Wednesday, March 29, 2017

Affordable, accessible, universal care for goodness’ sake

We all know and probably all periodically use the expression “for goodness' sake“! Perhaps it represents well the prevailing cynicisms of modern living that when we say “for goodness' sake” these days, we don't really mean doing something for the sake of its intrinsic goodness. Rather, we use “for goodness' sake,” when we aren't using less savory language, to vent exasperation.

I will borrow both the original denotation, and the current connotation of this idiom to make a case for universal health care coverage. Connotation, because yes, as a public health professional, I am more than a little exasperated with us. Denotation, because yes- this is something we should do for the sake of goodness first and foremost.

So, let's start with actual goodness, which maybe should come first routinely for its own sake. Our public discourse, and more often discord, about health care coverage rarely seems to consider it. But the provision of universally accessible medical care is first and foremost about goodness at a fundamentally human level.

We all agree, so far as I know, and across the expanses of politics and party, priorities and preferences, that any acute medical calamity warrants an acute response not subject to a financial test. The pedestrian struck by a car; the victim of a car crash, or shark attack; and the more frequent, sudden drop from heart attack or stroke precipitate emergency responses, and emergency care. The bill eventually comes due, and is generally very high- but it's not a factor in the initial delivery of care.

By itself, that makes so-called “health care,” and more aptly “disease and injury” care, different from any other free-market choice. There is nothing else we “shop” for while unconscious; very little else we must “buy,” or die immediately.

Such basic exigencies as these make health care unique relative to anything else we purchase. But not unique relative to everything; it falls in a category. That category is public good.

Our protection by police is a public good. So, too the protection of our homes and forests by fire fighters. And of course, so is the protection of our borders by the military. The U.S. military cannot possibly defend our borders for some of us without doing so for all of us; it is a public good.

So, too, are the diverse components of first and emergency medical response.

Emergency medical care is a public good. The only alternative to that is a society where a financial test is applied before care is rendered to an 8-year-old hit by a car on the way to school. I hope and trust our common humanity recoils at the prospect. Assuming it does, then urgent and emergency medical care becomes a human right. We should treat it as such.

Once we do, there are two immediate implications that nudge us toward a short but slippery slope. The first is that we are going to cover the costs of emergency care for all who need it one way or another, either rationally, or irrationally. The second is that universal coverage of emergency care without universal coverage of preventive care is a guarantee of more emergency care needed, at higher cost. It is the classic case of penny wise, and pound foolish- the failure to obviate costly pounds of cure with ounces of prevention. Let's briefly consider both.

If the ethical positioning of emergency medical care as a human right is formally recognized, it permits us to plan accordingly. We could acknowledge that such care will be provided both to those who can pay for it, and those who cannot. This, in turn, allows us to determine in advance how best to distribute those costs. The answer is the obvious one, derived from the most relevant precedents: much the way we cover the costs of our military protection. Costs for a given year are estimated and projected, and all who can pay, do- in our taxes. We understand and apparently accept that the military protection our taxes cover will cover those with no means to pay any taxes, too. Such is the nature of public goods.

This approach does not, of course, spare us the need to pay for others along with ourselves. But it does distribute those costs widely, and in the most equitable manner possible. The alternative, applied uniquely to health care, is to make no advance plans for distributing the costs incurred by those unable to pay, and then directing those costs haphazardly after the fact. The results generally range from painfully irrational, to overtly tragic- as when a much-needed hospital serving an indigent community is put out of business.

The costs of emergency care for all cannot be avoided by any society of the decent and humane. The only choice is to handle them rationally, or irrationally. The U.S. has opted for an irrational approach, paying for the folly of it in both dollars and lives. Even the Affordable Care Act is only a partial correction, but vastly better than the absence of any correction at all.

The second key consideration as noted is the choice between penny wise, pound foolish, and in-for-a-penny, in-for-a-pound. The latter is the obviously logical of the two for health care, as for other public goods.

Imagine, for instance, if we all agreed that military defense was a public good we, the people, should pay for on behalf of all, but only in response to emergencies. This would mean we would cover military responses to attacks, but we would not cover intelligence gathering or surveillance of any kind, because these are preventive measures. We would not pay to prevent the next 9/11, we would just pay to clean it up.

Such are the implications of covering emergency medical care for all, without covering preventive care. Preventive care, from cancer screening to immunization, is to medicine what surveillance, treaties, NATO, the United Nations, and intelligence gathering are to the military. Viewed that way, the folly of leaving them out of the planning for public good is, I trust, self-evident. Imagine a military that never did anything at all until after we were attacked and imperiled, and ask yourself if that's a satisfactory use of your tax dollars.

In case you are wondering, yes, we do have a source of the reliably evidence-based preventive services that contribute meaningfully, and cost-effectively, to the public good. The verdicts of the U.S. Preventive Services Task Force do not tell us everything we need to know, but we certainly need to know, and should cover, everything they tell us.

What stands in the way of progress and rationality is a toxic blend of cultural arrogance, misguided ideology, and selective blindness. The United States spends more on health care to achieve worse outcomes than many of our peer countries around the world, yet the arrogance of a “not invented here” mentality seems to preclude us from examining and adopting elements of best practices developed elsewhere. The contention that universal health care coverage is in any way more socialistic than universal military protection is not just ideological nonsense, but nonsense inconsistently applied. The failure to note the place for medical care among other public goods is selective, cultural blindness induced by the glare of ideology where epidemiology should be, and often by willful distractions, distortions, and overt deceptions.

The fate of the Affordable Care Act specifically, and health care coverage in the U.S. generally, are highly uncertain at present. All of the dialogue, however, seemingly begins with medical care as a discretionary commodity, and that is egregiously misguided. The ACA is less than it might be because it was the most that could be done in a culture that has never managed to position medical care where it obviously belongs, among other public goods. Doing so would open the door to innovative models that could shop the world's pearls, and string them in a uniquely American way.

Any such system, promoting preventive care for all, would save lives. By reducing the burden of preventable disease, such a system would save money. By applying best practices from elsewhere, such a system would add years to lives as well as life to years. By distributing inescapable costs rationally, such a system would save hospitals.

Such possibilities begin with a cultural reorientation: medical care is a public good. There are many good reasons to preserve and improve the Affordable Care Act, and dollars figure among them. But first and foremost, we should do it for goodness' sake.

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.
Tuesday, March 28, 2017

Coffee, tea and heart disease

Patients often wonder if it is safe to drink coffee. Since coffee and tea are two of the most common drinks in the world, it's valid to question their safety. A new analysis of many studies (called a meta-analysis) answers this important question. It was published in The American Journal of Medicine (Am J of Medicine, Vol. 130, No. 2, February 2017).

The researchers looked 6,508 participants in various studies and analyzed their coffee and tea usage over time. They measured coronary artery calcium progression and coronary events. The study found that drinking coffee had no negative effects on heart disease or heart attacks compared with non-coffee drinkers. And even better news; tea drinkers had less progression of coronary disease and fewer coronary events than non-tea drinkers.

My first thought was “How much coffee or tea”? We all know too much of anything can be bad. They didn't differentiate between black or green tea or decaf or caffeinated black coffee. They found that caffeine itself did not lead to greater coronary artery calcium progression. They found that being a regular tea drinker (over one cup every day) was associated with less coronary disease and heart attacks. Being an occasional coffee drinker, compared with never drinkers, increased the incidence of cardiac events but regular (daily) coffee drinkers did not have more events or coronary artery blockage. It was neutral.

