ACP Internist

Choices

noreply@blogger.com (Amanda Xi) — Wed, 16 May 2012 17:00:00 +0000

In the last hour, I suddenly became overwhelmed with just how many choices we make in a day. We choose whether or not to wake up in the morning to drag ourselves to school [some might argue that this isn't a choice ... but let's just go with it].

We choose what to eat when we're hungry. We choose which lane to drive in. We choose how we spend our time [such as right now, I am actively choosing not to study].

In life, we make a lot of choices that we don't think twice about because for the most part, they are trivial.

But if you really think about it, some everyday choices we make affect those around us. Something as simple as smiling at a stranger as you hold the door open could be the highlight of someone's day. Cutting someone off as you merge into another lane could ruin the rest of that person's day. Sometimes, I think we forget just how interconnected we all are; most of the time I think I am just minding my own business and living in my own little world, but there's no such thing. We all end up influencing another human's life at some point in time, whether we acknowledge it or not.

In medicine, our choices hold even more weight. This thought is exciting and chilling all at once; our choices can lead to bringing a new life into this world or ending one prematurely. Our words can tear a family apart or bring tears of joy to a patient. Our actions truly impact the life of our patient, whether we like it or not.

This is the path we chose. We want to help people. We want to heal people. But in the end, there is no escaping the reality that we won't always be right. Most of the time, there is no such thing as black and white; there is just an expanse of gray that will only morph into clarity retrospectively.

Amanda Xi is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Ann Arbor, Mich. She has a Bachelor of Science in Engineering [Biomedical Engineering] and Master of Science in Engineering [Biomedical Engineering, again] from the University of Michigan. This post originally appeared at her blog, "And Thus, It Begins," which chronicles her journey through medical training from day 1 of medical school.

The outlier's message, and evolutionary science in breast cancer

noreply@blogger.com (Elaine Schattner, MD) — Wed, 16 May 2012 13:00:00 +0000

This past week I read several attitude-altering articles about breast cancer.

The first lesson, if I might call it that, in the way an oncologist can learn from variations in her patients' pathology and clinical outcomes comes from the case of Katherine Russell Rich, who died last week at the age of 56. As reported by Katherine O'Brien in the I Hate Breast Cancer Blog, Rich lived with metastatic breast cancer for 18 years. That's phenomenal, was my first reaction to this news. The prognosis for metastatic breast cancer is said to be around 3 years, and Rich lived for 18 years beyond her tumor's recurrence with stage IV disease.

As sad and unsatisfactory as this outcome may seem, and it is, Rich's story offers hope for life beyond the 3 or 4 or 5 years some women with metastatic breast cancer pray, "ask" or otherwise bargain for, fingers-crossed.

As she detailed in an O article, Rich's initial diagnosis came when she was 32 years old, in 1988. The New York Times, in an obituary, tells of her lumpectomy, chemo and radiation. In 1993 her cancer came back in bones including her spine. She had a bone marrow transplant, but the disease progressed. Ultimately, she coursed through various and some archaic hormone treatments.

Along the way, she lost or quit a job in publishing, or both, and traveled to India, and authored two books . In a 2010 first-person story about her case, she told of updating her status--of being alive--at Breastcancer.org each year. She wrote: "... I tell the women how deeply I believe there's no such thing as false hope: all hope is valid, even for people like us, even when hope would no longer appear to be sensible."

Life itself isn't sensible, I say. No one can say with ultimate authority what will happen--with cancer, with a job that appears shaky, with all reversed fortunes--so you may as well seize all glimmers that appear.

My take, as an oncologist and former clinician, is that patients sometimes surprise you. Hard to know which woman will respond to a non-targeted treatment, or even a drug like an estrogen modulator, without trying. And I wonder--and this is speculative, but maybe, likely, the two together, doctor and patient, worked together to see what worked in Rich's case over nearly 2 decades, and what didn't work.

If a drug helps, keep it going; if it hurts, stop. There are so many algorithms in medicine, and molecular tools, but maybe the bottom line is how the, one, your patient is doing.

Which leads me to another post, by Dr. David Gorski, a breast cancer surgeon and researcher who blogs as Orac--what once was imagined as a fabulously capable information processor, at Respectful Insolence. He describes how tough it can be to define, and thereby target or destroy, any individual patient's breast tumor because the cancer cells are constantly changing. Within each woman's tumor, an evolution-like process is ongoing, leading to selection of treatment-resistant cells. This is not news in oncology; the concept has been understood for years as it applies to "liquid" tumors like leukemia, as he points out.

In breast cancer, understanding the complexity of each case is more recent. Dr. Gorski considers a genetic analysis of 104 triple negative breast cancer (TNBC) cases presented at the recent AACR meeting and published last week in Nature: "... The 59 scientists involved in this study expected to see similar gene profiles when they mapped on computer the genomes of 100 tumours.

"But to their amazement they found no two genomes were similar, never mind the same. 'Seeing these tumours at a molecular level has taught us we're dealing with a continuum of different types of breast cancer here, not just one,' explains Steven Jones, co-author of this study.

"... TNBC is not a single disease. In fact, even an individual TNBC tumor is not a single disease. Tumor cells evolve as they proliferate, so that the cells in them are genetically heterogeneous. The cells growing in one area of a tumor can and often do harbor markedly different genetic mutations from the cells growing in another part of the tumor ...

"The team found that each tumor displayed multiple 'clonal genotypes,' suggesting that the cancer would have to be treated as multiple diseases, rather than a single entity."

So besides that there are distinct subtypes of breast cancer, those labeled as TNBC are diverse and contain variation within; each patient harbors sub-clones of malignant cells that, in principle, respond differently to treatment.

Putting these links together ...

The message from Katherine O'Brien, who lives with metastatic breast cancer and blogs about it, is that one outlier, like Katherine Russell Rich, can provide hope to other patients and, maybe, clues for scientists about why she lived for so long with metastatic breast cancer. The message from Orac, a physician-scientist blogger, is how hard it is to pinpoint an individual breast tumor's molecular aspects, because the disease is so mutable and diverse.

The problem, and this reflects evolution in my thinking over a long while, is that published data--the gold standard, what supports EBM--are largely limited to findings based on trials of groups. We understand now, better than we did 10 or 20 years ago, that each patient's tumor is unique and can evolve over time, naturally or in response to therapy. Clinical trials, though rigorously planned and elaborately structured, are incredibly expensive and flip-floppy, disappointing overall.

What I'm thinking

Algorithms, except in the broadest sense, may not offer the optimal approach to cancer treatment. Maybe the median doesn't matter so much as we'd thought.

Here's a retro idea: In 2012, maybe the ideal and most cost-effective oncology practice would blend low-tech observations, like findings on physical examination and how the patient's feeling, with occasional, high-tech analyses, like markers for genetic drift within a tumor. If doctors are well-trained and non-robotic, in either the literal or figurative sense, and if they lack conflict of interests regarding treatment decisions, they'd provide better, more effective and personalized treatments than what's typically offered based on evidence reached through elaborate, costly clinical trials of many patients with similar but non-identical cancers.

This post originally appeared at Medical Lessons, written by Elaine Schattner, ACP Member, a nonpracticing hematologist and oncologist who teaches at Weill Cornell Medical College, where she is a Clinical Associate Professor of Medicine. She shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology and as a patient who's had breast cancer.

QD: News Every Day--Six in 10 doctors using digital tablets

noreply@blogger.com (Ryan DuBosar) — Wed, 16 May 2012 11:00:00 +0000

Six out of 10 doctors are using digital tablets for work, mostly iPads, and half use them at the point of care, according to a survey from health care market research and advisory firm Manhattan Research.

But is it a good thing?

The online study surveyed 3,015 U.S. practicing physicians in more than 25 specialties.

Tablet use for professional purposes almost doubled since 2011, reaching 62% this year.

