliably empowers—and, alas, it seems to do so quite imperfectly—ignorance does the opposite. Ignorance reliably disempowers, and is thus the common enemy to all who view the value in empowerment.

But bad as ignorance is, there is something far worse for the human condition, and the social diseases of every “-ism” and “-ophobia” to which the body politic is subject. Misinformation is much worse, a standout among the pernicious toxins to which we are vulnerable. Famously, it's hard to fill a vessel already full. Every vessel full of misinformation is actively resistant to the inconveniences of truth.

I graduated medical school in 1988, and have taken care of patients for most of the 28 years since. The Internet, in anything like its current incarnation, did not exist until 1990. Routine access for the masses of us came years later.

So it was that when I first started seeing patients, I encountered most often what every generation of my predecessors had encountered: relative ignorance. Our patients did not know nearly as much as we did about medicine.

This, of course, was no discredit to them or credit to us; it was a distinction four years of medical school were supposed to produce. It was a gap in knowledge that years of post-graduate medical training, five years in my case, were designed to widen. We doctors were supposed to acquire knowledge in matters medical our patients lacked, the very point of all that education. We were supposed to be the experts.

But the Internet has gone a long way toward killing expertise. For when information became universally accessible, so did misinformation. Increasingly, everyone knows everything- but much of it is wrong. Clinical care, outcomes, and the doctor-patient relationship, are all too often the worse for it.

Examples relevant to the broad expanse of clinical medicine, public health practice, and health promotion abound. In cyberspace, immunization is not one among the great advances in the history of public health, not the relief of immeasurable misery; but rather the cause of autism. This is not merely false, but robustly debunked, and yet the insidious meme of it refuses to die.

Internet conspiracy theories tell the gullible that the HIV epidemic was initiated intentionally by government, and that the CDC is complicit in genocide, fomenting anti-government passions. Every radical voice finds the echo chamber in which it reverberates to greatest effect, populating cyberspace with so many spider webs for unwitting flies. Excesses in one direction encourage the disgruntled to embrace “alternative” therapies proven not to work, while in the other staunch conventionalists make no effort to spare the baby in recurrent tirades about bathwater.

Applications of diet to health are an extreme case, subject to a bizarre balkanization owning much the same zealous hostility as religious wars. Every opinion, amplified by the like-minded in cyberspace, can masquerade as expert opinion, and impersonate truth.

Perhaps the greatest and most concerning illustration of all is the one that pertains to the one health that matters to us all, that of the planet. The filter-free broadcasting of misinformation about climate change and the fate of the planet propagates a volume of noise in which even the global consensus of experts is invited to drown.

The ramifications of rampant misinformation are ubiquitous.

The Arab Spring was made possible by the democratization of information. But it was followed not by summer, but rather by the tyrannies of winter in all of its reasons for discontent- aided and abetted by the democratization of misinformation, preferentially directed to divide and radicalize. The surprise of Brexit was borne along to England's now more isolated shores in just such currents. So, too, the restive flood waters soiling our own political house, now so flagrantly divided.

Ignorance has always been a malady of sorts, and universal access to information the obvious remedy. But universal access to misinformation is the quintessential case of a cure far worse than the disease. Only misinformation actively propagates the greatest plagues of human history, inspires the most heinous transgressions of our collective character.

The Internet is subject to few and uncertain laws, but was never immune to the law of unintended consequences. It proves to be an ideal purveyor of misinformation, whether born of willful demagoguery and propaganda, or the relative innocence of misdirected passions.

Either way, the Internet proves to be the dispensary for the worst of all medicines for the worst of all social diseases. The pharmacy is, irrevocably, open, and no prescriptions are required.

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.
Monday, December 19, 2016

Recovering--a sacred time

One day a few weeks ago, after returning from a set of seven 12-hour shifts in a hospital away from home, my husband convinced me to go to a concert. The group performing was the Deviant Septet, based out of Brooklyn, N.Y. They were an odd combination of instruments and they played mostly newly composed music.

The second piece in their program was by Chris Cerrone and was called “Recovering.” I expected nothing, perhaps a nap even, but was completely absorbed by the music which wordlessly represented a magical period that I get to observe regularly but rarely remark upon.

Patients come in to the hospital when they are sick, and often getting sicker. They are vulnerable and place themselves in the hands of strangers. Usually they feel terrible. We do things to them to try to make them better. Often we are successful. And then something magical happens. Their faces look brighter. Their vital signs stabilize. Their eyes focus. They make jokes. It's still not over, though. There are setbacks. There is pain. They are weak and their appetites are not vigorous. But a gate has been passed through.

I don't often take the time to appreciate this transition. For me it is often filled with new concerns. What next? How can we all avoid this kind of event in the future? How much more time before this person can leave the hospital?

This piece of music took me back to the times when I was sick and finally getting better, when the world around me began to be relevant again, and sometimes beautiful. It reminded me that there is a thing that happens, this “recovering”, and spending a little time noticing it will be a good practice.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.
Friday, December 16, 2016

Antibiotics and principles for best use

As physicians we worry about antibiotic resistance. Slowly, we understand that we can help slow down the development of more resistance through excellent antibiotic stewardship. Even Time has highlighted this problem.

