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.

Playing nice: infection control and clinical microbiology in the P4P era

As it's probably clear, it's been a great honor for me to work (and blog) with Dan Diekema, MD, FACP, and Mike Edmonds, MD, FACP, over the past 8 years. One of the things that stands out when talking shop is their ability to see both sides of an argument even while pushing for the changes they support. Many times, their ability to see both sides clearly is possible because they've lived both sides. Mike has been an infectious disease chief and hospital epidemiologist and is now our chief quality officer, and Dan is an infectious disease chief, hospital epidemiologist and clinical microbiologist. You know, if I was a fellow or faculty member looking for a hospital epidemiologist position with great mentorship and support, I would move to Iowa, but I digress.

One specific area where understanding competing goals is critically important is the interplay between the increasing sensitivity and precision of microbiologic tests and the growing pressure to reduce health care acquired infections (HAI). As you can imagine, with 3% of Centers for Medicare and Medicaid Services (CMS) payments potentially at risk, anything that could impact HAI rates in a negative fashion is bound to be a flashpoint for hospital administrators. With that in mind, I point you to Dan's excellent commentary just published in the Journal of Clinical Microbiology that examines the implications of advances in microbiological testing on HAI rates and provides specific suggestions for how hospital epidemiology programs and clinical microbiology labs can work together to respond to these changes.

Initially, Dan provides three scenarios where changes in the micro lab could directly impact HAI rates (1) The effect of matrix-assisted laser desorption/ionizationon central-line acquired bloodstream infection rates (2) The shift from enzyme immunoassay to nucleic-acid amplification tests (NAAT) for Clostridium difficile detection and (3) Pressure to block urine culture ordering to reduce catheter-acquired urinary tract infections. After delving into the current CMS reimbursement landscape, the unintended consequences of improvements in diagnostic testing and the use/misuse of surveillance definitions, he provides six valuable recommendations that clinical microbiology labs (CML) and infection prevention programs (IPP) should consider:

(1) CML leadership should select diagnostic approaches with the goal of improving individual patient outcomes

(2) Hospital and IPP leadership should not pressure the CML to alter diagnostic practices based on the need to demonstrate lower HAI rates for pay-for-performance measures.

(3) Public health authorities (CDC/NHSN) must be proactive in adjusting HAI metrics to changing CML technology

For recommendations 4-6, you're gonna have to read his commentary. But a hint at #6: CML and IPP leadership need to collaborate and advocate for their needs, because, unlike at Iowa, both sides aren't always present in the mind of a single person.

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, March 6, 2017

The joy of being a teaching and learning internist

Since Dec. 1, I have made attending rounds all but 10 days. As usual, this stretch has invigorated me.

As an internist (I am eschewing the phrase general internist because I believe that the adjective general is redundant), my teams care for a wide variety of patients. Some patients have given us diagnostic challenges, while others management challenges. Many patients need the right side of our brain, while others need the left side. The best internists have balanced brains!

As a teacher, I love inducing excitement in the learners. When we figure out the diagnosis, we feel like Sherlock Holmes.

As a learner, I love a diagnostic challenge. I spent several hours yesterday trying to better understand tachycardic cardiomyopathy and to diagnose a patient with intermittent left bundle branch block. Sitting there, reading articles to see if they shed light on our confusion gives me great pleasure.

As a physician, my greatest pleasure occurs when we connect with the patient. I recently cared for a patient who was angry with his health care team. We understand his anger, and refocused he and his family to a more patient-centered plan. He left the hospital satisfied and his family felt that we had addressed the important issues. We made no diagnostic coups. We focused on symptom control. But most important we let him know that we wanted to make him feel better.

Atul Gawande, in his recent article ”The Heroism of Incremental Care“, wrote this: “Success, therefore, is not about the episodic, momentary victories, though they do play a role. It is about the longer view of incremental steps that produce sustained progress. That, such clinicians argue, is what making a difference really looks like. In fact, it is what making a difference looks like in a range of endeavors.”

While he wrote particularly about primary care, I would state that these words and concepts often apply to hospital medicine. We provide care for patients who need a bit more intensity, but as internists we rarely provide heroic medicine. We help patients through their exacerbations of their chronic illness, or diagnose a new illness, or help improve the management. We act as conductors, hopefully getting the inpatient symphony of consults to play their solos without discordance. We bridge between primary care visits, tweaking things that need tweaking.