Physicians using tablets, smartphones and desktops/laptops spend more time online on each device and go online more often during the workday than physicians with one or two screens.

Adoption of physician-only social networks remained flat between 2011 and 2012.

Physicians reach out more frequently to and are more influenced by colleagues they formed relationships with at school or at work than peers who they first connected with online.

More than two-thirds of physicians use video to learn and keep up-to-date with clinical information.

Is this a good thing? How can doctors manage three computing platforms and still connect with patients? ACP Internist addressed this topic in its April cover story.

Frivolous medical malpractice lawsuits targeted by medical justice

noreply@blogger.com (Michael Kirsch, MD) — Tue, 15 May 2012 17:00:00 +0000

Whistleblower readers know my views on the perverse and dysfunctional medical liability system. I have read numerous plaintiff lawyers' blogs, and those of other tort reform opponents, to better understand the issue from other perspective. As a physician, I bring bias to the issue, as do all the players in the game. After 20 years of thought, and some legal brushfires, I am persuaded that the medical profession has the better argument.

I also do not believe that we physicians are as strident and ideological as the other side is, but perhaps this is simply because this gastroenterologist has a jaundiced view of the issue. For example, most physicians readily admitted that our health care system, before Obama and the Democrats cured it, had serious deficiencies that demanded reform. In contrast, rarely do I hear or read plaintiffs' attorneys remarking that the medical liability system needs some healing. What I read in their columns and postings is a spirited defense of the status quo.

When a physician like me points out flaws in medicine, as I have done throughout this blog, this is an attempt to improve our profession and public health. Indeed, physicians on blogs and in medical journals write openly and often about where our profession is falling short. Reflection and self-criticism are ingrained in the culture of the medical profession. If a plaintiff's lawyer were to publicly advocate medical malpractice reform, then I suspect he would be shunned for his blasphemous utterance, or banished to the gulag for some re-education.

In my tort reform meanderings through the blogosphere, I stumbled upon Medical Justice (MJ), a company that is devoted to protecting physicians against the abuses of the medical liability regime. This organization aims to:
--prevent frivolous litigation from being filed against a member physician
--attack internet defamation of physicians' reputations
--hold medical "expert" witnesses accountable

I was intrigued and reached out to them to learn more about their enterprise. When a member physician is unfairly sued, MJ gets into the other side's face to alert them that their national organization is squarely behind the doctor. This puts the plaintiff and the opposing medical experts on notice that their actions will be scrutinized and held accountable. There is a yearly charge for membership, which depends upon the amount of protective service the practitioner desires.

Some of MJ's services require the physician and the patient to sign certain agreements, which I think would be problematic for doctors to implement. While I understand why a physician would desire a signed agreement that would protect his interest, I am less certain why a patient would do so. In addition, such a discussion might erode the doctor-patient relationship.

Thus far, they have over 2,000 physician members and are in a strong growth phase. I think their fees are reasonable, a fraction of what I pay each year for my medical malpractice insurance. If even one lawsuit is prevented, it would be worth a decade or two of MJ membership charges. I wish them well and encourage Whistleblower readers to visit their site and their very fine blog.

In fairness, I should disclose my relationship with this organization. Admit it; you already think I'm an MJ shill, right? You suspect that I have a pay-for-click arrangement with them. I must get a kickback for every Whistleblower reader who signs up. Here is the arrangement I have with them, which I disclose publicly.

I am not an MJ physician member and they pay me nothing. They didn't ask for this blog post and the only reward they might offer me is gratitude for having done so. Keep reading, because I now must confess a potentially corrupt act as my conscience is torturing me. I did have lunch with their Cleveland rep months ago who rejected my offer to grab the tab and paid for my meal, which cost about 10 bucks. Readers must now weigh and decide if my integrity can be compromised for a free meal.

MJ added me to their blogroll for the usual reasons; they liked my Whistleblower tort reform content. I am plugging them for free because they are the only folks I've discovered who want to put a few arrows in our quiver so our unfair fight will be a little less unfair.

I expect that MJ's services will grow and become more refined as the company matures. If they are successful, then medical malpractice carriers might be willing to subsidize physicians' membership costs.

With so many out there stabbing us in the back, it's refreshing to have an organization that's watching our back.

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

More on screening for Barrett's esophagus

noreply@blogger.com (Richard Just, MD) — Tue, 15 May 2012 15:00:00 +0000

Recently, a friend of mine asked me for medical advice concerning his condition, Barrett's esophagus. When the diagnosis was initially made, he was advised he would require annual screening endoscopies with random biopsies. But, on his last visit, my friend was told he didn't need another procedure for 5 years, with no explanation. "What's up?" Since he had a copy of the biopsy report (not with him, but at home), I advised he read it and look for the word dysplasia. Wikipedia defines dysplasia as "maturation abnormality."

So far, I haven't heard back. But this stimulated me to review current recommendations on the subject.

Between 2-3 decades ago, there was a sudden increase of adenocarcinomas ("glandular cancers") of the lower esophagus usually in Caucasian males. This event was noticeable in that the usual esophageal cancers were a different cell type, squamous cell carcinomas, that tended to occur in black males.

Adenocarcinomas appeared to be correlated with gastroesophageal reflux disease (GERD), while squamous cell carcinomas (SCC) are associated with smoking and alcohol consumption. These are tends, not absolutes.

GERD causes irritation of the cells of the lower esophagus resulting in conversion of the cell type (metaplasia) from squamous cells to columnar cells, the definition of Barrett's esophagus. Barrett's, in turn, can progress to low grade dysplasia, high grade dysplasia, and adenocarcinoma. Thus, it has been proposed that patients with at least weekly GERD symptoms (heartburn, regurgitation, and dysphagia, meaning difficulty swallowing) that have been present for at least 5 years, and who have multiple risk factors for esophageal adenocarcinoma including white ethnicity, male sex, older age, obesity and long duration of GERD undergo screening for Barrett's esophagus.

Management of Barrett's esophagus involves 3 major components:

1) Treatment of GERD: Recommended to be initiated prior to surveillance endoscopies to minimize confusion caused by inflammation in diagnosing dysplasia. Not thought to reduce incidence of esophageal adenocarcinomas.

2) Endoscopic surveillance: If no dysplasia found, next scope in 3-5 years. Follow up for low grade dysplasia is 6-12 months For intensive endoscopic surveillance of high grade dysplasia, scope every 3 months.

3) Treatment of high-grade dysplasia: Recommendations can include esophagectomy, endoscopic ablative therapies, and endoscopic mucosal resection in addition to intensive endoscopic surveillance.

Since the above recommendations were updated in 2011, my assumption is that no dysplasia was discovered on any of the three studies and risk of progression to cancer is low. For the general population of patients with Barrett's esophagus, the risk of esophageal adenocarcinoma is 0.5% per year. Contrast this with 5 to 8% per year in patients with high grade dysplasia. The risk for low grade dysplasia falls somewhere between these two extremes.

I've written previously about the limitations and risks of mass screening techniques, e.g., mammography for breast cancer, PSA testing for prostate cancer and PAP smears for cervical cancer. The same applies to screening endoscopies for Barrett's esophagus. The procedure carries with it risks, including perforation and bleeding. It's also not very comfortable to have a hose snaked down your throat so that pre-anesthetics are sometimes necessary, creating more risk.

Random biopsies are performed because it's sometimes difficult for the endoscopist to identify areas of dysplasia from just metaplastic cells, leading to falsely negative results. In his new book "The Creative Destruction of Medicine", Dr. Eric Topal opines "We're not very good at detecting and fighting cancer. The mass screening model, as with mammography or prostate specific antigen (PSA) testing ... is enormously expensive and leads to an untold number of false positive results and more unnecessary biopsy procedures. Doing serial sensitive scans like PET or CT would likely make this problem worse, both by increasing the false positives and incidental findings and by exposing individuals to ionizing radiation that itself causes cancer."

