Tuesday, January 31, 2017

Can butter, possibly, be back?

These days, it is very much in vogue, literally, as well as figuratively, to ask: is butter back? But this question is ineluctably contingent on another: is it even possible for butter to be back? The answer to that one is, self-evidently: no.

Butter cannot possibly be back, because butter never went away. To be back, you need to have been gone. Butter never was.

My fellow Americans, have you eaten out any time in the past year, two, five, or 20? Assuming you have, then you know as well as I: butter never went away.

We may reasonably exclude ethnic restaurants that serve no bread, cafeteria-style fast-food joints, and vegan restaurants that impersonate butter with something made by tickling pine needles with ferns. But let's include every place else; every mainstream, conventional restaurant in America, including every neighborhood diner.

You sit down, and someone shows up to fill your water glasses. Then, or soon after, they turn up again with: bread and butter. Every time.

It is the norm in every conventional restaurant in the land to bring butter; and so it has always been. In fact, it's not just the prevailing norm, it is a norm almost stunningly resistant to change.

My family and I, for instance, don't much care for butter, and much prefer olive oil. So, if we are getting bread, we ask for olive oil to accompany it. What do we get? Bread, olive oil, and butter.

If the bread is good and we ask for more, what do we get? You guessed it,more butter, too, to add to our uneaten stockpile. About the only way to put a stop to this “you are having butter whether you want it or not!” scenario is to tell your server that if any more butter shows up, they are getting it back in lieu of a tip. Sometimes Pavlovian conditioning overwhelms them, and even this fails. They show up with more butter anyway.

No, butter cannot even possibly be back, because butter never went away.

But if we are honest, that's not really what this deceptive question is asking anyway. No one is selling books or magazine stories because some small amount of butter, always a part of the American foodscape, could still be a part of that foodscape. The question is really a feint, mattering far more for what it insinuates than what it actually asks. The question it insinuates is: are we now entitled to add butter to our diets for the sake of health, and stick a stick of it in the eye of conventional nutritional wisdom accompanied by a buttery “We told you so!”?

The answer to that, too, is emphatically “no” but this time, it's a “no” with a proviso. The proviso is also a question: butter, instead of what?

Colleagues I respect, for instance, have argued that butter is better than the white bread on which it is apt to be spread. I've looked for data to validate this, and found none, so it's a guess, albeit an educated one in some cases. But maybe more pertinent than the veracity of the claim is the relevant reality check: no one makes such a choice. In the real world, white bread is apt to be the reason for the butter that wouldn't be eaten otherwise, never an alternative to it.

As for my own guesses, I suspect butter is indeed “better” than jelly beans, soda, slurpies, pepperoni, and toaster pastries, but again, I don't know who in the real world ever makes such choices. Butter is certainly better than stick margarine made from trans fats, but that alternative is now effectively banned from the food supply.

I am uncertain about butter versus palm oil, with my concerns focused less on the ill effects of this saturated fatty acid versus that on human health, and far more on environmental impact. Palm oil plantations may be the reason the last rain forest tree in Borneo providing refuge to an orangutan is cut down, and that's a horrifying prospect. But then again, the Amazon rain forest is being cut down to create grazing land for beef and dairy cattle, and that's horrifying as well. When we are into the realm of “which of the world's remaining rain forests do we want to see razed first and fastest?” we are already out of good choices.

As for health, butter clearly is not remotely “back” relative to olive oil. While there are legitimate questions about whether or not butter is overtly harmful, olive oil is decisively associated with health benefits. This evidence is courtesy of both intervention studies, including randomized trials; and observational epidemiology in which the “active ingredients“ of the Mediterranean diet have been identified.

From my perspective, therefore, the literal question, “Is butter back?” is misguided and pointless. The implied question, “Should we be eating more butter?” is diverting, and deceptive.

The question I think makes far more sense is: can we finally get around to asking better questions about diet and health? I am not the first to propose it.

The answer, alas, is seemingly: not any time soon. It simply isn't in vogue.

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, January 27, 2017

How can patients advocate for lowering health care costs?

Being sick is a horrible enough time without having to worry about how much it's going to cost you. Unfortunately, the United States is unique among developed nations in not ensuring that the populace has a safety net that will protect them against exorbitant personal health care expenses. It's a horrible thing to have to deal with as a physician. I went to medical school to learn how to take care of people and give them whatever care they needed. It's heartbreaking to hear stories of when patients get hit with ridiculously high health care bills, that they haven't got a hope in hell of paying back. People who have worked hard all their lives going bankrupt because of medical costs, in a country as wealthy as this, is unacceptable. While I don't pretend to have all the answers, I think the best health care system for patients probably lies somewhere in-between a heavily centralized system like the United Kingdom's National Health Service (which I don't think any country should aspire to copy) and an insurance/private-based system like the United States. The closest I've ever experienced to that type of health care system is Australia—a system I worked when I did my final year medical school elective in Trauma Care with the Royal Flying Doctor Service in Adelaide.

So as patients in the United States unfortunately continue to suffer, here are three ways they can do everything in their power to improve things and make health care more affordable:

1. Shame those exorbitant charge-merchants

In the age of social media, there is no need to suffer in silence. Even if it's not your bill, but a loved ones' (e.g. grandma), expose those institutions which are doing crazy things. Shame them. A good example of a story which went viral recently was when a hospital in Utah tried to charge for holding a baby soon after birth. Let the world find out about what's happening and let the backlash take care of the rest

2.Negotiate

Many hospitals and clinics have payment plans designed to spread out health care costs. While it's a less than adequate situation to be in, sometimes there's no choice but to attempt a negotiation. They would rather be paid than not paid at all, but you have to ask and be persistent in your assertions that you can't pay the full bill

3.Become politically active

You are a citizen in one of the greatest democracies that's ever existed. Write letters and arrange meetings with your local congressmen and women. Be relentless in getting your message across and force them to listen to your stories. Speaking as someone who has been to Capitol Hill a couple of times to advocate on behalf of my medical specialty and patient concerns, I don't think people realize how open our democracy is and how you can easily get your viewpoint heard if you want to

Our health care system fails our patients on a daily basis. While I think there are a lot of great things about U.S. health care that we totally take for granted, cost is the single biggest area where we need to really do better. At this current time of massive transition politically, we must continue to make this one of the biggest drivers of health care policy, while also realizing that increasing bureaucracy and adding layers of administration is not the answer (something that is tempting for many policy folks to instantly do). We need to stay patient-centered and not place more barriers in between patients and their doctors. Politicians must also resist the special interests and lobbying groups, and do what's best for their constituents. It's going to be very complicated, but sooner or later, something will have to give if our patients are all feeling the same way.

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.
Wednesday, January 25, 2017

Hospital consent forms and other stories

Even though I am over 40 (by a long shot) I am familiar with the abbreviation “TMI” (too much information). We are inundated with so much noise, chatter and static. I feel that we are bombarded with information that we must sift through and ultimately delete. The news cycle is 24 hours and hits us from so many electronic sources simultaneously. I am deluged each day with so many unwanted and unsolicited e-mails from organizations that I have never heard of. One of my favorite words on their e-mails can be found when I scroll to the end. UNSUBSCRIBE!