We try to role model one of Osler's famous sayings, ”The good physician treats the disease; the great physician treats the patient who has the disease.”

We owe our patients that. We revel after our successes when we actually help another person.

I love it. I love helping patients. I love helping students and residents grow. I love the intellectual challenge and always having more to learn.

Forty-four years after falling in love with internal medicine, I still am amazed at how much I love the field.

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 3, 2017

It's time to finally fix health care worker vaccination policies

In 2010, the Society for Healthcare Epidemiology (SHEA) published a position paper that stated that annual influenza vaccination of health care workers (HCW) should be a condition of employment on the basis of four studies performed in nursing homes. In other words, SHEA advised hospitals to fire HCWs who refused to get a flu shot. Other professional societies jumped on this insane bandwagon, and Centers for Medicare and Medicaid Services (CMS) made vaccine compliance rates publicly reportable and a metric in their hospital Star Rating program.

From the beginning, I have argued on this blog that SHEA's position was misguided for a number of reasons that I won't rehash in this post (see here, here, and here). Moreover, the Cochrane group evaluated the same four papers on which SHEA based its recommendation and determined there was no conclusive evidence that vaccinating HCWs was effective in reducing influenza in patients. But SHEA didn't back down. Another systematic review by another group came to the same conclusion. But SHEA didn't back down. CDC significantly downgraded the effectiveness of influenza vaccination to worse than placebo in some years. But SHEA didn't back down. And there's even a lack of evidence that influenza vaccine of healthcare workers reduces influenza in healthcare workers.

Now comes a 21-page paper (free full text here) in PLoS One by a group of Canadian epidemiologists that decimates those four nursing home studies. And all I can say is: SHEA better back down.

According to these investigators, all four studies violate the principle of dilution by reporting greater percentage reductions with less specific outcomes (i.e., the studies report percentage reductions in all-cause mortality > influenza-like illness (ILI) > laboratory-confirmed influenza). The principle of dilution requires that vaccine efficacy must be lower when non-targeted events (non-flu illnesses) are included in the study outcome than when only the target (confirmed influenza) contributes. The authors give the simple analogy of using an item-specific coupon at the grocery store--the percentage reduction in price on that item will always be much greater than the percentage reduction on your entire purchase that includes multiple other items. It's an irrefutable law of mathematics.

They also note several sources of bias. Depending on the study, there were differences in mortality between the control and intervention groups accrued before influenza arrived in the community, and there were issues with the definition of ILI. Estimates of numbers need to vaccinate were so flawed (off by as much as 4,000-fold) that if extrapolated to all health care workers in the U.S., more deaths would be averted than occurred in the 1918 influenza pandemic.

Here's the bottom line per the authors: Each of the four cluster RCTs used to champion compulsory HCW influenza vaccination policies reports benefits that are mathematically impossible under any reasonable hypothesis of indirect vaccine effect. It's hard to imagine a stronger conclusion.

If you don't read the entire paper, please read the discussion. Here's the concluding paragraph:

“Through this detailed critique and quantification of the evidence we conclude that policies of enforced influenza vaccination of HCWs to reduce patient risk lack a sound empirical basis. In that context, an intuitive sense that there may be some evidence in support of some patient benefit is insufficient scientific basis to ethically override individual HCW rights. While HCWs have an ethical and professional duty not to place their patients at increased risk, so also have advocates for compulsory vaccination a duty to ensure that the evidence they cite is valid and reliable, particularly in the absence of good scientific estimates of patient impact. The diversion of resources from more evidence-based efforts and other important but less tangible costs related to loss of trust and credibility also need to be considered, including the implications for other immunization programs and workplace policies. Although current data are inadequate to support enforced HCW influenza vaccination, they do not refute approaches to support voluntary vaccination or other more broadly protective practices such as staying home or masking when acutely ill.”

And if that's not enough, there's a commentary in the same journal, responding to the Canadian study written by the lead author of one of the nursing home studies. He defends his study, but importantly he states that the findings should not be extrapolated beyond the nursing home setting.