I was discussant in a PCORI sponsored workshop for this topic:

Smarter, More Appropriate Use of Antibiotics

Moderator: Kara Walker, MD, MPH

Speakers: Carey Bickford, Jeffrey Gerber, MD, PhD, Kathy Goggin, PhD, Dan Merenstein, MD

Discussant: Robert Centor, MD, MACP

How can we use antibiotics more intelligently? I hope some of you will watch and listen to the discussion.

Antibiotic resistance is a growing public health concern in the US. My online panel on this topic was on Nov. 18 at http://bit.ly/2f0jY9G.

I discussed 4 issues:
1. Giving antibiotics when we have no evidence that they will help
2. Using narrow spectrum antibiotics when indicated
3. Using shorter durations when indicated
4. De-escalating antibiotics after culture or PCR results become available

I believe this was a useful discussion. We have a responsibility to become smarter in our antibiotic prescribing.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.
Thursday, December 15, 2016

Without question

I was taking care of this grown man who was sick. His mama was at the bedside and she was worried about her manchild. Which makes sense because she's his mama.

Now.

This patient of mine has his own life, his own house, his own kids, and his own concerns about his health. And when I first rounded on him that first day, I was explaining everything that was happening to his body while his mama sat at on a chair holding her pocket book and nodding deferentially. She asked one or two super generic questions, but only if I paused and asked. There was a lot going on with him and I knew it was a big thing to get their heads around. His mom looked kind of like a deer in headlights.

“You sure you don't have any questions?” I asked them both. Even though I was mostly aiming my thoughts at the mother.

The patient answered, not his mom. “Um, no. I think you've explained it all to me.”

“What about you, ma’am?”

She simply smiled, lifted one hand and said she was fine. And all of it was pleasant and good. Albeit a little bit unsettling.

Yeah.

So after that first day, for whatever reason, I always seemed to round on him when no visitors were there. I'd come in and he'd say, “Dang. You just missed my mom!” That would make me feel like his mom had more questions for me. And I would reassure him that he could have the nurses page me when his mother was there if she wanted to talk to me. He said he would and that was that.

No one ever called.

The last hospital day came. I walked into his room early that afternoon and prepared to examine him. He was the last person I was planning to see before heading over to the medical school across town for a small group teaching session.

“What you know good, sir?” I asked. After three or four days in the hospital, we'd moved to more informal greetings.

“Nothing, Miss Manning! I'm just waiting on you to give me the verdict.”

“Okay. How are you feeling?”

“As well as I think I'm gon’ feel ‘fore I leave here. I'm ready to get up out of here.”

“Okay. Well it looks like we're in a place where it's safe to discharge you.” He pumped his fist when I said that. “Sounds like we're on the same page.”

“Good stuff.”

I asked if he had any questions and he said he had none. I reached out to shake his hand and my eyes wandered over to the window sill. What appeared to be a pair of multicolored reading glasses were resting there next to a McDonald's coffee cup. There was lipstick on the edge of the cup, too.

“Did I miss your mama again?”

“Man. She just can't win for losin’. She went to go feed the meter and I said, ‘Watch Dr. Manning come in soon as you go.’”

“Aww man.”

“She all worried ‘bout me and stuff.”

“I hear you. Being a mama is hard like that.” That made him chuckle when I said that.

We made a little more small talk and I headed out. I picked my tote bag up from where the clerk was hiding it for me in the nurses station and scuttled up the hall toward the elevators. I looked at my watch and I was making excellent time for my commute over to main campus.

Yup.

I stepped onto the lift and took a deep breath as it stopped on what seems to be every single floor. After what felt like a million years, I finally make it out of the hospital. Checking the time once more, I smile since I know I'll make it with time to spare.

But then something happened.

I saw this man paying to meter for his car. And he looked relieved as he was doing it since the city of Atlanta will ticket you in less than one second if your meter dies. For some reason, I just sort of froze for a moment, watching him stick the “PAID” coupon on his dashboard. And, of course, imagining my patient's loved one doing the same.

Aaagggh.

I squeezed my eyes shut and gave and exaggerated sigh. My head swung to the right and stared up at the hospital. And then I made up my mind.

Five flights of stairs and five minutes later, I was back at my patient's room, panting and out of breath. Just as anticipated, as soon as I came trotting in I saw his mother settling back down into the chair--reading glasses in one hand and coffee cup in the other. And when she saw me huffing and puffing in that doorway, her eyes widened and a big smile erupted over her face.

You know? I'm not sure why but something made me feel intensely like I needed to go back to see her. Which, in a way, is pretty ridiculous, you know? I mean this patient was grown, man. And sure, he'd been handed a pretty heavy diagnosis, but still. This was not child.

But. He was her child. And, it appears, she was a big piece of his support team--a team he was definitely going to need.

And so. I came on in, pulled up another chair and sat down. I leaned on my elbows and tried not to look like I was in a hurry.

“Oh! I thought I'd missed you, Dr. Manning!”

“You know? I was leaving out and decided to come back. Just in case you wanted to talk.”

And you know what? She did want to talk. Talk about her son and his prognosis and how she could be of support. Of how she felt scared and how even when they are all grown up, they're still our babies. She wanted to know if I had kids and if they were boys or girls. And really, she just wanted to talk long enough to feel just a little less anxious about what her boy was up against. Not really questions. But there was more to discuss. There was.

Yeah.

So here's what I learned: I learned that sometimes people don't have questions. But that doesn't mean they don't want to talk. In that quick little instant, I shifted a piece of my practice based on a subtle new realization.