So what can you make of this? Regular tea drinking can be part of a heart healthy diet. Regular coffee drinking is probably safe and past studies have certainly shown this.

Keep in mind that good heart health is never just one thing and it is a combination of many choices like not smoking, eating a heart healthy diet and regular activity. But it's good to know we can have our morning Cup o’ Joe and sip on tea all day long.

This post originally appeared at Everything Health. Toni Brayer, MD, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.
Monday, March 27, 2017

Shot callers

He was estranged from his family. No one could fully put their finger on just why that was but all of the notes in the chart underscored that fact. Even though I knew he'd been living in shelters, I wanted to hear it from him. “Where do you live?” I asked. He didn't answer.

Wait. I take that back.

He mumbled something that I couldn't understand. His eyes were at half-mast when he spoke but then slowly drifted downward afterward leaving a teeny slit of the muddy whites of his eyes. And that? That was how most conversations with him went. Questions answered in shaky, garbled replies that slipped out of his mouth, rolled onto the floor and under the bed out of grasp.

Yeah.

According to the chart, he'd never been here. Well, unless you count the one fleeting visit he had to the ER triage some seven years back, he hadn't. And that made it just that much more difficult. His medical history gave us no point of reference upon which to reflect. No elaborate note from an earnest intern or dutiful social worker explaining all that had gone awry in his life and some glimmer of a clue about his mind or his world. Nope. There was none of that.

None at all.

And perhaps this wouldn't be such huge deal if he wasn't so sick. Not just sick. But sick-sick in that way that conveys an imminent demise unless some act of God occurs. The kind that calls for family members sitting around tables with long faces and troubled glances while doctors clear their throats and try their hardest to use only empathic body language. But, see, that wasn't happening in his case. Because there was no family to call.

Nope.

None. As in, not one person who could step in and help navigate all of this awful while at his side. No worried soul wringing their hands or scowling suspiciously in my direction. And especially, there wasn't any person to step in and speak up for him should his mind not allow full decision making capacity.

Yep.

By the time I came along, that's what was happening. His indiscernible speech sounded nonsensical during most interactions and had been deemed a lack of competence to make his own medical decisions, which basically left us with tied hands since there was no one. No one at all.

Our social worker data mined and found a phone number for a granddaughter. After speaking to her once or twice, it became clear that she wouldn't be the go-to person. The follow up calls went straight to voice mail.

And so. It went very predictably day after day. Him sick-sick and muttering inaudible replies to our questions and us chasing our tails trying to figure out what to do. The overall prognosis progressively dismal, without any clear evidence of meaningful recovery anywhere in sight. So, really, death with dignity appeared to be the best option. At this point, that could be achieved only through a decision to do nothing heroic. But that? That calls for a shot-caller. A person who not only knows and loves the patient well enough to know their wishes. But especially who's also willing to step in as an advocate to assure the patient the gets the treatment they'd want. Or, in this case, doesn't get the treatment that they wouldn't want. He didn't have that, though.

Nope.

So what it meant was a full court press. Doing it all even if it was mostly futile.

And wait. Let me be clear. No, I don't fancy myself the angel of death. I do think miracles can happen. That said, since I am a believer of said miracles, I know that they don't follow rhyme nor reason and happen regardless of what we do. Otherwise it's not as much a miracle as it is an intervention, you know?

So yeah, that's my thoughts on that.

Anyways. The point of this is really what happened the last time I saw the patient on rounds. We came in and it was that same thing as always. But at the very, very end of the encounter, something happened. He said something that struck a cord and gave me pause. “I'm all out of tears today.” It was still gargly but this time, it was enough for me to understand.

“Wait. What did you say?” And he repeated it. This time it was unmistakable. I rested my arm on the rail of the bed and spoke again, this time more softly. “This is a lot, I know.” And when I said that he nodded, a tear trickling from his eye and rolling under his chin.

Wait. Huh?

I paused to see if he'd say more but he didn't. “Sir? I am going to come back to talk to you some more, okay?” He grumbled an affirmative response.

We stepped out in the hall together. The interns and the med student studied my puzzled face. One finally bit and asked me what was on my mind.

“That last statement,” I said. “It was abstract.”

“What do you mean?” a student asked.

“I think he gets it. He knows what is going on. Like he's decisional.”

One intern squinted an eye. “You think?”

“I do think.”

And that was all I said.

We finished up our rounds and I returned to him as promised. This time, I pulled up a chair and sat as close to him as I could so I wouldn't miss a single word. “Hey there.”

He looked both surprised and happy that I'd actually returned. He smiled, bony cheeks rising high on his face and lips so dry that they cracked a tiny tear revealing glistening drops of blood when he did.

“I came back to talk to you some more.”

A string of sounds came out in response. I asked him to repeat what he'd just said and recognized it to be, ”‘preciate you for that.” And so. I dug down deep to pull out all the patience I could to hold what I hoped could be a meaningful conversation with this man. A discussion that everyone said he was incapable of managing. Trusting my gut, trying to see if this hunch I'd had earlier that he was still in there might be true.

Yeah.

So we talked. Or rather, I asked questions and he mumbled responses. But this time I was listening more carefully and asking for instant replays on the pieces I didn't get. Eventually, he said something that couldn't be confused for anything else:

“M-m-m-my body sick. Y-y-you c-c-can't find nobody ‘cause-cause-cause I bes to myself. B-b-but I’on't n-n-need nobody calling my shots. I-I-I can c-c-call’em my own self.”

I asked to hear that again just make sure. And he said the exact same thing again. He sure did.

Was he a quirky man? Sure. And had his life taken the rocky terrain of never-stable housing and disconnection from family? Definitely. But that didn't mean he couldn't understand his health problems for himself and have his own say. No, it did not.

The chart had note after note that said he had no capacity to make decisions. Over and over again that's what was written. By important people with lots of knowledge in this area. And honestly, I could see how that happened to some degree. But now I knew otherwise. He was decisional. And yes, reversing all that had been said and determined about him would likely be super difficult and a huge headache.

But still.

First, I documented our conversation. Then I started dredging through what I knew would be a painstaking process with a lot of push back. Except something happened. It wasn't hard, actually. I called my psychiatry colleagues and the social workers and the physician who saw him before me and told them what he'd told me. And all of those people were happy, not prideful or resistant. Happy that this man would be able to call his own shots--for his own self.

Wow.

He was discharged the very next day to the hospice care center that he chose himself. And it was seamless and free of any road blocks. He was smiling on his way out, this time without the cracked lips since somebody had slathered them down with petroleum jelly.

I learned a simple lesson and had another reinforced. The first was that I shouldn't assume things will be difficult. I mean, it's good to be aware and pragmatic, but I'm talking about dreading something to the point of thinking it's not worth the fight. A lot of times, it isn't as impossible as it looks. I think I'll fight harder for patients given that insight recognizing that I am not the only person who wants the patient to win.

And last is one I've always known but can always stand to think about again: Listen and decide for yourself. Clinical inertia is a mighty, mighty thing. You hear things and are told things that are life changing for patients. I was reminded to not let the exhaustion of a busy service of patients make me pull back and not look and listen with my own eyes and ears.

Yeah.

I hope if I'm ever in a situation where I'm up in age and very sick-sick but deep down inside can make my own decisions about my health that someone listens to me. I hope someone somewhere fights for me to call shots for my own self. I really do. And you know what else? If my lips get chapped, I hope they rub a little Vaseline on me, too.

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 <"http://www.gradydoctor.com/2017/02/shot-callers.html">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.

