ACP Internist

Diet, diabetes and Paula Deen: Southern fried comfort gone awry

noreply@blogger.com (David L. Katz, MD) — Mon, 13 Feb 2012 14:00:00 +0000

I needn't belabor the news that Paula Deen, a celebrity chef on TV (that was news to me; nobody tells me anything) "came out" with her Type 2 diabetes. Paula Deen's cooking has apparently long been a study in Southern-style indulgence, with an emphasis on the deep fryer and plenty of butter. From what I have gleaned, Ms. Deen has never met a nutrition fact she didn't like to ignore.

But I'm not inclined to wag a finger at Ms. Deen. Nor do I want to wade into the debate about her advocacy for a particular diabetes drug to treat a condition she need not have developed in the first place.

I want simply to talk about the opportunity to love food that loves us back, and the fundamental importance of making that the prevailing norm.

First, food matters. We have incontrovertible evidence, reaffirmed many times over the past several decades, that the major determinants of premature mortality and chronic morbidity in modern society are tobacco use, dietary pattern and physical activity. Or, as I like to put it, feet, forks and fingers.

We have clear evidence that even moderate improvements of diet and activity can prevent Type 2 diabetes in nearly 60% of high-risk adults, and evidence that more fundamental improvements to lifestyle could prevent almost all of it, and certainly more than 90%. We know that children now get Type 2 diabetes, while a generation ago it was called "adult onset" diabetes, because the condition in children was essentially unheard of.

We know that diet can be and often is the difference between good health, and ill health. This is not controversial.

The trouble is, we have propagated the view that we have to choose between food we love, and health we love. And since food provides immediate gratification, while good health is a long-term return on a long-term investment, the immediate gratification of food tends to prevail. We eat, drink and make merry, and defer worrying about the cost. But the cost eventually comes due, all too often in the form of a serious chronic disease that need not have occurred.

As chronic diseases develop at ever younger age, while we live to ever longer, the percentage of our lives encumbered by that "cost" is rising. And, consequently, so is the cost itself. We pay dearly.

In essence, then, we are mortgaging our health to pay for the pleasure of our palate. This may be hard to justify under any circumstances. But there would, at least, be a case to be made if the only way to enjoy food were to give up health. If the only food that tasted good were bad for us, we would have a tough decision to make. And some might say to hell with health! They might come to regret it, but we could all understand the choice.

But there is no such choice to be made. There are variations on the theme of optimal eating available to us all. Among them is the Mediterranean diet, which is itself a dietary theme and parent to a number of variations. Important about them all is this: Many of us would go to Mediterranean countries and gladly spend our good money on the excellent food! Not because the food is good for us, but because it's just plain good!

But it is also good for us. It offers us the opportunity to love food that loves us back. To get pleasure in the pursuit of health, and health in the pursuit of pleasure. The Mediterranean diet offers this -- and so do many other cuisines around the globe. Whatever your palate, there is room for you where culinary pleasure and health converge.

Given this possibility, why practice the brand of denial that seems to prevail? Those of us who advocate for healthful eating need not be culinary cretins. My wife, raised in southern France, is a fabulous cook. Catherine and I, and our kids love good food. We just love food that loves us back.

And chefs need not fry butter to show they care about cuisine. In an age of epidemic obesity and diabetes, chefs can shoulder the responsibility of making food that is both good, and good for us.

An analogy springs to mind. Cars can have incredible horsepower. They can also have great fuel efficiency. There was a time when great horsepower at the expense of lousy fuel efficiency was fine. But we now know the costs of that profligacy, monetary costs, and more importantly, environmental costs. We are now inclined to demand both fuel economy and performance, or strike a balance between the two. But the world no longer condones a "to hell with fuel efficiency" attitude, because the stakes are too high.

I suppose you might watch a car race for fun (I don't get that, actually, but different strokes), but in doing so, you generally aren't planning on getting that kind of car, or driving that way. Car racing is not intended as an audience-participation experience. If cooking shows were a similar diversion, it might not matter much what the chefs are cooking. But if, as seems probable, the intent is "go ahead and try this at home!" then what's cookin' truly does matter.

The stakes are every bit as high in our kitchens, as in our garages. Our health and the health of those we love are on the line. So maybe it's time for us all to draw a line in the sand and not cross. Chefs who can't make food both good and good for us don't really have enough expertise to warrant our attention. They don't have the full culinary skill set modern living requires. We should tune them out.

