ACP Hospitalist

Add Barrett's to the list of conditions impacted by smoking

noreply@blogger.com (Ryan DuBosar) — Thu, 02 Feb 2012 12:00:00 +0000

Barrett's esophagus patients who smoke tobacco are at twice the risk of developing advanced precancerous cells and twice the risk for developing esophageal cancer, according to a new study in Gastroenterology.

Tobacco, not alcohol, was the strongest lifestyle risk factor in Barrett's esophagus patients, the lead author commented. And, the risk was higher no matter how few cigarettes were smoked per day.

Researchers collected data from 1993 to 2005 on 3,167 Barrett's esophagus patients, representing 23,692 person-years of follow-up with a mean follow-up period of 7.5 years. In the study, 117 of the patients developed dysplasia or cancers of the esophagus or stomach. Current tobacco smoking was significantly associated with an increased risk of progression (hazard ratio [HR], 2.03; 95% confidence interval, 1.29 to 3.17) compared with never smoking, and across all strata of smoking intensity.

After adjustment for confounders, there was elevated risk for former smokers (HR, 1.53; 95% CI, 0.95 to 2.45) and for current smokers (HR, 1.83; 95% CI, 1.14 to 2.92.)

The number of cigarettes smoked per day was known for just over half of smokers in this cohort, and there was no additional increase in progression risk for those who smoked more than 20 cigarettes a day compared to less than that. Pipe smokers had an increased risk of progression after adjustment for potential confounders (HR, 2.18; 95% CI, 1.10 to 4.32), but cigar smokers did not, although less than 1% of the cohort reported using cigars. Current smoking of tobacco in any format was associated with a significantly doubled risk of progression to cancer or high-grade dysplasia compared with never smokers (HR, 2.07; 95% CI, 1.34 to 3.18).

Drinking more than 10 units of alcohol per week was not associated with the risk of progression compared with those who abstained (HR, 1.04; 95% CI, 0.60 to 1.78), nor was less alcohol consumption a factor. The type of alcohol didn't matter, but the authors noted that this information was only available for 15% of the cohort.

Life at Grady: First comes love

noreply@blogger.com (Jessica Berthold) — Wed, 01 Feb 2012 12:00:00 +0000

The following post, by Kimberly Manning, FACP, is adapted from her blog Reflections of a Grady Doctor and reprinted with permission. Names have been changed to protect privacy.

I saw this young couple in the residents' clinic several months ago. Super young--like not even twenty-years-old. And it was a rather odd visit to have in an Internal Medicine clinic at a public hospital. This couple was here together because even though they hadn't been using any birth control methods for several months, they hadn't yet conceived.

"So we just came to get checked out." That's what the young woman said as she looked over at her partner.

"Checked out?" I asked.

"Yeah, ma'am," he quickly answered. "Like to make sure we can have a baby."

And I looked at this teenage couple and coached myself not to have a judging facial expression. I hoped my face didn't show my thoughts.

Which included:

Say WHAT? What the hell are y'all thinking? A baby? A BABY!

But they sat there patiently--her in the chair next to the desk and him rolling around on the wheeled stool. Faces as innocent as little cherubs and eyes twinkling-twinkling like little stars.

Even though they were young, I liked how genuinely and lovingly they looked at one another.

"Do you mind me asking how old you all are?"

"Both of us nineteen," she replied. She scoldingly cut her eyes at him and he abruptly stopped rolling back and forth on the chair.

I cleared my throat. "Are you . . .like, trying to get pregnant?"

"Yes, ma'am. We're the last ones in our family. Everybody be asking what we waiting for." When he said that, he looked at her and laughed.

And honestly? This sounded completely crazy to me. Two nineteen-year-olds who'd been trying to conceive since age eighteen sitting in our clinic asking to have thyroids checked and sperms counted up to see what was keeping a bun from going into their oven.

Wait, huh?

(Click "more" below to continue reading.)

"Ma'am, do you think we gon' be here more than another hour? I got to go to work and need to know if I should call my job," he said.

His face was so boyish and the way he kept twirling from side to side on that chair made him look even younger. I couldn't imagine what kind of work he was doing.

"What kind of work do you do?" I queried.

He then told me of his job working in a storage warehouse. Good money. A very solid, substantially-more-than-minimum hourly wage. And health benefits even.

"Including dental," he added proudly.

And her? She was finishing up cosmetology school.

"It's going real good," she shared before launching into telling me about the upscale salon where she hoped to get a job.

"Yeah, she always been great with hair. She do everybody hair already so I'm glad she in school for it." He was quick to support her. It was endearing.

"That's great," I responded. Because that was great.

Great yes. Even though in my head I still thought the whole idea of two nineteen- year-olds intentionally trying to get pregnant was a little off putting. And even more, I found the thought of those same two nineteen-year-olds getting sweated by their respective families because they hadn't had a baby yet rather...crazy-ish.

That said, we ran a few simple tests on them both. Each received a full physical exam and everything checked out okay. After referring them to the family planning clinic, I bid them adieu and wished them well.

And by well I meant growing older and maturing some more before conceiving a human.

Anyway.

The other day I was standing next to the clinic elevators and who did I see? Them. Side-by-side and looking at each other just as lovingly as they had before. I glanced down at her unbuttoned coat and noticed an increasing abdominal girth poking out of the opening.

"Pregnant!" I said out loud when I saw them.

They immediately remembered me. He spoke first. "Yeah, ma'am. We just kept tryin' and we finally got pregnant!"

I love it when men refer to pregnancies as a "we" phenomenon. And you know? They were a "we." A nineteen-and-a-half-year-old we. But a "we" all the same.

I looked at their hands and their laced together fingers. Next I noticed the cursive name on his uniform. Just coming from or going to work again I supposed.

"You all having a boy?" I asked.

"Naw, it's a girl! We just fount out!" she squealed. "But everybody guessed it's a boy!"

They looked at each other again and smiled.

"She gon' be so spoiled," he said with a shake of his head. "I know it already." He glanced over at her again with her petite body with it's new miniature beachball in front. Beyond that, she didn't look pregnant at all.

"You know why they keep guessing boy, right? It's because you look so good." I figured I'd throw in my mother-wit as I mindlessly pushed the "down" elevator button repeatedly.

"Oh yeah," he chimed in, "'cause them girls rob you of your beauty right? Tha's what they say? Ha ha!"

"That's what they say." I giggled at that old adage.

"Well, not her. She been pretty since the day we start going together."

Going together. Wow.

"How long has that been?"

They both knitted their brows in tandem thinking. "Middle school," she finally answered. "Or a little before that."

We stepped onto the elevator and I watched them. He carried her purse and held up his arm for support even though she wasn't that big or tired appearing. It was just the gentlemanly thing to do for the lady you love.

And it was obvious that there was love there. Love between that young couple for sure. And no, they weren't married and yes, nineteen is hella-young if you ask me. But.

Nobody asked me. And even if they did...who am I to judge their readiness to start a family? A tax payer you say? Was this your initial thought?

Hmmm.

Funny that my initial thought was negative...or rather, it's actually not funny at all. The truth? Here I was imagining for them some life tethered to government support and generational poverty and ignorance. All because they wanted a baby at nineteen. Or was that all?

Hmmm.

Look. I sure as hell wasn't looking to have or feeling ready for a baby at nineteen. But that doesn't mean they aren't. Or that someone else isn't.

What if this hadn't been at Grady? What if this was some young ivory-faced nineteen year-old couple with tiny crosses around their necks and vermeil bands on their ring fingers?

I waved good bye to them and congratulated them once more on the pregnancy. As I watched them walk away, I froze for a moment.

Wait.

Had I passed judgment on them for being young, black and working poor? Had I sized them up and assigned them a life and a future that, in all actuality, I had no idea about at all? Had I?

Damn.

All that they had shown me up until that point was youth, yes...but more than that, just love and devotion. The same things we had when we were expecting our first baby. Harry taking off of work and holding my coat and my arm at those prenatal visits just like them. And just like our first baby and the one that came after...the main thing their little daughter would have in common with Isaiah and Zachary was that she was wanted....and conceived in love.

Young love, no less, but love all the same. I had no grounds for thinking anything else.

As they disappeared from my sight, this word popped into my head:

prejudice [prej-uh-dis]: an unfavorable opinion or feeling formed beforehand or without knowledge, thought, or reason.

I stopped at the glass door and caught my reflection...
I told that woman in the mirror, Careful, profesora....Be careful.

Appropriate use criteria updated for when to revascularize

noreply@blogger.com (Ryan DuBosar) — Tue, 31 Jan 2012 12:00:00 +0000

Updated appropriate use criteria guide were released Jan. 30 to guide physicians and patients when to use an invasive procedure to improve blood flow to the heart and how to choose the best procedure for each patient. Clinical scenarios affirm the role of revascularization for patients with acute coronary syndromes and significant symptoms.

Prominent among the changes are a re-evaluation of the indications for the treatment of multivessel coronary artery disease by percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) as a result of data from the SYNTAX trial, which came out after the original criteria were published.

The new criteria appear online at the Journal of the American College of Cardiology.

Among the many changes:
--PCI is changed from inappropriate to uncertain for low burden left main disease, and from uncertain to appropriate for low burden three-vessel disease. This is meant to generate careful selection of high-risk surgery patients for PCI.
--Coronary artery bypass is appropriate for patient scenarios with coronary artery disease involving two vessels to include the proximal left anterior descendent coronary artery and all variations of three-vessel and left main coronary artery disease.
--PCI is appropriate in patients with coronary artery disease in all three heart arteries only if the severity of coronary artery disease burden is low.
--It is uncertain whether PCI is appropriate in patients with three- vessel coronary artery disease and an intermediate to high disease burden.
--PCI is also deemed uncertain in patients with blockages in the left main coronary artery, alone or with blockages in other arteries and low coronary artery disease burden.
--PCI is considered inappropriate in patients with blockages in the left main coronary artery with intermediate to high disease burden

The updated appropriate use criteria, drafted in conjunction with 10 major cardiovascular and thoracic medical societies, replace a previous set published in 2009. New clinical data led to the update. For example, publication of the SYNTAX trial called for the reexamination of clinical scenarios for multi-vessel coronary artery disease.

The 2009 appropriate use criteria outlines nearly 200 clinical scenarios that reflect common heart problems seen by cardiologists. The appropriate use criteria scenarios were developed to mimic patient presentations encountered in everyday practice and to address the rational use of coronary revascularization. The ratings take into account such factors as symptoms, medication, results of stress testing, severity of disease burden, and number of coronary blockages.

Meaningful use core measure #13, the patient-generated clinical visit summary

noreply@blogger.com (Neil Mehta, MD) — Thu, 26 Jan 2012 16:00:00 +0000

One of the Meaningful Core Measures is to provide a clinical summary of the office visit to each patient. This a well-intended measure as we know that patients will often retain only a part of all the information that they received at the office visit. The summary needs to contain very important information about the visit and decisions made during the visit including patient instructions.

Patients when they leave the office often go out with a sheaf of papers and find it difficult to know which ones they really need to read.

I have been actually giving the patient the "task" of creating their own summary of the office visit. Once we have gone through the history and exam and labs, I will engage them in a discussion on next steps. Then I ask them to summarize the plans and action steps and write them down on a piece of paper. They write down what they agree to do instead of what I would tell them to do. They take this paper with them as a summary of the visit in addition to the EHR generated printed after visit summary.

This activity can take a couple minutes but is incredibly powerful. There is something about a patient's own handwritten plan that cannot be replicated by a physician generated print out.

This is a summary created by a hypothetical patient who was diagnosed with high blood pressure.

How different is it when a patient-physician discussion results in the patient writing down himself that he will cut back on the alcohol vs. a physician telling him to cut back and then handing him a printed patient instruction?

This process has another advantage. It gives the physician an idea about the patient's literacy level. This has to be addressed in a sensitive manner but is incredibly useful information that each physician should know but often does not. This may also not be appropriate for patients with writing disability (Parkinson's or rheumatoid). In these cases you can ask a patient to tell you what to write down.

If you want you can take scan the handrwitten document with an app on your iPhone or android and upload into the electronic health record (make sure your HIPAA police are OK with this. One option is not to have any patient identifiers on the image like the one above).