Do doctors have a right to free speech? Hippocrates weighs in

Free speech is one of our bedrock constitutional rights. The debate and battle of what constitutes lawful free speech is ongoing. The issue is more complex than I can grasp with legal distinctions separating political speech, commercial speech and non-commercial speech. And, of course the right of speech does not permit the free expression of obscenity or “fighting words,” along with some other exclusions. And, there is no right to free speech in a private work place, where an employee can be fired for speaking his or her mind. While worker in a private shop may claim that he had a right to call his boss a flippin’ jerk, he would likely find that he suddenly has an abundance of free time to contemplate his prior utterance.

Leaving aside the First Amendment, physicians have always enjoyed free speech in our offices. We ask our patients questions of the most private and intimate nature. And, they answer us. We ask such questions because, under appropriate circumstances, we need the information in order to provide our best medical advice. We ask about specific sexual practices. We ask about prior or current substance abuse. We ask if patients are alcoholics. We ask if patients are suffering from abuse or neglect.

While we may not invariably receive truthful responses from these inquires, often we do. Patients trust us to respect their confidentiality, which has been embedded into medical culture and practice since the time of Hippocrates,who said, “And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets.”

His admonition holds true nearly 2,500 years later. How's that for meeting the test of time?

In 2011, the Florida Republican legislature, with the approval of the governor, passed a law that restricted physicians from inquiring of their patients about gun ownership and safety. Physicians found to be in violation risked loss of their professional licenses or fines. Nearly two weeks ago, an appeals court struck this silly law down. Not only was such a law an obvious encroachment on physicians' First Amendment rights, but also posed a barrier preventing doctors from doing their jobs. Should a pediatrician, for example, be prevented from asking a parent if firearms in the home are properly secured? This is not a political or partisan issue, it's a medical and safety issue.

Of course, the appeals court got it right in a case that I regard as a judicial lay-up. But, how did such a ridiculous law get passed in the first place?

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

The fasting and the furious

I have yet to see any installments of the long-running Fast and Furious movie franchise, although my son and I recently agreed we probably should. There is, however, a much longer franchise that I've been watching closely throughout my career: the fad and folly franchise, devoted not to fast cars, but fast weight loss and promises of high-octane health, achieved magically and without effort.

The variations on the theme of quick-fix solutions for excess adiposity or deficient vitality are nearly as endless as they are inevitably useless, or nearly so. If any had worked, why would we need the next one? If none has ever worked, what are the odds the next one will?

Be that as it may, there is a “new” one on the marquee at the moment. I put “new” in quotes for two good reasons. First, we have known there is no truly “new” thing under the sun since Ecclesiastes. Second, that is more true of weight loss than anything else. Standard operating procedure in the weight loss space is to wait out the 20-minute attention span of our culture, and then re-peddle repackaged leftovers as new.

Do you really think your favorite health guru personally discovered the harms of excess sugar in her/his basement last Wednesday? Actually, they figure in the writings of Hippocrates. Jack LaLanne warned emphatically of them some 70 years ago. They have been prominent even in the Dietary Guidelines for Americans for 40 years.

Did you think Dr. Atkins really came up with a new idea about carbohydrate in the 1990s, reacting to a failed national experiment with dietary fat? Not true; he first wrote and published those books in the 1970s. He was able to publish them again in the ‘90s because … well, we forgot. And, by the way, we never cut our intake of dietary fat in the first place.

So, back to the marquee: the new item there is fasting. Fasting, of course, is the furthest thing from new. When actual scholars write about the Paleo diet, the intermittent cycles of “feast” and “famine” that figure in the catch-as-catch-can diets of hunter/foragers get prominent mention. Intermittent fasting has almost certainly, almost always been part of the human dietary experience for want of choice.

Eventually, of course, it did evolve into choices- such as those made by most major religions to impose times of fasting. Whether this was about public health, crowd control, spiritual concentration, or strategic rationing, I defer to historians, sociologists, and theologians. We may simply acknowledge that among the many non-new things under the sun, fasting is notable.

But there is a new study about it, and that has engendered a constellation of media attention, in which my own recent interviews have figured. The study assigned a group of overweight people to either their usual diet, or fasting five days per month for three months. Those who fasted lost weight.

What is being touted as new is improvement in an array of metabolic markers, spanning lipids, glucose, and measures of inflammation, in the fasting group. The study authors suggest this is a benefit of fasting, and the media have seemed fairly inclined to eat it up. If you are sensing I don't buy it, you are correct. It would be only one step less persuasive to credit Birkenstocks for the metabolic improvements if folks had happened to wear them while fasting.

Short-term weight loss among those with an excess of body fat improves metabolic markers, temporarily at least, no matter how it's achieved. Cholera works. So does cocaine. That does not make either of these a good idea.

Playing to the popular palate, coverage of the fasting trial implies something uniquely, even magically beneficial about fasting. But as I see it, all we've got is this: eating some of the time leads to weight loss relative to eating all of the time. Weight loss, in turn, produces short-term improvement in all of the biomarkers that weight loss always improves, whatever good or bad, sustainable or fleeting thing is causing the weight loss. Fasting has not been shown to have anything that cabbage soup, or grapefruit didn't have before.

Is intermittent fasting a good idea? I think it can be. If the fasting is suitably intermittent, sustained over time, and combined with sensible eating the rest of the time, it can be beneficial. That said, if it is done temporarily and then stopped; or associated with eating poorly or binging on the other days- I think it can just as readily be harmful. It's certainly no panacea.

Of course, when fasting is being peddled to us, we are unlikely to get any such provisos. The Fast Diet, for instance, makes all the customary promises. The assertions that invariably accompany diet claims always make me think of Bertrand Russell: “The whole problem with the world is that fools and fanatics are always so certain of themselves, and wiser people so full of doubts.” I think Bert should have included swindlers on his list, but otherwise he pretty much nailed it.

Until or unless my son and I indulge in that movie marathon we've discussed, I won't really know where those guys are going fast, or why they are furious. I do know, however, that public health nutrition has been going nowhere fast for decades, spinning our wheels instead in the repetition of folly. I do know that we should all be furious about a culture propagating obesity and chronic disease for profit with willfully addictive junk food.

And alas, I also know that misplaced hope will likely triumph over experience yet again, and the public will line up to buy tickets to the latest installment of fast-weight-loss-meets-false promises, never noticing that fools, fanatics or swindlers are in the driver's seat just about every time.

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.

What doctors can learn from La La Land

Last week I finally got round to watching the movie “La La Land.” As a fan of musicals, I had wanted to watch it for quite some time, and before I stepped into the theatre, didn't really know what it was about nor what kinds of reviews it had been getting. Spoiler alert: Don't read on if you haven't seen it and intend to watch it (and I've never told anybody before not to read my blog, but the movie is so good, please go watch it before you read this!).

Very rarely would I use the word masterpiece to describe a movie, but La La Land would be it. The storyline involves two main characters, brilliantly played by Ryan Gosling and Emma Stone. It has absolutely everything you would want in a movie. A riveting story about persistence and overcoming odds, great music and choreography, fantastic screenplay—and yes, a love story. All while being a light-hearted and essentially family movie. The ending is particularly profound, a cruel and accurate depiction of reality that would have even the most hard-nosed movie critics feeling emotional. La La Land is up there with the best, and I hope it wins all record-breaking 14 Oscars that it's been nominated for.