Yes.

I will still finish my discussions with ”What questions do you have for me?” I sure will. But from now on, I'm going to start following up with one more question--”Is there anything else related to you hospitalization that you'd like to talk to me about?”

Yes. That.

And you know what? I've only been doing this for a couple of weeks now. But it's astounded me how many people bite on that second request. Questions? No. More you want to talk about? Yes.

Ah hah.

And no. The whole “listening to that hunch that you need to go back” lesson wasn't the take away for me. Although it is a very important thing to recognize when it happens and one that I've learned previously the hard way.

Anyways.

By the time we finished, there was only ten minutes remaining before my teaching session was to start. I texted my second year student small group and asked them for a last minute modification in our meeting plans. I apologized profusely and felt appreciative for their understanding. We ended up meeting outdoors on the patio of a local restaurant closer in than campus--which was easier for me coming from Grady. They were gracious and easygoing and that lightened my load.

Tremendously.

When we finished, I said I'd stick around in case anyone had questions.

Or things they wanted to talk to me about.

You know what? No one had questions. But two people did have something they wanted to talk about. Important stuff, too.

Imagine that.

I'm so glad that I'm still learning, man. Still listening and learning and growing and trying.

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.
Wednesday, December 14, 2016

Your food is making you sick

I was listening to a call-in show on the radio this week and a listener from Colorado bragged about buying flour that was free of growth hormone and genetically modified organisms (GMOs). At first I laughed, and then I worried. Scientific ignorance is killing us. It allows climate change denialists to stop us from saving our homes. It allows quacks and drug companies to sell fake cures. And it blinds us to the real problems in food safety.

So how can we know what the real dangers in food are? Is it better to buy organic or GMO-free or locally sourced foods? The answer is actually pretty simple, much simpler than all the organic marketing and the GMO fights.

First is economics. In 2015, nearly 13% of U.S. households experienced food insecurity (the current term for “hunger”). Many more are forced to rely on poor-quality foods that lead to obesity, diabetes and high blood pressure. Many poor Americans live in “food deserts.” They may want to purchase healthy foods, but there aren't any grocery stores near enough, and they are forced to buy fast foods or unhealthy prepackaged foods. So, being able to choose healthy foods is itself a privilege.

The 87% of us who aren't going hungry are subjected to a flood of bad information about what is and what isn't healthy. Stores stock foods that are “GMO-free,” “hormone-free,” and “gluten-free,” but the only thing most of these foods share is a hefty price tag.

A good starting point here is author Michael Pollan's one line eating plan: “Eat food, not too much, mostly plants.” By “food,” he means things that look like they came from the ground, or a ranch, or any place other than a factory. This makes things pretty simple.

If you're worried about “hormones” in your meat, don't. Just eat less meat. If you eat a few servings of meat every week, you'll never get more than a few molecules of hormones in your food, if that. And the hormone-free, GMO-free flour that the Colorado baker was excited about? Wheat is a plant: you can't feed it growth hormones. And none of the flour available to consumers is ground from GMO grains.

Health food hype is based purely on marketing and not on science. Much has been made of growth hormone in meat, and much of it is flat out wrong. If your chicken is advertised as “hormone-free,” make sure you aren't paying a higher price, because no poultry in the U.S. is given hormones.

Gluten-free is very popular right now, but even if you are one of the 1% of Americans with celiac disease, marketers are fooling you. Whole Foods sells “gluten-free” baby shampoo. First, please don't eat baby shampoo. Second, gluten is a protein found in wheat. Meats, cheeses, and personal care products don't normally have wheat in them.

But there are real risks in food, risks that require some science to understand and prevent. In the U.S., food-borne illness is a big threat, with 48 million Americans getting sick each year. Much of this is due to poor food handling starting in the fields and farms and going all the way to the final person to touch the food before it goes into your mouth. We do a terrible job in this country preventing infections we acquire from the meats and produce we eat. Preventing these requires good policies and good regulation. (Antibiotics in agriculture is a separate issue. Farmers use it to increase yield in meat, and the antibiotics get into our food chain, not hurting us directly, but decreasing our ability to use antibiotics to help humans.)

While we wait (and wait, and wait) for better food safety legislation and enforcement, there's a lot you can do at home to prevent infections. The CDC's guide to safe food handling is a good place to start. And scientific literacy, as always, is so important. Raw milk (milk that isn't pasteurized) has been a growing fad for a number of years. With that fad has come a quadrupling of the number of outbreaks due to raw milk. An easy way to prevent infections is to stick to dairy that's treated and handled properly, and to avoid food fads.

Eat food, not too much, mostly plants. Follow basic food handling safety guidelines. And learn to separate fact from fiction in food safety.

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog at Forbes. His blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.
Tuesday, December 13, 2016

Of plate, state, and the calculus of hope

In my customary purview, nutrition, public health, and disease prevention, I have had cause to lament periodically the apparent hegemony of Newton's third law. For every silly action we've taken over recent decades to address the effects of badly constituted diet on weight and health, we have appended an opposing, but comparably misguided reaction. Believe it or not, this pertains to the high drama of our current political situation, too.

Let's start with our plates; the state of the State can wait.