Neil Mehta MBBS, MS, FACP, practices internal medicine at a large tertiary care hospital in Ohio. He is also the Director of Education Technology (Academic Computing) for his medical school and in charge of his hospital system's home grown Learning and Content Management System. He is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management. This post originally appeared at Technology in (Medical) Education.

Top 10 technologies a hospital might test this year

noreply@blogger.com (Ryan DuBosar) — Thu, 26 Jan 2012 12:00:00 +0000

A top 10 list of important technologies and technology-related issues that hospital and health system leaders should pay close attention to this year questions each the need for each one based on economics, patient safety, reimbursement and regulatory pressures, as assessed by staff at the ECRI Institute.

1) Electronic health records: Hospitals will need not only IT infrastructure, but also the ability to integrate patient care device data into the electronic health record.
2) Minimally invasive bariatric surgery: Hospitals will need to develop interdisciplinary teams, invest in equipment, care setting and staffing models
3) 3D digital breast tomosynthesis: It requires more capital outlay and operational costs without a clear clinical benefit, and it doesn't replace full-field digital mammography.
4) New CT radiation reduction technologies: dose monitoring and measuring are critical to achieving lower radiation doses, and this aspect of the treatment is as important as the technology itself
5) Transcatheter heart valve implantation: hybrid cath lab models may be the ultimate destination for many of these procedures due to its lower cost and patient volumes. But this may happen only after procedures mature and proficiencies improve.
6) Robotic-assisted surgery: There's steady growth in the number and types of surgeries being done, despite a lack of definitive evidence for the superiority of it compared to traditional laparoscopic surgery.
7) New cardiac stent developments: A 60% use for off-label indications, high complication rates from treating bifurcated lesions with current stents, and higher-than-desired reocclusion and reintervention rates all signal the need for a more personalized approach to stents.
8) Ultrahigh-field-strength MRI systems: 3T systems offer better image resolution than their 1.5T counterparts, but cost about $1 million more than standard systems. Looming next: 7T systems.
9) Personalized therapeutic vaccines for cancer: The many new and high-cost pharmaceuticals and biotechnologies can cost $100,000 and more per patients, and they are all add-ons to existing therapy regimens.
10) Proton beam radiation therapy: Building these centers is a monstrous cost, as is running them. But no randomized controlled trials have proven to be more effective than photon beam treatments. And even newer (but just as expensive) regimens are also in development, carbon ions.

"Themes emerging on our 2012 list reflect ongoing impacts of healthcare reform initiatives and new technology developments that emphasize patient-centered care, including safety improvement, interconnectedness of technology, personalized medicine catering to individual care needs and preferences, and ever-increasing cost pressures," ECRI staff wrote in their white paper. "While the imperative to integrate health information technology with healthcare technology marches on, emerging devices, drugs, and procedures are tailored more than ever to individual patients' medical characteristics."

Life at Grady: The Old Man and the Knee

noreply@blogger.com (Jessica Berthold) — Wed, 25 Jan 2012 12:00:00 +0000

The following post, by Kimberly Manning, MD, FACP, is adapted from her blog, Reflections of a Grady Doctor. It is adapted with permission.

Hey there, Miss Manning!"

You announced that greeting to me while craning your head out of the door of a clinic room. Me, I was hustling and bustling through the hallways trying to get things situated for the afternoon session. I glanced back in your direction and couldn't help but slow down.

"Hey sir! What you know good?" I spoke to you in that easy and familiar language that we both know so well.

"Awww, I ain't no count!" And then you laughed out loud, slapped your knee, and then winced a bit. "Woooo! I bet' not stir ol' Arthur up."

Arthur. As in Arthur-itis.

I stopped in the doorway with a stack of papers in my hands and smiled at you. Today you were alone instead of with your daughter. This was fine because even though she sees about you, you "do for yah'self." Your dark leathery complexion has weathered the storm of your "eighty-some-odd" years quite well and I decide today that I love it all. Including those milky, bluish rings now filling the irises of your aging eyes. An interestingly beautiful contrast against that coffee-colored complexion.

Yes, I love it all because it represents so much of what I love about Grady. Storms weathered with beautiful contrasts.

(Click "more" below to continue reading.)

"I don't think I recall you havin' so much gray hair, Miss Manning!" You announced this in that unapologetic way that only the Grady elders can. "But tha's alright. I still think you a pretty little thang."

Pretty little thang? Ha. That's what I'm talking about.

I carefully watched you as your mouth moved. Cheeks with deeply chiseled lines and scarce remains of what was once a beard pasted around your chin and cheeks. The teeth in your mouth looked to be the ones you were born with; large and rectangular but now with a tannish hue and old school dental work gleaming from the sides. Your neck with its redundant skin is supported by shoulders that have remained unusually broad and strong.

"Chopping wood," you said. "Asked my grandson to do it, but he ain't no count." We both laughed again.

You've taken the liberty of removing your coat, folding it neatly on top of the plastic bag you'd carried in that day. And like the perfect patient that you are, you'd also removed every single one of your medication bottles from that same bag and lined them right up on the table.

"I stopped coloring it," I added in reference to the gray hair again. "Too much trouble, you know?"

"Yeah, I hear you. I never got too much gray but I thank I woulda took the gray over losing it all!" You cackled while rubbing your shiny hairless scalp. Then you slapped that knee again and woke ol' Arthur up again. "I jest went on and shaved on off. It never really came back after that."

"Less trouble though, right?"

"Reckon it is!"

I saw your cane leaning against the wall. Weathered but still quite functional. Just like you.

"Knee still giving you a lot of trouble?"

"You know? Not as bad since they inject that medicine in it. But you know, these ol' knees been good to me so I manage just fine. This right one like to get stiff in the mornings. He get to loosenin' up as I get up and around though." The pronoun reference to your knee warmed my heart. You warmed my heart even more. I knew I could stand there talking to you all day so I decided to move on.

"Alright then, sir. Your doctor is checking your lab work and will be in here in a few minutes."

"Okay then, baby. Good seeing you, alright?"

"You, too, sir."

"And Miss Manning? Keeping a smile on your face make you look prettier than any old hair dye can any day."

That's what I'm talking about.

One of the nurses overheard that part as she came in to check supplies in the room. I looked over at her from the doorway. "You hear that? That was a good word, huh?"

She laughed and replied, "Ummm hmmm. But I think I'm gonna smile AND dye my hair."

Ha.

This day was a good day.

Providing health care in the wild via technology on a shoestring budget

noreply@blogger.com (Neil Mehta, MD) — Thu, 19 Jan 2012 16:00:00 +0000

Students in our medical school have since 2009 "adopted" a village in rural Peru. They go there for a month at a time accompanied by faculty members to provide various health services.

While there are many challenges, technology is a big help.

One key challenge was to learn about the population and document this and pass it on to the next group of students using an electronic medical record system. This would help them plan on bringing appropriate supplies (e.g. eye glasses, education material, etc.)

Solution:
OpenMRS: This is an excellent, robust open source electronic medical records system that was developed out of a partnership (Regenstrief Institute @ Indiana University and Partners in Health).

It lets you create custom fields, forms and reports. We wanted to capture the data at the point of care at the clinic where we would work. This would save the time of entering data from paper forms to the database and hopefully decrease errors.

One problem we have in rural Peru is a reliable power supply. So we decided to create an ad-hoc wireless network using a laptop as a server or host and tablet computers as the data entry devices. The plan is to take some extra extended batteries for the laptop so it can run constantly for about eight to 10 hours, and the tablets should last for at least six to eight hours if we don't use them for anything else. We would charge everything overnight at the hotel be set for the next day at the clinic.

Another challenge is language; the folks there speak Spanish.

Solution:
The students and faculty are getting a crash course in Spanish from some of the students who are quite fluent in this. Luckily there is a free medical Spanish app.

Another challenge is checking the visual acuity so we can give the correct eyeglasses. We have an ophthalmologist in the group who is training all the students. But getting them to learn refraction using retinoscopy may not be feasible.

Solution:
Just saw this amazing video of a $2 device that can be attached to a smartphone that lets you measure the refractive error in a few seconds. Am hoping to get in touch with the genius inventor to see if we can get one or two of these devices to help the cause.

It is quite amazing how we are getting to a point where the portable devices are going to be able to change the world, a model where the health care provider goes to the patient rather than the other way around! This may seem like something we need in rural and underserved areas in third world countries, but why can't we use this right here in the U.S.? Is it because of our financial models or the legal system?

Neil Mehta MBBS, MS, FACP, practices internal medicine at a large tertiary care hospital in Ohio. He is also the Director of Education Technology (Academic Computing) for his medical school and in charge of his hospital system's home grown Learning and Content Management System. He is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management. This post originally appeared at Technology in (Medical) Education.

Google tracks flu peaks faster than the CDC

noreply@blogger.com (Ryan DuBosar) — Thu, 19 Jan 2012 12:00:00 +0000

Google can calculate flu incidence peaks a week faster than other diseases surveillance systems, including that of the Centers for Disease Control and Prevention. With hospitals already stretched to capacity and using just-in-time logistics to serve patients, the seven extra days of warning could help them during a pandemic, researchers concluded.

Google Flu Trends uses search engine query data to estimate influenza activity. By counting how often Google sees 45 flu-related search queries, it estimates how much flu is circulating in different countries and regions around the world.

The data are available in near real time, unlike previously developed surveillance systems such as call volume to telephone triage services, over-the-counter drug sales and volumes of emergency department patients with influenza-like illness.

Researchers studied correlation of Google data to influenza and crowding from an inner-city emergency department at an urban academic hospital in Baltimore from January 2009 through October 2010. Data were collected weekly for the emergency departments, the CDC, laboratory-confirmed influenza data and emergency department crowding (patient volume, number of patients who left without being seen, waiting room time, and length of stay for admitted and discharged patients). Pediatric and adult data were analyzed separately when compared to Google Flu Trends.

Results appeared online Jan. 8 at Clinical Infectious Diseases.

Google Flu Trends correlated with number of positive influenza test results (adult ED, r=0.876; pediatric ED, r=0.718) and number of emergency department patients presenting with influenza-like illness (adult ED, r=0.885; pediatric ED, r=0.652). Pediatric but not adult crowding measures, such as total emergency department volume (r=0.649) and leaving without being seen (r=0.641), also had good correlation with Google Flu Trends. Adult crowding measures for low-acuity patients, such as waiting room time (r=0.421) and length of stay for discharged patients (r=0.548), had moderate correlation.

Researchers concluded that Google Flu Trends provides near-real-time surveillance data seven to 10 days before the CDC's U.S. Influenza Sentinel Provider Surveillance Network, correlating well "but not perfectly" with flu activity.

The imperfection was that Google Flu Trends was prone to spikes caused by news coverage rather than sick people seeking information.

One flu peak was not detected by Google Flu Trends, "possibly because of the previous month's flurry of Internet activity surrounding the news coverage of the H1N1 outbreak," the authors wrote. Another flu peak recorded by Google was not mirrored in the number of patients with flu-like symptoms or positive influenza tests, and instead was probably caused by news coverage of the CDC declaring H1N1 as a national public health emergency.

Life at Grady: The Two Gradys

noreply@blogger.com (Jessica Berthold) — Wed, 18 Jan 2012 12:00:00 +0000

The following post, by Kimberly Manning, MD, FACP, originally appeared on her blog, Reflections of a Grady Doctor. It is reprinted with permission.

Today is January 15, 2012. My name is Kimberly D. Manning and I am a medical doctor. I received my medical degree from Meharry Medical College in Nashville, Tennessee. For the past ten years, I have had the honor of teaching Emory University medical students and training Internal Medicine resident physicians at Grady Memorial Hospital in Atlanta, Georgia.

And I am a black female.

Fifty years ago today the date was January 15, 1962. Dr. Martin Luther King, Jr. was somewhere blowing out thirty three candles on his birthday cake. During that time, the vast majority of black physicians in the United States were educated at either Meharry Medical College or Howard University School of Medicine--both historically black institutions. In January of 1962 more than a quarter of the population in Atlanta, Georgia was black.

And Grady Hospital was segregated.

"White" Grady and "Colored" Grady. Known by most during those times as "The Gradys"; this plurality serving as the perfect descriptor for these separate but not-so-equal hospitals within one hospital. Yes, in 1962, Grady hospital was segregated.