But this being primarily a healthcare and medicine blog, the story did get me thinking a little about the situation that physicians find themselves in. That's because the main plot revolves around both Gosling and Stone pursuing their career dreams. Emma Stone is an aspiring actress and faces a monumental struggle chasing her goal. After much heartache, she finally lands a role which is totally unique and enables her to evolve independently into her character and thus show off her talents to the world. She soon becomes famous. As for Gosling, his dream is to have his own independent jazz club. He starts off as something of a nobody, and after several experiences, including being part of a rapidly growing touring band with huge potential, he decides that dancing to someone else's tune is not for him. Hence, he eventually leaves that apparently secure life to open up his own jazz institution.

The reason why certain movies do well is primarily because the audience can relate to the underlying story and identify with the characters. Away from the love story aspect to this production, the career truths embodied in La La Land are very relevant to physicians pursuing their ideal work scenario. Let's draw the following parallel: Over the last 10-20 years we've witnessed an epidemic of physician burnout and job dissatisfaction. This has correlated directly with physicians losing autonomy and independence i.e. the move away from small private group practice, to being employed, often by large corporations. All against a background of exponentially increasing regulations and bureaucracy.

Speaking as someone who has done this job now for many years and worked in every type of hospital and health care system along the way, I've come to one simple conclusion: Physicians can never be happy as controlled employees with the inevitable loss of autonomy and barriers that are placed between them and their patients. There is just no way around this. The more you attempt to make physicians into “assembly line workers” and take them away from patient care (whether it's because of dreadfully designed electronic medical records or other mandates), the more physicians will hate what they do. Especially because physicians are among the most intelligent, hard-working and dedicated professionals in society. It's a simple fact.

The healthcare system must allow doctors to be doctors, and practice the medicine (the art) that they dreamed about when they started medical school. And importantly, do so in an autonomous fashion. Just as how Ryan Gosling and Emma Stone only reached true career fulfillment once they were allowed to become independent, staying true to their talents and dreams. The question is, how do we take doctors to their La La Land?

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, March 23, 2017

Listen

“Wait. When did you say you started that medication?”

“Two weeks ago.”

“And when did you say you started having those symptoms?”

“Uh … about … uh … let me think … it was … two weeks ago.”

This kind of circumstance is my holy grail. It is my ultimate moment where I connect the dots. It has happened several times recently where patients have had chronic symptoms and have related to me that they have been taking medications started by other physicians within the time frame of those symptoms. One of my rules of thumb (I don't know how the thumb always gets involved) is, when in doubt, blame the medication. And, yes, stopping the medication in these circumstances fixed the problems the patient was having. It doesn't always work that way, but it often does when you listen enough.

I recently had a diabetic patient come to me embarrassed with his poor control.

“Why have you been having such a hard time lately controlling your diabetes?” I asked.

“Well,” he said, looking down at his hands as he spoke, “I just haven't been taking my medications over the past month. It's hard for me to take them.”

“And why is it hard for you to take them?” I pressed.

He shuffled in his chair. Looked up at me, and then said, “I can't swallow pills. The metformin. They are so big. I just have a hard time getting them down. So I just gave up taking my pills.”

I looked at him and smiled. ”You do realize that you can cut those pills into halves and quarters?”

He looked down. Obviously not.

“Okay,” I said, “Let's come up with a plan that doesn't require you to swallow big pills all the time. I know that it's not easy when you have a strong gag reflex and you have to take big pills. Let's find something that works well for you.”

He smiled broadly and seemed to relax. I actually listened to him. I took the time to find out why he wasn't taking his medication instead of judging his suboptimal diabetic control like he expected me to do.

That's what people want. They want to be listened to so that they are understood. It's not just being heard that is important; it is being heard and appreciated that is the key. Everyone has a story to tell, and everyone has a reason to be in the place they are in at the moment they interact with you. It's your job as a clinician to figure out what got them there and what exactly they are looking to accomplish at this moment. My patient really did want to control his diabetes, but was very much prevented from doing so by his inability to swallow large pills. He believed (falsely) that this was a complete roadblock to good diabetic control and had given himself up to amputations, dialysis, and other inevitable complications of poor diabetic control. All I needed to do was to listen a little and his myth was dispelled.

One of the big unfortunate things about the medical system is that it turns listening into a rarity. ”You are the only doctor who has ever listened to me,” I often get told. Really? That's like being told that I am the only chef who has ever cooked food for someone. Isn't listening the essence of care? How could so many people go through our system feeling like they never get listened to? Yet they do. It is incredibly sad. It causes a huge amount of pain. It probably kills a fair number of people.

But if we are rewarding doctors for spending less time with people, what do we expect? If we are making computer time more profitable than patient time, ICD more important than bowel sounds, Medicare compliance more important than the emotional state of the person in the room with you, then it's hard to blame clinicians for ignoring patients. They are just doing what they are told.

Our system needs to be better than that. The reason I can spend time with people is because I don't have to worry about the codes I can generate from each visit. I don't have to worry about Medicare audits, or meaningful use, or MACRA. I just focus on the person in the room with me. I'm lucky that way. I'm lucky that I raised my middle finger to the system that required me to spend so much time documenting that I could no longer give care. I'm lucky that I walked away from a system that made profits for me when my patients had pain or illness, and hurt me when they were healthy. Yep. I am lucky. Pure luck.

But in any situation, even in one where profits are paramount, listening is always best. When we listen we can understand. When we listen we can solve. When we listen we can make good plans of action. Without listening we are left to become box-checkers, form-fillers, and data entry monkeys. We don't want that, and I'm pretty sure our patients don't want that.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.
Monday, March 20, 2017

Communication between doctors and patients: Words matter

Here's a quote that readers will not readily recognize: “It is a pity that a doctor is precluded by his profession from being able sometimes to say what he really thinks.”

I'll share the origin of the quote at the post's conclusion. How's that for a teaser?

Physicians by training and experience are guarded with our words. To begin, we are never entirely sure of anything, and we should make sure that we do not convey certainty when none exists. This is why physicians rarely use phrases such as, ”I'm positive that …,” “I'm 100% sure …,” “There are no side-effects …”

Because of the uncertainties of the medical universe, sometimes we sanitize our own concerns when we are advising patients and their families. We may see an individual in the office with unexplained weight loss and a change in her bowel pattern. While we may fear that a malignancy is lurking, we would be wise to keep our own counsel on this impression pending further study. This patient, for example, may be suffering from a curable thyroid disorder.

Words matter. We all have heard how patients and families can dwell on one or two words uttered by a physician, who may have spoken at some length on a patient's condition. In these cases, the families may have inferred more serious news than the physician intended. Doctors need to be mindful of this phenomenon when we are communicating. Which of these messages would you prefer to receive on your voice mail?

“Please make an appointment to review your biopsy results.”

“Your biopsy results are benign. Please make an appointment so we can discuss them further.”

On other occasions, physicians may opt to leave out certain words or suspicions. Why unload anxiety on folks before the truth is known? Additionally, not every patient wants the whole truth administered in a single dose. These scenarios demonstrate the advantage that a physician has when he has an established rapport and relationship with his patient.

Conversely, I don't feel we are helping patients and their loved ones when we overly sanitize the medical situation in order to postpone an unpleasant physician task or to create hope that may not be realistic. There's a balance to be attempted, and I still struggle to achieve it.

The quote that started this post was published 90 years ago, not by a doctor or a nurse. I stumbled upon it when reading The Murder of Roger Ackroyd, one of the greatest works by the master of mystery, Dame Agatha Christie.

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.

Always remember that the patient is a person

The title could (and should) provoke controversy and concern. Yesterday, I was giving feedback to my interns and resident after a two-week VA rotation. We had an interesting half-month. Several patients stand out, not because of their disease, but because we focused on them and how to help them.