The use of innovative technologies such as circulating tumor cells (CTC), genomics (circulating DNA and RNA) and wireless sensors including implanted nanosensors are described. Obviously, hope runs high that at least some of these techniques will be validated so that the ultimate goal, prevention, is achieved.

This post by Richard Just, MD, ACP Member, originally appeared at JustOncology.com, a joint publication of Richard Just, MD, aka @chemosabe1 on Twitter and Gregg Masters, MPH, aka @2healthguru on Twitter. Dr. Just has 36 years in clinical practice of hematology and medical oncology.

45 forms of health care that you should avoid

noreply@blogger.com (Albert Fuchs, MD) — Tue, 15 May 2012 13:00:00 +0000

Why wouldn't you want an EKG every year as part of your check up? Why would you not want to be screened for prostate cancer at the age of 80 (or maybe at any age)? Why should you decline the annual chest X ray that your doctor keeps ordering? Is it because you're eager to save money for your insurance company? Is it because you think going without the test will help others who are more needy get the test in some complex rationing scheme? No. You should forego the above tests because they are much more likely to harm than help you.

Unfortunately, some of the care physicians deliver is entirely without benefit. I'm not saying merely that some care hasn't been proven to be effective. That can be excused, since in many fields the scientific evidence is scant and the individual doctor's judgment is our only guide. I'm saying that much of the care that is delivered has been rigorously proven to be ineffective or harmful.

Why are doctors ordering so many useless tests and treatments? Some blame "defensive medicine" the practice of ordering tests or treatments not for the patient's benefit but to protect the physician from liability. Some blame unsophisticated or demanding patients. Neither of these explanations is fully persuasive.

Whatever the cause of this pervasive delivery of care that is worthless or worse, a group of American physician specialty societies have partnered with the American Board of Internal Medicine Foundation to do something about it. Their initiative, Choosing Wisely, lists 45 tests and treatments in nine different specialties that physicians should stop ordering and informed patients should decline. These tests and therapies have been definitively found to have no value and yet remain widely utilized.

Some of the 45 recommendations of Choosing Wisely are:
--Don't order sinus CT or prescribe antibiotics for uncomplicated acute rhinosinusitis.
--Don't screen for osteoporosis women younger than 65 or men younger than 70 with no risk factors.
--Don't order annual EKGs or any other cardiac screening for low-risk patients without symptoms.
--Don't repeat a colonoscopy for colon cancer screening sooner than 10 years after a normal screening colonoscopy.
--Avoid admission or preoperative chest X-rays for ambulatory patients with unremarkable history and physical exam.

I strongly encourage you to explore the website and read the recommendations yourself.

Of course, physicians who have been trained recently or who keep abreast of the medical literature already know most of these recommendations, and patients going to doctors who practice evidence-based medicine have already been taught many of them.

But if these treatments and tests are known not to help patients, why are they still performed so frequently? The "defensive medicine" excuse rings false. After all, the best legal defense is ordering what's best for the patient. Some use of ineffective tests and treatments could be attributed to ignorant and demanding patients, but where would the patients initially have learned to ask for an annual EKG or an annual chest X-ray if their prior doctor had not been ordering these tests?

I think the only convincing explanation for the misuse of most of these tests and treatments is economic. Doctors make much more money in ordering these tests than in educating patients that they're bad for them. Moreover, the patients don't suffer the economic consequences of this misuse, since the cost is frequently borne by insurance. Our broken health care system insulates patients from the costs of their health care decisions and thereby encourages the use of expensive therapies that have little value.

In other marketplaces, in electronics, or transportation, or clothing, or food, expensive goods that have little value are usually called rip-offs. A few unsuspecting customers might fall for them, but word soon spreads and consumers soon learn to watch their wallets. But in health care the patient isn't paying, so he doesn't bear the price of the rip-off but redistributes it to the other enrollees of his insurance company (or to taxpayers if he has Medicare or MediCal). The insurance company can then try to limit the utilization of these tests, but the insurance company isn't in the examination room. The highly "motivated" doctor can simply add a word or two to the patient's symptoms to have the test approved. The EKG can be billed for chest pain even if the patient doesn't have any. The chest X-ray is indicated for a cough that the patient doesn't have.

The doctor gets paid. The patient is fooled into thinking that he got a useful test for free. Someone else gets the bill. Costs keep skyrocketing. Any efforts by the insurers to limit payment are answered with emotional shouting about "rationing". Rationing is when you don't use something so someone else can have it. We're talking about things that simply have no benefit and shouldn't be given to anyone.

Choosing Wisely is a welcomed effort. I hope it succeeds, but I predict it will not. As long as the perverse economic incentives persist so will the useless but expensive therapies and tests. I've written before about how our health care marketplace broke and what I think will be needed to fix it. Until then, we are wise to remember that we get what we pay for. And we're all paying for expensive and ineffective health care.

Learn more:
The Choosing Wisely website
Doctor Panels Recommend Fewer Tests for Patients (New York Times)
Doctors seek end to 5 cancer tests, treatments (Chicago Tribune)
Doctors unveil "Choosing Wisely" campaign to cut unnecessary medical tests (CBS News)
WolframAlpha U.S. health care expenditures time series (click on "linear scale" by the graph to get a clear picture)

Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.

QD: News Every Day--30 minutes of secondhand smoke enough to affect blood vessel endothelium

noreply@blogger.com (Ryan DuBosar) — Tue, 15 May 2012 11:00:00 +0000

Inhaling even low levels of lingering secondhand smoke for a short period produces signs of cardiovascular dysfunction among nonsmokers, according to small study that tested lower concentration levels than have been researched before.

The study involved 33 healthy nonsmokers with no known history of diabetes, heart or kidney disease. Researchers checked participants’ salivary cotinine level to confirm they had no evidence of smoke exposure leading up to the one-day study.

Participants ranging from 18 to 40 years old were then assigned to one of three exposure levels: filtered clean air, levels of smoke typically found in the homes of smokers or lingering in a restaurant, and levels expected in a smoky bar or casino. In a laboratory-type environment, filtered non-menthol cigarettes were smoked using a smoking machine, and the aged smoke was routed to participants in a measured way, allowing researchers to control the smoke concentration.

Results will appear in the May 22 issue of the Journal of the American College of Cardiology.

Vascular studies including testing brachial artery reactivity with ultrasound measurements were performed before and after exposure to secondhand smoke. The brachial artery didn't dilate optimally among those exposed to lingering secondhand smoke, suggesting the endothelium was not functioning as it should.

Risk factors for impaired vascular function including age, sex, body mass index, total cholesterol, baseline cotinine values, and baseline arterial diameter were not significantly related to absolute changes in endothelial in this healthy population.

Endothelial dysfunction has been linked to all phases of atherosclerosis, from its inception to cardiac events such as stroke or heart attack.

The authors called for clinicians to not only focus on asking patients if they smoke, but to ask whether they live with or are even occasionally around a smoker, even if they are not in the same room when smoking occurs. They also called for broader policies to ban public smoking.

Interprofessional education, and how to do and teach it

noreply@blogger.com (Alexander M. Djuricich, MD, FACP) — Mon, 14 May 2012 17:00:00 +0000

Last week I had the incredible privilege of attending a workshop on interprofessional education (IPE). Although I believe that I have been inclusive of the views of other health care professionals, this workshop opened my eyes to new possibilities for how we educate the future health care professionals in all areas.

First of all: kudos to the absolutely amazing people from the Centre (note Canadian spelling here, eh?) for Interprofessional Education at the University of Toronto. Ivy, Mandy, Lynn and Belinda were just wonderful people to get to know (absolutely some of the friendliest people I’ve ever met). They truly embody what the world of working together with other backgrounds can and should entail. Their work is truly inspiring, and is all the more impressive given the limited amount of dedicated time that they have to do it.