(Click "more" below to keep reading)

Not only segregated. On January 15, 1962, there were no black physicians with staff privileges there. None. As a matter of fact, during that time there were approximately 4,000 hospital beds at hospitals in the Atlanta area. But physicians who looked like me could only practice in less than 500 of them. 438 to be exact.

Fifty years ago today.

If an African-American patient that I cared for as a primary care provider was hospitalized fifty years ago today, yes, they could be admitted at Grady. However, I would have to give up all patient care privileges at the moment they hit the door. Because, you see, while black people could receive care on the segregated C and D wings of the hospital, they could not receive that care from physicians of their same race.

No, they could not.

In January of 1962 there were groups picketing in front of Grady Hospital. Groups like SNCC and others in the community inspired by a thirty-three year old preacher who had become the face of the Civil Rights Movement. The same preacher who preached around the corner from Grady Hospital at Ebenezer Baptist Church. So there they stood. The Student Nonviolent Coordinating Committee withstanding hateful stares and venomous words. Young people bravely holding up signs criticizing the inequity of the care offered to "negro" patients at Grady Hospital -- and also the fact that black physicians weren't allowed there.

Fifty years ago today.

Other than it being just wrong, there were other problems with that whole no-black-doctors thing. See, just like it is now, Grady was the hospital that served the indigent patient population in Atlanta. And just like now, many of those patients were black. With segregation like it was, many of those folks were cared for by black physicians in the community. And back then, your primary doctor was usually who cared for you in the hospital, too.

Unless, of course, you needed to be admitted at Grady. Regardless of your wishes, that nice black doctor of yours would likely have been called a "boy" and sent on his way.

Or "gal" or "nigra" had it been me.

Fifty years ago today.

I guess it was good that there was at least the "colored" Grady. I mean, it could have been worse. In addition to Grady, at least there was Hughes Spalding Hospital (the colored hospital) across the street. Across the street. Yeah. So fifty years ago today, your negro doctor caring for you across the street from Grady couldn't come to care for you there. No, he or she could not. Oh, and if you weren't poor enough to be considered "indigent"? That made it even more complicated.

All that was going on on this day in 1962.

In January of 1962, my father was a freshman in college at Tuskegee Institute. He had graduated from high school in Birmingham, Alabama that previous year and, like many black folks back then, was the first person in his family to go to college. But also like many black folks back then, he wasn't the first smart person in his family.

No, he was not.

My paternal grandmother valued education. She celebrated my father for his academic achievements and applauded his decision to get higher education. Like me, my father excelled at science and things involving interpersonal skills. He enthusiastically told his counselor in 1961 that he wanted to major in Biology and go to medical school. Unfortunately, that counselor discouraged him. Shot down that dream quick, fast and in a hurry telling him that it was too much of a gamble. If a black man is going to go to college and he wants a job, he needs to go get an engineering degree. And let go of this pipe dream of being a doctor.

"What if you don't get into medical school? Then what?"

Going to college was already a big deal. And it wasn't like there was a doctor in the family for him to call for advice or to counter with, "But what if you do get in, son? What if you do?"

Yep.

So fifty years ago today, on January 15, 1962, my gifted-in-science father was struggling in math and engineering classes at Tuskegee Institute where it would take him more than six years to graduate. Because that's where the world was back then. Race and gender clearly dictated decisions and created ceilings made of a hell of a lot more than glass.

Me? I chose to go to Meharry Medical College because it was a good fit for me. Not because there was no other option or other place willing to let me fit. But had I thought of medical school on January 15, 1962, my medical education story would be different. It would have been Meharry or Howard or bust.

Or perhaps, for a woman, nothing at all.

Fifty years ago today.

Today I'm reflecting on how far things have come on what would have been Dr. Martin Luther King, Jr.'s eighty-third birthday. I am imaging a life for me in his world, a life at Grady Hospital some fifty years ago. And what I am realizing is that I wouldn't have had any kind of life there. At least, not as a doctor. And damn sure not as a teaching physician at Emory.

Oh, did I forget to mention? 1962 was also the first year Emory University integrated its student body. 1963 marked the admission of the first black student in Emory's School of Medicine-- a young man named Hamilton E. Holmes. As for the faculty part, I'm not sure when that part fully changed. I do know that Dr. Asa Yancy Sr. was the first brother-faculty member appointed at Emory which technically took place in the late 1950's (even though he still couldn't get privileges at Grady.) Something tells me that it probably took a little more time to get some sister-doctors on the roster.

But that's just my guess.

So yeah. A lot has gone down in fifty years. So instead of posting the "I Have a Dream" speech or even discussing some of the annoying criticisms that have come up about Dr. King after his death or talking about President Obama or even ranting about how black history should be discussed in more than just the winter months . . . .I am simply sitting here quietly feeling thankful. Thankful that I am right here right now and not fifty years ago today.

And even more thankful that people like Dr. King and my daddy were there.

Sometimes I feel angry that the doors open to me were shut in my father's face. But when I see how proud he and my mother are of their children and what we have become, I feel a little better. And when I listen to his stories of growing up poor, black, and one of eleven children in the epicenter of the Jim Crow era--and I see what he has become--I feel proud, too.

I literally get to be a Grady doctor because somebody wasn't afraid to be spit at and hosed down and hit across the head with a brick. I get to be a Grady doctor because some surely terrified individuals put themselves in harm's way on Freedom riders' buses and some peaceful young person in my own father's neighborhood got attacked by German shepherds just for standing up. Because of them I get to be where I am right now. A doctor. At Grady.

So to all who lived through it, I say thank you. For every time you had to stand there and hear someone call your grown-ass father a boy or a ni**er or your beloved matriarch a gal or a ni*ra, thank you. To those who bravely went against the grain when it would have been much easier to hunker down in some false sense of pink superiority, thank you, too. Because I know that there was a lot more moving in that movement than just black folks.

Today is January 15, 2012. My name is Kimberly D. Manning and I am a medical doctor. I received my medical degree from Meharry Medical College in Nashville, Tennessee. For the past ten years, I have had the honor of teaching Emory University medical students and training Internal Medicine resident physicians at Grady Memorial Hospital in Atlanta, Georgia.

And I am a black female.

Happy Birthday, Dr. King.

Residents aren't learning how to treat diabetes properly

noreply@blogger.com (Ryan DuBosar) — Tue, 17 Jan 2012 12:00:00 +0000

Internal medicine residency programs aren't doing enough to teach quality treatment for diabetes, concluded a study, which doesn't bode well for doctors who will eventually care for one of the most common diseases in the United States.

Researchers at the American Board of Internal Medicine compared the quality of diabetes care provided in residency clinics with that of practicing physicians, using the Diabetes Practice Improvement Modules of the American Board of Internal Medicine (ABIM) as an assessment tool.

The research was done by staff at the American Board of Internal Medicine and appears in the January issue of Health Affairs.

Sixty-seven clinic sites from 37 residency programs completed baseline data collection for the Diabetes Practice Improvement Module from 2005 to 2010, and were compared to a geographically matched sample of 703 practicing general internists who completed the module in the same period.

Practicing physicians performed three of four process measures more frequently: retinal exam, foot exam, and addressing smoking cessation. (The fourth was urine testing). Patients of practicing physicians had better blood pressure and blood glucose control, but there was no difference in control of LDL cholesterol. Residency clinics received lower ratings on patient-experience measures (P values less than 0.001).

The residency clinics performed substantially lower on the composite measure (mean: 61.8) than did the practicing physicians (mean: 71.4) (P less than 0.001).

The authors wrote, "Our results clearly signal a problem: Residency clinics are not providing high-quality care for one of the most common chronic conditions in the United States."

Even practicing physicians have room for improvement, the authors noted from their results.

"Habits are formed during residency training," the authors wrote. "When residents work in clinics that deliver high-quality care, there is a greater likelihood that they will deliver high-quality care after completing their residencies. But the fact is that residents' ambulatory training does not often occur in high performance settings."

Filling the void (... the young docs, vol. 2)

noreply@blogger.com (John Schumann, MD) — Mon, 16 Jan 2012 16:00:00 +0000

The CDC released a recent report ("data brief") on the subject of physician assistants (PAs) and advanced practice nurses (APNs).

Physician assistants are a growing cadre of professionals who practice medicine under the supervision of doctors. Advanced practice nurses are registered nurses with advanced training, who work independently (but in collaboration) with doctors.

PAs and APNs are often referred to in health care-speak as "physician extenders," a term I loathe. To me it implies that these professionals are somehow not fully formed human beings, but rather mere appendages of almighty doctors.

There was a lot of initial resentment toward PAs and APNs by doctors. I can still hear some of the claims:

--They will take our patients, thus stealing our business.
--They don't have enough education.
--Will patients really want to see them, with their "lesser" education and experience?
--They can't be trusted to prescribe mediation independently.
--They're not doctors.

Those cries have greatly diminished as their numbers have grown. Doctors in the private world relish working with "extenders," because they help improve volume (i.e. patients seen) which brings in additional revenue. And because they earn less (presumably because they have less in the way of education [two years vs. four for medical school] and experience [one year internship vs. three years-and-beyond residency training periods], they are in fact quite economical for private physicians who hire them, or the larger groups (especially hospitals) that employ doctors.

In a prior brief, the CDC demonstrated that nearly 50% of office-based physicians work with PAs and APNs. The larger the practice, the more likely this is to be true.

The most recent brief, highlighted courtesy of V.S. Elliott in American Medical News, looked at "allied health workers" (PAs and APNs) working specifically in hospital-affiliated medical practices. The data shows a 50% increase in visits to these office sites in which a patient saw only a PA or APN over the most recent eight years.

I find this important for a couple of reasons. As we inch closer to health care reform, with several million uninsured people expected to enter the insured pool, allied health workers will be more frequently counted on to pick up the load, as the number of primary care doctors isn't growing enough to meet demand. In addition, under health care reform it's expected that one of the formats for improving delivery of health care will be the Accountable Care Organization (ACO). In this model, doctors will supervise teams consisting of nurses, PAs and APNs, who will see most of the patients. It is argued that this will be the most efficient, cost effective, and highest quality deployment of health care personnel.

Some beg to differ on those assumptions. My own feeling is that doctors don't go to medical school to learn to manage teams of other professionals. Some of us may actually like it or have talent for it, but current medical education models don't have any bearing on these skills.

It's a tumultuous time to be in health care. Stay tuned.

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

Goldilocks offers insight for potassium blood levels after heart attack

noreply@blogger.com (Ryan DuBosar) — Thu, 12 Jan 2012 12:00:00 +0000

There's a lower risk of death among hospitalized heart attack patients who maintained blood potassium levels between 3.5 and 4.5 mEq/L compared to lower or higher levels, a retrospective study concluded.

Applying the Goldilocks rule, not too much and not too little seems to just right for acute myocardial infarction [AMI] patients. But two clinical practice guidelines (here and here) recommend maintaining serum potassium levels between 4.0 and 5.0 mEq/L in patients after a heart attack.

The study authors commented that up to now, "Potassium homeostasis [equilibrium] is critical to prevent adverse events in patients with cardiovascular disease. Several studies have demonstrated a relationship between low serum potassium levels, usually less than 3.5 mEq/L, and the risk of ventricular arrhythmias in patients with acute myocardial infarction [AMI; heart attack]. On the basis of these studies, experts and professional societies have recommended maintaining potassium levels between 4.0 and 5.0 mEq/L, or even 4.5 to 5.5 mEq/L, in AMI patients.

However, most prior studies were conducted before the routine use of beta-blockers, reperfusion therapy, and early invasive management, the authors noted in the Jan. 11 issue of the Journal of the American Medical Association.

A retrospective cohort study included 38,689 patients with biomarker-confirmed AMI admitted to 67 U.S. hospitals between January 2000 and December 2008. All patients had in-hospital serum potassium measurements and were categorized by average postadmission serum potassium level.

Of all patients, 1,707 (4.4%) had an episode of ventricular fibrillation, ventricular flutter, or cardiac arrest during hospitalization. Rates of ventricular arrhythmias or cardiac arrest were higher (compared with the reference group, 3.5 to 4.0 mEq/L) only for the lowest and highest average postadmission potassium levels (less than 3.0 mEq/L and 5.0 mEq/L or greater).