Another genre of information assault is the panoply of warnings and disclaimers that we confront. Of course, we are all numb to them since we have been so supersaturated. I'll prove it to you. The next time you are about to take off on an airplane, the flight attendant will review safety information in the event that a catastrophe occurs. While one might think that folks would be attentive to information that might be useful if the plane loses altitude or is headed for a ‘water landing’; no one is paying any attention at all. Most of us are browsing through the Skymall catalogue which showcases amazing gadgets, such as a device that can dispense feedings to your cat during a week of your absence. For the cat's sake, I hope there won't be a power failure. Moreover, the flight attendants who are issuing the briefings seem more bored than the passengers.

How often do we hear the nonsensical phrase, this product is not intended to diagnose, treat, cure or prevent any disease? In other words, we admit our product does nothing, but please buy it to for your ailing bones and prostate glands.

How often do we hit the I Agree icon, which follows pages of lawyerly small print, just to get to the next page?

We have been over-warned, over-disclosed and over-disclaimed.

While rounding at the hospital, I saw a sign posted on a coffee machine that said “Caution: Liquid is hot.”

Look what fear of litigation has done for us. Prior to ligitomania, we might not have realized that hot coffee is actually hot and might injure of us if we spilled its steaming contents onto us. Now, we are all much safer knowing that hot beverages, which we desire to be hot, are hot.

Of course, these protections extend beyond steaming beverages. If I were in charge, I'd issue rules and regs that would mandate the following warnings.
• Caution: these steak knives are sharp and not intended to remove feet callouses.
• This chain saw is for industrial use by trained lumberjacks. It is not intended as a toy for children under the age of 7.
• This lighter fluid is dangerous and should not be stored in a child's crib.

The medical profession is a part of this game also. Every day, I have informed consent discussions with patients regarding procedures that I have advised them to undergo. These are informal conversations when I try to give patients sufficient information so that they can make informed decisions. This is reasonable and a fundamental part of the doctor-patient relationship.

The hospital, however, is not satisfied with my efforts and requires that patients sign lengthy consent forms, which most patients sign blindly without reading them. For any readers here who have had the pleasure of having enjoyed hospital life, I'm sure that you can attest how many different forms you have signed from the moment you arrived at the hospital door to your discharge. Most patients and physicians regard these signings to be mere formalities, which are intended to protect hospitals, and not patients. If patients actually took the time to read through all of these legal CYA forms, it might grind the hospital to halt. There's not enough time for patients to read and understand all this drivel.

Caution readers! This blog is not intended to inform, enlighten, provoke, challenge or amuse readers. Readers accept all responsibility for any resultant angst or mental torment and hold blogger harmless for any and all perceived damages until the end of time. Click I AGREE.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Tuesday, January 24, 2017

Feeding people, and democracy, to death

As a physician, and a specialist in disease prevention and health promotion, I have long been nothing less than sickened by the unending flow of misinformation about food. My job is protecting the health of people, and misinformation about diet and health is toxic to them. It makes me figuratively sick because it makes so many actually sick.

Diet is profoundly important to every aspect of health. When bad, diet is a major contributor to chronic disease, disability, and premature death, to say nothing of comparably ghastly impacts on every aspect of planetary health. When optimal, diet is a major contributor to both vitality and longevity, and fortuitously, to sustainable food systems, climate stabilization, preservation of aquifers, and the protection of biodiversity, too.

The prospect of such benefits, however, is perennially threatened by the unending deluge of diverting alternatives to fundamental truths about healthful, sustainable dietary patterns. The truth competes endlessly with everything from marketing hype to outright lies, false promises to propaganda.

I spend a lot of time wrestling with the forces that converge where information and misinformation about diet and health come together. Over the past 20 years or so, I have authored three editions of a nutrition textbook for medical education and practice, the principal purpose of which is to differentiate what we know and should apply to patient care from all the rest. A few years ago, I was asked to write a review article on much the same topic. Similar efforts populate these very columns.

And, of course, this very matter has been germane to the care of my patients all these years, to the health promotion programming my lab has developed, and to the basic care and feeding of my own family. Since just about everybody eats just about every day, differentiating between dietary sense and nonsense is the furthest thing from a theoretical exercise. It is practical, up close, hands on, and personal. In my family's case, thanks to my wife, we've made our own conclusions about the matter accessible to everyone else, too.

Feeding people well, in other words, depends a lot on reliable information. It depends on truth.

Lately, we've all had a reminder that exactly the same pertains to feeding democracy well. Democracy, too, thrives on truth, and sickens on propaganda.

We are all bearing witness to this now, as each day brings new revelations about fake news, social media distortions, echo chambers, and most ominously, the intercession of a foreign power in the sanctity of our election process, and thus our very sovereignty.

For reasons best expressed by Bertrand Russell, it may often be easier to sell lies than truth. However much we may value popularity, it correlates very inconsistently with credibility.

This is pretty dire, no matter our party or native preferences. We've all been told that propaganda is toxic to democracy by no lesser source than the Founding Fathers.

The Second Amendment, whatever its merits, is, inarguably, second. Something else comes before it, because something else is presumably even more important, and that something else is truth. The First Amendment protects the freedoms of speech and the press, and it's not likely to be an accident that the Founders gave it primacy.

Of course, there's a bit of a conundrum here. The unfettered flow of information allows for the unfettered flow of misinformation, too. The best defense against that is not the law, but sense the Founders may have hoped would be more common than it proves to be.

The Founders, and our Constitution, tell us just how toxic propaganda can be: it is the number one threat to the viability of our democracy. In this modern age, I believe it is the number one threat to our personal vitality as well. I am far from alone. Even the National Institutes of Health, in developing a strategic plan to guide all of its nutrition research, includes the distinction between what we know reliably from all the rest among its priorities.

The fundamentals of diet for the promotion of human health really are very clear to just about everyone not actively involved in marketing alternatives. Yes, of course calories do count. Yes, of course, an absurd excess of sugar is bad for us. No, of course added sugar isn't the ‘one thing’ wrong with our diets, any more than saturated fat ever was. No, we will never get good answers to silly questions about diet. Yes, we can beneficially customize diets for health, and weight loss, but only in the context of fundamental truths that pertain to us as a species, all but universally.

I have previously lamented that whatever the respective toxicities of bad carbs and bad fats, the ingestion of nonsense about diet by gullible masses is far worse than either. Propaganda is the real poison. As it turns out, it is now a fixture in both our diets and our politics. That leaves me worried as doctor and citizen alike. We are seemingly inclined to look on passively as both we the people, and our democracy, are fed to death on much the same diet.
Friday, January 20, 2017

Why pick on those independent hero physicians?

Since finishing my residency several years ago, I've worked in almost every type of hospital up and down the East Coast, ranging from big urban academic medical centers to more rural community outposts. Although I primarily practice hospital medicine, working with both smaller private groups and being a hospital employee, I do empathize a lot with my independent practice colleagues and brethren. I almost certainly would have gone down the route of trying to open up my own practice had the conditions for doing so been more favorable (and had I also been able to better suppress my insatiable desire for travel and moving to different places while I'm still young and single!).

What's happened to so many private practice independent physicians over the last decade has been a great shame, because these doctors have been the traditional backbone of our health care system. They are extremely hard workers and labor tirelessly for their patients, typically in an admirably free-spirited and autonomous fashion. But now, due to a combination of regulations and policy directives—it's almost impossible now for these solo practice and smaller group physicians to exist. Without getting into all of the technical reasons why, it all boils down to changes in reimbursement models and policies that favor doctors working in larger health care corporations over small private practice.