Pretending that food doesn't matter to health is at best denial, at worst a serious delusion. We should not mortgage health to pay for culinary delight, any more than we should give up culinary pleasure to purchase health. We can love food that loves us back.

Bring on the chefs talented enough and responsible enough to help us bake that particular cake, and eat it, too!

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--Young doctors pick up the slack in palliative care

noreply@blogger.com (Ryan DuBosar) — Mon, 13 Feb 2012 12:00:00 +0000

Palliative care is a growing need and a growing career choice for doctors. Professional societies are recommending palliative care at the first diagnosis, and young physicians are flocking toward the field to meet that demand.

American Society of Clinical Oncology issued a provisional clinical opinion that patients with metastatic non-small-cell lung cancer should be offered palliative care and standard oncologic care when they are diagnosed.

The opinion reads, "Although there's no proven survival benefit, substantial evidence demonstrates that palliative care--when combined with standard cancer care or as the main focus of care--leads to improvement in symptoms, quality of life and patient satisfaction, with reduced caregiver burden. Earlier involvement of palliative care also leads to more appropriate referral to and use of hospice, and reduced use of futile intensive care."

The provisional clinical opinion was released in the Journal of Clinical Oncology on Feb. 6.

Currently, palliative care is synonymous with end-of-life care, often within the final month of a patient's life. End-of-life discussions don't take place until then, too. But the provisional clinical opinion comprised seven published randomized controlled trials that showed there have been no trials to date have demonstrated harm to patients and caregivers, or excessive costs, from early involvement of palliative care. The panel's expert consensus is that combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high symptom burden.

Palliative care physicians have long advocated for earlier integration into health care delivery, citing the advantages. They want to overcome the myth that palliative care equates throwing in the towel.

The Center to Advance Palliative Care reported last year that the number of palliative care teams within hospital settings has increased approximately 138% since the year 2000, from more than 600 then to more than 1,500 today.

Fortunately, there's a growing workforce to potentially match the need. The San Jose (Calif.) Mercury News reports that about 12% of the doctors certified in hospice and palliative care in 2010 are now 36 or younger, citing data from the American Board of Medical Specialties. One factor is that mid-career physicians would have to undergo a one-year fellowship to become certified, which many doctors would find financially prohibitive.

This leaves the younger doctors to pick up the slack.

Broken system #1: The distance between work and pay

noreply@blogger.com (Rob Lamberts, MD) — Fri, 10 Feb 2012 16:00:00 +0000

I think people missed my point. Let me say again to those who misunderstood my last post: I am talking about the health care system being broken, not health care itself. Our system is broken, which means that the money put into it is being wasted in staggering amounts. Yes, we are getting some amazing results in regards to the care itself, but those happen despite the system, not because of it (most of the time, at least). My first item of broken-ness will make the point.

Our office is not getting paid this year. We used our credit line to fund my last paycheck.

Bad business? Not at all! We have worked very hard, seeing lots of patients in the usual surge that happens at this time of year. So, one would expect, more work means more pay, right? Not in our system. While we do collect some money from patients up front, most of our billing goes to a third-party (insurance or government), and in many cases a fourth party (supplemental insurance). The most important bill we send for our work goes to the "carriers," not to the patient. We have all accepted this as the norm, and it may be the only way to do health care in some circumstances. But this year there is a major glitch in the system.

I was actually not 100% truthful in my statement about who we bill. The truth is, we don't actually send our bills to insurance companies. Since there are a gazillion insurance companies, all with different contracts with different doctors, we actually send them to a clearinghouse. These companies (not to be confused with those who present giant checks at people's doorsteps) take electronic submissions from doctors' billing systems and re-route them to the appropriate insurance vendor. This saves us the hassle of remembering where to send each bill, which would be nearly impossible. They do take a little bit of our money in the process, but the time it saves us is worth it.

Assuming the clearinghouse gets it right and sends the bill to the proper place, the insurance company then either pays on the claim, or denies it. The news of their decision then goes back through the clearinghouse and to us. If it is denied (which it often is), we figure out why that happened, and whose fault it was. Sometimes the insurance company made a "mistake" and denied it in error. Sometimes the clearinghouse sent it to the wrong branch of Blue Cross or got our identifiers wrong. Sometimes we submitted it using a bad diagnosis or other technical error. Sometimes the patient forgot to tell us their insurance changed or lapsed.

This is the day-to-day complexity of medical billing in our system.