Of the study patients, 2,679 (6.9%) died during hospitalization. There was a U-shaped relationship between mean postadmission serum potassium level and in-hospital mortality, according to the study.

Compared to patients with potassium blood levels of 3.5 to 4.0 mEq/L (mortality rate, 4.8%), mortality was comparable for patients with postadmission potassium levels of 4.0 to less than 4.5 mEq/L (mortality rate, 5%; odds ratio (OR), 1.19 (95% confidence interval [CI], 1.04 to 1.36). Mortality was twice as great for potassium levels of 4.5 to less than 5.0 mEq/L (mortality rate, 10%; multivariable-adjusted OR, 1.99; 95% CI, 1.68 to 2.36), and was even greater at higher potassium levels. Similarly, mortality rates were higher for potassium levels of less than 3.5 mEq/L.

"In conclusion, our large study of patients with AMI challenges current clinical practice guidelines that endorse maintaining serum potassium levels between 4.0 and 5.0 mEq/L," the authors concluded. "These guidelines are based on small, older studies that focused only on ventricular arrhythmias (and not mortality) and were conducted before the routine use of beta-blockers, reperfusion therapy, and early invasive management in AMI patients."

An accompanying editorial noted the report doesn't establish treating hypokalemia alters outcome. However, a randomized, controlled trial is unlikely, so based on current knowledge, the inexpensive and relatively low-risk repletion of potassium for levels of less than 3.5 mEq/L remains reasonable, but repletion for higher levels than this "do not appear justified."

Life at Grady: Stayin' Alive

noreply@blogger.com (Jessica Berthold) — Wed, 11 Jan 2012 13:13:00 +0000

The following post, by Kimberly Manning, MD, FACP, first appeared on her blog, Reflections of a Grady Doctor. It is reprinted with permission.

It was chaotic. People running and pointing and reaching and grabbing. So many moving parts. And so all-of-a-sudden, too. This wasn't supposed to happen. I mean technically it could happen at any point. But it wasn't on my radar. Or anyone's radar.

And neither was she.

I'll never forget that day. This lovely phlebotomist was on the ward preparing to draw blood for that four hour time block before it happened. Smiling with her wide smile--unusually striking because of the large diastema between her two front teeth--but stunning and beautiful in its imperfection and in how she owned it. Every time I saw her, I always made time to chat and laugh, mostly because that smile of hers warmed my heart. Gap and all.

So this is how I remembered the timeline from that afternoon. That easy exchange with the phlebotomist standing in front of her rolling cart of Vacutainers punctuated the start of the time clock.

"Hey lady!" I greeted.

"Hey there, doc! You cut your hair some more?"

I rubbed by hand over what little hair I have and chuckled. "Probably since the last time you've seen me. You know? I'd buzz it right down like a little boy if I thought my husband wouldn't disown me!"

And just like that she unrolled that high beam grin on me while simultaneously unrolling a rubber tourniquet to use on the next patient. She caught me looking at her wispy hair--also a short style--but with long bangs swept behind her ears and held snugly with bobby pins. "Yeah, chile. This is about as far as my husband will let me go."

"I like it. It suits you." She blessed me with that perforated grin once more, letting me know that it was time for her to get back to business. Off she went into that room, easy and confident--perfect ingredients for someone charged with the task of finding tiny rolling veins under redundant skin folds.

I could hear similar pleasantries being exchanged between her and someone inside the room with a tone that sounded relaxed and familiar. She was more than likely talking to the daughter of Mrs. Gentry--the patient in bed two--who had been dutifully at the bedside throughout her mother's entire hospitalization.

I went back to what I was supposed to be doing which, at this moment, was typing a note into a portable "W.O.W."-- workstation-on-wheels. I waved at a group of rounding residents and students walking by and gave a fist bump to one of the environmental services workers. I yawned and returned yet again to my task.

I must have zoned out because what happened next caught me by surprise. One minute things were calm and mundane. The next, people were moving all around with a sense of urgency. When the phlebotomist had gotten to bed two, she found Mrs. Gentry to be unresponsive and with cool extremities. She yelled for a nurse to come help and Stan, the nearby nurse, leaped into action.

"Get a crash cart in here!" he bellowed to the other nurses while placing the heel of his hand into the center of Mrs. Gentry's sixty-something year-old chest. "And call a code. NOW!"

(Click "more" below to keep reading)

By the time I got into the doorway, the team of residents that had just passed by, along with a Cardiology fellow, had already swarmed the scene and a code was underway.

Chest compressions. Monitors being connected. Meds being drawn up. Lines being emergently inserted. And Mrs. Gentry lying there listless like some kind of lifeless ragdoll.

"What's the story? Does anyone know this patient?" The Cardiology fellow had taken over as the leader of the code and tried to grab some history while getting her heart in motion. Those words flew out over the room to whomever had the answers.

"She was. . .I mean I was. . . Oh my God! I thought she was just sleeping!" her daughter squeaked out in response just before someone else spoke over her with a booming voice.

Of course she knew the patient. He wasn't talking to her. He was talking to everyone else.

"Sixty-seven year old female with a known history of coronary artery disease status post two stents placed last year and ischemic heart failure who'd been admitted for acute decompensated heart failure. I think her ejection fraction is around twenty percent and this is hospital day three." That description offered by the intern was firm, loud and controlled. "Slightly elevated potassium this morning but otherwise everything lab-wise was okay."

I noticed the beads of sweat popping out on Stan's brow as his stiff arms rhythmically worked to revive Mrs. Gentry's heart. Right on beat, almost like a pendulum was swinging to help him. That or he was hearing what they teach you in Basic Life Support to sing in your head to help you keep a steady compression pace--"Stayin' Alive" by The Bee Gees.

"Hold compressions!" announced the Cardiologist. "Checking rhythm. . . . .pulseless electrical activity! Resume compressions!"

More voices. More chaos. More people in white coats swarming around the bed.

"Shit! I can't get this guidewire to pass!" The twisted face of the gowned and gloved resident speaking these words showed his frustration. He'd been charged with putting in the central venous line necessary for giving lifesaving medications but wasn't succeeding. "Dammit!"

Members of the critical care team had come in from the intensive care unit and flooded into the room by this point. One of them stepped in to take over for the frustrated resident. Before you could say Rumplestiltskin, that guidewire was passed and the line was being flushed with saline.

More chest compressions. More voices. More people. More medications, now being pushed through a working line fast and furious. Controlled chaos all around.

"Hold compressions!" That Cardiology fellow had the kind of quiet confidence that was needed in these types of situations. All eyes on the monitor to check the electrical activity of the heart at this point.

"V. Fib! Prepare for cardioversion!" he announced--still sure and controlled as he gave his interpretation of the monitor: ventricular fibrillation.

"That's still PEA! I don't think that's shockable." These were the words spoken (loudly) by a member of the critical care team to the code-leader. He had just arrived from the ICU where running codes is their thing. But he wasn't running this code. The Cardiology guy was.

Eek.

"Look, what do you want me to do?" pressed the nurse holding the paddles over the patient's chest. Her eyes were on the Cardiologist who was standing there with folded arms and a now furrowed brow.

"Exactly what I just said. Prepare for cardioversion. All clear!" All of those moving parts and moving people stepped back from the bed as those paddles pushed down firmly on Mrs. Gentry's chest.

I remember the first time I saw someone get defibrillated with an electrical current. I was a third year medical student and was right there front and center doing the chest compressions. My arms were exhausted and I was nearly out of breath; I couldn't tell if it was from the actual act of pumping a chest to "Stayin' Alive" or just the adrenaline pumping through my own veins. Those paddles went down and someone shouted "CLEAR!" and that patient got a big shock.

Well, sort of. His body made a tiny flinch that looked nothing like codes I'd seen on "E.R." No high arching torso flying upward and then landing back onto the bed like some kind of deep water fish recently reeled out of water. Disappointing.

So Mrs. Gentry's shock was equally disappointing but for different reasons. That shock didn't bring her heart back to where it should have been and what was worse was that there was now a question about the heart rhythm altogether.

Clear again. Shock again. Meds again. Nothing again. Intubated by Anesthesia. Shocked some more. More meds pushed but nothing improved. That roomful of chaos that initially looked like some rapidly swirling twister was dying down. . .swirling slower and slower. . .a spinning top that was losing its spin. The frantic bodies were moving with less deliberation; the voices now twinged with the sound of defeat.

"Do you want to call it?" spoke the paddle-holding nurse to that Cardiology code-leader in a voice that was as tender as it was tired.

Call it. Stop the hope. End the twister.

"Ummm. . . .let's try some bicarb," the Cardiologist finally said with a quiet clearing of his throat. Anyone in that room senior enough to have run a code knew that this was the worst part. Calling off the fight.

Bicarb. Yes. Let's try it. The pharmacist began drawing it up and that tired twister spun a little more.

That's when I saw something from the corner of my eye. Backed against the wall wedged between an IV pole and the wall-suction shaking and weeping and looking horrified. Mrs. Gentry's daughter. Who had been standing in the room and present for the entire code.

It was like every person in that room began to move in slow motion and become blurry amorphous blobs. Her eyes were wide like saucers and she was clutching her mother's purse against her chest probably out of shock more than anything else. Those saucer eyes were darting around the room, bouncing from voice to voice and horror to horror. Aimlessly tossed about like some sort of ball in a pinball machine.

No one was holding her hand or rubbing her shoulder. No thoughtful soul had eased her out of the room or compassionately bearhugged her as she kicked and pleaded to stay. No, not one person at all. Not even that charming gap-toothed phlebotomist with her easy laugh and steady hands. Instead, we had all let Mrs. Gentry's daughter melt into the background and become a fly on the wall of what would likely represent the worst day of her life.

I heard it over and over like a nauseating chant. . .

"Life going nowhere.
Somebody help me
Somebody help me, yeah.

Life going nowhere.
Somebody help me, yeah. . "

It was like she had been singing that refrain to "Stayin' Alive" the whole time and no one had been listening. Not even those who weren't doing anything but standing there watching.

Mrs. Gentry wasn't my patient but I'd chatted with her and her daughter in passing. I'd cracked a joke with them on that first hospital day about her stack of Word Find books and had even made small talk when I saw them both doing bible study together on the bedside tray table. No, she wasn't my patient but I felt like I had somehow failed them both.

Sometimes there are so many people inside of a code that if you arrive even one minute into it, you feel useless. You count up the cooks in the kitchen and make a decision--join in or not? Then, if you don't join in, you might decide to wait near the door in case someone needs you to make a fast break down the hall to grab some kind of supply. And if there's someone there to do that, sometimes. . . you just stand there watching. . . .which is what I did on this day. Humming to the internal beat of "Stayin' Alive."

How could I have neglected to look to see where her daughter was?
How could I have just stood by as a foot-tapping voyeur without catching that part?

But it was chaotic. People running and pointing and reaching and grabbing. So many moving parts. And so all-of-a-sudden, too. This wasn't supposed to happen. I mean technically it could happen at any point. But it wasn't on my radar. Or anyone's radar.

And neither was she.

"Time of death: Four thirty-two P.M." said the Cardiology fellow. He called it. Finally. And just like that, the chaos ceased and like many twisters there was nothing but debris and destruction to show for it.

The only sound in the room was the whimper of Mrs. Gentry's daughter, now burying her face downward into that weathered pocket book. Holding on to this piece of her mother. . . smelling her smell and holding on to her energy. Those whimpers morphed into some guttural moans; sounds that I wish I could say sounded unusual. But at least an earnest medical student had thought to wrap her in a hug. Still young and non-jaded enough to follow some instinctive rules of empathy. And to still be intensely bothered by the sight of this kind of grief.

Thank God.

People filed out. A death packet was completed. Hushed words were spoken to the family. Everyone went back to work and doing whatever they had been doing; the phlebotomist went to draw some blood from the patient in the next room. And that was it. Just like that, a mother, a grandmother, a Bible-reader and a word-finder was gone.

Even though that happened a long time ago, something about that scene still haunts me. I hate knowing that this is how someone has to remember losing their mother. I hate that. Even more than that, I hate knowing that someone in that room could have done something to make that memory different for Mrs. Gentry's daughter. . . through a simple touch . . a kind word of explanation. . .by gently guiding her out of that code-algorithm tornado . . . .or . . . .something. Anything. Something. But not just nothing.