Let's look at the type of doctor who has been affected the most. We'll call him Dr. Johnson. Dr. Johnson finished medical school in the early 1980s. He immediately started his own practice after residency and has been his own boss for the last 30 years. He's very popular in his community and loved by all his patients and their families. He is subspecialty board certified but also practices primary care. He embodies the principles of that good old-school physician (the best doctors around). He is a thoughtful problem-solver and enjoys spending time with his patients. But over the last few years it's got more and more difficult for him to keep his practice open. He's had to fulfil a huge number of “tickbox” criteria just to keep up with reimbursements, installed an expensive slow and clunky electronic medical record in his office (or faced stiff penalties if he didn't do so), and is now on the verge of facing an avalanche of even more central regulations. All these things have taken their toll on Dr. Johnson. He's a fine doctor who used to love spending time with his patients. Now he's forced to spend the majority of his day clicking and typing away in front of a screen. His practice was very successful and has already been eyed by a couple of local health care conglomerates—who want his patients. Dr. Johnson would have been happy to work forever (and his patients certainly wanted him too), but now retirement just seems so much more attractive to him. The employees who worked in his office are concerned, because they know how much their lives would change as controlled employees in just another large corporation, instead of the relaxed and friendly environment they currently work in (they'd probably rather just do something else than face this new reality).

So as Dr. Johnson retires from his illustrious and dedicated career, let's ask ourselves 3 questions:
1. Was Dr. Johnson ever the reason why our health care system had such high costs and suboptimal outcomes, and is there a better way to improve “quality” that engages rather than alienates Dr. Johnson?
2. If our health care system is going to have a “patient-centered” and “bottom up” philosophy, why hasn't anyone asked the patients what they thought of their popular independent physician Dr. Johnson?
3. Are we completely missing the other targets, when there are plenty of additional reasons why health care is so expensive—including big pharma and costly new interventions and treatments—all against a backdrop of an ageing population?

I simply fail to believe that losing physicians like Dr. Johnson and just accepting that as “collateral damage” is acceptable. There would have been far better ways to improve health care and cut costs rather than losing our independent doctors and replacing their practices with large health care organizations that actually have multiple additional layers of bureaucracy and expense.

We're barking up the wrong tree and should stop picking on the Dr. Johnsons of America.

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.
Tuesday, January 17, 2017

What we know about diet, and why time is of the essence

As a year of particular assaults on everything anybody thinks they know about diet and health, including if not particularly the science underlying the Dietary Guidelines for Americans, winds down, it's inevitable to reflect on what anyone truly knows about diet, and how we know it. The merchants of doubt, profiting handsomely from the status quo and perpetual confusion, would have you think no one knows much of anything, so enjoy some Coke with those fries.

I disagree. We are, emphatically, not clueless about the basic care and feeding of Homo sapiens, and I think that would be vividly clear to all but for time. Time, it turns out, is of the essence.

To explain what I mean depends on a thought experiment, and I ask for your indulgence here; it's just a bit macabre.

Imagine that, heaven forbid, you or a loved one is the victim of a gunshot wound to the abdomen or chest, be it the product of a bullet gone astray, or one willfully targeted. There are far too many of both flying around our culture, but that's a topic for another day.

First responders show up promptly to find you crumpled on the ground, bleeding profusely, surrounded by hysterical family members. They do what they do, and rush you into an ambulance, family in tow, and speed off to the closest hospital, which fortunately for you, has a Level One trauma center.

They burst through the emergency department doors, with you on a gurney soaked in blood, rushing to the operating room, where a top notch surgical team is scrubbed and waiting.

But before they get there, you and this entire, frantic entourage are intercepted in the corridor by a raised hand from a calm, imposing figure in a white coat.

Just a minute,” he (it could be she) says. ”Why the hurry? I am Dr. Reni Gaid Jeanyus. I am here to point out the folly of this rush to judgment.

“I am guessing you don't know about the literature debating whether this scalpel or that scalpel is best; it's intense! You may not have dived into the roiling controversies regarding the use of mosquito versus alligator forceps, to say nothing of the Rochester Pean versus the Rochester-Carmalt for hemostasis. And this is just the tip of a foggy iceberg. Clamps? Don't even get me started!”

Sensing the growing restlessness of your paramedic team, Dr. Reni (these types are, for some reason, always ‘Dr. First Name’ rather than ‘Dr. Last Name’) puts a restraining hand on your gurney. No one is going anywhere until the peroration is done.

As I was saying,” he says, “the debates are all but endless, and I- and perhaps ONLY I- know what they really mean! There is no proven value in trauma surgery at all.

“The whole thing is a scandal; a conspiracy, orchestrated by the tired old forces of the status quo. The Trauma Surgeon Mafia is in on it, of course; as is the Royal Order of OR Nurses. Naturally, The Surgical Scalpel Society and the International Corporation of Unnecessary Surgical Instruments have skin in the game. And, of course, all concerned are aided and abetted, as ever, by the Federal Authorities.

“I tell you it's shocking! Do you realize that there are NO randomized trials comparing the benefits of prompt trauma surgery to, say visualizing goat cheese? Or counting the hair follicles on your fourth toe? Or schmearing rutabaga marmalade on your nipples? None!

“Fortunately for you, though, I happen to have with me several jars of Dr. Reni's Rutabaga Marmalade- which, by the way, goes beautifully with that goat cheese- available for those actively hemorrhaging at the bargain price of $24.99 a jar. Credit cards are OK, but I prefer cash. Personal checks work, but only when signed in blood, and I'm not sure you have any left …

This scenario is, of course, absurd. Were there to be such a Dr. Reni, he would be intercepted by security, and escorted off the premises. If he did manage to trouble you and your family, you would promptly push past him to the operating room, and rightly so.

But why do we know that “alternatives” to trauma surgery are absurd? Are you drawing on your expert knowledge of the topic? Can you cite the relevant randomized, controlled trials? Can you refute the claims about debate over clamps, scalpels, and forceps? Isn't it possible that the conventional wisdom is all wrong, and visualizing goat cheese might have worked just fine?

The answer to all this is: duh. It's perfectly obvious that when people are shot and bleeding out, if expert hands don't do expert things to stop that bleeding and repair the macerated vital parts promptly and expertly, those people die. You, in that corridor, might well die in the time it took to hear this huckster's case.

As implied at the start, this is not about bullet holes or trauma surgery. My point here is that the only difference between this scenario and what we know about diet and health is time. Bullets kill us fast; diets kill us slowly. Tobacco kills slowly, too, by the way, and that fact has been exploited in the prevarications of Big Tobacco for decades.

If the timeline between what we eat and its diverse effects on health were as instantly vivid as the effects of a gunshot, there'd be no place for the agents of pseudo-doubt, pseudo-discord, and pseudo-confusion.

Don't get me wrong; there is legitimate doubt and discord, too. There is still a LOT to learn about a lot of details. Nobody really knows the optimal level of most micronutrients. Understanding of how best to personalize diets based on biometrics, anthropometrics, and genomics is still nascent. And, of course, there is no truly decisive, 100-year-long randomized trial involving tens of thousands to say what diet is “best” across an entire lifespan for longevity as well as vitality.