In principle, and famously, we had advice some decades ago to reduce our intake of dietary fat. For purposes here, we need not belabor the relevant provisos: the advice originated with studies showing the advantages of the high-fat Mediterranean diet. So, really, it was advice to reduce our intake of saturated fat from the usual sources. The message got mangled as it was passed along, just like in a game of ‘telephone.’ The idea that all dietary fat should be cut, while genuinely favored by some, was actually a distortion of the original mainstream message, but took on a life of its own.

Be that as it may, nobody with any actual expertise- not proponents of eating low fat, and not opponents of eating low fat- ever advocated for low-fat junk food. The original idea was to reduce dietary fat intake by swapping out the salient sources in the prevailing diet- fatty meats, processed meats, processed dairy, fried and fast foods, snack foods- for foods naturally low in fat: vegetables, fruits, whole grains, beans, and lentils, for instance. And, where that was actually done, rates of heart disease and premature death were slashed, and life expectancy extended dramatically. It just hasn't played out that way in America.

No one worth listening to ever said: just eat Snackwells, and all will be well. But, of course, that, or something much like it, is just what the makers of Snackwells, along with every other version of low-fat junk food, implied. And since they implied it with all of the resources of “Big Food” at their disposal, they implied it to great effect.

How great? Well, intake of all the best, natively low-fat foods changed almost not at all in the U.S. over the past 40 years. For that matter, total dietary fat intake never even went down. Rather, fat only ever went down as a PERCENTAGE of total calories, because total calorie intake has gone up, driven mostly by, you guessed it, low-fat junk, laden with added sugar and refined carbohydrate. Total fat intake, actually has trended up over recent decades, it's just that total calorie intake has gone up even more. That is the legacy of the “low fat” era in America. As they say in the old country: oy, vey.

Then, to make matters worse, Newton's third law kicked in. Apparently, human nature shares an affinity for it with all the rest of nature. Perhaps it's because it is so much easier to say, “I was wrong,” than to admit, “I DID wrong.” What's the difference?

If the low fat message simply “was wrong,” then we got bad advice, and can scarcely blame ourselves for following it. If we had actually cut fat, and gotten fatter and sicker- we may have been given bad advice, but what we did, we did well. That's the kind of admission we seem inclined to make: I was wrong, but I was misled.

Far harder, it seems, is this: the advice was fine, but I bungled its implementation horribly! This confession, unlike the other, leaves us little space to avoid a self-indictment of gullibility, nincompoopery, and/or fundamental incompetence. That's a very bitter pill to swallow, so apparently, most of us spit it out.

Instead, we claim: It's not that we implemented advice to cut fat (and, really, saturated fat) moronically; rather- the advice must have been wrong! Much easier to lay the blame there.

But it's just not true. In the U.S., we did, indeed, apply advice about dietary fat as moronically as possible: we conflated saturated fat with total fat; we never reduced our intake of fat anyway, nor even our intake of saturated fat more than trivially; and we added low-fat junk food. If anyone can legitimately claim surprise that THIS formula didn't vanquish obesity and chronic disease, I will give up my day job and become a hula dancer.

So we took the easy way out. We blamed the advice, rather than our monumentally stupid response to it- and then surrendered ourselves to Newton's third law. It was, obviously, time for some equally silly, but opposing reaction, like: cutting carbs. And so we did, bungling it every bit as badly as the “cut fat” message that preceded it.

Whatever the merits or demerits of Atkins' platform, it's only fair to note that he never advocated for low-carb junk food, any more than Keys ever advocated for Snackwells. But at the Atkins' Diet heyday, low-carb junk food is just what we got- and it has stuck with us ever since.

Nor were those sequential boondoggles enough to cure us of our Newtonian proclivities. We have since welcomed the advent of non-GMO junk; gluten-free junk food; “no longer made with high-fructose corn syrup” junk food; and probably other varieties I'm overlooking.

And that brings us, however tangentially, from the state of our plates, to the state of our Union. For, as opposed to Nate Silver, it may be that Isaac Newton correctly predicted the outcome of this election.

It is rather ironic that a population of allegedly thinking Homo sapiens behaves so much like the native inertia of celestial flotsam. Ironic, but apparently true.

The past eight years represented a remarkably progressive action in American politics. Those personally disappointed, for whatever valid reason, by their trajectory during that span, were presumably invited to express that disappointment with an equal, opposing, and by the reasoning of many of us, regressive, reaction. So here we are.

As with our plates, it is convenient and expedient to blame any personal disappointments on the bluntness of the action, rather than all the subtleties of context and implementation. The Affordable Care Act, like a car with no wheels, was designed to “fail,” by those wanting it to do so. The administration of the past eight years faced relentless obstructionism, and if we are honest- racism, too. And, of course, the Obama era began in the gaping hole of the Great Recession. There is a limit to how “good” getting back to ground level can ever feel, relative to reaching actual heights- no matter how monumental the climb out of the depths actually is.

Whether the topic is the content of plates, or the status of our State, physics itself seems to stipulate that an uninterrupted sequence of forward steps is little less than unnatural. But equal and opposite need not mean equivalent and self-canceling. When you run, you push against the ground, and the ground pushes back; but the ground stays put, while you move. Progress is possible.

In spite of it all, the objectively measured quality of the typical American diet has improved over recent years, albeit it little, and slowly. But it's progress just the same, and maybe the only kind the third law allows. And perhaps what's true of dinner is true of our democracy.