Most of all, I hate knowing that that someone could have been me.

Hospital of horror

noreply@blogger.com (John Schumann, MD) — Mon, 09 Jan 2012 16:00:00 +0000

Every once in a while, a tragic news story pierces though the emotional wall we set up to handle the endless torrent.

The news of a hospital fire in Kolkata [formerly Calcutta], India is one such story for me.

The name of the hospital is the "Advanced Medical Research Institute," known locally as AMRI.

It seems that any place wanting to call itself advanced would consider basics like a fire safety plan and how to execute it.

I was particularly horrified by the utter abandonment of patients by the medical professionals. From a New York Times article on the blaze: "The doctors on duty fled the hospital almost immediately, leaving patients stuck in their wards and at the mercy of the billowing black smoke, witnesses and patients told reporters."

I was reminded of Hurricane Katrina and the brave docs who stuck around tending to those so critically ill that they couldn't be moved out of the storm's path.

The Kolkata fire tragedy was compounded by inept administration, security, and rescue response. From the same article: "Local people who tried to get inside the hospital to help rescue patients said they were turned away by security guards who assured them it was only a small kitchen fire.

"Hospital officials were slow to call the Fire Department, and then fire trucks were slow to arrive, hospital officials said.

"In fact, it took firefighters more than 12 hours to subdue the blaze, Fire Department officials said. The hospital's fire detection and suppression system did not function ..."

Who bears responsibility for such a tragedy?

"Six senior hospital officials were charged with culpable homicide in connection with the fire, according to government officials."

Goodness.

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

Endocrine Society recommends glucose tests for all hospital patients

noreply@blogger.com (Ryan DuBosar) — Mon, 09 Jan 2012 12:00:00 +0000

The Endocrine Society released new recommendations that suggest all hospitalized patients receive blood glucose testing, regardless of their current diabetes status.

The guidelines, which appeared in the January issue of the Journal of Clinical Endocrinology & Metabolism outline recommendations on glucose monitoring for hospitalized and primary care patients, as well as transitions between home and hospital, surgical considerations and other special scenarios.

Observational studies report that hyperglycemia is present in about one-third of patients in community hospitals, The Endocrine Society stated in a press release.

"Hyperglycemia is associated with prolonged hospital stay, increased incidence of infections and death in non-critically ill hospitalized patients," said Guillermo Umpierrez, MD, FACP, chair of the task force that authored the recommendations. "This new guideline contains consensus recommendations from experts in the field for the management of hyperglycemia in hospitalized patients in non-critical care settings."

Specific recommendations include:
--Glycemic targets should include a pre-meal glucose target of less than 140 mg/dl and a random blood glucose of less than 180 mg/dl for the majority of hospitalized patients with non-critical illness;
--All patients with diabetes treated with insulin at home should be treated with a scheduled subcutaneous insulin regimen in the hospital;
--All patients with type 1 diabetes and most patients with type 2 diabetes who undergo surgical procedures should receive either intravenous continuous insulin infusion or subcutaneous basal insulin with bolus insulin as required to prevent hyperglycemia during the perioperative period;
--Bedside point-of-care glucose testing should be initiated in all patients with high glucose values on admission and in patients with or without a history of diabetes receiving nutrition either through IV or a feeding tube; and
--All patients with type 1 and type 2 diabetes should be transitioned to scheduled subcutaneous insulin therapy at least one to two hours before stopping IV continuous insulin infusion.

A companion patient guide is online.

What is distracting doctors more than electronic devices?

noreply@blogger.com (the Better Health network) — Fri, 06 Jan 2012 18:00:00 +0000

I admittedly snorted out loud when I read a New York Times article earlier last week regarding increased physician distraction due to electronic devices, especially with the advent of the smartphone with its emails, text messages, calls, and other alerts that ping intermittently throughout a typical work day.

There is no question that electronic devices distract physicians, as the article pointed out. But that's like complaining about a leaky faucet when there's a flooded basement and a hole in the roof.

The bigger problem that should be mentioned is hospital bureaucracy, which probably creates just as much if not more unintended distractions for physicians and nurses.

What many patients and lay public may not realize is that there is a ton of paperwork that goes into the care of a patient. Regulatory bodies like the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) that accredits hospitals have made it mandatory in many cases, though I suspect hospital administration often carries it a step above and beyond what is truly necessary.

What all this "mandatory" paperwork means is that nurses are calling physicians all the time just so they can check a box on a form, and there are a lot of boxes to check.

Take a simple ear tube placement, a procedure that takes about 1-2 minutes to perform under sedation in the pediatric population. It takes about 15-20 minutes to fill out all the nursing and physician forms (whether paper or electronic medical records). When the surgery actually begins, the nurse is too busy filling out even more forms rather than paying attention to the surgery, and often the surgery is already over, and the nurse is still busy filling out forms.

Talk about distraction, a registered nurse has been relegated to being a mere secretary rather than helping (or paying attention) in the care of a patient.

I recently asked a nurse how much time they spent on actual patient care versus how much time filling out forms during a typical shift. It saddened my heart when I was told 60-70% of a nurse's time is spent on filling out forms (whether notes, chart documentation, medication reconciliation, etc.) and only 30-40% on actual patient care. This time disparity was not always true in years past.

Ask any physician how many times he or she gets called during a typical day because some form or paperwork was not completed or needs completion or just to remind to get it completed by nurses, who themselves are the main individuals who suffer under the crush of mandatory documentation in a hospital setting.

It is irritating to say the least to get a phone call during the middle of an operation, say dissecting a tumor off the facial nerve during a parotid cancer resection, by someone who wanted to remind me to sign off on a medication list on a patient I've already provided prescriptions for.

Another classic experience of mine was when the anesthesiologist had trouble intubating a patient who started to suffer a severe lack of oxygen. I was immediately called to the bedside and performed an emergency tracheostomy.

Of course, the nurse (well-indoctrinated in form completion) involved in the case immediately instructed me to stop performing the trach and to get consent as per the regulations, which is true 99% of the time but never mind that. Heaven forbid we now can't check that little box that states "consent obtained prior to surgery." But in the interest of patient care, I did suggest that it would be better if the patient lived with an unconsented trach rather than died due to time spent obtaining consent.

Though electronic devices may be considered a "distraction" analogous to a mosquito buzz that comes and goes, one must not forget the avalanche of paperwork which is a much more pervasive and insidious distraction that deliberately takes attention away from the care of the patient. I understand the need for documentation, but at some point when the documentation itself dominates the majority of heath care rather than the actual administration of care, there's something fundamentally wrong going on.

It's probably why medical missions are so gratifying to participating nurses and physicians where 90%+ of the time is in actual patient care.

This post by Christopher Chang, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

Rural hospital recruits doctors through leave for missionary work

noreply@blogger.com (Ryan DuBosar) — Wed, 04 Jan 2012 12:00:00 +0000

A rural hospital on the verge of closing because of problems retaining its rotating door of physicians offered two months of leave for missionary work to keep a more stable roster. It worked, according to a profile written by the Associated Press.

All employees at Ashland Health Center in Kansas, from maintenance staff to the doctors, get two months off to do missionary work in other countries or other volunteering duties for the community. The move has attracted socially minded physicians and their families, many of whom had backgrounds in missionary work already and wanted an environment to keep doing it. The recruitment was developed with support of the Via Christi medical residency program in Wichita, which is sponsored in turn by the University of Kansas School of Medicine.

It's not the only effort underway in Kansas. The shortage of primary care physicians in most of Kansas' 105 counties, coupled with the state's recognition that most of its rural counties are medically underserved, prompted other programs, such as recruiting medical students from in-state who would choose primary care and return to their small-town Kansas roots.

Other programs across the country are fast-tracking medical students or providing real-life training environments to get the students to rural communities sooner.

There's a dire need for such programs, one physician explains in her post about creating a palliative care consulting service in rural America.

Life at Grady: The Nod

noreply@blogger.com (Jessica Berthold) — Wed, 04 Jan 2012 12:00:00 +0000

The following post, by Kimberly Manning, FACP, originally appeared on her blog Reflections of a Grady Doctor. It is reprinted with permission.

Our team was big that month--two interns, three medical students, a pharmacy resident and a senior resident. The gender mix was nice, too. Nearly half women and half men, which was kind of unusual because for whatever reason, I'd often find myself with nearly all of one or the other.

What wasn't unusual, though, was that I was the only black person on our team. And no, it didn't feel funny or odd or bad for me. It was okay. Despite the homogeneity of our racial mix that month, culturally we couldn't have been more different.

One person was from the Middle East. Another had one Indian parent and one East Asian parent. Two were Jewish but widely varied in their levels of observance. And there was even a dude on the team that described himself as a "good ol' boy." As I got to know him, I think what he meant to say was that he was a Southern gentleman. Last but not least, there was this one medical student who, after hearing all of these sorted backgrounds, shrugged and said, "I guess I'm a regular white girl from the Midwest."

And that was cool, too.

That team was particularly memorable because we seemed to spend just as much time getting to know our patients as we did each other. We talked about feelings and backgrounds and life experiences. How it all played into our doctoring and our professional interactions. The climate was easy and conducive to such discussions.

Case in point: One day, the Midwestern girl asked me:

"Dr. Manning? Does it upset you seeing so many black women addicted to crack cocaine?"

And this question was asked right in front of the entire team. My answer was honest. Not watered down by some need to cut the "blackness" of it or truth behind it. I also liked that she wanted to know how I felt and wasn't asking me to speak on behalf of all African Americans.

(Click "more" below to keep reading)

"I think crack is complicated," I answered. "But to answer your question, the answer is yes. Yes, I hate seeing so many black people--especially black women--dependent upon crack. It kind of hurts to see how badly my people have been affected by the whole crack epidemic."

"Self medication, you think?" she asked. Again, in front of the whole team.

"Sometimes that. Sometimes something else. I don't know. I just know that it's a horrible cycle of supply and demand. It's cheap. It's available. And yes, I guess it is a way to self-medicate. But I'm not sure that everyone means to get so caught up."

"You know? I sometimes wonder what it must feel like for you to be here and see all that you see. I mean from your perspective, Dr. M." That's what another person chimed in. And that was cool, too, because that's how things went on this team.

This answer was honest, too. "Honestly? Mostly I feel proud to be a black doctor working in Grady. On most days, I feel that more than I do disappointed." I smiled wide and added a nod of affirmation because that statement was true.

And that was the end of that conversation.

So this was what our team was like. We just asked and explored and learned about and from each other. And it was cool.

One day we were rounding on one of our short call admitting days. Five new patients, lots going on, and for some reason, the patients were scattered all over the hospital. We went from the twelfth floor step down unit to the TB isolation unit to the cardiac telemetry floor over to our home ward and down to the emergency department on the ground floor to boot. And all along we moved in this swift pack of white coats of varying lengths. Heads held high with intention. Eyes forward and shoulders squared.

I remember this day not because it was particularly striking in its elements but more because of a particular question I was asked after we'd rounded on the last of our five patients. That final patient was down in the emergency department and if you know anything about emergency departments in urban settings, you know that there were people everywhere. Nurses. Doctors. Patients. Pharmacists. Family members. All kinds of folks. All over the place.

Like always my eyes scanned the room as we entered--casing out the room as my senior resident led our brood toward the room. One of the first people I noticed was the clerk sitting behind the front desk in the Red Zone. Her face was round and caramel--almost like a Werther's candy. I'd never seen her before but she quickly locked eyes with me--noticing my lone brown complexion in that posse--and offered a tiny head dip of salutation. I returned her gesture.

A few steps later I caught the eye of an elderly man leaning on a gurney with an old four-prong cane. Though his complexion was fair, his facial features were distinctly afro-centric. His broad nose and wide lips were my initial clue of his ethnicity and as we got closer, his throaty voice and laugh sounded like he could have been any one of my uncles if I simply closed my eyes. A smile crept across his face and just like that, he shot me a downward nod of his head. . . . so subtle that unless you understood it or had been carefully watching for it. . . you'd have missed it.

But I understood it. In fact, I understood it so well that my own nod in his direction occurred in synchrony with his.