A phrase I often use points out that we have two jobs, treat the disease and treat the person. Understanding the person with the disease often trumps understanding the disease. We have many patients for whom we have no more options to eradicate the disease. We always have options to help the person.

Patients can tell if you are focused on them as well as their disease. Patients expect (rightly) that we will help them and not just worry about the disease.

We who teach medicine have a great responsibility to role model and encourage this attitude. Patients often complain about disease oriented care without concomitant patient-centered care.

So every day, ask yourself, who is this person who has the disease. What are their goals and expectations? Let them know that we want to help them, even if that help does not change life expectancy. Patients want to have better days. Quality of life matters, and perhaps especially as they are facing their mortality. We make a huge difference, even when we have no cures. Our presence, reassurance, and caring matter to most patients. Make certain these people are not abandoned. They need our presence and caring. Good doctoring combines the science and the art. Please never ignore the art of medicine. It matters.

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.
Friday, March 17, 2017

A diet of alternative facts

The events culminating in our election outcome were characterized as the advent of a “post truth era.” We have since devolved from post-truth, to “alternative facts:” essentially, a choice between bald-faced lies about verified reality, or delusion, calling out for medical care. Either way, we are being fed a daily diet of unpalatable (to most of us), insalubrious (for all of us) deceit.

Tempting as it is to address that matter, I have a related case to make that keeps me ensconced more decisively in my native professional purview. We are now all dealing with a diet of alternative facts. While that's a new twist, alternative facts about diet have been our cultural standard for decades. The perils overlap, and it may even be that alternative facts about diet were the appetizer, and a culture-wide diet of alternative facts the inevitable main course to follow.

Nutrition has been mired in a post-truth era in the U.S. since long before anyone in our country had thought to coin the term. Let's go back a little over half a century.

Leaving aside the contentious particulars, rival perspectives, and forays into revisionist history, we may simply note that Ancel Keys did indeed note an association between variations in dietary patterns, and variation in the rates of heart disease. In this country, where corporate interests got involved early, that ultimately came to mean: eat low fat junk food, and all will be well. I have challenged my peer group to find me a single instance of Keys advocating for Snackwell cookies, and promised to give up my day job and become a hula dancer if ever they do. My wardrobe is still thankfully free of grass skirts.

Low fat junk food did not exist when advice about the benefits of more plant foods, less meat and cream, was simplified, excessively in hindsight, into “cut fat.” The only way to cut fat when the advice originated was to eat more foods natively low in it, notably vegetables, fruits, beans, lentils, whole grains, and such. In North Karelia, Finland, Keys' insights were applied in exactly that manner, and the result has been an 82% reduction in the rate of heart disease, and a ten-year addition to average life expectancy.

In this country, we not only contorted sensible advice about dietary pattern into a new variety of highly profitable junk food, we never in fact applied the advice at all. Had we actually reduced our fat intake, and replaced it with sugar and refined starch, it's unlikely our health would have improved. But despite entire careers predicated on this notion, it is false. Dietary intake data from multiple sources confirm that Americans never reduced our intake of fat. Instead, we simply added the low fat junk foods, and reduced the percent of calories we derived from fat by increasing our total calories. We even know why this occurred. Is anyone really still confused about why this didn't make us all lean and healthy?

That was the reality, and its expression would have forced us to acknowledge our folly, confront the forces fostering it, and perhaps avoid replicating it. Instead, we were served a provocative set of alternative facts about diet, blaming our problems on bad advice rather than our absurdly bad use of reasonable advice, and providing us inevitably a scapegoat, in the form of an alternative macronutrient class. And so, we moved on to cutting “carbs,” in all the silly ways we cut fat- and despite the fact that everything from lentils to lollipops is a source of “carbs,” making summary judgment about the entire class not a whit better than idiotic.

Any hope that this second deep dive into nutritional nonsense where sense might have prevailed would have cured us of our penchant for replicating the follies of history capitulated long ago to experience. We moved on to cutting gluten as a cure-all, or blaming our woes on genetic modification. There is a booming cottage industry in discovering the harms of excess sugar, again, and again. But the truth about excess sugar is also corrupted into falsehoods to provide cover for the pecuniary interests of the meat industry.

Diet helped establish the pattern that bad execution of reasonable advice could be blamed on the advice; that the remedy for picking the wrong scapegoat was not to renounce the practice, but to pick another; that all opinion was the same as expert opinion; that a dissenting voice anywhere, whatever its motivations, meant lack of consensus; and that the forces of profit perverting the messages of public health could be overlooked as we wonder what went wrong.

I hope this sounds as ominous as it should. For one thing, it has meant we have squandered decades of opportunity related to diet and health, and instead find ourselves fatter and sicker than ever. For another, it means the lessons of alternative facts learned in the marketing of dietary nonsense, and tobacco too, have now been applied to the climate, with calamitous consequences, and are currently very much de rigueur in the running of our country.

There are fundamental truths about diet and health, to say nothing about dietary impacts on the planet, born of massive aggregations of diverse scientific evidence, backed by a global consensus of multidisciplinary experts. All that stands between us and the extraordinary good use of those truths could do―the addition of years to lives, the addition of life to years, and the protection of our natural resources―are alternatives to the truth.

Whatever the domain, it is toxic to conflate conviction for knowledge; isolated dissent for general controversy; principle for practice; the part for the whole; to say nothing of outright lies for the truth. It is toxic in its immediate effects, but perhaps even more so over time. For the conflation of alternative facts with actual facts propagates distrust at best, and disgust at worst. It propagates a background din of discord and doubt inhospitable to truth, however unassailable and urgently needed that truth may be.

Presidents of both parties have long affirmed that America is a global leader less for the many examples of our power, and more by the power of our example. That sentiment was echoed this week by Pakistan's former Ambassador to Washington, who noted the power of American credibility. That very source of authority is surrendered when alternatives to fact are peddled as alternatives for them.

Bad practice does not belie good principles, not in nutrition and not in the national interest. Bad principles are a remedy to no ill in either case. Isolated dissent does not a controversy make. Dissenters about climate change are a rounding error, and they are wrong. So, too, dissenters about the net benefits of vaccination. As for dissenters about the general merits of science who tweet about it, they are not merely wrong, but hypocrites, too.

Ultimately a diet of alternative facts and alternative facts about diet can be harmful in all the same ways, undermining credibility, sowing dissension, misleading the public, curtailing human rights, and damaging the planet.

Alternative facts about diet have long been poisoning public health, and our bodies. Instead of heeding the lessons in that precautionary tale, we now look on as a diet of alternative facts about everything else poisons the body politic, too. Now, as ever, it is ours to decide when to swallow, and when to spit.

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.

Hand hygiene and the power of Labbit

Yesterday, Mike wrote about “The Power of Habit“ and taught us that “40% of our daily activities occur without any active decision making” and suggested that “the trick … is for us to figure out how to get hand hygiene and stethoscope wipedown established as habits.” Of course, this all sounds reasonable. Besides hand hygiene, wouldn't it be great if we could get primary care doctors to stop prescribing antibiotics? Surely, poor stewardship is also a habit.