Second, it opened my eyes to some awesome people who are already here working for my own institution (Indiana University), whom I had not yet met. It is fascinating when people work so hard in their own arena and do not know that others with like-minded interests are sometimes literally right around the corner.

Third, it reinforced the belief that no matter what health care field one may work, it is still all about the patient! I am reminded of this every day in my work, and this workshop cemented that even more.

Fourth, it is exciting to see that my own institution has a plan for how to embed IPE into the curricula of the medical school, the nursing school, the school of social work, the dental school, the school of optometry, the school of rehabilitation sciences, and others (we do not have a school of pharmacy). There is much work to be done, but we are well on our way.

I was not originally scheduled to go to this, but had the privilege of attending portions of the workshop. I am so glad that I did, even if I missed some of the sessions for patient care duties. It has invigorated my interest in what I do in medical education. And isn't it great to be invigorated every once in a while?

Here are two links on IPE in medical education:
University of Toronto Centre for Interprofessional Education
AAMC Core Competencies for interprofessional collaborative practice

Alexander M. Djuricich, MD, FACP, is Associate Dean for Continuing Medical Education and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis. This post originally appeared at Mired in MedEd, where he blogs about medical education.

Anxiously awaiting the Supreme Court's decision on health care reform

noreply@blogger.com (Toni Brayer, MD) — Mon, 14 May 2012 15:00:00 +0000

The nation is anxiously awaiting the ruling of the Supreme Court on health reform (the Accountable Care Act, aka Obamacare) which will be announced in June. Six days of hearings were unprecedented in their partisan tone and we got a good idea of how the justices will vote. But no-one can truly predict how it will turn out until the last minute Each one has already rendered a private decision and the next two months will be for counterarguments and more deliberation before the final decision.

The justices can overturn the entire law, which would nullify many important health provisions that have already taken effect For example, 2.5 million young adults under the age of 26 could lose insurance coverage through their parents' plans. Patient safety improvements that are already in effect would be reversed Preventive care goes away and value based purchasing has just begun under ACA and could be reversed if the act is struck down

The justices could strike down the individual mandate part of the law After all, we are a free country and no-one should be forced to buy health insurance, right? Never mind that everyone is forced into Social Security and Medicare through payroll taxes and car insurance is mandated if you drive. Millions of people pay into Medicare and never use the service if they die before age 65 or are Christian Scientists or just hate doctors. No-one gets a rebate Never mind that emergency rooms and physicians are REQUIRED by law to treat uninsured people in the emergency room. No-one seems to mind about that mandate!

If they strike the mandate, they also nullify the provision for community rating and guaranteed insurance. There is no ACA without the mandate, something the GOP knows Mitt Romney and Newt Gingrich were fervent supporters of the mandate before they ran for President. If the mandate is eliminated, it's back to the status quo.

The Republicans would like to make Medicare into a voucher program. That shifts the buck back to people who can least afford it and guarantees higher administrative costs It essentially dismantles Medicare.

The Accountable Care Act is simply a start. It doesn't go far enough to reduce spiraling costs It does address inequalities of care and helps reign in abuses It is a start at shifting from "do more, despite the outcome" to focusing on value.

I support it and I hope the Supreme Court does too.

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

Dangerous electrolytes, part 1

noreply@blogger.com (Robert Centor, MD) — Mon, 14 May 2012 13:00:00 +0000

At the Internal Medicine 2012 meeting, I presented a one-hour session on dangerous electrolyte disorders. The patient presentation I used has many parts, so I thought you would like to work through this one.

The patient, a 40-something-year-old woman, has a long history of alcohol abuse. Recently she has had minimal oral intake with much vomiting. BP 100/60, pulse 120
120, 67, 32, 99
1.9, 21, 0.7, 8.9

pH=7.6
pCO₂=26
pO₂=100
HCO₃=21

Your job is to identify all the abnormalities in this panel, and suggest the sequence of events most likely to result in these numbers. What other information do you want? More information will continue next week.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.

QD: News Every Day--Jogging leads to longevity, but it's more like addiction

noreply@blogger.com (Ryan DuBosar) — Mon, 14 May 2012 11:00:00 +0000

Joggers may live longer and be happier, but the euphoria might just be more like the response some addicts experience.

Research presented at a conference suggested that jogging does work for longevity. Modest jogging from 1 to 2.5 hours per week divided into two or three sessions at a self-described slow to average pace was associated with a 44% reduction in the relative risk of death over 35 years compared with deaths among non-joggers, MedPage Today reported.

The "runner's high" is anecdotally well-documented, so researchers tried to put a little data behind it. They compared dogs, notable long-distance runners, to ferrets, which are not, reported NPR. Dogs naturally produced cannabinoids, and the ferrets didn't.

Physicians in the story reported addiction-like responses among their patients, including those who mentally fall apart when injuries force them to rest instead of run.

"THIS is Marketplace"

noreply@blogger.com (John Schumann, MD) — Fri, 11 May 2012 15:00:00 +0000

Thousands of fans wrote in after hearing my commentary this past Friday on the radio program Marketplace. Many of them had important questions:
"Did they fly you out to USC for the interview?"
"Is Robert Reich really that short?"
And of course, "So what does Kai Ryssdal actually look like?"

Well, sorry to disappoint.

I recorded the commentary at KWGS, the Tulsa NPR affiliate, several weeks ago. Not only did I not get to meet Kai Ryssdal at USC, apparently former Labor Secretary Reich records his commentaries somewhere in Northern California and doesn't trek down to L.A., either. [Though I hear he wears platform shoes when he records to make his commentaries sound more authoritative.]

If you have about two minutes, you can listen to the piece right here on GlassHospital by clicking on the play button embedded just below:

Feel free to go to the Marketplace website and leave comments on the commentary (!?) if you like this sort of thing and want to further my egotistical campaign to become a regular contributor there.

If you're really a glutton for medicine and radio (and GH), you can also catch a whole episode of the medical student-hosted and produced show RadioRounds right here.

Lastly, to complete the radio trifecta of media over-saturation for the week, click here sometime after 5 p.m. central on March 25 and you can hear StudioTulsa host Rich Fisher interview me about the rise of hospitalists in the U.S., based on the article I wrote for the Atlantic.com. You can also stream the show live from the KWGS website; the show airs at 11:30 a.m. and 7:30 p.m. central time

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

Where are the 'lollipop men' during handoffs?

noreply@blogger.com (Vineet Arora, MD) — Fri, 11 May 2012 13:00:00 +0000

I recently watched Dr. Atul Gawande on video describe how what American health care needs is pit crews and not cowboys. This sentiment is also memorialized in his thought-provoking writings for the New Yorker.

Interestingly, Dr. Gawande is not the first person I have heard to suggest such a thing. A colleague named Dr. Ken Catchpole actually studied Formula 1 pit crews and used the information to guide improvements in pediatric anesthesia handoffs. His observations were astounding and really highlighted how the culture of medicine is different from Formula 1.

In health care, the first time we often do something is "on the fly." Moreover, on-the-job training usually means checking the box by attending an annual patient safety lecture. In Formula 1, pit crews have a fanatical approach to training that relies on repetition. Perhaps the most important was the role of the "lollipop man" in pit crews. And yes, even though it's a funny name, it's a critical job.

As shown in the video, the lollipop man is responsible for signaling and coordinating to the driver the major steps of the pit stop. When it is safe to step on the gas, the lollipop man will signal to the driver. Sounds like a thing so perhaps it can be automated. Wrong. When Ferrari tried replacing the lollipop man with a stop light that signaled the driver, the confusion created (Does amber mean stop or go?) led to a driver leaving the pit with his gas still connected. Quickly after this incident, Ferrari announced it would go back to the tried and trusted lollipop (hu)man.