But things aren't working this year. The problem is in the clearinghouse part of the equation. As of Jan. 1 there was a new standard that clearinghouses had to comply with, called the "5010 of the x12 HIPAA transaction and code set standards." It puts me into a dazed stupor when I read the explanation of just what this is, but the HIPAA part has to do with patient privacy, so I suspect this is a patch to some privacy leaks in the billing system.

This also has to do with the change to ICD-10 (another broken thing I'll hit on in future posts), which is the code we have to use to submit our bills to the clearinghouses and ultimately to the insurers. The problem is, many of these clearinghouses are not compliant with the 5010 rule. Since it was a government rule dealing with HIPAA and since these clearinghouses are not paid if they do not run through transactions, I assume it was a highly complex and confusion standard. In other words, they had a hard time doing all the things the government required.

But the upshot of this for us: Nothing is going through. Nothing. And that means that we don't get paid.

Word on the street is that this is a nationwide problem, and we aren't the only practice not getting paid. The insurance companies have no problem with this, as they are hanging on to "their money" a little longer. The clearinghouses are frantically trying to fix this, but we're not sure when that will happen. When it does, the queue for submission will be enormous, and so the payments will undoubtedly be more delayed.

All of the complexities in our system add cost, and the billing/payment system is mind-boggling in its complexity. The bottom line is that there is always a long separation between the work I do and the payment I get. There are many steps requiring many people and giving room for many problems. These problems, of course, give more people work to do (all of whom get paid faster than I do) cleaning up the mess made by the confusingly complex system.

It reminds me of the game I played when I was a kid, where one person whispers "Llamas hygiene is next to godlessness" to the person next to them, and that person in turn whispers what they heard to the next person. When it gets to the end of the line of people, the last person tells what they heard, usually something like "the elevator spins in an ornate bathtub."

This translation is often similar to what happens in our payment system, with payments not quite resembling the bill that was sent. It is, of course, our responsibility to find any errors in the payment, re-submitting them through the chain to get the payment we should get from the billing. It is our responsibility because everyone else got paid. We used to have multiple employees to do this, but now have a company that specializes in this to do the job (they get a cut of what they collect).

This gives a glimpse into a reason the cost of care is so high. I have to negotiate a higher bill than I need because of all of the other people earning money off of the transaction. I have to count in the cost of the complexity of the system. This happens everywhere a medical transaction is made, with a very large percentage of people working in health care only doing so because of the onerous complexity of the system. All of those people between those who work and those who pay them will get more work to do if that distance gets further.

It's just like that game, except: "I worked hard" translates to: "Error. Please resubmit with proper documentation and coding."

It's crazy folks.

It's broken. It's also #1 out of 53 so far.

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.

Nicotine patches work if you take the short view

noreply@blogger.com (Matthew Mintz, MD) — Fri, 10 Feb 2012 14:00:00 +0000

Here is another example of less than responsible journalism. Both the Wall Street Journal and Fox News report "Quit smoking: A new case for going cold turkey." Even NPR asked Do Nicotine Patches And Gum Help Smokers Quit?

Other reports similarly headline with questions regarding the effectiveness of the nicotine patch, which has been a tried and true treatment to help smokers quit. All these reports stem from a study done by researchers at the Harvard School of Public Health and the University of Massachusetts in Boston and published online in the journal Tobacco Control, that found that over a 5-year period, former smokers who used nicotine-replacement products were just as likely to relapse as those who quit on their own.

This is indeed an important study because it shows that relapse rates are high, and nicotine patches may be insufficient to prevent quitters from relapsing. Indeed, other methods should be sought for recent quitters to prevent them from relapsing.

The problem with the way the media is reporting the study is that it is confusing quitting and relapse. Countless studies show that nicotine replacement about doubles the chance that you will successful quit, which is usually defined as not one cigarette for 12 weeks (though better studies use 52 weeks to define quitting). In this study, all the people studied had recently quit.

This study was not measuring whether or not the patch helped these folks quit, but whether people who had quit using the patch were any different than people who had quit without the patch in terms of relapse several years down the road.

People interested in quitting smoking should not be confused by the reports in the media. Nicotine replacement will help you quit. The evidence for using medication (nicotine, bupropion, varenicline) is so strong that the U.S. Surgeon General's guidelines recommends that all smokers (even those at risk to medication side effects such as heart patients and pregnant women) be offered some form of medication, since it is so effective.