I used to believe, as Mike does, that infection prevention was a matter of education and re-education until good practice becomes habit. But after years of watching us fail to improve antibiotic prescribing and increase hand-hygiene compliance, I no longer believe in the magical thinking surrounding education and habits. First, there is minimal evidence that we can encourage folks to develop better habits, such as hand hygiene compliance. Take for example this recent systematic review on hand hygiene trials by Kingston et al. The authors reviewed studies published since 2009 and reported a baseline hand hygiene compliance of only 34.1% with a mean improvement to 57%. Some folks may look at this data and become excited about a 23% compliance improvement! But a realist would look at the data and realize that these trials couldn't have been the first time the health care workers in the intervention hospitals were exposed to hand hygiene interventions. Their baseline compliance of 34% was after numerous rounds of “habit-forming” educational training.

Thus, we need to be honest with ourselves and acknowledge that difficult system changes are needed to improve practice. For hand hygiene, for example, we need shelves outside rooms so nurses can rest things they're carrying while cleaning their hands. For clinicians we need rapid diagnostics and health information systems to inform antibiotic prescribing. Any talk of habits suggests that change can occur at an individual health care worker or prescriber level. And any suggestion that this is an individual health care worker problem will necessarily lead to learned helplessness and blame, neither of which will be productive.

In the end, we're going to need to move past our focus on “habit” and its flipside, blame. Let's work towards system change and innovation that directly address the barriers to hand hygiene compliance and proper antibiotic prescribing. You might have another name for it, but I'm gonna call it The Power of Labbit.

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.
Thursday, March 16, 2017

Face pain? It could be the jaw

In primary care we commonly see patients with ear pain, sinus pain or headache. It's often hard for patients to self-diagnose where the pain is originating and they want treatment for sinus or ear infections. When examination of the ear or sinuses doesn't show a problem, many times we find out that it is from the jaw.

Temporomandibular joint (TMJ) or temporomandibular disorder (TMD) is a common cause of facial pain and can affect as many as 10 to 15% of adults. It presents with pain, ear discomfort, headache, and jaw pain. It is caused by inflammation in the joint that opens the jaw, right in front of the ear and sometimes there can be a snapping of the jaw as it is widely opened. You can think of this joint as a hinge that connects the jawbone to the skull. Like any joint, it can get inflamed and the surrounding muscles of the jaw hurt.

The treatment for TMJ is resting the jaw from wide opening and anti-inflammatory medication. Most of the time it resolves within about two weeks. Some patients get relief with a mouth splint that keeps them from grinding or clenching the jaw at night. For severe cases, physical therapy with ultrasound and ice can help. Rarely a corticosteroid injection or Botox can relieve pain and relax the muscles.

Remember, not all face pain is from sinuses or ears and antibiotics will not help if it is TMJ pain. Usually a course of anti-inflammatory medication (ibuprofen) is all that is needed.

This post originally appeared at Everything Health. Toni Brayer, MD, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

The power of habit

Over the past few years, I have focused on wiping my stethoscope down with an antiseptic wipe after I examine each patient. Initially, a problem was that I couldn't always find the wipes. We've focused on getting them available throughout the medical center so that's rarely a problem anymore.

While on the infectious disease consult service last week, I walked out of a patient's room, and wiped down my stethescope. Halfway through that action, I realized that I had not used my stethoscope on the patient. I was thrilled! The stethoscope wipedown had become a habit, since I demonstrated a key characteristic of habits: automaticity. I didn't think about it. I walked out of the patient room and my cue (crossing the threshold of the room) prompted me to automatically sanitize my stethoscope. Just like sitting down in the seat of a car prompts me to latch my seatbelt.

If you haven't read The Power of Habit by Charles Duhigg, I highly recommend it. From the book I learned that 40% of our daily activities occur without any active decision making. These activities are habits. The trick, of course, is for us to figure out how to get hand hygiene and stethoscope wipedown established as habits. We need more psychologists working with us in infection prevention since the field is increasingly dependent on influencing the behaviors of health care workers.

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.
Monday, March 13, 2017

Should patients order their own lab tests?

Knowledge is power. Increasingly, patients are demanding and receiving access to levers in the medical machine that would have been unthinkable a generation ago. I have already opined on this blog whether the informed consent process, which I support, can overwhelm ordinary patients and families with conflicting and bewildering options.

Television and the airwaves routinely advertise prescription drugs directly to the public. Consider the strategy of direct-to-consumer drug marketing when millions of dollars are spent advertising a drug that viewers are not permitted to purchase themselves. The public can now with a few clicks on a laptop, research individual physicians and hospitals to compare them to competitors. The Sunshine Act, an Obamacare feature, publicizes payments to physicians and hospitals by pharmaceutical companies and other manufacturers.

Every physician today has the experience of patients coming to the office presenting their internet search on their symptoms for the doctor's consideration. “Yes, Mrs. Johnson, although it is true that malaria can cause an upset stomach, I just don't think this should be our first priority.”

There are now laws that permit patients to order their own lab tests such as cholesterol or glucose. Even registered nurses working in intensive care units are not permitted to order these tests without a physician's authorization. Ordering diagnostic tests and medical treatments has always been under the purview of a physician or highly trained medical professionals. Who interprets the results? The patient? The lab tech who drew the blood? The cashier at the retail health clinic? A policeman? A hospital custodian?

I had an office visit with my own physician to discuss how best to manage my own cholesterol level. While this discussion did not have the drama of cardiac bypass surgery, it took time to consider the risks and benefits of various options along with my personal and family risk of cardiac disease. My point is that even two medical professionals had to navigate through an issue that had more complexity than one might think. Understanding the significance of a lab result takes nuance and medical judgment.

Patients already purchase all varieties of heartburn medicines over-the-counter, that years ago were out of reach. Should we permit patients to buy antibiotics, blood pressure medicines, statins for elevated cholesterol, and anti-depressants? Why not?

Think of all the money the system would save. A depressed individual, for example, doesn't have to waste time and money with a psychiatrist. He already knows he's depressed. He can proceed directly to the Mood Aisle of the local drug store and get the pills he needs. Wouldn't it be easier and cheaper if patients could just buy antibiotics themselves for those pesky colds and flus? No office visit or time off work for a doctor appointment. The fact that antibiotics don't combat colds and other viruses never seemed to deter their use.

Eventually, patients can order their own colonoscopies, stress tests, cardiac catheterizations and gallbladder removals. Perhaps, we will see the creation of Amazon MEDPRIME. Feeling a little chest tightness? Just click the app, and the Cardiac Cath Mobile will be at your door in 30 minutes or less.

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.

On binge drinkers

Doing hospital medicine, we often have patients come in for complications of binge drinking: acute pancreatitis, gastrointestinal bleeding, trauma, hypothermia, etc. Many such patients know they are alcoholics, and have spent considerable time not drinking. Over time (often I am a slow learner) I have realized that most such patients are drinking to become numb.

I should have known. How often do we watch a television show or movie and see a character go off on a bender because of some traumatic event? Just last night I was watching Lethal Weapon (the TV show). Riggs (the main character) starts drinking very heavily as the anniversary of his wife's death approaches.

Patients often endorse this. They try to treat their situational depression with alcohol. Now alcohol is a miserable antidepressant. It likely enhances the depression.

As internists we have a responsibility to help these patients through a recognition of the trigger. Almost all patients will admit to the trigger and many want help. Diagnosing alcoholism without understanding the variety of the disease misses the point.

So as a reminder to myself, always ask the patient why they restarted drinking or why they have accelerated their drinking. It rarely happens randomly.

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.
Friday, March 10, 2017

The clear and present danger of silence

I heard from a public health colleague this week, whose work and time are partly funded by the Centers for Disease Control and Prevention, that the CDC did not want to be acknowledged as a funding source in a research paper addressing gun violence. Apparently, CDC scientists have marching orders to be more concerned about unflattering facts about gun violence, than about gun violence itself. That's ideology 1, epidemiology 0.