So, who are the lollipop men (or women) in health care? Turns out that Dr. Catchpole and his team observed that it was often unclear who was leading the handoff process that they were observing in health care. With team training and system reengineering, Dr. Catchpole's team was able to reorganize the pediatric handover so there was a lollipop man (anesthesiologist) at the helm.

While these handoffs represent a critical element of health care communication in a focused area, it is symbolic of a larger problem in health care. We are still missing lollipop men to coordinate health care for patients across multiple sites and specialties. This is even more critical on the two-year anniversary of health care reform and this month's match results.

At a time when we need to cultivate and train more lollipop men to coordinate care for patients, we have had stable numbers of students who enter primary care fields. And like the lessons from the Ferrari team, it is doubtful that a computer (even Watson who is now working in medicine apparently) will be able to do the job of a lollipop man.

So, how can we recruit more lollipop men? While it is tempting to blame the rise or fall of various specialties and market forces, it is important to recognize that being this is a difficult job to do when the lollipop is broken or even nonexistent. Without the tools to execute the critical coordination that lollipop men rely on, they cannot do their job.

So, the first order of business to ensure that the lollipop, or an infrastructure to coordinate care for patients through their race that is their health care journey, exists. As the Supreme Court debates the future of the Accountable Care Act, there is no greater time to highlight the importance of the lollipop.

Vineet Arora, MD, is a Fellow of the American College of Physicians. She is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist, supervising internal medicine residents and students caring for general medicine patients, and serves as a career advisor and mentor for several medical students and residents, and directs the NIH-sponsored Training Early Achievers for Careers in Health (TEACH) Research program, which prepares and inspires talented diverse Chicago high school students to enter medical research careers. This post originally appeared on her blog, FutureDocs.

QD: News Every Day--Involving internists in knee surgery teams reduced complications

noreply@blogger.com (Ryan DuBosar) — Fri, 11 May 2012 11:00:00 +0000

A consortium of leading U.S. health care systems found that managing knee surgery patients with comorbidities with medical teams that included internal medicine specialists among their ranks resulted in improved care.

The High Value Healthcare Collaborative (the Cleveland Clinic, Denver Health, Dartmouth-Hitchcock Medical Center, the Dartmouth Institute for Health Policy and Clinical Practice, Intermountain Healthcare, and Mayo Clinic) used administrative data to examine differences in their delivery of primary total knee replacement. The goal was to identify ways to improve care and cut costs, and tested more coordinated management for medically complex patients.

In the entire sample of total knee replacement patients, 45.6% were ages 45 to 64, and 59.7% were female. Almost 90% of patients were classified as overweight, obese or morbidly obese. The majority of patients had a Charlson score of 0.

Results appeared in Health Affairs. The study authors identified three key findings, including that the one health system with the lowest in-hospital complication rate had brought together patients with a multispecialty team prior to the surgery, including members from anesthesiology and internal medicine to co-manage medically complex patients.

Not surprisingly, other factors included facilities where experienced surgeons and other medical caregivers had the fastest operating times and shortest patient stays. Also, involving patients in their discharge planning process and managing patient expectations resulted in shorter hospitalizations.

"Because our initial analyses confirmed the relationship between greater comorbidity and higher inpatient complication rates, we anticipate that more coordinated management of medically complex patients should reduce complication rates and total knee replacement costs across the participating systems," the authors wrote.

Would you read peer review journals on e-readers and tablets?

noreply@blogger.com (Neil Mehta, MD) — Thu, 10 May 2012 17:00:00 +0000

I recently became involved in redesigning the web presence of a journal of a national academic medical society. The company tasked with the web design process conducted a small number of interviews with current and potential journal readers. They interviewed 3 people, with various backgrounds, training levels and interests in technology.

Some of the responses on these interviews were quite interesting and maybe surprising. Here are two opinions that were quite unanimous.

1. Everyone wanted to have the ability to download articles as PDFs.
2. None of the respondents wanted to read the articles on a mobile device (even a large screen one like a tablet).

As I was pondering about this, I saw a piece about eBooks and whether they impact learning negatively. The article discusses how one uses one's visual memory to link information with its location in a text book and why this can help recall.

I had a great discussion on this article with some folks over on Google+. The piece also has a nice video of how people use visual channels to remember information.

This morning I saw a presentation by Michael A Mabe, CEO of International Association of STM Publishers, recorded at the UKSG 35th Annual Conference in Glasgow, March 2012. I found a link to this talk on posts on Google+ by two folks who are thinkers and terrific curators on information in my areas of interest, Bertalan Mesko and A.J. Cann. The presentation discusses what researchers and readers want in their academic publishing and why these needs have led to the current format of the print journal and why technology has not made much of a change in this format.

Just to make matters more interesting, I remembered reading a piece by Clay Shirky on Social reading. I had saved it to my Evernote and I dug it up again. It is titled "How we will read."

Clay talks about how when he used to read on the original Kindle it did not have e-mail to distract him. He mentions Nick Carr and the use of Frost's quote as a book is a "momentary stay against confusion". He talks wistfully of the times when he was bored and the importance of boredom as a way to recognize the gap between what you are interested in and your current environment. But he moves on to discuss the benefits of annotating on his new Kindle and the value of social reading.

Maybe with evolution of the appropriate apps on mobile devices and as readers experience them, we will change our habits? Here is an image from @gtuckerkellog describing his workflow for reading his scientific literature on tablets. TechCrunch has an article about how Netizine might be a solution.

Where did I read the Clay Shirky interview? On Evernote app on my Motorola Xoom of course!

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.

Suffering and its expression in psychiatric and medical disease

noreply@blogger.com (Justin Penn, MD) — Thu, 10 May 2012 15:00:00 +0000

Stephen Ginn, MD, a psychiatrist for BMJ, recently tweeted an interesting article about explanations and suffering written by Jon Jureidini that was published in the Australian & New Zealand Journal of Psychiatry. The author provides an interesting review of how the medical-psychiatric community labels the manifestations of suffering as psychiatric diagnosis and how these labels do nothing but describe the manifestations and ignore the underlying issue(s) at hand with "unexplanations."

Any internist will be able rapidly identify with the portrait of the state of medical/psychiatric diagnosis and its treatment which leaves many patients with labels but no understanding of their suffering.

An analogy to medicine would be labeling someone with anemia without any thought or workup of why someone had anemia. The anemia is a symptom of a complex pathway of hematopoesis. Patients suffering from anxiety or depression are more than just those labels. There are complex biochemical, personal, familial, and cultural factors that are at play.

The article is a good, fun read.

Justin Penn, MD, ACP Associate Member, attended medical school at the University of Washington School of Medicine and trained in internal medicine at the University of Rochester, where he is serving as Chief Resident. This post originally appeared at his blog, Musings of an Internist.

5 implications of 'pink slime' (and how to get beyond them)

noreply@blogger.com (David L. Katz, MD) — Thu, 10 May 2012 13:00:00 +0000

As those who know me best will attest, I am far from crude. If anything, I tend to err the other way with an excess of Monkish fastidiousness. It is in deference to that inclination, and on the chance you may share it, that I warn you in advance of a departure this conversation requires. I am about to use the word "snot" in a less-than-pleasant context.

I was having dinner in an airport restaurant last week, around the time nutrition news was slathered in pink slime. Two young businessmen were sharing a meal and spirited conversation at a nearby table. I was not listening in, and don't know what their conversation was about. But I couldn't help but notice, out of the corner of an eye, that one of them was repeatedly dipping a fork into a small plastic container of salad dressing, before spearing some portion of his salad.

That's a good practice, by the way, because dressing on the tines of a fork imparts flavor to the salad with a lot less dressing, and many fewer calories, than if the dressing douses the salad. But the relevant consideration was something else. As he raised his fork from the container of dressing, it hung down from the tines in strands each time, looking for all the world like long strings of purple snot. Sorry, I warned you.