As we headed out of the Red Zone, that same thing happened at least three more times. Understated salutes left and right. Once with the man waxing the floors in the hallway. *nod* Another time with one of the Morehouse physicians working in the ER all the way across the room in a trauma bay. *nod* And even with a lady who'd just rolled by on a stretcher coming from or going to X-ray. *nod*

Somewhere in all of this the Midwesterner squinted her eyes and took all of this quiet communication in. Even though I was oblivious to it, in that ER her wheels had begun turning. We headed out of the emergency department and it happened a couple more times in the hallway. *nod* *nod* Our big pack stood waiting for the elevator and I noticed the Midwesterner watching me intently. I wasn't sure if it was the hairy eyeball or what. I figured that I'd eventually find out what that look was all about.

Once we reached 7A, we convened in the team room to recap our plans on the patients and for the rest of our day.

"Okay, guys," I said cheerfully, "Good rounds. I'll catch up with you all a little later."

I pushed my hands down onto the table preparing to stand. That's when she decided to go there.

"Dr. M? Did you. . .like. . . know all of those people today?"

And the team kind of looked at her like she was crazy because no one even knew to what she was referring. But I did.

Aaaah. Did I know them?

When my dad was a young engineer at Hughes Aircraft, he walked through a plant one day that he'd never been in before. And in that sea of people, those who looked like him were scattered like specks of pepper in some country gravy. To each one, as if on cue, he nodded. And they did the same.

Someone asked him that same question, though framed differently. "How do you know so many people here, Tony?"

Dad answered, "I've never been to this plant before." And that was the God's honest truth.

So with that story in my head, I knew where she was going with that. This young woman had decided that the environment was open enough on this team to ask about one of the most universal yet untaught gestures of black American culture--"the nod."

The nod is an interesting thing. Growing up in my neighborhood, I always saw young brothers tipping their chins upward at one another. This was their little way of saying, "What's up, man?" That type of nod was mostly a dude thing. Now that I think of it, it still is. Kind of like when you run into a girlfriend in a public place and she's with a man. Long before the formal introductions, brothers are guaranteed an up-nod from the start. Who taught them this? I do not know.

But that masculine up-nod was not what I was doing that day. This nod--the tiny downward head bow--is gender neutral and interestingly is most often reserved for those you don't know at all.

You may be wondering. . . .how do you know to do this? Does someone tell you? Is it like "ma'am-ing" and "sir-ing" -- where some older family member corrects you early and often with each "yeah" and molding it into a solid "YES, MA'AM?" or at least a "YES?"

The answer . . . at least for me. . .is no. No one has ever told me to do this. You just . . . .sort of intuitively know.

Let me explain. The black-on-black nod of acknowledgement is usually given in situations where there is only one or only a few other black people in an environment with you. For example--when I come to a PTA meeting at my sons' school (where the attendees are predominantly non-Black) without fail, the handful of black parents in the room exchange nods with me. The other example would be an instance where someone notes that you are the only black person in a group you're with--which on this day was my ward team. This is another situation where, as if it had been scripted for them to do so, folks would catch my eye and salute.

Why is this? And why does it even still happen? Is it even necessary?

Hmmm. My guess is that it goes back to some of the darker times in black history where quiet nods were your safest bet. It was your way of saying to someone in a room "I see you." Also your way of demonstrating that no matter how important you are (i.e. A DOCTOR) you aren't too important to let someone know that "Yes, I see you."

No, it isn't necessarily something you do everywhere as I mentioned before. Like, for example, when I attend my predominantly African American church, I'm not nodding left and right like some sort of bobble head doll. In these environments, for whatever reason. . . it simply isn't indicated.

Whoops. Just realized that I used some medical jargon. I meant "indicated" in the medical sense. . . meaning "necessary and appropriate for the situation."

Wait--where was I? Oh. . so yeah, that Midwestern student leaned in on her crossed legs and asked me flat out about "the nod." And let me tell you--now that? That was a first.

Did I know them?

And so I replied, "What would be your guess?"

"My guess is that you didn't know any of them. Not a single one of them."

I smiled at her in return and raised my eyebrows. This had flown over the heads of the entire rest of the team. Their heads swung back and forth at us, wondering what we were talking about.

I kept my eyes intently on her earnest face. "No. I didn't know any of them personally. But I guess. . .in a way. . .I knew them all."

And this student being the thoughtful and astute young person she was got exactly what I was saying. She placed her hand on her chest and shook her head.

"I think that's beautiful," she said quietly. I could tell by looking at her that she meant it.

Beautiful?

"I guess I never thought of it. . . .but you know? I guess it is." We sat there quietly waiting for the next person to speak. She decided to break the silence.

"Do you nod. . . instinctively?"

I nodded my head in affirmation allowing myself to let this idea resonate.

The Midwesterner sighed hard as she took this all in. "Wow. . . that's amazing. . .and beautiful."

Amazing and beautiful.

Man. I appreciated that. I really did.

I remembered the day I ran for forty minutes on a treadmill next to my good friend in residency while we watched the same television. A commercial for a movie with an all-black cast kept showing over and over for the entire time we were there in that gym. A few hours later we were having coffee in Starbucks and I mentioned that movie. She was completely puzzled and had no idea what I was speaking of.

"But they showed the commercial a minimum of five trillion times in the time we were on the treadmills!" I laughed. "You HAD to have seen it!"

But she hadn't. Not one bit. She did catch the Jennifer Anniston trailer and also all of the other things that popped up. As did I. But for some reason, she had tuned this out. Seemingly instinctively, even. And she wasn't "that kind" of person, either so I do believe that in some way she simply hadn't "seen" it.

Wow.

It was both baffling and hurtful to imagine being tuned out like that. It made me wonder who is tuning me or Harry or my boys out without trying? You know? The leading lady in that movie was a woman named Nia Long--a big star to black folks. But to my friend? A complete nobody.

In her defense, she and all my co-residents back then were all appalled when I didn't know the words to some Meatloaf song. And even more appalled when I admitted that I wasn't fully clear on who he was.

Anyways.

So yeah. I appreciated that Midwesterner picking up on what she saw and I was proud of myself for creating a climate that allowed her to flat out question me about it. Now some black folks might be reading this thinking, "I cannot believe she has broken down 'the nod' for the masses! Blasphemy, I say!"

But to me, getting each other is a good thing. And sometimes you have to break a few things down for folks to get you. So this? This dialogue was good. It was very good.

A few moments later, she explained to the team what she'd seen and we all talked about it together. It was a really memorable moment in cultural competency. I deeply appreciated her interest in understanding this part of me. . . .a part I share with many of our patients.

That month I learned about the differences in the lifestyles of people of different levels of observation in Judaism. One Jewish girl on my team even told me that "God" wasn't a word that was written out after she wrote "g-d" when quoting a patient's words in a note. I told her that we write it out and capitalize the 'G.' Another person said we write it out and leave the 'g' lower case.

Interesting.

I was also taught all about hunting season by the self-described "good ol' boy" and learned that the best Christmas he'd ever had involved a bow and arrow. The biracial Indian/Chinese woman described how her grandparents had disowned her father for marrying her mother. And how her Chinese family wasn't sure what to do with her and her siblings since they looked different and didn't speak Mandarin. We talked about more than just food and slang and holidays that month. We talked about those things that cannot ever be found in any book and those things that you can only learn if you ask.

In a way, we gave each other nods every single day. Nods of acknowledgement saying "I see you." Yes, I do. And that was cool, too.

As for the universal nod of acknowledgement by black people. . . . is it still necessary? Hmmm. Well, my guess is that if it weren't, we wouldn't keep instinctively doing it.

You know? I just want to pay more attention to people. I'm no world traveler by any stretch of the word, nor do I even desire to be. But the older I get, the more I am realizing that if you just pay attention...to people and to experiences...in a way, the world comes to you.

*nod*
I see you.

Life at Grady: Mentors

noreply@blogger.com (Jessica Berthold) — Wed, 28 Dec 2011 12:00:00 +0000

The following post, by Kimberly Manning, FACP, is adapted from her blog Reflections of a Grady Doctor. It is reprinted with permission.

One of the first things people tell you when you take a faculty position in medical education is this: "Get yourself a mentor." It doesn't matter if you're a clinician educator, a clinician researcher or both. At some point somebody is going to catch you at the coffee maker and ask you all nonchalantly:

"So. . . .who's mentoring you?"

This is the point where you break out in a cold sweat. Unless, of course, you have a clear idea in your head exactly who that person is. Maybe you're so savvy that it's more than one person, even. But if you are like many fairly junior folks, that answer isn't as clear as you'd like for it to be.

Here's why. Many institutions help you identify a mentor right from the start. Someone looks at you and your accomplishments and serves as a professional "match.com" for you and your future. The problem is. . . as well meaning as these arrangements are, ofttimes it doesn't result in "eharmony."

And so. You give that name that was given to you whenever someone asks, but secretly you kind of recoil because there hasn't been the kind of magic you'd been hoping for.

I know that some professional person somewhere is reading this thinking, "Yes! Yes! Yes!" Yes, because it's true.

At this point, a few of you might be saying, "What do you mean 'mentor'? Is it like having a guru? Because if it's that, I'll pass, thanks."

(Click "more" below to keep reading)

Alright, so check it. Back in the Greek mythology day, Odysseus (as in the dude behind "The Odyssey") had this right hand man named Mentor (yes, this was the dude's real name.) Anyway, Odysseus had some big things going on--and by big things I mean The Trojan War. Odysseus, being the responsible dude he was, was concerned about who would hold things down for him in his absence. And remember when I said that all women need good women friends and all men need good men friends in their corners? Fortunately, Odysseus had that in his running mate Mentor.

Odysseus had a son who was the apple of his eye named Telemachus, and he needed somebody to keep an eye on his boy while he was away. Even though Telemachus wasn't a baby or anything, this was necessary because his father was kind of a big deal. So, in a way, Mentor was kind of like having secret service for the Obama girls but like, before the secret service was invented.

So the story goes on, a lot of stuff goes down, but the bottom line is that Odysseus' Mentor held down the fort big time and proved to be a great guide to Telemachus. When it was all over, Telemachus probably said, "'preciate you" to Mentor and Mentor, like any good mentor, just smiled all proud-like and replied by saying something poignant like, "Ah, my lad. . . . when you succeed, I succeed."

This is where that whole word comes from in the English language. The gnarly thing about the story of Mentor is that he wasn't just a babysitter. He was wise counsel, a cheering section, a coach, and a trusted confidant. And although Telemachus had a good father who could serve in that capacity most of the time, it ended up being good to have someone else in that role as well.

So I say all this to say...I think good mentors help us to get close to our full potential. We all need good mentors to nudge us, advise us and sometimes taze us into doing what we need to do. The most effective mentors coach, inspire and lead by example. It took me a minute (a Grady minnute) to recognize and identify my mentors in medical education. And man, am I glad that I finally did!

Haven't found one yet? Or don't realize who yours are? Never fear because today, in the first installment of my Mentor-ific series, I bring you:

The Top Ten Ways to know a GREAT mentor when you see one.Use this to help guide you to the promised man or wo-man. (Not in the romantic sense but in the mentor sense, alright?)

Drumroll please. . . . . .

#10 -- R-E-S-P-E-C-T

A mentor that's right for you is someone that you respect. Now, this is trickier than you might imagine. Just because someone is a rock star professionally doesn't mean that you'll fully respect them. Perhaps you don't like the way he or she speaks to his or her administrative assistant, or that they never leave work to be with their family. Whatever it is, if there's a disconnect in your ability to feel genuine respect for the person, it's probably not a good fit.

#9 -- PRODUCTIVE

It's kind of ideal to have a mentor who has actually done some of the things that you aspire to do. Don't confuse that for EXACTLY the things that you want to do.

Case in point: My main professional mentor is NW., who happens to have some interests that don't exactly mirror my own. But. He is a highly accomplished teacher on the local, national and even international levels. His teaching style is quite different than my own, too. And that's fine. Because he is very, very productive and helps me to push harder both through his encouragement and his example. Plus he's a greatteacher, which I always aspire to be. I respect that. It works.