The score does not improve after that. In high-profile media coverage you have likely seen, we learned that the Trump administration had, in an early indication of its ominous priorities, effectively issued gag orders to the U.S. Department of Agriculture and the Environmental Protection Agency. Apparently, we the people are to be kept uninformed not only about guns, but also about such matters of minor importance as our food supply, and the environment. And perhaps everything else, too, since the White House message to the press was: just keep your mouth shut.

The new normal, apparently, is to stand our ground, except where facts are concerned. We want no part of those.

Let's be clear, silence where science ought to be is a grave threat to us all. Those of you who are avowed fans of science as I am need no convincing. To anyone else: well, there is no one else. Just about everyone is a fan of science, it's just that some don't realize it. Everyone using the Internet; everyone who has ever flown on a plane or driven across a suspension bridge; anyone who has ever gone out to enjoy the spectacle of a perfectly predicted eclipse or meteor shower…is a fan of science. So, too, is everyone who has ever thrown a light switch.

Apparently, the switch is being turned off in the White House to keep disquieting facts in the shadows. The EPA, for instance, told us about lead in the water in Flint, Mich. In a world where the EPA is muzzled, we might still be in the dark about that. The USDA tells us about food-borne outbreaks, and recalls. Silence, in this case, aids and abets the designs of salmonella.

Admittedly, the conclusions of science can be inconvenient. The problems in Flint, for instance, began with a focus on cost cutting. Science pointed out that the brains of children were being mortgaged to pay for it. Does any parent, whatever your stock portfolio, think this is something we'd be better off not knowing?

And lead in Flint is just one entry in an infamous parade that puts profit ahead of public health. If recent concerns about BPA, or glyphosate, or dioxin fail to convince you, it's time to see Erin Brockovich again.

We are all dependent on the unfettered work and the unmuzzled communication of the EPA, and USDA, and FDA, and CDC to make informed decisions about the risks around us. Unless you have a toxicology lab in your garage, or are conducting elaborate epidemiologic surveillance in your basement, you are very unlikely to learn about them on your own. Absent access to the work of agencies serving the public health, we'd be none the wiser, a few might well be richer, and the rest of us sicker without knowing why. Conspiracy theorists could blame it all on vaccines, or sunspots.

Good science is an enemy to no one, since it advances understanding and knowledge, and thus choice. Good science empowers us with options. In medicine, we speak of “informed consent,” because uninformed consent is oxymoronic. Censorship, of course, keeps us uninformed, or worse, misinformed. Ignorance is the ultimate form of repression.

Scientists are the first to acknowledge that the sounds of science are not always, immediately, perfectly in tune. It can take any number of revisions to get the lyrics and melody of truth just right. But this very process leads us robustly and reliably toward truth and understanding. This very process informs and empowers us, as reliably as the progress from Kitty Hawk to the moon and Mars and beyond; from Morse to Microsoft; from miasms to the microbiome; from van Leeuwenhoek to Hubble; from the iron lung to drug-eluting intracoronary stents and pharmacogenomics. Science reliably, robustly, relentlessly informs and empowers us.

In a world of science silenced at the whim of tyrants, the sun would still revolve around a flat earth. Polio would still menace every parent's beloved child come spring. And the lead would still be flowing in Flint. We would know nothing about dioxin, or BPA, or hexavalent chromium. The first we would learn about the mass extinctions we are inducing would be the disappearance of the last remaining lion, and tiger, and bear. And our first clue about climate change would be the cooking of our own goose in it, to an irrefutable cinder.

I have a friend who told me he voted for Trump for one reason only: the Second Amendment. I have a question for him and others like him: what purpose can the Second Amendment possibly serve when the First Amendment is desecrated? When science is subordinated to silence, and the press to propaganda, only tyrants control the flow of information. However patriotic your intentions, you will be aiming your arms at all the wrong targets. It is the pernicious nature of propaganda in the service of tyranny that it can convert even true patriots into pawns. In the guise of pop-culture diversion, Captain America: The Winter Soldier, conveys this very point.

Science informs and empowers, and is the enemy only to those who have cause to fear truth and understanding. Silence where science ought to be, sciLence, serves the unscrupulous secrets that favor shadows, and the profits of few over the good of many. SciLence is a vividly clear danger to us all that is suddenly, alarmingly present.

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.

3 questions hospital administrators keep asking

A few years ago, I was in a position where I was fast going down the route of hospital administration. I thought it was interesting at first, but quickly realized it wasn't quite my cup of tea, at least in the circumstances that I was previously exposed to. What I didn't like most about it was the feeling that I was losing touch with the frontlines. Wherever my career takes me, that's something I simply never want to do. It's a shame that for so many hospital administrators across the country, it's an “us versus them” mentality. It doesn't have to be that way. A totally different attitude is needed.
Watch this post as a video

Here are 3 questions that keep on making hospital administrators scratch their heads:

1. Why can't we improve patient satisfaction?
Giving our patients a better experience is really not rocket science. It requires a back to basics approach of addressing issues such as reduced noise (especially at night), comfortable rooms, more palatable food, and clarity on wait times. Human communication is paramount. It's not about funky tech apps, tacky slogans, or adding a new expensive layer of administration. Get away from viewing patient satisfaction as a “bumper sticker” and look at what the highly rated institutions are doing right.

2. Why is that quality improvement initiative failing?
It sounded like such a good idea when it started, but failed miserably. There are probably lots of reasons for this including lack of frontline buy-in (could be doctors or nurses), a loss of energy and enthusiasm, or being disheartened by initial unsatisfactory results. Go back to the drawing board and look at all of these possibilities, especially having physicians on board with the project.

3. Why are doctors not cooperating with us?
Probably one of the biggest questions asked. Let me re-phrase: Why should doctors cooperate with you? Physicians are among the busiest, most highly educated and hard-working professionals out there. You as an administrator need to make clear with exemplary communication why you want things to happen. Explain in understandable ways and be honest. If the reality is that the hospital is losing lots of money by not doing something, show the doctors the figures. If you need to tick boxes to avoid hefty fines, do the same again. But don't just leave it as “this needs to happen for the organization”. Appreciate that doctors are already unbelievably rushed off their feet, and if necessary, throw in an incentive for all the extra work—just as you would expect for yourself.

With the health care pendulum swinging towards more physicians being employees in recent years, the need for administrators and doctors to work together is greater than ever. There is unfortunately so much distrust at the moment, much of it unnecessary. If you are a health care leader, the advice is the same as for any form of leadership: strive to be thoughtful, show empathy, always lead by example, and above all else—be an excellent communicator.

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.

When a dead horse is your only horse

I'd like to thank Tom Talbot and Hilary Babcock, two of the authors of SHEA's position paper on mandatory influenza vaccination of health care workers, for their response to my recent post on why I think this policy is misguided. Hilary and Tom are excellent hospital epidemiologists that I respect. Nonetheless, on this issue, I remain unconvinced by their arguments.

They point out that that I mischaracterized SHEA's position being based on four nursing home cluster randomized trials, when in fact the position paper has 63 references. There are, indeed, 63 references, the majority of which do not address the impact of vaccinating healthcare workers on patients. In fact, most of the references lay out the biologic plausibility that vaccinating healthcare workers should have an impact on patients, as well as other issues, such as the impact of mandatory programs on vaccine rates. The biologic plausibility argument is very nicely laid out in their blog post, and I agree with it completely. So, I'll be more precise: SHEA's best evidence for their policy is contained in the four cRCTs.