But as Dr. Reni would point out, there is no single, decisive randomized trial to prove that some particular sequence of particular surgical instruments is best for patching a hole in your chest, either. That's a poor argument for parking yourself in the corridor and bleeding, with or without marmalade. Arguments that divert you from the profound benefits of a diet comprised principally of minimally processed vegetables, fruits, whole grains, beans, lentils, nuts, seeds, and plain water for thirst are comparably unjustified.

Variations on the theme of good diets foster vitality and longevity, and fortuitously, redound to the benefit of the planet as well. Alternatives that do just the opposite prevail. This would all be perfectly clear to everyone were the causal pathway better matched to human perception.

The truth about broccoli, beans, and bratwurst is about as clear as the truth about bullets. It's just slower.

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, January 16, 2017

Prevention paradox

Every clinician knows that “framing,” how we present information to patients, has a big impact on decisions they make about their care. Even something as simple and apparently transparent as talking about “survival” versus “mortality” is important, with “a 90% chance of living” sounding a lot better than “a 10% chance of dying” even if both phrases convey the same estimate of risk.

Things get even more dicey when doctors start talking to patients about more subtle concepts like risk-reduction or number needed to treat. The clinical impact of a big relative risk reduction operating on a low absolute risk can be hard for doctors to explain and patients to understand.

The impact of that complexity was the subject of a recent editorial in Circulation. In it, Diprose and Verster speculate that doing a better job of explaining these things to patients, which certainly seems like a good idea, may paradoxically lead to worse population health outcomes. Here's how it could happen.

They cite several sources that suggest that as patients gain a better understanding of the modest impact of most preventive measures (e.g. statins for primary prevention), they are less inclined to accept the prescribed therapy. This is presumably based on their weighing the small benefit against the disutility of taking medications that may produce side effects or just having to take a pill that makes them feel like a “sick person.”

The rub is that if lower utilization were to become widespread in the population, then measures of population health would decline. This is because even modest improvements in disease incidence in a large population can lead to a large number of averted adverse events. Of course, those population measures don't account for the side effects and general reluctance to taking pills, which is why things look different at the individual and population level.

I feel strongly that a clinician's primary responsibility is to the patient in front of him, not to the population as a whole, so I don't see an easy way out of this

Do you?

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.
Friday, January 13, 2017

Government employed physician—no thanks

Every health care system in the world is facing its fair share of challenges. Ageing populations, the exponential increase in chronic diseases such as heart disease and diabetes, expensive new treatments—all at a time when most countries desperately need to curtail rising health care costs to save their economies. At the two extremes we have fully public-funded (socialized) medicine versus entirely free-market (private) health care delivery systems. I've written previously about my own experiences working in a number of different environments including the UK, Australia and US—three countries with vastly different systems, and how the ideal probably resides somewhere in-between the two extremes. I don't think that a fully centralized system such as the United Kingdom's National Health Service (NHS) is something that any country should ever be aspiring to. As fair as it sounds—completely free health care at the point use—patients unfortunately don't always get the choice or service that they need in a top-heavy bureaucratic set up.

Looking at things from the physician's point of view, there are also many profound differences when it comes to working in these different health care systems. I took the decision over a decade ago to come to the United States to do my residency training, and wasn't too sure whether I would stay in the country afterwards. I was young, a foreign adventure beckoned, and I had no idea what would await me as I started my residency in Baltimore. All these years later, I'm very glad I took that decision to come here. One of the first things that struck me when I started working here, was just how free-spirited and independent-minded doctors in America appeared to be, compared to the (also very hard-working) doctors I had just left behind in the UK. They were more in control of their own destiny and weren't constantly lobbying the government for their next $1,000 pay raise. As much as health care and the medical profession may be changing, I still think that America's doctors have it very good compared to most other countries. That isn't to say that we shouldn't stand up and fight for the autonomy and working conditions we still desire, but merely to put things in perspective. Given the chance, if you reduced the barriers for entry (e.g. taking the USMLEs, doing residency training again), doctors from probably every single country in the world would come to this country in a heartbeat to practice medicine.

Let's consider the current situation in the United Kingdom. It made news here several months ago when thousands of “junior” doctors were striking. Unlike the US, “junior” in the UK also includes some very senior physicians who may still be below Attending level (in a country where it takes a lot longer to complete a medical residency). I've discussed the strike in more detail here, and what lessons U.S. doctors can draw from it.

I still have many physician friends in the UK at various levels of seniority, and not to put too fine a point on it—the vast majority of them are quite miserable in their profession. Much more so than any job dissatisfaction that exists here in the US. Over there, the government controls absolutely everything, and a random health minister with absolutely no experience in health care can make cut throat decisions and enforce mandates that have an immediate and dramatic effect on the frontlines. The loss of control and autonomy that results from a completely centralized health care system is staggering. In the United States, despite our well-publicized problems, doctors still enjoy a much greater choice of working conditions and contracts. There are a variety of different ways any physician can work and types health care organization they can work in. In the UK: there's only one. The NHS bureaucrats control how many Attending physician posts are created, and doctors are completely beholden to their decisions. The private sector is tiny. During training, doctors frequently have to keep moving every 6 months to different towns as they complete their residencies, a process that can easily last a decade. Pay scales are published online, and are generally the same wherever you go, plus or minus maybe a few thousand pounds according to how many “antisocial hours” you work. Interestingly, because of the quirks of this government pay-scale, the salary for a senior Registrar (equivalent to a final year resident) could actually be higher than an Attending!

If you ever look at social media patterns of physicians in the UK (and I say this not to belittle them, but merely to state a point), you will notice a very government-employee type European attitude, filled with highly left-leaning statements, articles, and resolves to fight for better pay and conditions via striking and other organized union action. I'm quite middle of the road when it comes to politics, but there is definitely a very palpable difference in physicians' attitudes on both sides of the Atlantic—a result of what naturally happens when one becomes a “government worker”.

A final huge and important difference between physicians in a public versus a more private free-enterprise system, is that those from the latter are generally much more creative, innovative and entrepreneurial. Working for the government can indeed be a total ambition-killer.

A close physician friend of mine in the UK summarized it really well recently when he said to me that having a sole-employer in any profession is “always bad news”. I agree profoundly. That's why I have no intention of ever being a full-time government employed physician again in a completely centralized health care system.
Thursday, January 12, 2017

We should encourage exercise, but how can we be successful

The reasons for encouraging exercise are many. Readers know that I am an exercise addict. As a child, adolescent and young adult, basketball was my main addiction. I remember deciding to stop playing at the age of 44. As we age, we get hurt more and take longer to recover. I hated giving up my favorite sport. The joy of a great pass, or a clutch shot remains in my memory.

Over the next 20 years, I exercised intermittently. I would go through periods of steady exercise, and then revert to extra couch time. Over these years I gained more weight than was healthy or desirable.

I have reported on my return to regular exercise. I lost almost 40 pounds, and have maintained that weight loss for over 2 years now. I schedule my exercise religiously.

I should have done this all along, but it was just easy to pretend that I was still in reasonable shape.

One day it clicked and I became a weight loss and exercise addict. The frustrating part of remembering that experience is that I cannot really explain to anyone else what triggered my positive lifestyle change.