Again, the study is an important one because it shows we need to look beyond nicotine replacement to prevent long-term relapse. However, the journalists who reported on this study shouldn't have suggested that smokers consider going cold turkey.

Matthew Mintz, MD, is a Fellow of the American College of Physicians. He is board certified in internal medicine and has been practicing for more than a decade. He is also an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients. This post originally appeared at Dr. Mintz' Blog. Conflict-of-interest disclosures are available here.

QD: News Every Day--Trans-fat levels falling in adults

noreply@blogger.com (Ryan DuBosar) — Fri, 10 Feb 2012 12:00:00 +0000

Trans-fatty acids in white adults decreased by 58% in the U.S. from 2000 to 2009 according to a Centers for Disease Control and Prevention (CDC) study published in a Research Letter in the Feb. 8 edition of the Journal of the American Medical Association.

The Centers for Disease Control and Prevention studied four major trans-fats, elaidic acid, linoelaidic acid, palmitelaidic acid and vaccenic acid, by measuring their levels in 229 fasting adults from the 2000 National Health and Nutrition Examination Survey and 292 from 2009 survey.

Those two study years bookend a Food and Drug Administration regulation that took effect in 2006 that required food makers to list the amount of trans-fats on product labels. Many food makers and restaurants began to drop them prior to the law taking effect, followed by some local and state health departments that required restaurants to limit their use of trans-fats, famously, New York City, then Philadelphia and California.

From the year 2000 to the year 2009, the overall decrease in trans-fatty acids was 58%. Specific decreases included elaidic acid (63%), linoelaidic acid (49%), palmitelaidic acid (49%), and vaccenic acid (56%).

This is the first time CDC researchers have been able to measure trans fats in human blood, the CDC said in a press release.

This research is a part of CDC′s National Biomonitoring program, which currently measures more than 450 environmental chemicals and nutritional indicators in people.

Unlike other dietary fats, trans fats are not essential to human health and do not promote good health, the CDC said in its release. The suspicion is that a lot of trans-fatty acids increase LDL cholesterol.

Politics, religion and sex--avoiding 'third rail' topics in the exam room

noreply@blogger.com (David Sack, MD) — Thu, 09 Feb 2012 16:00:00 +0000

An ancient maxim of dinner party etiquette, which I believe has been proffered from more than one source, is "Never discuss politics, religion or sex in polite company." In some ways, for me as a physician, entering the exam room with a patient seems to require some similar degree of discretion. But the consequences of straying outside the bounds of polite discussion in the doctor's exam room are quite different from any awkwardness that might ensue after a social misadventure.

Dr. Henry Lee, the well-known Connecticut State forensic medicine expert, likes to relate a tale of his own introduction to dinner party etiquette, which I will try to relay somewhat faithfully. His English was poor when he arrived in the U.S. and, invited to a party in which guests were seated in the traditional "boy-girl-boy-girl" arrangement, he knew he would be pressed to make conversation with the women on each side of him. A friend reassured him, "You'll have no problem if you can just get the woman talking about herself and then all you have to do is listen politely. Simply ask 'Are you married?' and then ask 'Do you have any children?' This should get things going just fine."
Armed with this stratagem, Dr. Lee was seated and turned to an attractive young woman on his left and asked if she was married. She replied "No." So of course, he went on to the next question, "Do you have any children?" He was surprised when she reacted with a look of indignation and quickly turned her attention to the guest on her other side.

Puzzled at her reaction, he surmised that he must have gotten the sequence out of order. Trying out the other way around, he turned to an older woman on his right and asked confidently if she had any children. "Three!" she replied happily. Delighted with his progress, he then inquired if she was married. Dr. Lee says he spent the dinner conversing with his soup and salad.

I have also had exam room encounters come to grief because of sex, politics and religion, but nothing has caused me more regret than politics. I will explain.

Sex is not taboo. In fact, it is something I am expected to inquire about as part of the medical history. A sexual history is essential if one is concerned about infectious diseases, reproductive health, domestic abuse, and even what drugs are prescribed and which are proscribed. I was taught even back in the dark ages of medical education in the 70s that one should take a careful "non-judgmental" stance in taking a history. Students are taught to ask first, "Are you active sexually?" If the answer is yes, we ask "Do you have sex with men, women, or both?" Then the question is asked in a way that allows the patient to discuss past behavior that he or she might be ashamed of: "In the past, did you …?"