Tom and Hilary go on to cite newer studies that they believe support SHEA's position, one of which is a cluster randomized trial from the Netherlands. I was not familiar with this paper so I reviewed it. In this trial, 6 hospitals were randomized—3 had an intervention to increase vaccination rates in HCWs and 3 did not. Significantly higher vaccination rates were demonstrated in the intervention hospitals. The patient outcomes were divided into adult and pediatric patients and the outcomes reported for patients were influenza and/or pneumonia and pneumonia. Influenza was not an outcome. Thus, the influenza rates cannot be determined. If the two outcomes are mutually exclusive, then the influenza rate is actually higher in the intervention hospitals (though not likely significantly so). For children, there was no difference between the intervention and control hospitals. And interestingly, the intervention hospitals had significantly higher HCW absenteeism rates, a metric Hilary and Tom argue as important for demonstrating the effect of employee vaccination. Thus, I don't think this paper in any way supports mandatory vaccination.

Despite the studies published in the seven years since the SHEA position paper was published, there remains an irrefutable fact: there is no high level evidence demonstrating that vaccinating health care workers reduces influenza in hospitalized patients. I agree with Hilary and Tom that the four nursing home studies are a dead horse. Unfortunately, however, that dead horse is their only horse.

Everyone has opinions about infection prevention interventions biased by their own experiences and perceptions, and I'm glad that Tom and Hilary pointed out one of mine—bare below the elbows. As I write this post while on service, I'm, you guessed it, bare below the elbows! There's clearly biologic plausibility that clothing can transmit pathogens to patients, but there is no evidence that following a bare below the elbows approach to patient care lowers infection rates, and in every talk I give on this topic I make that very clear. I would never argue that health care workers wearing white coats should be fired; otherwise, Tom and Hilary would have to be fired (based on their photos). And unfortunately, they missed the entire point of my post. I'm not arguing against vaccination of health care workers. My point is that you can't mandate an intervention (and in this case threaten a person's livelihood) when the intervention is not supported by high level evidence. In other words, you can't mandate on opinion, but that's exactly what SHEA did. Expectations for compliance with an intervention must be correlated with the strength of the evidence.

SHEA made a huge mistake when they published this position. And seven years later, there's still no published evidence that can bail it out. It was wrong seven years ago, and it's still wrong. Health care workers in the U.S. deserve better, especially from a professional society that prides itself on using science to guide practice.

Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on improving the quality and safety of health care, and sees patients in the inpatient and outpatient settings. This post originally appeared at the blog Controversies in Hospital Infection Prevention.
Thursday, March 9, 2017

Universal health care and a single payer system are definitely not the same thing

I hear many of my progressive friends say that, “Obviously what we need is a single payer.” That could work, but it is definitely not a sure thing. Overall what we want most is universal access to health care at a cost that is affordable.

Why, some may ask, does it need to be affordable? Why can't it just be free, like in Canada?

That's a wonderful thought, sort of. It also ignores the big truth that health care is like any other resource and is not free. It is always paid for by all of us. The difference between a single payer and multiple public and private payers, which we have now, is the degree to which we feel the pain of paying for it. Health care costs are paid by our employers, and thus from our wages, our taxes and directly from our purses in the forms of premiums and copays.

There are problems with universal access to health care, too. As a nation of people with various values, it is probably safe to say that most of us want sick people to be able to go to a doctor or hospital and get the help they need. And, if it makes it so that there are fewer people getting sick and thus more people who are happy and productive, we could probably agree that we want interventions that will prevent illness, things like vaccines and preventive testing for treatable diseases. But what about nursing home care and transplants and the newest drug therapy for chronic diseases and expensive medical devices? Is this stuff included in what we believe is essential to offer people in order to be a civilized nation? What about critical care interventions for people who drink too much or use injectable drugs and continue to do this despite developing health problems? What about smokers who get chronic lung disease and cancer and continue to smoke? What about the ravages of obesity, including diabetes and osteoarthritis? What do we do about the associated need for ever more costly new antidiabetic drugs and joint replacements? Is there a point at which we cannot reach consensus?

Having our diverse collection of private insurers does allow for some creative approaches to the above dilemmas. They can adjust the cost of their product based on certain unhealthy behaviors. They are free to develop programs to help people eat less, exercise more or go in for regular preventive maintenance. With multiple private insurers competing, this becomes less restrictive.

A single payer could build some of these same incentives and could potentially do some other things to reduce costs. It could negotiate with the various segments of the health care delivery system in order to reduce their charges. Many services are excessively expensive and prices could probably come down with some pressure from a single payer who was the only client available. If that single payer is the government, it could potentially do some innovative things to reduce costs.

If a single payer were to notice (as many doctors have noticed) that some of the most costly patients were ones who abuse drugs or alcohol, resources could be directed outside of health care to reduce those risks. Rehabilitation programs might be targeted for more funding, but more effective would be to support high risk communities where education is poor and there are few decent jobs available. This is something that a private insurance company has no ability to do.

What is kind of strange, though, is that we do have a single payer for a large portion of Americans: almost 1 in 3 of us is insured by either Medicare or Medicaid. But they don't negotiate prices of medications or devices or many services and they don't have fun and accessible programs to increase healthy behaviors and, as far as I'm aware, they don't target high risk communities for improvement projects as a way to reduce health care costs.

What makes our government unable to control costs, then? If we are thinking about having the federal government be our single payer, we should consider its success in managing the health care of over 100 million people now under its umbrella. It is possible that the existence of private insurers that will pay more than Medicare or Medicaid rates limits these government funded payers from lowering prices still further. I think, though, that the inability of opposing sides to work together to come up with solutions is at the heart of it. Our government has become one in which the two parties definition of success is to obstruct the ideas of the opposing party. The fact that Congresspeople can serve many terms means that everyone is trying to appear to their constituents to be the most magnanimous and to make their opponent appear to be stingy and unkind. At the same time they are attempting to please powerful business interests, particularly in the health care industry, in order to benefit from generous campaign contributions. Ideas that would cut costs by limiting benefits or reducing reimbursement can also reduce the chance of being re-elected. Moving resources to underserved communities buys few friends among the powerful.

On the other hand, Medicare probably does deliver health care with lower administrative costs than private insurance. Although it is not free to recipients, most of them love their insurance, which is more than most private plans can claim.

So what, then, is the best route to a universal health care system that can control costs and encourage people to take better care of themselves? Our present system, under the affordable care act, has provided a framework in which increasing numbers of people were covered by a single payer, though Medicare and expanded Medicaid. It did not allow people to buy into Medicaid when they made more money than 138% of the poverty line, which would be useful. Instead, it subsidized private insurance to do the same thing which has run into some problems. Offering either Medicare or Medicaid for a fee based on a sliding scale for income would allow people to move further toward a single payer without taking away private insurance companies' ability to do business. Private insurance might continue to innovate in ways that larger scale federally funded health care could not do. Independent health care cooperatives such as Group Health/Kaiser Permanente could do the same. Cost pressures on federally funded health care might lead to price negotiations and attempts to address the social causes of the diseases of self-neglect.

I and, I suspect, the vast majority of Americans would appreciate bipartisan work on patching together universal health care out of the unstable bits and pieces that are presently making a mess of it. That may require changes in government that seem far removed from health care reform, such as term limits and campaign finance reform. It is not going to be simple and will likely involve both compromise and willingness to make some sacrifices.

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.