So why did I write so long about myself? I knew for many years that I should do more exercise, but I did not do it. I knew the literature and risks, yet changing behavior required something to switch from off to on.

We know what our patients should do, but how do we flip their switch to on for exercise.

We can explain the benefits without much difficulty. We can be good role models, and yet many patients will not follow our suggestions.

As a society we should strive to make exercise easier. Too many patients live in situations where exercise is difficult and even potentially dangerous. Our door-car-door existence does not help.

Given my current exercise obsession, I wish I could do a better job influencing my patients. Any suggestions?

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.
Wednesday, January 11, 2017

Credit where credit is due

A couple of weeks ago I started taking medicine to lower my blood pressure and another to reduce my cholesterol. This was a controversial move, given my deep distrust of the practice of medicine, when it is practiced on me, and pharmaceuticals in particular.

I know that, as a woman of 55 with an very active and healthy lifestyle, no chronic diseases and most importantly as a nonsmoker, I am at very low risk for any of the conditions that high blood pressure or high cholesterol could cause to happen. I am unlikely to have a stroke or a heart attack, develop narrowing of the arteries to my legs or develop kidney failure. The blood pressure and cholesterol levels have no effect at all on how healthy I feel. But one day, while pointing an ultrasound probe at my own neck, I saw a small plaque (a thickened area) in my left carotid artery. It was very calcified, which meant that it had been there a long while, but my carotid was not pristine. It is undeniable: I have vascular disease.

Will this lead to a stroke? Does it imply that the arteries around my heart are also affected? I don't know, and I may not find out. But I do know that taking a cholesterol lowering drug helps reduce heart attacks in patients with vascular disease around their hearts and I extrapolate that it may help reduce further changes to my carotid arteries which might lead to a stroke. My blood pressure is a bit high, and bringing blood pressure down does reduce stroke risk. I don't know that it will reduce my stroke risk, however.

So it was not entirely clear that I should take either cholesterol or high blood pressure medication. A little reduction in my very low risk may not be worth taking a medication with potentially profound side effects and associated high costs.

I decided to try the medication in order to assess whether it gave me trouble of any kind. If it did not, I might have nothing to lose. The blood pressure medication, lisinopril, has been on the market for decades. It is strongly associated with reduction in the usual complications of hypertension. Its main side effects are a nasty nagging cough and dizziness. It can also cause life threatening swelling, often of the face, but this is rare. I have had no swelling, no dizziness, and though I can feel just the tiniest bit of increased tickle in my lungs, it is hardly noticeable.

Regarding the cholesterol medication, atorvastatin (formerly known as Lipitor), it, too, has been around for a long time and has been extensively tested and found to be pretty safe and effective. It can cause muscle cramps and weakness, and I have been told by some patients that it makes them less mentally acute. It can cause gastrointestinal upset and may be associated with weight gain and a risk for diabetes. I am having no trouble so far.

As for the cost, I have had to shell out nearly $5 in copays each month, with my insurance footing about $1 of the bill. This is not expensive. This is a superb deal. I get it from my local pharmacist, not even from a mail order or Walmart's $4 plan. It is cheaper than Walmart's $4 plan! In 20 years I will have spent around $1,200, plus there will be the occasional blood tests to monitor my kidney function. I checked my cholesterol after being on it shy of two weeks, and it was dramatically lower. I, once again, am not sure that this will translate into better health, but it is not odious at all.

The moral of this blog is that not everything is terrible in the U.S. health care system. I could, and will, complain about the surrounding process that leads to people like me being on medicine at all, including issues like medicalization of the healthy and blockbuster drugs being widely adopted without adequate scrutiny, but presently I will give generic atorvastatin and lisinopril a big high five.

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, January 10, 2017

Bullet holes in dietary guidance

In case you missed it, the Center for Science in the Public Interest, with a long and illustrious history of doing just what their name implies, issued a statement that the once prestigious British Medical Journal (BMJ) had stained its reputation by perpetuating support for a discredited opinion piece attacking the work, and report, of the 2015 Dietary Guidelines Advisory Committee here in the U.S.

This is a scene, and perhaps not the final one, in a long-running saga, so a brief overview of the drama up until now is likely in order.

The official report of the 2015 Dietary Guidelines Advisory Committee, constituting the science and expert opinion intended to guide the development of the official Dietary Guidelines for Americans, was submitted as required to the Secretaries of the U.S. Departments of Health and Human Services (HHS) and Agriculture (USDA), in February 2015.

Any ink involved had not yet dried before this report was erroneously assaulted in the New York Times as “the government's bad diet advice.” Leaving aside the fact that a who's who in the world of nutrition and public health thinks this report excellent rather than bad (and I concur), it is, quite simply, not the government's advice. The DGAC report is, in fact, advice to the government about what the official dietary guidelines should be. This, too, was in February 2015.

Around that same time, Politico reported that the beef industry was planning robust opposition to the DGAC recommendation that the Dietary Guidelines address sustainability, and in the service of it as well as health, clearly advise the American public to reduce meat consumption.

The BMJ got involved in September 2015, when they published an expanded version of the very opinion piece published months earlier in the New York Times, calling it an investigative article. Early in October 2015, responding to these rather inexplicably prominent assaults on mainstream nutrition science by a journalist with no known relevant expertise and a book to sell into the bargain, Politico once again weighed in, disclosing links between an effective publicity campaign and deep pockets affiliated with the beef and fossil fuel industries.

Then, in November 2015, the Center for Science in the Public Interest submitted a letter to the BMJ, signed by 180 scientists from 19 countries, calling on the journal to retract the critique of the DGAC report, laying out in detail the inaccuracies, and pointing out the rather prominent conflict of interest involved. Later that same month, the BMJ editorial office indicated they would have the matter reviewed-and all concerned have been waiting ever since. In the interim, the official Dietary Guidelines for Americans, a very disappointing relative to the DGAC report, was published in January 2016. It was disappointing in part because the mischief recounted above worked as intended. Lobbying by special interests altered the key messages, and expunged the attention to sustainability altogether.

Which brings us to December 2016, when the BMJ announced completion of its independent review of the matter, indicating that they would not retract the critique. The journal published both “corrections” and “clarifications” of the critique, appended to corrections made earlier in the process. Responding to this outcome, and the positive public relations spin circulated on behalf of both the journal and the critique author, CSPI made its public allegation about a stained reputation.

The BMJ ”review” was conducted on the journal's behalf by two independent experts, Dr. Mark Helfand of Oregon Health and Science University, and Professor Lisa Bero of the University of Sydney. I have read both of their reports. Prof. Bero's report was submitted to the BMJ nearly a year ago, on Dec. 11, 2015. Dr. Helfand's report is not dated, so we are left not knowing whether its delivery, hand wringing at the BMJ editorial office, or something else- accounts for the delay of many months.

The selection of these two particular experts is very interesting. With all due respect to them both, and I think they are both quite deserving of plenty, neither has established expertise in nutrition. Both are experts in methods of evidence review. In terms of content, Dr. Helfand has noted expertise in hospital medicine and clinical decisions, and Prof. Bero in pharmacology.

Having devoted years to writing textbooks about methods of epidemiologic research, and the statistical underpinnings of clinical decisions, and additional time conducting meta-analyses of my own, I fully appreciate the methodologic expertise of Drs. Bero and Helfand. That said, inattention to content expertise in nutrition is a profound deficiency in this review.