As for Newton, he bequeathed us other gifts too, like calculus. Conjoining that to the third law, I wind up with the calculus of hope. Progress is possible, even likely, but not likely ever to be linear. In accord with the rest of nature, human nature too is disposed to a meandering path of actions and reactions.

Here's to progress, in all areas, 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.
Monday, December 12, 2016

We used to sell cigarettes in hospitals

Nice article in STAT, a relatively new Boston Globe-affiliated publication devoted entirely to health care. Melissa Bailey reminds us that Candy Stripers used to sell cigarettes to patients to comfort them while hospitalized.

How quaint.

She goes on to point out 5 practices that will seem just as antiquated. Soon, we hope.
1. Advising doctors not to say, “I'm sorry.” Hospitals still do this. It can be seen as an admission of guilt, the thinking goes.
2. Have prescription labels that don't indicate what the medicine is for. How smart. And not even close to standard at present.
3. Not washing our hands in front of you every time. ‘Nuff said.
4. Spending more time typing than talking and listening to you. We can hope, can't we?
5. Easily getting your medical records, without your having to pay, wait, fill out forms, or just be hassled like you're asking for state secrets.

I think this is an excellent list. There are no doubt dozens more. (Why do we awaken people in the hospital so often?) What are your ideas for health care pet peeves you'd like to see abolished?

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.
Friday, December 9, 2016

Did you get your money's worth today?

It started as a joke, but it has become a mantra. I discuss this phrase on the Curbsider's podcast.

Our medical students pay (in my opinion) an obscene tuition. They are buying a medical education. Therefore we should remember that they are customers who have paid for our service.

As a clinician educator, I try to remember every day that I owe the learners my best effort. I have a wonderful career caring for patients and teaching those learners. The learners make my patient care responsibilities much simpler. But my job involves helping all the learners grow each day.

Learning internal medicine requires persistence and hard work. Our field is vast and complex. We start with naive third year students, have fun with acting interns (fourth year students), help interns through that difficult year and have the pleasure of fine tuning our excellent residents.

Inpatient rounding and clinic attending require us to strive that our patients receive high quality care. During patient care delivery we provide role models and work daily to stretch our learners. We owe them our best effort at helping them grow.

Each day I ask myself, did I give them adequate value. Ask yourself and your learners. Did you give them their money's worth?

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.
Thursday, December 8, 2016

The how-to guide for Mycobacterium chimaera

A few cases at a time, the Mycobacterium chimaera outbreak associated with heater cooler units (HCU) continues to grow. For reasons unclear to me, the response from CDC and FDA to this train wreck in slow motion has been underwhelming. We continue to field calls from hospitals struggling to deal with an approach to the outbreak.

On today's IDSA list-serv (IDea Exchange) Dr. Luther Rhodes wrote: ”The silence is deafening. I call on those physicians with hands on experience in evaluating post open heart patients referred to ID for evaluation of concerns, signs or symptoms of possible NTM infection to speak up loudly and clearly. Lessons learned, protocols developed, evaluation and testing tools learned dealing with large scale regional patient notification should in my opinion be shared …”

We have posted several times on this topic, but I thought it might be useful to summarize how a hospital could approach this problem in a single post. To view older posts, type chimaera in the search box in the top right hand corner of your display.

Step 1: Determination of risk

Whether you have seen a case or not, the first question is whether your hospital has used the LivaNova Sorin T3 heater cooler unit (HCU) in the last six years. If the answer is no, there is no immediate action you need to take. If yes, then the investigation begins, as you must assume the units are contaminated, regardless of the manufacturing date.

Step 2: Risk mitigation

If you are currently using the LivaNova (Sorin) T3 unit, the most important risk mitigation strategy is to get the units out of the operating room. The molecular epidemiology clearly points to contamination of the HCUs at the manufacturing facility, which allows the units to produce an infectious bioaerosol that contaminates the operative field. Separation of this bioaerosol from the operative field is the key to eliminating the risk. Why the FDA won't clearly state this is very puzzling.

At the University of Iowa Hospitals and Clinics our engineers were able to quickly (within a few days) devise a solution by creating a 6” x 6” hole through the operating room wall on the semi-restricted side of the room. The area identified for creation of this portal was determined by hose access to the OR table with minimal interference with staff and equipment; access to power; and the ability to leave proper corridor width per life safety code.

Testing demonstrated that positive pressure was able to be maintained in the OR after creation of the portal. The portal itself with a sliding door was constructed of Corian in some cases and stainless steel in others. A hose protection mat was placed in the ORs to protect the HCU hoses and to provide a ramp effect for equipment to be relocated as needed during the cases. One advantage of the T3 HCU is that remotes can be purchased that allow the perfusionist in the OR to control the HCU located outside of the room.

Once the HCUs were moved out of the OR, we demonstrated no difficulty with appropriate heating or cooling. Remember, given the long incubation and detection period of these infections (maximum 6 years to date), if you do not eliminate the risk now, you will likely be chasing cases for many years with no end in sight.

We do not believe that culturing HCUs for M. chimaera is helpful. Most laboratories are not adept at performing environmental cultures for mycobacteria, so the negative predictive value of cultures in this setting is poor. In other words, if cultures are negative, you cannot assume that your machines are not contaminated. Moreover, even when cultures are performed in expert labs, the culture results for any given HCU are not consistent over time; they may be negative at first sampling, then positive on subsequent samples, or vice versa. And it has yet to be demonstrated that once a HCU has tested positive it can be successfully decontaminated, which is an additional reason that we believe that elimination of risk requires removal of the HCUs from the OR.