What WAS it? The purple was, presumably, imparted by balsamic vinegar, no problem there. But I'm sure you know as well as I that the consistency of vinegar is not remotely snot-like. What gives salad dressing the consistency of the mucopolysaccharides we do all we can to banish from our nares, sinuses and bronchi? I don't know.

I received a plastic cup of "balsamic vinaigrette." It was pink, and slimy, and I ignored it. I asked for olive oil and balsamic vinegar and made use of those. No slime, or snot, was involved.

I have been reflecting on pink slime, and purple snot, ever since, and think there are five important implications here, only one of which, and the least important, has to do with pink slime, per se.

1. Pink slime is rather yucky. As you likely know by now, this less-than-flattering but well-deserved moniker applies to lean finely textured beef, a widely-used food additive. Some of you now know that you have been eating the stuff all along, in blissful ignorance.

Whether or not pink slime is bad for health, a topic generating impassioned debate, may be moot. If people don't like the idea of eating it, it will go away. I have an opinion about the likely health effects of pink slime, but there's no need to go there. What I know best is that the foods best for health are generally not prone to any such adulterations.

2. Pink slime is the visible tip of an invisible iceberg. I know this from working in nutrition for 20 years. I know it, in particular, from work related to NuVal, which has required that over 100,000 foods, literally, come over the transom, with full ingredient lists on display. I had much better-than-average knowledge of the food supply before this, but looking at ingredients in 100,000 foods, I certainly have learned things I never knew I never knew!

Pink slime tells us much about the character of a modern food supply comprising hundreds of thousands of packaged foods, and a whole industry devoted to additives. Pink slime has been "outed," so you can get it out of your diet.

But how many other variations on the theme of pink slime might there be? What IS that purple snot salad dressing, anyway? How many food components have yet to be outed, and thus are still finding their way into you, and your family, as a matter of routine? Food for thought.

3. Beware the post-apocalyptic Twinkie. Jokes abound that little other than cockroaches and Twinkies will survive the apocalypse. But this is only funny up to a point. Many studies show that higher intakes of pure foods, mostly plants, enhance the length and quality of life; while diets of mostly processed foods generally mean less years of life, less life in years. In other words, if it lengthens the shelf-life of foods, there is a good chance it shortens the shelf-life of people eating those foods! When the "people" in question are, for instance, your kids, suddenly it's not at all funny. What we eat matters!

4. If you want to know what ISN'T in your food, you only need to know what is! OK, so you didn't know about pink slime before last week, and you don't know what makes purple snot either. And neither of us knows how many other things there might be in our food that we don't really want to eat. But we don't have to. The immune system doesn't know every pathogen in the universe, it just knows "self," and what belongs in the body. By knowing what belongs on the reservation, it can do a pretty good job of keeping everything else off.

We can do the same, by eating foods with ingredients we know, recognize, can situate in some part of the plant or animal kingdom, and can pronounce. Don't assume that what you don't know about food can't hurt you. There is some evidence to suggest that in some instances, it has been engineered to do exactly that. Or at least to make sure ... that you can't eat just one.

5. Demand, or lack thereof, trumps supply! The major supplier of pink slime to the food industry is filing for bankruptcy. This did not require any legislation, just widespread consumer outrage. If you won't buy it, they can't sell it.

Of course, I feel badly for any factory workers losing jobs over this, they are the innocent, collateral damage in the war for food integrity. But the real message here is that the food supply is not some inviolate, immutable thing. When the food demand changes, the food supply changes! We have real power, folks, so let's use it. If every loving parent and grandparent in the nation took a real interest in, acquired a working knowledge of, and made purchases in accord with what's in our food, the food supply would get better in a big hurry.

Pink slime happens to have been outed. But what other things that you never knew you never knew were in your food are still finding their way into you, and your kids? "You are what you eat," combined with either pink slime or purple snot, make a rather unappetizing recipe.

So let's know what we eat, and eat what we know. The most important thing this tale reveals is that when we do so, we're in charge!

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

QD: News Every Day--Internists to see Medicaid pay rise to match Medicare rates

noreply@blogger.com (Ryan DuBosar) — Thu, 10 May 2012 11:00:00 +0000

Primary care physicians serving Medicaid patients would see their payments rise under a proposed rule announced by Health and Human Services (HHS), the agency announced.

The increase would take effect for calendar years 2013 and 2014. States would receive a total of more than $11 billion in new funds to bolster their Medicaid primary care delivery systems.

The proposed rule would implement the Affordable Care Act’s requirement that Medicaid reimburse general internal medicine, family medicine, pediatric medicine, and related subspecialists at Medicare levels. The federal government will fund the increase entirely, with no matching payments required of states.

Other recently announced initiatives under the Affordable Care Act include grants to help build and expand community health centers.

Also, HHS announced that more than 150,000 primary care providers nationwide received almost $560 million in higher Medicare payments in 2011 under provisions of the Affordable Care Act.

In other news, two members of the U.S. House of Representatives introduced a measure calling for a permanent fix to the Sustainable Growth Rate formula currently used to pay doctors. The Hill reports that one of the lawmakers, an osteopathic physician, called the bill a way to begin a conversation about long-term Medicare reforms.

Dr. Eric Topol and the creative destruction of medicine

noreply@blogger.com (Elaine Schattner, MD) — Wed, 09 May 2012 15:00:00 +0000

Before reading Dr. Eric Topol's Creative Destruction of Medicine, I wasn't sure what to expect. Dr. Topol, a cardiologist with a background in genetics, was a prominent figure in the take-down of Vioxx. He was at the Cleveland Clinic back then, around 2004, and has since moved to direct the Translational Science Institute at Scripps. He was a few years ahead of me in academic medicine and, by almost any parameter, far more successful.

He's a TED speaker, I knew. From the TED bio: "Eric Topol uses the study of genomics to propel game-changing medical research." His work sounds exciting! I first read of the new book in a recent, tech-minded interview in Wired. Seemed like it might be all theory, no touch-y, little reality. With this lead-in, I wasn't quite prepared to like this book, although I was interested.

Dr. Topol's book is fantastic. I couldn't put it down because it's chock-full of good, critical ideas about clinical medicine. The title, "Creative Destruction," is a reference to Joseph Schumpeter's theory of radical transformation through innovation. In Chapter 1, he outlines the "Digital Landscape" and explains, simply, how a convergence of advances in technology over the past 40 years, like personal computers, cell phones, the Internet, connectivity and instant access to data, have set the stage for a dramatic shift in medical culture and practice. Doctors, for some reason, have been slow to adapt digital technology to health care, but this is changing, fast.

One theme that emerges through the book is the capacity for technology by "knowing" and processing so much real-time information about each person's condition to inform more effective, individualized treatments. This comes up in his critique of evidence-based medicine and later, when he considers progress in molecular oncology and again, in a section on the pitfalls of old-fashioned, large clinical trials involving many (hundreds or thousands of) patients unlikely to benefit.

Dr. Topol's comfortable writing about the intersection of science and medicine as few physicians are. He describes several clinical episodes, like when the first patient with a stroke received tPA, a clot-dissolving agent. The point is, he's been there, at some of the world's best hospitals, where innovative treatments have been applied. But he's also seen first-hand disappointment, too. This grounds the work. There's a long chapter on "Biology" which offers, among other insights, a realistic critique of genetic information that many doctors don't understand. He identifies value in hypothesis-free research, and considers high-throughput screening.