Consider, by way of analogy, the case of fighting fires, or treating gunshot wounds. An expert in the methodology of “evidence” would be forced to conclude that the evidence justifying either current means of fighting fires, or treating gunshot wounds, is not reliably informed by randomized trials (e.g., emergency surgery versus watchful waiting; spraying water versus spraying gasoline; etc.)- and thus, the conclusions of the world's best fire chiefs and trauma surgeons are “open to debate.” Does that imply that we should just let houses burn down, and watch people bleed?

The problem with this is the obvious one: ignoring the mass of observational information, predicated on actual outcomes in the real world. Were fixed criteria for evidence applied to all creatures, great and small, in the world's zoos, the conclusion would doubtless be reached that we have no basis to feed any of them anything-since all of the relevant insights are almost entirely observational; I have it on good authority that the koalas have ever been randomly assigned to wildebeest steaks, nor the lions to eucalyptus leaves. Since the evidence we have is debatable, I suppose we would thus be justified to starve them all, while waiting for better data.

Let us also recall it wasn't randomized trials that proved the harms of smoking. But it was arguments about the lack of randomized trials that aided and abetted the tobacco industry's efforts to stall actions against their poisonous product for years. The BMJ's strange saga, and disturbing if indirect ties to the beef industry, looks a lot like those calamitous follies of history, revisited.

Science for practical application, which is what the DGAC report is intended to be, cannot function independently of sense. We obviously know a lot about feeding captive animals, putting out fires, and treating gunshot wounds- the want of randomized trials notwithstanding.

The evidence base for diet is, in fact, much informed by RCTs and meta-analyses. But as the actual content experts in diet know, that's not remotely the whole story. There is no RCT or meta-analysis to tell us what the Blue Zones can tell us. There is no RCT to tell us what happens to an entire population's health over a span of decades when diet advice is well applied. The notion that such evidence is invalid for failing to meet some preconceived standard for evidence is every bit as sensible as tossing out everything we ever thought we knew about fire fighting for want of randomization.

Nutritional epidemiology is, ultimately, about the effects of dietary patterns on outcomes over lifetimes. Since little about that can be derived from RCTs, a robust blend of sense and science, intervention and observation, is necessary to reach even reasonable conclusions, let alone the right ones. The work of the DGAC explicitly embraced and represented just such principles.

My view accordingly, and in excellent company, is that not only the conclusions of the DGAC were right, but so were their methods in context. I would not expect experts in methods to know this; it requires expertise in both methods and content- namely, nutrition; the very expertise on abundant display among the members of the 2015 DGAC.

As for the reviews of the BMJ critique, they were in fact quite harsh, with one stating: ”The decision to publish the article as a BMJ Investigation is regrettable. The article is better described as an opinion piece, editorial, or even an example of lobbying literature than an independent investigation.”

The characterization of what the BMJ touted to be an “investigative article” as lobbying is truly brutal, with or without a retraction. The notion that the BMJ, or the author of the original critique, have cause to celebrate the lack of retraction in the context of scathing criticism like that is tantamount to celebrating your conviction for negligent homicide, since, after all, it's better than murder in the first degree.

Lack of clearly articulated dietary guidance based on the abundant and diverse evidence we have, including RCTs, would encourage the food industry to exploit us all even more appallingly than they already do. It would also suggest we really have absolutely no idea whether pinto beans or jelly beans, walnuts or doughnuts, cruciferous vegetables or Crisco were better for us. Because, let's face it- if you think you know which is better in any of these cases, I challenge you to cite the specific randomized trial on which that knowledge is based. As noted, science works best in the company of sense.

Apparently, the BMJ supported this statement: ”Given the ever increasing toll of obesity, diabetes, and heart disease, and the failure of existing strategies to make inroads in fighting these diseases, there is an urgent need to provide nutritional advice based on sound science.”

This assertion is misleading in every way imaginable. First, important health outcomes, such as rates of dementia and diabetes, actually are improving in the U.S., and in tandem with modest but real improvements in overall diet quality. For the most part, “existing strategies” failed to make inroads where they were never applied; where they were well applied, the inroads have been little less than stunning.

In the end, the BMJ's commissioned review of its commissioned critique appears to have been an exercise in face-saving. The reviewers focused solely on the methods of assimilating evidence, means not ends, and concluded that the best way to collate the world's evidence related to diet and health is debatable. Maybe, therefore, the DGAC methods were the best they could be, maybe not. Just about every colleague I have around the world would agree with that, as would every member of the DGAC itself.

How odd, though, that the review was silent on the topic dietary guidance is all about, namely: dietary guidance. This is especially bizarre since every parent of every child must use the “evidence” they have, and make decisions about food every day. Diet is not theoretical, and humans have been making decisions in this area based on observation and experience since long before the invention of science, let alone the launch of the BMJ.

One certainly understands, however, why the BMJ review avoided the big question: did the DGAC get it right by recommending wholesome foods, mostly plants, in sensible, heritage-based combinations? The committee's recommendations are informed by sense as well as science; line up well with the conclusions of other such groups commissioned by countries around the world; are massively informed by diverse evidence; and are supported by an overwhelming consensus of experts in disciplines from biochemistry to biodiversity, sustainability to agroecology, epidemiology to endocrinology, public health to clinical counseling, and vegan to Paleo. Arguments to eat more “meat, butter, and cheese,” well, not so much.

After all these months, it's tempting to look at the machinations of the BMJ as much ado about nothing. A biased opinion piece, badly marred by many errors and masquerading as investigation when it was, in fact, “lobbying,” was not retracted because the best ways to gather and interpret all that we know about diet and health are open to debate. Yes, that is true. But what it means is that, for all we know, the DGAC methods were as good or better than any others, to say nothing of the conclusions they reached.

However, there is reason for real consternation about this saga. In the age of the Paris Accord and water shortages, climate change and crop failures, The BMJ gets credit for helping the beef industry banish sustainability from nutrition policy in the United States.

Trained in methods of science or not, we all know the inevitable outcome were trauma surgeons, for want of systematic reviews of randomized trials, to do nothing while gunshot victims hemorrhaged: a tragic, awful, bloody mess. The summary contribution of the BMJ to dialogue about useful dietary guidance for human health, to say nothing of environmental impact, seemingly amounts to much the same.

So, the Center for Science in the Public Interest was quite correct to say that the BMJ has made a bloody mess of dietary guidance, and has a stain on its reputation. Now, we even know the color.

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, January 9, 2017

Mushrooms (psilocybin) studied for oncology and depression

In “study of the week” news, major media outlets reported on two small studies looking at the possible benefits of the chemical psilocybin, the ingredient found in psychedelic mushrooms.

Both studies were conducted in volunteers with cancer who also had concomitant depression and anxiety that was assumed related to their cancer.

The interesting headline-grabbing finding was that after a single dose (“trip”) with psilocybin, a majority of patients in both trials reported improved mood, decreases in mental health symptoms, and positive experiences with the drug (i.e. good trips).

Here's the kicker: Six months after their trips, without additional drug, many of the study participants still reported improved mental health.

Study 1 was conducted at NYU and involved 29 patients. The study found that at 6.5 months, “60-80% of the participants continued with clinical significant reductions in depression or anxiety.”