Follow manufacturer's recommendations for cleaning and disinfection of HCUs.

Step 3: Case identification and notification
1. Develop a line list of potentially exposed patients by determining exposure to HCUs over the past 6 years. At our hospital, we found that the easiest way to do this was to identify whether a perfusionist was assigned to the operative case as identified via billing records. It is important to note that you will need to include off pump cardiac cases, since the HCU is typically on “stand by” status, turned on and running in the OR, even if the patient is not on cardiopulmonary bypass. Also, cardiopulmonary bypass is not restricted to cardiac cases; some lung and liver transplants are performed with cardiopulmonary bypass.
2. Notify potentially exposed patients. We began by sending a letter, explaining the problem and asked patients to call a toll free number to speak with a nurse who did a symptom screen on the phone. Patient who screened positive, were advised to see their local physician or to come to a clinic that we set up for evaluation. A letter to physicians was included with the patient letter and patients were instructed to take the letter to their physician. Patients who did not call in response to the letter were contacted by phone and screened. Our marketing and communications group was very helpful in developing patient materials. They also prepared press releases and established a webpage on the hospital's website with information for patients and healthcare providers. It's important to note that patients who are asymptomatic presently will still be at risk for development of infection for several years, so they need to be instructed to seek medical attention should they develop symptoms in the future. The patients at highest risk are those with implants (e.g., cardiac valves, vascular prostheses, ventricular assist devices), though a few cases have been reported in patients without implants.
3. Notify referring providers and internal physicians who may end up seeing infected patients. We sent letters explaining the infection to all referring providers and broadcast emails to our providers internally. It's important for providers to think about this infection when they evaluate potentially exposed patients with culture-negative endocarditis, fever of unknown origin, unexplained weight loss, or unexplained granulomatous inflammatory processes, including sarcoidosis. Obviously it's important for your infectious diseases physicians to be made aware, but other physicians may be involved with cases as well. One of our cases was simultaneously being evaluated by a hematologist, a hepatologist, and an ophthalmologist for a disseminated granulomatous process. Once you have developed your list of potentially exposed patients, you can run it against a list of patients with the aforementioned diagnoses, and further review any patients who appear on both lists.
4. Ask your lab to produce a list of patients who had MAC isolated from blood, bone marrow or wounds in the last 6 years. Run this list against your list of potentially exposed patients to identify any matches for further review.
5. Any patient with a consistent syndrome should have 2-3 mycobacterial blood cultures obtained. If suspicion is high and mycobacterial blood cultures are negative, consider obtaining bone marrow biopsy for histopathology and culture.
6. If mycobacterial cultures grow MAC, depending on your lab's capabilities, you may need to send the isolates to a reference lab for species identification.
7. Report M. chimaera cases to the FDA via MedWatch.

Given that the implicated heater cooler unit is the predominant brand, many hospitals will be embarking on an investigation, so hopefully they will find this information of value.

Useful publications:
Latest review (Infection Control and Hospital Epidemiology), November 2016
IDWeek Presentation of US Multicenter Investigation, October 29, 2016
MMWR, October 14, 2016
CDC guidance
FDA guidance, October 15, 2016
Emerging Infectious Diseases, June 2016

Clinical Infectious Diseases, July 2015

Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on improving the quality and safety of health care, and sees patients in the inpatient and outpatient settings. This post originally appeared at the blog Controversies in Hospital Infection Prevention.
Wednesday, December 7, 2016

Deaths from alcohol hand rub fires: 0

I just returned from the Healthcare Epidemiology Training course in Ho Chi Minh City, Vietnam, where I had a wonderful time interacting with the students and other faculty. Thanks to Professor Le Thi Anh Thu, we had the opportunity to tour an 1,800-bed hospital in the city and observed many barriers to infection control, including an average daily census greatly exceeding the bed capacity. Many patients are forced to share beds with other patients. However, in one area Vietnam is far superior to the United States; they allow alcohol hand rub at the bedside! You can see Joost Hopman, Andreas Voss and I touring a medical ICU in Vietnam - notice the green hand rub dispensers at the end of the beds.

In the U.S., fire code prevents alcohol hand rub from being placed at the bedside, rendering the practice of the WHO 5 moments impossible. Health care workers simply don't have the time to leave the room to practice hand hygiene after each contact with the environment or patient.

Here is the WHO's take on the fire risk of alcohol hand rubs: ”The benefits of the alcohol in terms of infection prevention far outweigh the fire risks. A study in Infection Control and Hospital Epidemiology (Kramer et al 2007) found that hand rubs have been used in many hospitals for decades, representing an estimated total of 25,038 hospital years of use. The median consumption was between 31 L/month (smallest hospitals) and 450 L/month (largest hospitals), resulting in an overall consumption of 35 million L for all hospitals. A total of 7 non-severe fire incidents were reported. No reports of fire caused by static electricity or other factors were received, nor were any related to storage areas.”

So let's review the U.S. situation:

Deaths from resistant bacteria? 23,000
Deaths from alcohol hand rub fires? 0
Changing state fire codes to allow alcohol hand rubs at the patient bedside? Priceless

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.
Tuesday, December 6, 2016

Burnout

Physician burnout has received a lot of well-deserved attention lately. Characterized by emotional exhaustion and professional frustration, it has been tied to array of bad outcomes, from physician suicide to poor patient outcomes. Organizations are waking up to the need to measure its prevalence and ameliorate its impact.