#8 -- AVAILABLE

Doesn't matter how amazing of a fit a person is for you if they don't have time for you. Some folks are well-meaning but ridiculously busy. Too busy to reply to your emails or your phone calls. And if that's the case? Regrettably, it's probably not a good fit.

There are some times when the mentee falls short and isn't assertive or prepared enough. This might leave said busy potential mentor less than enthusiastic about making time for them. But when it's not that, then at some point you just have to cut your losses and keep it moving.

Yes, you are published in the highest tiered rock star journals and you present at the biggest deal conferences every year. But you won't call me back so . . . . oh well.

#7 -- WISE

A great mentor has been around the block enough to have gained some wisdom here and there. Sometimes you need to turn to your mentor for insight on what to do when those paths diverge in a yellow wood. It helps if they don't have to use an eight-ball to give you some advice.

#6 -- EXAMPLE

Those I identify as mentors are people whom I consider role models. Not just professionally, either. I like knowing that, yes, you work hard but that you also go on vacation with your family or take a cooking class with your husband on Tuesdays after work. No, you don't need to be perfect. Just working to achieve some sort of balance, you know? It also helps if you're nice.

By the way--I gave a speech once called "Let your life be a mentor." It was about how even when folks don't know you personally, they can be mentored by your example and the lessons in your life. I am mentored, for example, by Angella L. on many things. She is a mom and professional and a wife and when I read her writings, I get guidance. That's just a little bit of food for thought.

#5 -- UNSELFISH

I'm sure Mentor had a whole bunch of things he needed to do while Odysseus was gone to the war. Even though it is technically a myth and was technically waaaaaay back when, I know for sure that not that much has changed in the world since then. Real talk? Time is a precious thing. This is why many people would much rather write a check toward food for the homeless than going to a shelter and actually feeding them. Time. Energy. Commitment.

It takes an unselfish person to spend time focusing energy on someone other than themselves. Exceptional mentors are willing to sacrifice their time, ideas, and energy to bring out the best in you.

Oh, and don't be fooled. Sometimes productive mentees find themselves working with people who seem unselfish. Ask yourself a question: Would this person still be as interested in working with me if they weren't last author on all of my papers in their field or if I wasn't completing the manuscripts that were sitting on their desk for the last five years? If the answer isn't an immediate absolutely yes, then know that the relationship could be difficult to sustain.

#4 -- INSPIRATION

Mentors come in all shapes and sizes. Some serve as "coaches". They stand on the sidelines watching you and telling you how to improve your technique. They come up with ideas that you never thought of, point out strengths and weaknesses that never occur to you, and. . . .they just. . . .they just invigorate you.

One of my mentors who serves in this capacity is a Grady doctor named CD. CD is quite possibly the busiest, most hard-working person I know. But he does all of the things he does with such zeal, man. He teaches with zeal. Treats patients with zeal. And even responds to my most simple text messages with a spunk that often makes me laugh out loud. I learn so much from watching him and listening to him. And though he is not my mentor in the formal sense I count him as one because he makes me better.

There's a whole movement about peer-mentoring that I have to mention here, too. Many of my peers in medicine hype me up so much! I watch them teach or talk or do what they do and I feel invigorated. Ready to try something new. That list is long. But I count these people as the swirling moons around me that serve in a mentoring role, too.

#3 -- NO-COMPETE CLAUSE

Your mentor should NOT be in competition with you. Period.

#2 -- FUN

Mentor-mentee relationships can be time consuming. It sure can be painful to spend all that time with someone who's a stick in the mud. When I meet with my mentor we spend at least 70% of the time laughing out loud. It's productive, yes. But always fun.

Okay, except for the last chapter we wrote together. That wasn't fun. But he did laugh at all of my jokes regarding how un-fun I found that whole process. And the reason he insisted I do it was because he thought it would help me professionally. (He also helped a WHOLE lot with the hard parts which takes me back to number 5.)

#1 -- GENUINE INTEREST IN YOU.

Not what you can do. Not how fast you write. Not how willing you are to work long hours. And not just what you can do to make them look good.

You.

They remember that your son is turning five and they fly back from wherever they were to be at his birthday party because it's important to you. (Yes, I remembered that, NW.) They want to hear your ideas and have the patience to help you flesh them out. They take the time to look at your unique qualities and try hard to come up with the best ways to utilize them. They know when to push you and when to back off because they've taken the time to get to know you.

In other words, they care. About you. You. Even if you don't have great comic timing. Even if you got a 'B' on the medicine clerkship or if you didn't get awarded that big grant from the NIH. They still make room for you in their schedule and start that meeting off with simple things like:

"How are you? How was Harry's birthday? Are the kids out of school yet? Have you ever eaten at Antico Pizza?"

And then they get down to business. I think everyone knows that there is a very fine line between business and pleasure. It sure helps when it gets blurred.

Oh and mentoring isn't just a doctor thing or a medicine thing either. Many of my mentors coach me in life and motherhood and everythinghood as well. And. Many people mentor you without even knowing it. Kind of cool, isn't it?

Bottom line? The best mentors get it. And they get you.

Nearly 9 in 10 doctors stressed on any given day

noreply@blogger.com (Ryan DuBosar) — Thu, 22 Dec 2011 12:00:00 +0000

The vast majority of U.S. physicians are moderately to severely stressed or burned out on an average day, with moderate to dramatic increases in the past three years, according to a survey.

Almost 87% of all respondents reported being moderately to severely stressed and/or burned out on an average day using a 10-point Likert scale, and 37.7% specifying severe stress and/or burnout.

Almost 63% of respondents said they were more stressed and/or burned out than three years ago, using a 5-point Likert scale, compared with just 37.1% who reported feeling the same level of stress. The largest number of respondents (34.3%) identified themselves as "much more stressed" than they were three years ago.

The survey of physicians conducted by Physician Wellness Services, a company specializing in employee assistance and intervention services, and Cejka Search, a recruitment firm, was conducted across the U.S., and across all specialties, in September 2011. Respondents mirrored the AMA 2009 Physician Masterfile, with 2,069 completed surveys representing a 99% confidence level with a +/- 3% margin of error compared to about 750,000 physicians. The survey respondent sample skewed more toward non-primary care practices by 11.1 percentage points, possibly reflecting a younger survey sample and fewer primary care medical school graduates.

The top four external stress factors are the economy (51.6%), health care reform (46.4%), Medicare and Medicaid policies (41.2%), and unemployed and uninsured patients (29.7%). Only 8.6% of respondents reported no external stressors.

The top four work-related stress factors are administrative demands (39.8%), long work hours (33.3%), on-call schedules (26.2%), followed by medical malpractice lawsuits, insurance company interference, conflict or disagreements with administrators, increased complexity of care and electronic health/medical records. Only 1.1% reported no stress from work.

The top three personal life-related factors were not enough leisure time (52.6%), not enough time for exercise or wellness (50.6%), concerns about work/life balance, in general (45.0%), followed by concern about finances or sleep. Only 8.4% of respondents indicated that there was nothing stressing about their personal lives.

The result of the stress is declining job satisfaction (51.2%), a desire to reduce hours (41.2%) and a desire to retire early (29.9%), nearly tied with a desire to leave the practice of medicine entirely for another career (27.6%). The next two were also related to changes in their work situation: desire to switch jobs (21.8%) and desire to switch to a new practice (15.9%). Only 6.9% of survey respondents reported no work-related stress.

Fourteen percent of respondents indicated they had left their practice as a result of stress, among whom 56.7% continued practicing, but in a different setting, 33.3% continued working in medicine, but in a different job or role, and 10 left medicine entirely. Most noted some improvement, with 42.6% each saying leaving improved their stress and burnout.

Not surprisingly, all the stress triggered tiredness (41.4%), sleep problems (36.7%) and general grouchiness (33.9%), personal health problems (24.7%) and conflicts with a spouse or partner (22.6%). But 9.1% of respondents reported no impact on their personal lives due to stress and/or burnout.

Most doctors handle the stress through exercise (62.8%) or time with family and friends (56.9%). The next cluster involved vacation (47.8%), movies or music (44.3%), reading (38%) and getting more sleep (35.8%). Mentoring, yoga, meditation or peer support were not as prevalent, and doctors commented that finding the time and, in some cases, money to do something was, well, stressful.

Nearly one-third of respondents indicated that better work hours/less on-call time and better work/life balance would help to reduce their stress. Nearly two-thirds of respondents said ancillary support would help. This feedback and the growing trend of part-time work schedules for physicians indicate a need for advanced providers such as nurse practitioners and physician assistants who can provide accessible and effective care as physicians scale back their hours in order to pursue better work/life balance, the companies said in a press release.

Holiday decoration-related ER visits: Are these statistics sending the wrong message?

noreply@blogger.com (the Better Health network) — Wed, 21 Dec 2011 18:00:00 +0000

Yesterday's American College of Emergency Physicians Member Communication e-mail (titled Emergency Medicine Today, in affiliation with BulletinHealthcare) had this as its top story: Injuries Linked to Holiday Decorating on the Rise, from a website called HealthDay News. The reported cites a U.S. Consumer Product Safety Commission press release, crafted with help from Underwriter Laboratories (the wire engineers).

They claim: "In November and December 2010, more than 13,000 people were treated in U.S. emergency departments for injuries involving holiday decorations, up from 10,000 in 2007, and 12,000 in 2008 and 2009, according to the U.S. Consumer Product Safety Commission (CPSC). A well-watered tree, carefully placed candles, and carefully checked holiday light sets will help prevent the joy of the holidays from turning into a trip to the emergency room or the loss of your home," said CPSC chairman Inez Tenenbaum in an agency news release.

Good advice. Though it's been said (many times, many ways. So when it came time for CPSC and UL to raise the topic, did we need the very questionable statistics to justify it?

If you're having trouble wrapping your head around the number of decoration-related emergency department visits, consider this similarly bizarre statistic: 8,000-10,000 kids are injured each year from falling televisions. So, for perspective: in the November to December period, Americans now endure more holiday-decoration-related trauma than an entire year's worth of falling TVs (though, now that I think about it, there may be some overlap, like if while putting up some Christmas lights, Dad knocks over the TV and it lands on Junior's foot. That could be one ED visit logged in both categories.)

Another way to think about it: 13,000 visits over two months spread over the approximately 1,800 EDs in the U.S. translates to about seven holiday-decoration-related visits per ED. Not much, when the average department sees 5.000+ patients a month (and Americans visit the ED 130 million times a year). I'm not even sure it's significantly more than it was a few years ago, when EDs could expect, get ready for it, six (6) visits related to holiday decorating.

Still, I've yet to see my first mistletoe-hanging trauma. I have seen more than my share of frankincense and/or angel dust intoxication lately, but I don't think that counts as a decoration-related ED visit.

In fact, I handle a lot of statistics and analysis for our ED, and I could not tell you how many holiday decoration injuries we've seen this year, or last. To really do it right (i.e., publication-quality data that could stand up to peer review or Joint Commission scrutiny) we'd have to build a query to retrospectively through the text of all patient notes, looking for mentions of menorah fires or tree-felling injuries, then do a chart review. Or we could code a checkbox and ask our triage nurses to prospectively screen for this, along with suicidality, domestic violence, and HIV.

Probably what CPSC is doing, instead, is drawing from a few statewide databases or surveys like NHAMCS and generalizing broadly (certainly, there are no scholarly papers on holiday decoration emergencies; the literature on falling TVs is much more robust).

Survey data is fine for identifying new threats to the population, or changes in abuse patterns, but it's hardly precise and when I see dozens of headlines about the rise in ED visits from holiday injuries (Google news counts 291 stories at the time of this writing) it makes me cringe. If next year's holiday decoration visits fall back down to 10,000, does that mean we've turned a corner on educating the public about the menace of holiday decorations? And so we won't need to be so vigilant anymore? Or is it just a statistical blip, well within the margin of error, not at all worthy of a headline?

And on that note, I must break off to do some holiday-related shopping, confident (but somewhat disturbed) in the knowledge I've now spent more time mulling this over than anyone involved in writing or selecting that press release for inclusion in ACEP's daily email.

This post by Nicholas Genes, MD, PhD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

Life at Grady: Slip Slidin' Away

noreply@blogger.com (Jessica Berthold) — Wed, 21 Dec 2011 13:43:00 +0000

The following post, by Kimberly Manning, MD, FACP, first appeared on her blog, Reflections of a Grady Doctor. Names and indentifying information have been changed to protect privacy.