The second study was conducted at Johns Hopkins, involved 51 patients, and had similar findings. Note how the second study describes the orchestration of its sessions:

“Psilocybin sessions

“Drug sessions were conducted in an aesthetic living-room-like environment with two monitors present. Participants were instructed to consume a low-fat breakfast before coming to the research unit. A urine sample was taken to verify abstinence from common drugs of abuse (cocaine, benzodiazepines, and opioids including methadone) …

“For most of the time during the session, participants were encouraged to lie down on the couch, use an eye mask to block external visual distraction, and use headphones through which a music program was played. The same music program was played for all participants in both sessions. Participants were encouraged to focus their attention on their inner experiences throughout the session. Thus, there was no explicit instruction for participants to focus on their attitudes, ideas, or emotions related to their cancer.”

Both studies appeared in the Journal of Psychopharmacology. While I agree this news is of general interest, I think the media reporting on the studies is overly sensational. Many doubts remain about the safety of psilocybin. Cancer patients, and indeed the lay public, are vulnerable to this sort of unchecked hype. Issues unaddressed:
• negative effects of psilocybin (i.e. no reporting on any adverse effects), which were listed in the studies
• cost
• alternatives
• small sample sizes in the studies

Overall, I'm glad that researchers are reconsidering ideas long thought too risky or out of bounds. But more science needs to be done before psilocybin is ready for mainstream use.

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, January 6, 2017

Health care is incapable of giving 'customers' what they want

The mantra of striving for excellent customer service is a very American concept. I'm reminded whenever I travel around the world and experience general service expectations elsewhere—even in some very advanced nations in Europe—how far ahead we are in the United States. We totally take it for granted that we can expect high levels of customer care almost everywhere we go, and any complaints and feedback we have will be taken very seriously by those in charge.

Health care is, by its very nature, a very caring arena. While I'm not in favor of ever thinking of our patients as “customers” (or worse still, as some in the corporate world advocate for, “clients”), there is still a lot we have learned from the business world in terms of striving for higher standards in a competitive environment. And because the United States health care system is still very privately-oriented compared to most other countries, that places us far ahead of these other nations in maintaining that customer-service mentality. Having said that, we are still pretty bad at giving our patients what they truly want. Here are 5 examples where we fall woefully short:

1. Time

Our patients and their families want nothing more than adequate time with their doctors (and nurses). Time to sit down, talk about things face-to-face, understand, and then make informed decisions. They don't want a doctor who is rushed, distracted by their computer screen, or one whose pager is going off constantly with other issues.

2. Type of doctor

I've written previously about how great “old-school physicians” are, and how every patient is yearning for a doctor like that. A doctor who they trust, knows them thoroughly, and practices good and thorough medicine. The system we work in however, does everything possible to discourage this.

3. False ideals

A huge concept that administrators fail to grasp (maybe because they are partly in denial over something they can never have any control over) is that patients couldn't give a hoot about your shiny corporate logo, swanky office building, or bumper-sticker slogans. Patients come to clinics and hospitals, because they like and want to see their chosen doctor. If you have a good caring doctor with happy and well-treated nurses around them (assuming the medical care is right)—patients could be seen in a middle of a power plant, and they couldn't care less!

4. Computers

The health care information technology train, which has enriched so many, spawned a whole new industry, and served so many different agendas—has been a disaster for the practice of good medicine. Statistics suggest that new doctors spend as little as 10 percent of their day in direct patient care, with the majority of the rest staring at a screen and ticking boxes. While information technology represents the future in all aspects of our lives, health care IT has not lived up to anywhere near its promise, and is the biggest daily frustration for doctors (and nurses) all across America. We need a revolution with health care IT, and need to make it more seamless, efficient and quick to use—so that doctors can get back to where they should be: with their patients.

5. First do no harm

It's the motto of medicine, but we lose the forest for the trees when it comes to simple common-sense things that make life so much better for our patients. These include measures such as allowing our patients a restful nights' sleep, getting them up and moving earlier, and even feeding them more palatable food!

You may notice a contraindication above. While praising the business-oriented customer service mentality, we are also saying that the big-business mentality is what gets health care into trouble. Note the words: Big Business. Small business is fine, and encourages closeness with our “customers”. It's when a large corporate cookie-cutter mentality prevails, that we find ourselves stuck in a top heavy administrator-led health care system. One which views patients as numbers in an assembly line—an unacceptable mentality when we are talking about real human lives. This philosophy is rarely compatible with the practice of the good and thorough medicine which our patients demand. Therefore, while we must bring the best of business in certain ways, we must also realize how different we are to business at the same time.

Finally, we mustn't forget the influence that big government regulations and mandates are having on the ability to give our patients what they truly want from us. Any health care system that fails to take into account the effects that all top-down directives have on the frontlines is going to eventually collapse under its own weight.

In all industries nothing matters more than the final “product” and how it's perceived by the people who are using it. So let's start listening more to our long suffering patients and giving them the type of health care they've been asking for.

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.
Thursday, January 5, 2017

Thankful to have become an internist

In November 1973 I had an epiphany. During my first week on my internal medicine clerkship, I realized that I had found my specialty—internal medicine.

Prior to medical school I had worked with emotionally disturbed children in an inpatient hospital. I really enjoyed the experience, and learned a great deal. During my first two miserable years in medical school (I disliked how they taught the basic sciences and even more how they tested), I had considered pediatrics, psychiatry, and a great blend in adolescent medicine. Parts of medicine fascinated me, but getting out of the classroom was freedom.

I started my third year on surgery, and quickly realized that I was not a surgeon. I loved talking to the patients, examining and studying their test results, but I had no interest in the operating room. One week during those three months I had an ophthalmology rotation that temporarily attracted me (they had great equipment and interesting problems), but that was a short flirtation.

They I started internal medicine and discovered who I was. Why do I love being an internist?

Internal medicine allows me to be a detective. Often on the inpatient service we address diagnostic challenges. Many internists (this writer included) love the diagnostic process. We love talking with patients, listening carefully to the story, asking probing questions, reading the body language. We get excited when a physical exam finding gives us a clue. We pore over the labs and try to understand how they may help explain the patient's current status. We order imaging to help narrow the diagnostic process.

Most internists that I have met love Sherlock Holmes. We all have patients for whom we have played that role successfully. Unfortunately, few of us are that good all the time.

Great internists like patients, and I do mean the great majority. Some patients make developing a positive doctor-patient (or patient-doctor) relationship, but we find them to be unusual.

We like helping patients, providing comfort, decreasing their uncertainty, showing our empathy and often decreasing their distress. Sometimes we make diagnoses and develop a treatment plan that obliterates the disease (most often with infections); sometimes we make diagnoses that lead to lifelong treatment (think type II diabetes, systolic dysfunction, COPD, etc.) and we can often prevent secondary complications or at least delay them.

We offer comfort and dignity when we can no longer treat the disease. We strive to treat every patient like we would want ourselves and our family treated.