Nonetheless, if at all possible, I avoid asking about sexual activity as part of a history unless it is essential to the diagnosis. Why? Because I have only so much time to see the patient, and time spent on sex is time lost to discussing bowel habits, which is essential if you are a gastroenterologist. A few years ago it was found that women with irritable bowel syndrome (IBS) have an increased incidence of childhood abuse, emotional or otherwise. We were encouraged to add that element to our discussion about emotional factors in IBS.

I found that a colleague at the other practice in our hospital added that question to his interviews, at least for a time, because I had the pleasure of having to review the charts of several of his former patients who took offense to that line of questioning. Even if sexual abuse was an easy topic to discuss, I would not want to go there. If I did I would have become a Freudian psychiatrist. It's tedious enough as it is, listening to detailed descriptions of stool from people who think they are suffering from a rare and unusual type of excretory syndrome, not to add to it tales of childhood trauma. In sum, discussions of sex are appropriate in the exam room, but I avoid them because they take too much valuable time.

On the opposite end of the scale, religion is no problem because it is rarely a necessary aspect of the medical history unless it has some bearing on dietary habits. I like to know if my patient is a Hindu and follows a vegetarian diet. If my patient is a worried older Jewish woman, I like to blame her symptoms on having eaten trafe, i.e. non-Kosher food, just to get a laugh and break the ice. But as far as I know, the Presbyterian diet is not too different from the Episcopalian, and beyond that I really have no interest.

I never bring up my patient's religion unless it is germane to our discussion, as in "Are you certain your communion wafer is gluten-free?" Occasionally a patient will ask me if I happen to be Jewish. When I say "Yes, although not very observant," they will sometimes even betray that they subscribe to an old prejudice that is as amusing as it is false: "Jews make the best doctors, you know." I reply that good doctors come in all shapes, sizes and colors. So much for religion.

But politics in the exam room, that's a pitfall and a booby trap that makes me wary as soon as I sense the subject is about to come up. I try to avoid politics whenever I can, because it is the biggest time-waster of all when it comes to getting through my day. It would only take three minutes per patient to set me back 30 minutes by the end of the morning, and that would be in addition to the extra 5 minutes taken up by additional unexpected complaints and reports about my patients' jobs, families, social lives and other circumstances which are the glue that holds our relationships together in a way that simply prescribing medications cannot. Keeping on time is already a challenge I have described in my last post, and politics is yet another impediment.

Even so, politics comes up. Mostly it is because my patients want to know my political opinion. They especially want to know what I think about medical care and how our elected (and don't forget, appointed!) officials are handling it.

Many of my patients want to discuss "Obama-care" and my attitude toward how it will affect me, although I think their concern is how it will affect our relationship. Some of my patients want to discuss "socialized medicine," or how care is delivered in Canada. Some just want to know who I plan to vote for, or who I think will win the Republican primary. Maybe they want to get to know me better, or maybe I am the first person they have encountered since they read the morning paper and they want to air their strong feelings about who said what. Whatever the reason, if I allowed myself to be drawn into political discussions, my schedule would be an even greater disaster than it often is.

Surprisingly, many of my patients assume my politics are conservative because I am a doctor. Because so many doctors are Republicans they assume I am too. Many patients assume that I am fiercely opposed to socialized medicine, since surely I don't want to be told how to practice or what I can earn. Some people even presume that I must be angry at the government laying claim to such a large share of my income.

When they bring it up, I never hesitate to tell them that I think the financing of medical care in this country is a disgrace and we should have a single-payer system. Some people react with shock. A doctor in favor of socialized medicine? I confess, when I get that reaction I take a certain amount of malicious amusement in following up by a provocative statement such as medical care in Canada has a great deal to recommend it and we might be better off here if we adopted such a system. I am especially amused at the story of the Tea Partier who held up a sign at a rally two years ago, "Government hands off Medicare!" For all its faults, I tell my patients, Medicare is the most generous insurance plan out there. Why not extend it to everyone? Of course, we would have to control utilization. Upon hearing that, some of my patients seem almost apoplectic.

It doesn't much matter whether my political opinions agree or disagree with those of my patient; either way it's a sticky wicket. Some will be particularly eager to have a discussion especially if they find the least suggestion I share their beliefs. Who better to lend a sympathetic ear to your opinions on the absurdity of the term "death tax" than your doctor? After all, doesn't he have an intimate acquaintance with life and death? Who better to unburden your political prejudices to than the person who is paid and obligated to listen to your most intimate fears and anxieties about life? Surely your doctor would lend you a sympathetic ear, right?