There seem to be two broad schools of thought about the causes, and by extension, the fixes, of physician burnout.

The first is focused on the inner life of the physician. Yes, the demands of medical practice are high, but if doctors were a little more “Zen” about things, then life would be better for them and the people around them, including their patients. There is now a substantial cottage industry peddling retreats, wellness classes, yoga and more to help physicians find inner peace in our tumultuous times.

The second school of thought focuses on the externalities of physician practice. Increasing demands for productivity, economic stress, loss of control over scheduling, and higher “hassle-factors” associated with EMRs and regulations have made medical practice harder and less rewarding. Burnout is just the natural reaction of sane, well-adjusted, intelligent people put into an insane environment.

Here's what I think. I do believe that the life of practicing physicians is often difficult, but that doesn't seem to me sufficient to explain what is going on. Medical practice has always been demanding of physicians' time and emotional energy. But I also don't believe that physicians of today are weaker or whinier than their predecessors. So what's going on?

I think that the root of burnout is the transformation of medical practice from a solitary craft to an industrial process. This has led to two related consequences. The first is that the current generation of mature physicians is suffering from a “bait and switch.” The world they signed up for when they began their medical training is not the world they inhabit professionally. The second is a widespread belief among physicians that we have lost our professional autonomy, and thus burnout is a manifestation of profound loss.

So here's my assessment and plan. I don't think that “old world” is coming back, and I don't believe physicians have or should surrender their professional autonomy. Rather, physicians can and should shape the world that takes its place, by asserting their collective professional autonomy to design systems of care that work better for physicians and their patients.

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.
Monday, December 5, 2016

Diet for a hungry, fat, dry, wet, hot, sick planet

I have been privileged this past week to preside one final time as President over the annual meeting of the American College of Lifestyle Medicine, held at a lovely venue in Naples, Florida. The venue is special not just because the hotel did such a fine job hosting us and satisfying our demands for delicious, nutritious, plant-based fare, nor just because of the long boardwalk through mangroves to the beautiful, powdery beach on the Gulf of Mexico. This area, with leadership from local healthcare systems, is a Blue Zones Project, working to turn the habits of the longest-lived, most vital people on the planet into blue prints for new, local norms. What a perfect place to celebrate the primacy of lifestyle in health!

At my initial suggestion, our conference theme this year was Healthy People, Healthy Planet. I wanted to showcase to our membership, and learn more myself about, the implications of human lifestyle choices for not just our own health, but that of everything around us.

My hopes in this area were richly fulfilled, as leading experts from around the world gave illuminating talks on chronic disease, emerging infections, climate change, water supply, biodiversity, soil quality, sustainable agriculture, and more- and how they all relate to the behavior, and in particular dietary choices, of the roughly 7.5 billion Homo sapiens currently on the planet.

This particular professional college traces its lineage to faculty at Loma Linda University, home to the famous Seventh Day Adventist Study, and has always placed a very strong emphasis on plant-based diets for preventing, treating, and reversing chronic disease. I have respected this for the simple reason that it is just where the weight of evidence inclines. But, I have also pushed back against the tendency, whenever and wherever I've seen it, to make claims past the margins of that evidence.

I won't belabor that case here- I've made it many times before, in columns, in peer-reviewed papers and invited commentaries, in an entire textbook, and in the best of company. The evidence regarding diet for human health extends to variations on a broad theme of minimally processed foods, mostly plants, in sensible combinations that are often time-honored, and rooted in heritage and cultural practices.

But this is just the evidence related directly to human health. There is a critical, indirect consideration at one nominal remove: what about the health of the planet? There is, quite simply, no human health left to worry about on a planet no longer hospitable to our species.

That danger truly looms, and more proximally than most of us care to admit. The case was made in its alarming particulars by a veritable parade of luminaries to our conference podium.

Dr. Samuel Myers, director of the Planetary Health Alliance, talked about the many interactions between human lifestyle choices and the health of ecosystems. He then completed the circle in several vivid examples from fieldwork around the world, showing how perturbations of ecosystems often translate into human health threats, from emerging infectious disease, to respiratory disease- a salient issue in Indonesia as rich forests are felled for palm oil production, and the smoke chokes Singapore. Perhaps the greatest surprise in Dr. Myers' presentation was elegantly gathered evidence showing that higher carbon levels in the air, regardless of effects on climate, translate directly to lower nutrient levels in plants- including nutrients already consumed at inadequate levels by millions of people around the world, notably iron and zinc.

Refreshingly, Dr. Myers also called out the routinely overlooked elephant in the room: the size of the global human population. The combination of a growing human population, and growing access to ever more manufactured goods by each of us, is a formula for catastrophe. We must do all we can to stabilize the global population at current levels, and shift our demands for goods and services to those that do not ravage the planet in the making.

In passing, Dr. Myers also noted that animals raised in human agriculture outnumber people by at least 10 to 1. So as we assault the planet by the billions, they do so at our behest in the tens of billions.