Internal medicine provides the ideal balance of our never ending intellectual fascination with medical science and our commitment to comforting our patients. Some classic internal medicine quotes:
“The good physician treats the disease; the great physician treats the patient who has the disease.”
– William Osler

“. . . For the secret of the care of the patient is in caring for the patient.
” – Francis Peabody

“No greater opportunity or obligation can fall the lot of human being than to be a physician . In the care of the suffering he needs technical skills, scientific knowledge, and human understanding, he who uses these with courage, humility, and wisdom will provide a unique service for his fellow man and will build an enduring edifice of character within himself. The physician must should ask of his destiny no more than this, and he should be content with no less.”
– Tinsley R. Harrison

“Time personally spent with the patient is the most essential ingredient of excellence in clinical practice. There are simply no short cuts and no substitutions.”
– Philip Tumulty

So on this wonderful day of Thanksgiving, I am thankful for family, friends, our wonderful country, and the good fortunate I have had in becoming an internist. I have tried to help patients in distress. I have tried to help learners see internal medicine in a positive light, and help them become internists if that fit their aptitude.

Being an internist has always been a great privilege. Every time we help a patient, even in the smallest way, we do something worthwhile. Happy Thanksgiving!

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.
Wednesday, January 4, 2017

Why we can't control medical costs

Most of us are skeptical that insurance companies are devoted to our health. Answer the following question. Do you think your insurance company is more interested in your health or in controlling costs? Pretty tough question, huh?

There is a tension between medical quality and medical costs. If we had a system that offered perfect quality, it would be unaffordable. If we imposed rigid cost controls, then medical quality would be compromised. Where do we draw the line?

It is clear to most of us that the medical industrial complex is riddled with waste. Keep in mind that one man's medical waste is another man's income. For example, physicians define waste as excessive charges by hospitals. Government officials define waste as excessively high drug prices. Patients define waste as high co-pays and deductibles. Drug companies define waste as outrageous legal expenses to get drugs to market and to defend against frivolous lawsuits. Primary care doctors define waste as unreasonably high reimbursement that medical specialists receive. Keep in mind that most folks don't feel they are overpaid, but are quick to point to others whom they accuse of being overcompensated. For example, when a politician floats a proposal to tax the rich, we hope that the definition of rich is anyone richer than we are.

Get the idea? In summary, medical waste is easily defined. It is money that someone else earns.

This is why excising medical waste from the health care system is so difficult. Who would you trust to decide which waste should be wasted? The government? Physicians? Pharmaceutical companies? I don't have an easy answer here. Part of the solution, in my view, is when patients have a little more skin in the game. Here's how this works.

A physician advises an MRI of the back on two different patients. Patient A has full coverage for the study and would face no out-of-pocket costs. Patient B has a $5,000 deductible and would have to write the radiologist a big check.

Patient A: “Thank you, doctor. My back has been hurting for over a week. I'd like to get it done as soon as possible.”

Patient B: “$940! Can I try those exercises you recommended instead?”

It's always easier to spend someone else's money. Do you find that you order differently in a restaurant when it's on someone else's dime?

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

ID Match 2017: turning point or artifact of 'all in' approach?

The dust is still settling from this year's infectious disease match, but at first glance it looks like a much-needed step in the right direction. Compared with last year, the number of unfilled positions (on Match Day, that is, which doesn't count positions that will be filled after the match) is down to 80 from 117, and the number of unfilled programs is down to 54 from 82. This is not to minimize the pain for programs that didn't match. More than 50 is still way too many, and comparable to the number of unfilled programs in 2014.

This dramatic shift from the trend of the last three years must be due in part to the “all-in” strategy that IDSA is pursuing (requiring that all ACGME positions be offered in the match, trying to minimize those positions offered before or after). The question is how much of this shift reflects an absolute increase in the number of trainees after the post-match numbers are included. For example, there is still the chance that interested individuals opt out of the match, hoping to snag a good position afterwards (obviating the expense, time and anxiety the interview circuit).

The challenges to attracting the next generation of ID physicians remain daunting, and this one-year change in match results (temporally associated with a new “all in” policy) shouldn't detract from the urgency of these efforts. We'll have a much better sense of how we are doing (at least from the training program side) after another one to two years of the “all in” match. If programs and applicants continue to adhere to the “all in” approach (i.e. how will it be enforced?), at least it should give us a more accurate assessment of the supply-demand situation.

I'd welcome input from other program directors, IDSA leadership, and anyone else with thoughts on this year's match results!

Daniel J. Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. This post originally appeared at the blog Controversies in Hospital Infection Prevention.
Tuesday, January 3, 2017

The many microbial effects of proton pump inhibitors

We have written frequently about the many health care acquired infections and multi-drug resistant organisms that have been linked to proton pump inhibitor use, including ventilator association pneumonia, community acquired pneumonia, health care associated pneumonia in non-ICU settings, spontaneous bacterial peritonitis in patients with cirrhosis, and, of course, Clostridium difficile. In the U.S., proton pump inhibitors are the third most prescribed medication, they are addictive because withdrawal symptoms can develop, and are now available over-the-counter.

Researchers at Amphia Hospital, an 850-bed teaching facility in the Netherlands, completed two prevalence studies (November 2014 and 2015) on all adult patients who had stayed for no more than two days. The cross-section study just published in Clinical Infectious Diseases (free full text) linked rectal carriage of extended spectrum beta-lactamase–producing Enterobacteriaceae to pre-admission use of PPI and H2-antagonists, among other factors.

Rectal cultures were available from 570 patients and 259 (45%) had a history of proton pump inhibitor use, while very few used H2-blockers or antacids. I have included the univariable and multivariable analyses below. More than concurrent antibiotic use or prior hospital admission, proton pump inhibitor swere associated with four times the risk of extended spectrum beta-lactamase rectal carriage. (OR 3.89; 95% CI, 1.65 to 9.19). This is a very nicely completed study and provides more evidence supporting the inclusion of proton pump inhibitors targets in our “antimicrobial” stewardship programs.

Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands). This post originally appeared at the blog Controversies in Hospital Infection Prevention.
Monday, January 2, 2017

Is this about doctors or patients?

A recent story in Crain's New York Business cited the difficulty small independent medical practices face coping “with declining reimbursement rates from insurers, rising overhead costs and a torrent of new regulations that have come into play in recent years.” According to the article, only 26% of NY State physicians now own their own practice, compared with national rates of physician ownership of 76% thirty years ago. Honestly, I was not surprised by the numbers. Consolidation of independent medical practices into larger organizations is old news, and it is no secret that the drivers include those mentioned.

I was, however, struck by the subsequent letter to the editor by Malcolm Reid, the president of the Medical Society of the State of New York. In it, Dr. Reid states: “Physicians should have a fair choice of practice setting to deliver care to patients, whether that is in a large health system, large medical group or within a smaller medical practice,” and goes on to say that “Many physicians enjoy independent practice because of the personal attention that can be directed to their patients without external interference.”

I am sure they do, but honestly, why should we expect the government or the public to assure that physicians have a “fair” choice? To put it bluntly, Reid (and the rest of us) should get over the idea that the organization of care should revolve around what's good for doctors. He makes it quite clear that he is not advocating that “fair choice of practice setting” is about patients, since he concedes that effective patient-physician relationships can be maintained in a variety of practice and employment arrangements. Rather, he is saying that doctors should have the right to practice in independent practices because, well, that's how they like to practice.

To be clear – and before the pitchforks come out – I am NOT saying that independent practice is bad, and I am NOT saying that I don't care about how physicians feel about their practice arrangements. What I am saying is that if an independent practice is worth preserving, then the case for it has to be made on the basis of what it provides to the patients we serve, and not on the basis of what it provides to the doctors who care for them.

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.