As I see it, unless SHEA cites alternative facts, it has three choices: change its position to recommending (not mandating) annual influenza vaccine for health care workers, articulate a damn good reason to support its current policy despite the evidence (hard to imagine what that would be), or simply retire the guideline (as it has quietly done for the 2003 highly controversial MRSA/VRE search and destroy recommendation). Given the assault on science that we are likely to see over the next four years in the U.S., SHEA must lead by ensuring that all of its recommendations are solidly based in evidence and that expectations for compliance with interventions correlate with the strength of the evidence. Just as we must defend vaccines from false claims of adverse effects, we must also truthfully acknowledge their limitations and shape our policy on science not opinion.

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 2, 2017

What defunding Planned Parenthood really means

Planned Parenthood clinics have been a political football for over a decade. Planned Parenthood operates about 650 health centers across the United States and 2.7 million men and women visit the clinics each year. In fact, an estimated 1 in 5 women has received care from Planned Parenthood at least once in her life. For many women, Planned Parenthood may be the only place to receive reproductive health care near where they live. They provide basic women's preventive care (pap smears, sexually transmitted disease testing and treatment, counseling, contraception, intrauterine device placement and long acting reversible contraception) and even basic primary care.

Of all the health services Planned Parenthood provides, they report that about 3% are for abortion. Most women receive other services at the same time (pregnancy testing, future contraception) that can skew this number and critics say the abortion percentage is higher (calculated to as high as 7%), but there is no dispute that Planned Parenthood provides more needed health care for women that goes far beyond terminating pregnancies.

Repeal of the Affordable Care Act would ban Planned Parenthood from receiving Medicaid reimbursements and federal family-planning funds, accounting for loss of over $500 million in government funding per year, about two-fifths of its total revenue. It is important to know that Medicaid funds already cannot be used for pregnancy termination unless the mother's life is in danger. So defunding Planned Parenthood is really defunding women's health care. Period.

We currently have a shortage of primary care doctors in the United States and fewer doctors have sufficient training and expertise in the full range of reproductive health services. Planned Parenthood provides this needed care.

Defunding Planned Parenthood is an act that Congress should not undertake. American women deserve better.

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.

Beating back the norovirus devil

Well, many of us have sick feelings in our stomachs these days. It's norovirus season and the media is filled with the usual scary reports, “hard to get rid of“ and “schools closing“, that generally provide non-specific information about how to prevent transmission in your home. The Centers for Disease Control and Prevention (CDC) does have useful information online and in graphic form. So, with homage to Maryn McKenna's excellent book about CDC's EIS, I offer my tips for beating norovirus in your home.

A bit of background on why I've put forth these recommendations: We've had three episodes of likely norovirus cases in our home since my initial norovirus post in 2013 and zero cases of transmission. Below is my 2017 case report with steps we took to prevent transmission:

Approximately 3 weeks ago, we had a group of five 10-year-old kids at our house for a party. At some point, one of the kids started feeling sick and spit up a bit in our trash can and then while trying to get to the bathroom vomited in our family room and near our front door before finally making it to a toilet. Thus, we had 3+ areas to decontaminate and 7 at-risk people we needed to protect. We immediately sent the other kids to the lower level, donned gloves and began the clean-up procedures.

1) We made sure that the sick child stayed in or near the bathroom and also made sure he closed the lid prior to flushing the toilet and poured a cup of bleach into the toilet before we flushed the toilet again. Once the child was picked up by their parent, we put the bathroom off limits.

2) We quickly blotted up the emesis in the living room and front hall with towels, being careful to not spray the virus. We then washed all of the towels twice in the hottest water setting and dried them until practically burnt (humor).

3) We removed all glasses, plates, silverware, xbox controllers and other things the child might have touched from circulation. The things we could wash in the dishwasher were washed 3 times and we used the drying cycle (which we usually don't use).

4) We used these bleach wipes (Clorox 35309 Healthcare Bleach Germicidal Wipe), which have activity vs. norovirus, twice on each hard surface (bathroom, floor, XBox controller) to make sure we achieved adequate contact time.

5) For soft surfaces, that couldn't be laundered, we used (Clorox Healthcare Hydrogen Peroxide Spray) after first testing that it was color safe on our carpet.

6) And we enforced strict hand hygiene in the house for the next few days, using only soap and water.

I hope this helps; be careful out there.

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.