I should mention two provocative details, among many. One appears in Chapter 3, on "empowered" medical consumers. At the Cleveland Clinic Foundation, where he'd worked and served on the Board of Governors, Dr. Topol observed busy, otherwise-occupied trustees who contributed significant time and money to the hospital. One reason they did so, he says, was so they might have access to the best doctors "in case anyone in my family or I get sick" (p. 50). He cites flaws in popular hospital ranking systems, like U.S. News & World Report, and offers tips for how to find a good doctor for a particular condition, like checking publications in Google Scholar and looking for senior authors of highly-cited papers. He writes: "The heterogeneity of the quality of care is not adequately appreciated, and all too often consumers accept the convenient, easy alternative ... If this involves a physician or surgeon who does procedures or operations, it is essential to ask for the exact number of procedures performed per year and cumulatively over his or her career ..." (pp. 52–53)."

The point here is that physicians are not machines. Some are more capable than others, and the quality of care received depends on the doctor's training, experience and other human qualities.

Another gem, in Chapter 11, pertains to the "science of individuality." We're at a threshold, Dr. Topol says, of eliminating ignorance in medicine. For doctors and informed patients who happen upon this review: idiopathic, essential and cryptogenic diseases will be gone. Instead, we'll have conditions defined molecularly or, even if not understood, rooted in the concept of n=1. He writes: "... a new body of data that can be derived from any individual, both at baseline and after an intervention ... This opportunity leverages the immense molecular biological, physiologic, and anatomic data that can be determined for any individual, and reinforces that the ultimate goal of an intervention is to have a markedly favorable impact on each n-of-1, rather than the current model, which emphasizes population medicine with the relatively small chance that any individual may derive benefit."

What he's saying is that the more quickly and inexpensively we can gather and process details about a patient's medical condition, the more cleverly we can apply treatments designed to help, even in the absence of large trials.

I love this idea.

This post originally appeared at Medical Lessons, written by Elaine Schattner, ACP Member, a nonpracticing hematologist and oncologist who teaches at Weill Cornell Medical College, where she is a Clinical Associate Professor of Medicine. She shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology and as a patient who's had breast cancer.

So very special(ist)

noreply@blogger.com (Zackary Berger, MD) — Wed, 09 May 2012 13:00:00 +0000

This wouldn't be so confusing if I had thought about what specialists and general practitioners are each supposed to do. But I have no such a priori understanding. I send a patient to a specialist, and my thought is something like this: "Gee, I hope they pursue a self-limited course of diagnosis and treatment based on the clinical question I have in mind!"

And the patient, on the other hand, thinks something like: "Dr. Berger wants Dr. Gutskener to figure out why my belly hurts."

Dr. Gutskener, on the other hand, possesses a treasure of expertise around the gastrointestinal tract, and doesn't generally feel his role to be limited in the sense Dr. Berger (me) is thinking of. He takes "limited" to mean "within a given subspecialty"--he does GI, not neurology or cardiology. But within GI, he is taking care of the patient referred to him as best he knows how, and that does not mean a minimal approach.

At some point, telling a specialist not to further test and treat a patient is like Ronald Reagan trying to recall a missile that has already been launched by submarine. But I have had patients where I would like to e-mail the specialist and say, politely, Stop!

Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.

QD: News Every Day--Is obesity because of society?

noreply@blogger.com (Ryan DuBosar) — Wed, 09 May 2012 11:00:00 +0000

A new forecast projects 42% of Americans will be overweight by 2030, and experts are now doing some blamecasting of their own. It's too easy to eat and drink extra calories, and to not exercise, said public health officials at a three-day conference.

The Centers for Disease Control and Prevention released their figures at an obesity conference, and other organizations presented their reports as well. The study, published by the American Journal of Preventive Medicine, is actually a better projection than some previously published ones that estimated half the population would be overweight or obese by 2030.

One of the report's panelists commented to Reuters, "[W]when you see the increase in obesity you ask, what changed? And the answer is, the environment. The average person cannot maintain a healthy weight in this obesity-promoting environment."

After all, research has shown that moms think their chubby toddlers are normal and healthy. A study in the May issue of Archives of Pediatrics and Adolescent Medicine showed that Nearly 70% of mothers were inaccurate in assessing their toddler's body size. Compared with mothers of healthy-weight toddlers, mothers of overweight toddlers were 87% less likely to be accurate. More than 70% of all mothers and 81.7% of mothers of overweight toddlers were satisfied with their toddler's body size.

The Institute of Medicine issued its ownreport that identified societal changes such as making healthy foods and exercise "easy, routine, and appealing aspects of daily life."

The report focused on five goals: integrating exercise into people's daily lives, making healthy food and beverage options available everywhere, better marketing about nutrition and activity, making schools a gateway to healthy weights, and recruiting employers and health care professionals to support healthy lifestyles.

Specific strategies include requiring at least 60 minutes per day of physical education and activity in schools, setting industry-wide guidelines on which foods and beverages can be marketed to children and how, expanding workplace wellness programs, fully capitalizing physicians to advocate for obesity prevention with patients and in the community, and increasing the availability of lower-calorie, healthier children's meals in restaurants.

The changes would involve fast food restaurants, which would ensure that half their menus comply with federal dietary guidelines for moderately active children and charge little or no more for these options, the report says. But shopping centers, convention centers, sports arenas, and other public venues that make meals and snacks should do so as well.

The food, beverage, restaurant, and media industries should step up their voluntary efforts to develop and implement common nutritional standards for marketing aimed at children and adolescents up to age 17. Government agencies should consider setting mandatory rules if a majority of these industries have not adopted suitable standards within two years, the report said.

Other suggestions included:
--develop a private and public marketing campaign that encourages healthy activities and habits,
--offer tax credits for sidewalks near new housing and for supermarkets in communities without them, and
--give schools the resources and support to implement federal nutrition standards for meals and for products served in vending machines, concession stands, and other venues, as well as make food literacy part of their curricula.

If I wrote the questions for the boards

noreply@blogger.com (Peter A. Lipson, MD) — Tue, 08 May 2012 17:00:00 +0000

1) A 24-year-old male walks into your office. He is 40 minutes late for his appointment. He begins to talk loudly at the check-in so he is brought back to spare the other patients. On questioning he reports that his chronic back pain is worsening and his roommate has stolen his pain medication. Now what?

2) A 60-year-old divorced woman is seen for "fatigue." When you ask her how she is doing she begins to cry. She states that she is losing her job, and her sister, with whom she lives, is suffering from dementia. The patient's salary pays for their living expenses and the job provides the patient with health insurance. She has insulin-dependent diabetes and peripheral vascular disease. She went to a social worker who told her that she would have to sell her house before qualifying for Medicaid. Now what?

3) A 52-year-old man with a history of alcohol abuse comes to see you after being released from the hospital. In the hospital, two drug-eluting stents were placed as treatment for an acute myocardial infarction. He was sent home with five prescriptions, one of which is clopidogrel. The cost of this drug is $200 monthly and he lives off money from odd jobs. He is functionally illiterate. Now what?

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

Autism, and Pandora's box

noreply@blogger.com (Rob Lamberts, MD) — Tue, 08 May 2012 15:00:00 +0000

Hello, Pandora. What do you have in that box?

Yes, I am going to talk about autism. The last time I did so I was inundated with people trying to convince me of the dangers of immunizations and their causal link to autism. I really, really, really don't want to go anywhere near that one.

No, I am not going to talk about the cause of autism; I am going to talk about my observation of the rise of the diagnosis of autism, and a plausible explanation for part, if not most of this fact. The thing that spurs me to write this post is a study by the CDC that was quoted in the New York Times: "The new report estimates that in 2008 one child in 88 received one of these diagnoses, known as autism spectrum disorders, by age 8, compared with about one in 110 two years earlier. The estimated rate in 2002 was about one in 155."

The rise in numbers is cited as one of the main evidences for some external source, a new thing in our environment, that is causing this rise. The article, however, gives another clue: "The frequency of autism spectrum diagnoses has been increasing for decades, but researchers cannot agree on whether the trend is a result of heightened awareness, an expanding definition of the spectrum, an actual increase in incidence or some combination of those factors. Diagnosing the condition is not an exact science. Children "on the spectrum" vary widely in their abilities and symptoms, from mute and intellectually limited at one extreme to socially awkward at the other. Children with such diagnoses often receive extensive state-financed support services, which some experts believe may have contributed to an increase in numbers."