You'd been sleeping for what seemed like three days. Your admission diagnosis was for a common reason--"altered mental status"--but what would happen next wasn't clear.

The first day they brought you in with soiled pants and underwear. Your body was limp like a rag doll, or better yet, like some sort of carnivorous animal shot with a tranquilizer dart and chemically restrained. Strong in body, muscular like the king of the jungle...but still and quiet.

Someone pushed their pointed knuckle deep into your sternum hoping it would arouse you but...nothing. Another doctor came and mashed hard on your finger nail with an ink pen while a medical student watched. "Noxious stimuli," the doctor said. "This helps me see if he responds to painful stimuli." The student nodded in acknowledgment.

That first day, you didn't respond to much of anything. Your loss of continence combined with the gash on the back of your head made someone think that maybe you'd had a seizure. That was enough to get the Neurology team in to see you. It was also enough to prompt several tests to be run on you including a spinal tap and an MRI.

By the time I got there, you had moved from somnolent to "groggy." Heavy eyelids, slurred speech, words that came out as nonsense--but this was better than how you reached the ER. I glanced at your arms and found them sprinkled with red dots like confetti. Next I saw the middle-aged woman whose pained expression from the bedside chair clenched the diagnosis for me:

Drugs.

(Click "more" below to keep reading)

You were too out of it to participate in that conversation, so on my first visit I just spoke with your mom. Watching how her lower lip quivered when she told me of your long battle with substance abuse and depression hurt me deep in my heart. Sips of alcohol in middle school. Then some marijuana. A few wild friends nudged you into harder things like powder cocaine and prescription pills. Before you knew it, this became too difficult to manage. You needed something quick and predictable to see you through the complexities of your mood disorder and your physiologic dependence.

"Heroin will help you not be sick." This was the word on the street so you clenched your teeth and got over that fear of needles that you'd had since your boyhood.

And from there things went crazy.

This was the story your mother gave me with her quivering lip and tired eyes. This wasn't the first time she'd been here.

When you finally woke all the way up, I happened to be there rounding. You were astounded at the fact that you were in an adult diaper and you asked about your mother right away.

"Oh my God. My mom--was she here?"

I nodded. "Her and, I think, your sister."

"Did my mom...agghhh...was she crying?" you asked while smacking your palm to your forehead. I noticed your fingernails then. Painted black.

"Not really crying. She was just kind of. . . ."

"Trying to talk with her lips trembling? She only does that when she's trying not to cry."

I didn't want to answer that so I just stood there staring at you. That was enough, though. You dropped your face into your hands. You swore. You balled up your fist and pounded it onto the bed.

I reached out and gripped the hand rail. I wasn't sure what to do.

"She's done this with me so many times. I'm so tired of dragging her through this." You punched the bed again, this time startling me.

"She didn't seem mad. I mean, she just seemed concerned," I finally said. I wanted you to feel better and this was all I could think to say.

"That's the freakin' problem. She's not mad. She freakin' forgives me and prays over me and lets me back into her house. And it's fine at first and then I mess it right up."

I bit the inside of my cheek awkwardly. I didn't really know what to do, so I just sort of stood there like I'd been frozen with some kind of remote control.

Your situation was different for me. I mean, yes, I have seen people addicted to intravenous drugs but in Atlanta at this hospital, it's definitely not the method of choice. I was used to hearing about relapses of crack cocaine and tales of bodies being sold to get hands on it. Bodies neglected from the full time job of smoking tiny white rocks in little glass pipes. And empty promises to get out of hospital beds.

You were this college educated person with blue blood lineage. The one whose behavior screamed black sheep but whose mother loved him like a precious lamb.

"Is it the craving...like...feeling sick that makes you keep coming back to it?" I asked this really dumb question, yes. But only because I was curious.

"It's the hating myself, really." You looked down at your arm band and twirled it on your wrist. "That's what makes it so hard when somebody is trying to love you through it. It's really, really hard to have someone loving you like that when you don't love yourself."

"Why do you think that is? I mean, that you don't love yourself?"

You pause for a moment and laugh. Your eyebrows raise and with a tiny shake of your head you replied, "Now that's the million dollar question, isn't it?"

I guess that was when I realized how dumb that question was, too.

"I'll get myself all clean and then it goes full circle. Feeling like I don't deserve to be happy."

"Hmmm." I tapped my fingers on my lower lip as I listened. Maybe it was out of nervousness or maybe it was to keep myself from saying the wrong thing. "Have you been talking to the psychiatrists still?

"I do. I mean, I always do. It's so messed up...you know? I realize that this isn't normal, you know? I know the drill...talk it out...get to the root of the pathology. What happened to you? What messed you up as a kid that now has you extra-messed up as a grown-up? See? That's what's so messed up. I can't put my finger on that thing...that one awful thing that allegedly started all of this."

"Pathology." "Allegedly." You were obviously highly intelligent and your insight was unreal. And you were right. I had no idea what the answer was to all of it. So I just sat there listening because honestly, I'm not a psychiatrist and I don't exactly know what to do with all of this information or even the first place to start psychoanalyzing any of it.

"Wow, that's deep," I said instead.

"Yeah, that's one way to look at it," you replied. Just then you looked down at the adhesive from the IV taped to your arm. Next to that was a scar from the IV drug use poorly disguised by a tattoo. You caught me looking at it and shook your head. "I bet you're thinking, What a waste."

I looked at you and thought about my words before speaking them. "That's not what I'm thinking at all."

You chuckled and covered the scar with your hand.

"I'm thinking I wish that you didn't have to be in this situation. You or your loved ones. I'm wishing I knew the key to making this go away."

"I know the key," you responded. That kind of surprised me. You put up your thumb like you were going to hitch-hike and then turned it in on your chest. Next came a big sigh and you added, "That's the problem."

I narrowed my eyes and nodded. "Do you pray?"

"Naah. Not my thing. That always seems to come up, but I don't know. It never has soothed me or made me feel anything."

I chose not to respond to that, recognizing that my first question on the subject was enough.

"So...it looks like you're recovering from the overdose. I spoke with your mother and she says she's willing to bring you back to North Carolina with her."

"Of course, she did."

"How do you feel about that?"

"Undeserving."

I reached for your hand and squeezed it. You let me.

"You're a pray-er aren't you? I can just tell you are. You probably have Jesus on the mainline, don't you?"

I smiled and released a little laugh. "Hmm. I guess that's fair to say. I think he even has a text package these days."

"Wow, man. L-O-L and O-M-G, literally," you retorted. That idea amused us both.

We sat there with our eyes locked and our hands locked, too.

You spoke first. "Well do me a favor, okay? Pray for me, will you?"

"I will."

"You promise?"

"I promise."

"And my mom, too, alright?"

"Got her covered."

After I finished up my exam and the necessary elements of the visit, I gave you a hug. Tight like the way a mother hugs a son. Something tells me that you felt that part of it. I sure hope you did.

That night I prayed for you. And never saw you again.

Using GoAnimate to create case scenarios

noreply@blogger.com (Neil Mehta, MD) — Tue, 20 Dec 2011 16:00:00 +0000

Case scenarios are critical in medical education. They make the content more real and applicable to work and thus add value. This point was borne out during a recent course I co-directed on the use of technology in medical education. As a part of the course, physicians worked in teams to create eLearning modules.

Four out of the five teams chose to use an animated video to introduce their module. One of these team chose Xtranormal for their video but the three other teams chose GoAnimate. Physicians found it relatively easy to use these tools.

One of the most striking examples of these videos was one to help introduce the importance of describing a skin lesion.

Besides priming the learner for clinical content, these videos can be used as lead ins for training on communication skills or focused history taking. Here is a link to an animated video to lead in to a discussion on communicating with an angry patient.

Education technology folks working with faculty in medical schools or with residency programs should consider introducing these educators to use of animated videos in their teaching.

Summary of advantages of animated videos for medical education:
1) Relatively easy to create
2) Can be embedded or linked from any eLearning content or Learning Management System
3) Makes the course content more real and thus adds value
4) Makes eLearning more fun
5) Can you used as basis for a face to face discussion with learners
6) No HIPAA issues
7) Easy to share/disseminate

Neil Mehta MBBS, MS, FACP, practices internal medicine at a large tertiary care hospital in Ohio. He is also the Director of Education Technology (Academic Computing) for his medical school and in charge of his hospital system's home grown Learning and Content Management System. He is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management. This post originally appeared at Technology in (Medical) Education.

5 steps for flu prevention should include mandates for health care workers

noreply@blogger.com (Ryan DuBosar) — Tue, 20 Dec 2011 12:00:00 +0000

Health care facilities should consider mandatory flu vaccinations for their employees if other attempts don't increase rates to 90%, a draft statement from a U.S. Department of Health and Human Services (HHS) working group stated.

All public health services, HHS staff and Federally Qualified Health Centers should follow suit, stated the Health Care Personnel Influenza Vaccination Subgroup in draft recommendations.

The working group released five steps to boost vaccination rates:
--Employers should establish comprehensive flu infection prevention programs as recommended by the Centers for Disease Control and Prevention (CDC) to achieve the Healthy People 2020 influenza vaccine coverage goal of 90%.
--Employers should integrate flu vaccination programs into their existing infection prevention programs.
HHS should encourage CDC and the Centers for Medicare and Medicaid Services to standardize the methodology used to measure health workers' flu vaccination rates, as well implement incentives, penalties or requirements that facilitate adoption.
--Employers and facilities that still can't achieve 90% flu vaccination rates among workers after following the three previous steps should strongly consider an employer requirement.
--HHS should encourage developing new and improved vaccines and vaccine technologies, including support for research, development and licensure of vaccines with better immunogenicity and duration.

According to the Advisory Committee on Immunization Practices, annual vaccination is the most effective flu prevention strategy. Immunizing health care workers protects them, keeps them at work during flu season and protects coworkers and patients.

The report notes that while vaccination is the best-documented and most effective intervention to prevent the flu, it's tough to definitively measure. Outcomes for patients varied widely between the studies considered by the working group.

Do doctors feel that they need permission to share ideas?

noreply@blogger.com (the Better Health network) — Mon, 19 Dec 2011 18:00:00 +0000

Let's say you're a doctor and you have an idea, opinion, or a new way of doing things. What do you do with it?

It used to be that the only place we could share ideas was in a medical journal or from the podium of a national meeting. Both require that your idea pass through someone's filter. As physicians we've been raised to seek approval before approaching the microphone.

This is unfortunate. When I think about the doctors around me, I think about the remarkable mindshare that exists. Each is unique in the way they think. Each sees disease and the human condition differently. But for many their brilliance and wisdom is stored away deep inside. They are human silos of unique experience and perspective. They are of a generation when someone else decided if their ideas were worthy of discussion. They are of a generation when it was understood that few ideas are worthy of discussion. They are the medical generation of information isolation.

I spoke with a couple of students recently about medical education reform. And as I often like to do, we discussed what was needed to prepare doctors for life in 2050. I picked up on the most remarkable ideas and suggested that they publish their views as a position paper or editorial. They looked puzzled, and for good reason. They believe that the simple expression of their brilliance is not their responsibility or even their right. It's that of some national professional body or editor. You need the keys to the kingdom to be heard. You need permission. You need to be invited.

In Poke the Box, Seth Godin calls this the tyranny of the picked: Waiting and hoping "acknowledges the power of the system and passes responsibility to someone else to initiate."

But the way the world communicates is changing. The barrier to publish is effectively non-existent. The democratization of media has given every physician a platform to the world. But the physicians have yet to speak up. We're preoccupied with how our voices will sound. We pine over what someone might think. We're too concerned with how we'll look and not concerned enough with how our thoughts, ideas and passions could be an instrument for the world.

If the 20th century was marked by the physician-as-silo, the 21st century will be marked by the dissolution of barriers and the emergence of new ways of collaboration and thinking. This will be a generation marked by information and networks. The institutions that existed to organize us will give way to social structures compatible with the way we communicate. Tools for sharing and drawing from collective intelligence will capture our restrained wisdom. And I suspect that we'll see the most amazing things emerge.

This post by Bryan Vartabedian, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.