Thus I have learned over the years that it is best to keep politics from intruding into my medical encounter, but recently I encountered a patient's political views in a way I could not avoid. I was glancing through the letters-to-the-editor page of our local small town gazette when I came across a letter submitted by one of my patients who I have attended to for many years. He is a very pleasant, intelligent and appreciative gentleman in all respects and we have had many conversations about his career, family, hobbies and retirement pursuits. The letter was prompted by some issue about the town budget, if I recall correctly. I was dismayed to find it proceeded to a reactionary and bigoted diatribe against immigrants, poor people, liberals, our President and his party, so laden with half-truths, vitriol and outright nonsense that even a Rush Limbaugh could not have concocted it!

I could hardly believe it was written by my very same patient. I wondered immediately how that might affect the care I provide him in the future. Will I be less sympathetic? Will I unconsciously skew my use of health care resources on his behalf? Will my advice regarding end-of-life issues be influenced by his views on the "right to life"? Should I recuse myself from his care? But that would constitute a form of retaliation to someone who has entrusted me with his life, and what sort of person would I be if I only plied my skills with those I agree with? In fact, wasn't it part of my Hippocratic Oath not to be swayed by such considerations? I have a few times cared for criminals and felt as though I was doing my duty, and they presumably have committed far more egregious offenses than were committed by my patient.

In the end I decided to file it away and never mention I had seen the letter. But my relationship will never be quite the same, in the same way that one might be put off to find that someone we respect has committed some act that betrays that respect. Sometimes patients find that their doctors have feet of clay, but it is a rude shock for me to learn that my patient is not all the man I thought he was. I guess this is just something else I have to accept: I have to maintain my role as a healer regardless of whether I have contempt for a patient's substance abuse, legal problems, sexual misconduct, or abhorrent political attitudes. Somehow the last one feels uniquely difficult today.

David M. Sack, MD, is a Fellow of the American College of Physicians. He attended Harvard and Johns Hopkins Medical School. He completed his residency at Lenox Hill Hospital in New York City and a gastroenterology fellowship at Beth Israel-Deaconess, which he completed in 1983. Since then he has practiced general gastroenterology at a small community hospital in Connecticut. This post originally appeared at his blog, Prescriptions, a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Set the right frequency for bone mineral density tests

noreply@blogger.com (Toni Brayer, MD) — Thu, 09 Feb 2012 14:00:00 +0000

The recommendations for when and how often women should be tested for osteoporosis with bone density testing (DXA Scan) has been vague. Many women are tested in their early 50s when they go through menopause with follow up tests as frequently as every year. Others break a hip without ever being tested.

A new study published in the New England Journal of Medicine states that bone loss develops slowly and women who have a normal test when they are 65 do not need to be retested for 15 years. Even women who show some bone loss can wait many years before they are tested again, according to the study authors.The study followed 5,000 women over age 67 for over 10 years. These women did not have osteoporosis at the beginning and they found fewer than 1% of women with normal beginning bone density developed osteoporosis over the next 15 years. Only 5% of women who started with mild bone loss developed osteoporosis.

This study points to the fact that we have been over testing normal women who would not develop significant bone loss. But there are a few aspects of the study that are important to note. They only studied women with normal or slightly low bone mineral density (BMD). Women who have had prior broken bones, or who have significant bone loss at the time of screening should be followed more closely, perhaps every 3-5 years.

Not everyone agrees with the 15 year recommendation either. "An interval of 15 years is too long", says Felicia Cosman, MD, senior clinical director for the National Osteoporosis Foundation. She cites flaws in the study design. Here is what I recommend for patients. Get a screening BMD test at age 60-65. If you are a smoker, take corticosteroid drugs, are thin and fair, or have a mother or sister with osteoporosis or a broken hip, have the first screening test within 5 years of your last menopause period. If that first DXA test is in the normal range, there is no reason to repeat the test for at least 10 more years. If the first test shows mild to moderate bone loss, repeat in 3 years to assess stability. The most important test is the first one to establish a baseline and further testing should be tailored toward each individual woman.

There is an easy online tool that can help women and men calculate their risk of having a fracture in the next 10 years. It can help guide us to when we need to get a bone mineral density test by taking account of certain known risk factors.

This post originally appeared at Everything Health. Toni Brayer, 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.