That last sentence holds the golden ticket. What would make me think this? My experience.

I started practice in 1994, taking care of both adult and pediatric patients. At that time, autism was a sink-in-the stomach diagnosis. When I suspected autism in a child it felt the same as when I suspected cancer. The diagnosis of autism was as devastating as any diagnosis I could give, as it told many parents that their child would not ever be "normal," requiring special education, visits to specialists, and a lifelong burden of care. It was a very, very big deal to diagnose a child with autism, so I didn't breathe the word unless I was certain of the diagnosis.

Fast forward to 2012, and an incredible change has occurred: the emergence of "autism spectrum disorders," the most well-known of which is Asperger's syndrome. This syndrome was first described in 1944, but it wasn't until 1994 that it was formalized as a clinical syndrome (i.e. the big-wigs believed it was real and docs could bill for it). The emergence of these disorders made the diagnosis of autism much less scary, as many of these kids were quite functional. We would have just called them "odd kids" when I was young.

So why the sudden importance of a diagnosis that is basically "sort-of autism?" I remember when parents first came in asking me if their kids had Asperger's syndrome, and it took me a while to figure out why they wanted this diagnosis. The reason? To receive specialized services from the state. Teachers and parents both could get better schooling for these children who would have not thrived in the standard system, so both were motivated to want the diagnosis. What was once the equivalent of a diagnosis of cancer became a ticket to a better education and brighter future for the child.

Please note that I am not saying that this shift is wrong or that it is a bad thing. Early intervention does, in my opinion, help these kids immensely. I do believe it is good to tailor the education of kids to their needs, and a medical diagnosis is an easy way to accomplish this.

But also note the 180-degree shift in the relationship of both parents and doctors to the diagnosis; it used to be a horrible thing, and now it is a very good thing to diagnose. I am diagnosing much more autism; but I believe this is not because I am seeing more of it. I simply have more motivation for the diagnosis and more latitude as to what that diagnosis entails.

Is this the whole reason for the increase in autism? I have no idea. I don't even know if my assessment that I am not seeing more autism is accurate. What I do know, however, is that a significant portion--the vast majority--of the increase in my practice is due to this change in attitude toward the diagnosis and the addition of the "spectrum."

Again, I am NOT claiming anything about the validity of others' claims that environmental factors have a role in this. I am simply saying what I have observed and how I interpret that. I think any argument ... uh ... discussion on autism has to take this into consideration.

Thanks, Pandora.

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

Weight-loss surgery more effective for diabetes than medication

noreply@blogger.com (Albert Fuchs, MD) — Tue, 08 May 2012 13:00:00 +0000

About 20 million Americans currently have type 2 diabetes, three times more than in 1980. Diabetes is a major risk factor for stroke and heart attack, is the leading cause of new cases of blindness, and is the largest cause of the need for dialysis. Diabetes is also usually progressive, meaning that on the same medications and on the same diet and exercise regimen, the blood sugar of a patient with diabetes will slowly increase, necessitating constantly increasing amounts of medications.

So despite new families of medications for diabetes, and despite the fact that most patients require more than one medication, many patients never achieve good control of their blood sugar.

Two studies published this week in the New England Journal of Medicine offer tantalizing hope for overweight patients with diabetes. Both studies attempted to discover whether overweight patients with diabetes would achieve better control of their diabetes through weight loss surgery or through standard medical care.

One study, conducted in Italy, randomized 60 patients to three groups. One group was treated with medication. Another underwent gastric bypass surgery. The third group underwent biliopancreatic diversion surgery. (See the helpful graphic in the New York Times article for an explanation of the different surgeries. I thought biliopancreatic diversion was the name of a gastroenterology theme park.) The endpoint of this study was very ambitious: remission of diabetes, defined as normal sugars without medication for over a year.

None of the patients receiving medical therapy achieved remission, compared with 75% of the patients who underwent gastric bypass, and 95% of the patients undergoing biliopancreatic diversion.

The second study, from the Cleveland Clinic, randomized 150 overweight diabetic patients to gastric bypass, sleeve gastrectomy, or medical therapy. The patients in the surgical groups had much better control of their diabetes than the medical therapy group, and many in the surgical group were able to stop their diabetes medications.

Those are very impressive results, but some questions remain unanswered. Does the remission of diabetes mean that the patient is cured? We don't know. Since the studies followed patients for at most two years, it is entirely possible that years from now their diabetes will recur. Will the excellent control of diabetes translate to fewer diabetic complications, like strokes, heart attacks, and kidney disease? Do diabetics who are less overweight than those in these studies still benefit from surgery? Larger long-term studies will be needed to find out.

But for now it is clear that for overweight patients with diabetes, surgery should no longer be thought of as a last resort. Surgery is increasingly a proven therapy with much greater effectiveness than other alternatives.

Learn more:
Weight-loss surgery effective against diabetes, studies show (Los Angeles Times article)
Surgery for Diabetes May Be Better Than Standard Treatment (New York Times article)
Bariatric Surgery (New York Times, instructional diagrams explaining the anatomy of various weight loss surgeries)
Bariatric Surgery versus Conventional Medical Therapy for Type 2 Diabetes (New England Journal of Medicine article)
Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes (New England Journal of Medicine article)
Surgery or Medical Therapy for Obese Patients with Type 2 Diabetes? (New England Journal of Medicine editorial)
Evidence Mounts in favor of Weight Loss Surgery (My last post about weight loss surgery in 2011, with links to my previous posts about this topic)

Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.

QD: News Every Day--Authoritarian doctors and the fear of being labeled 'difficult'

noreply@blogger.com (Ryan DuBosar) — Tue, 08 May 2012 11:00:00 +0000

Surely, it's not the first time the television comedy "Seinfeld" was cited in the scientific literature, was it? A study in Health Affairs interviewed patients on why they don't challenge their doctors more often on shared medical decisions, and the answer was clear. They don't want to be labeled as "difficult" for fear of reprisal.

Study participants were recruited from three primary care practices in Palo Alto, California, an affluent suburb in the San Francisco Bay Area. Data collection took place between October and December 2009. The patients trended to be older than 50, affluent and well-educated.

Forty-eight patients first watched a video that depicted equal and reasonable alternative to treat coronary artery disease and then broke out into focus groups. Four themes emerged.

Patients feel compelled to conform. Patients want collaborate with their physicians in making clinical decisions, but they also noted that their ability to do so depended on the physician. They described a sense of needing to adopt the role of a "good" patient and awareness that questioning a doctor raised the impression of challenging their expertise and raising the risk of reprisals.

Physicians can be authoritarian. "Although participants recognized the expertise of physicians, they also felt that the authoritarian stereotype was often perpetuated by physicians themselves," the authors wrote.

Patients work to fill information gaps. Patients reported seeking online information, either to not "rock the boat" with the doctor or because the allotted visit time left them with no other option.

Patients feel the need to bring social support to the consultation. participants talked about bringing family members or friends into clinical encounters, to help take notes, assimilate details and ask questions.

"Knowing they may need to return at some later time, participants felt they were vulnerable and dependent on the good will of their physicians. Thus, deference to authority instead of genuine partnership appeared to be the participants’ mode of working," the authors wrote. "These findings are striking, given that participants were mostly wealthy, highly educated people from an affluent suburb in California, generally thought to be in a position of considerable social privilege and therefore more likely than others to be able to assert themselves in a medical consultation."

The authors suggested a few steps to alleviate the problem: adequate reimbursement, decision support tools, increasing efficiency and directly addressing the difference in perspectives with physicians. They didn't provide an entry in the study references for the Seinfeld episode, but the clip about the character of Elaine being labeled difficult is here.