Danielle Nierenberg, founder of Food Tank, took us on a worldwide tour of small-scale, agricultural innovations that show promise in defending us against food insecurity, soil degradation, and the civil unrest that ensues when people are hungry and thirsty. All such roads around the world lead to an emphasis on plant foods, grown in variety. They also lead, it's worth noting, to an emphasis on parity and respect and empowerment for women across all cultures, as women figure so prominently in food production where it's needed most, yet face considerable disadvantages in accessing the needed resources.

Dr. Richard Oppenlander took these worries up a notch, highlighting the confluence of immediately urgent threats to the stability of natural systems around the world. The simple message is the most inconvenient of all truths: our species, so good at propagating extinction, could certainly be the architect of our own.

Even as the planetary issues were elaborated, talks in our customary purview- human health- reaffirmed the principles of healthy living to which the College, and the True Health Initiative, are pledged.

We were honored to host Dr. Erkki Vartiainen, Director of the National Institute of Health and Welfare in Finland, and co-director of the rightly famed North Karelia project. Dr. Vartiainen took us through nearly 50 years of data, showing how interventions to reduce saturated fat intake and blood cholesterol levels, salt intake and blood pressure, and tobacco use have translated into stunning improvements in health and life expectancy. With the most recent data, however, he revealed that as the North Karelians buy into some of the currently popular memes, like “butter is back,” with attendant changes in diet, heart disease rates are creeping back up for the first time in decades.

Dr. Christopher Gardner, Director of the Prevention Research Center at Stanford University, shattered myths about the need to eat meat to get adequate protein, and highlighted the opportunity to put the joy of delicious food in the vanguard of efforts to move toward health-promoting, planet-friendlier, plant-predominant diets.

Dr. Michael Greger made a compelling case (with customary lilt and panache) for the capacity of the status quo to deny what in time become self-evident truths, using the history of tobacco to illustrate. Caught up in the denial of tobacco's terrible harms were not just the obvious industries and usual suspect, including athletes, actors, and individual doctors- but the formal structures of medicine, like the AMA. The evidence was available, but lots of money was in play- and the weight of evidence was long disregarded, as people died.

The parallels with food today are striking. Big Soda uses money to fight soda taxes, obscure the obvious connection of their signature product with obesity and diabetes, and try to influence our understanding of energy balance itself. Big Sugar has, we learned recently, has long fought to limit the list of crimes against human health for which they are held to account.

Big Dairy has long made sure there is a wedge of cheese in every formal dietary recommendation. Big Beef not only fights to include meat in all dietary guidelines, but against all reason and decency, fought effectively to expunge any consideration of sustainability. And again, the major health organizations, from the USDA to the NIH, to the AHA, are somewhat complicit in denial of the truth.

That simple, environmental truth is that we must eat less meat- much less. This is the truth both for those long favorably disposed, and for those who find it monumentally inconvenient. The truth is not a contestant in a popularity contest; it's just the truth. Many of the environmental scientists revealing this truth are not yet vegetarian, and many in this conversation don't want to be- but they are doing what honest scientists do, and following their data where they lead.

The audience of diverse health professionals at our meeting was, by all indications, inspired to do everything in our collective power to propagate the message, and advance the mission: diet and lifestyle can, and therefore must, change at scale to help save the planet. In case you want in on it right away, two direct substitutions would make an excellent start: drink plain water instead of soda, and eat more beans and lentils in the place of all varieties of meat, but especially beef.

There has, indeed, long been a reasonably broad theme representing “the” optimal diet for human health, couched within a small portfolio of other lifestyle practicesdiverse authorities call by different names, but prioritize in common. The planet's many imminent perils, and unchecked population growth may, however, be narrowing down our dietary options rather rapidly. This is directly analogous to human health threats. When a person is still mostly healthy, there tend to be many ways to stay that way. The treatments for advanced disease are much more narrowly circumscribed. What happens to patients in ICUs is generally unpleasant, and highly protocolized. The planet is fast headed toward the ICU.

Fortunately, the imperatives of lifestyle for our own health promotion are highly confluent with the needs of the planet. Experts tell us, however, that the needs of the planet may be more urgent, and less accommodating. For now, we can address both by moving our diets away from processed foods, soda, and animal foods, and toward ever more vegetables, fruits, beans, lentils, nuts, seeds, whole grains, and plain water. It may not be too long, though, before a planet of both the starving and the obese, of parched fields and rising seas, of rising temperatures and dwindling aquifers, of dying birds and bats and bees- leaves us no choice at all.

Epilogue: I recognize the above may seem a bit gloomy, and rightly so; but all is not lost. We are, alas, very late to this party- and even now willing to consider, at least, electing a President of the United States who overtly denies climate change is even happening. That we will undo enough to reverse our calamitous momentum seems all but impossible. But we are an ingenious species, and along with what we fix by undoing our mistakes, I am hopeful, and even optimistic, that we will fix much more by exploiting our inclination to invent. I am admittedly non-expert in this area, but I envision new technologies, and soon, running on carbon-neutral, renewable energy sources already available, that are used to sequester and repurpose atmospheric carbon; desalinate our rising seas and produce abundant fresh water; systematically divert food waste into constructive use; and more. To borrow a line from The Martian, in the face of overwhelming odds, we are going to have to “science the sh#@ out of this,” and I believe we can. I believe we will. But as we count on our engineers to “science” us out of this mess of our own devising, none of us should spend another day blithely propagating the problem; it's plenty big enough already to test the limits of our ingenuity.

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.