QD: News Every Day--Not all doctors fully disclose errors, pharma ties, bad prognoses

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

One-third of surveyed physicians did not completely agree that they should disclose serious medical errors to patients, two-fifths said they did not completely agree that they should disclose their financial relationships with drug and device companies to patients, and that one-tenth said in the previous year they had told patients something that was not true.

It seems the patient-centered medical home needs a few small repairs.

Researchers surveyed 1,891 physicians from internal medicine, family practice, pediatrics, cardiology, general surgery anesthesiology and psychiatry nationwide in 2009 to find out if they followed the standards on communication laid out by the American Board of Internal Medicine Foundation’s Charter on Medical Professionalism, which was co-authored by the American College of Physicians. The survey excluded osteopaths, residents and those who practiced in federally owned hospitals.

Results are published in the February 2012 issue of Health Affairs.

Nearly 20% of physicians said they had not fully disclosed an error to a patient in the previous year because they feared the admission would trigger a malpractice case, even though some studies show that prompt communication about an error can reduce anger and make patients less likely to sue.

Other important findings from the survey are:
--More than 55% of physicians said they often or sometimes described a patient’s prognosis in a more positive manner than warranted;
--Women and under-represented minority physicians were significantly more likely to follow the Charter’s provisions than their white male counterparts; and
--More than a third of physicians did not completely agree that they should disclose all financial ties with drug and device makers to patients.

Women were more likely to report never lying, fully describing benefits and risks, disclosing financial relationships, and never having told an untruth in the prior year.

Race or ethnicity was significantly associated with never telling a lie and never disclosing confidential information. In both instances, underrepresented minorities were more likely than white or Asian respondents to report attitudes consistent with charter commitments.

International medical graduates were more likely to respond never lying, never disclosing confidential patient information, and never having revealed confidential information.

General surgeons and pediatricians were most likely to completely agree about needing to disclose all serious medical errors to patients, while cardiologists and psychiatrists were least likely (P less than 0.001). Anesthesiologists, general surgeons and pediatricians were most likely to report never having described patients' prognoses in more positive terms than warranted, while internists and psychiatrists were least likely (P less than 0.05). Cardiologists and general surgeons were most likely to report never having told patients an untruth in the previous year, while pediatricians and psychiatrists were least likely (P less than 0.001).

Physicians in universities or medical centers were more likely to completely agreed with the need to report all serious medical errors than physicians in solo or two-person practices (78.1% vs. 60.5%; P=0.03). Those practicing in regions with the lowest third of malpractice claim rates were more likely to agree that physicians should fully disclose financial ties to drug and device makers compared with physicians in regions with the highest third of malpractice claims (68.9% vs. 60.9%; P=0.40).

And, even though the survey was anonymous, it's likely to underestimate the rate at which physicians do not comply, the authors wrote. The reasons why are more subtle, however.

"The survey results suggest that many physicians do not completely support the charter requirements related to communication with patients. An alternative interpretation is that treating support for the charter precepts as 'black or white'--physicians either do or do not completely endorse and adhere to these principles--fails to recognize complexities of patient physician communication in everyday practice," the authors wrote.

"Despite the relative clarity and unambiguous language of the charter precepts, many factors can affect how and what physicians communicate to patients," they continued. "Some might argue that knowing when to breach or bend these rules-when individual patients require a different approach constitutes clinical wisdom and true patient-centeredness."

Cyberchondria rising, or can we call it 'Googlitis'?

noreply@blogger.com (Elaine Schattner, MD) — Wed, 08 Feb 2012 16:00:00 +0000

Yesterday American Medical News informed me that cyberchondria is on the rise. So it's a good moment to consider the term's meaning and history.

Cyberchondria is an unfounded health concern that develops upon searching the Internet for information about symptoms or a disease. A cyberchondriac is someone who surfs the Web about a medical problem and worries about it unduly.

Through Wikipedia, I located what might be the first reference to cyberchondria in a medical journal: a 2003 article in the Journal of Neurology, Neurosurgery and Psychiatry. A section on the new diagnosis starts like this: "Although not yet in the Oxford English Dictionary, the word 'cyberchondria' has been coined to describe the excessive use of internet health sites to fuel health anxiety." That academic report links back to a 2001 story in the Independent, "Are you a Cyberchondriac?"

Two Microsoft researchers, Ryen White and Eric Horvitz, authored a "classic" paper: Cyberchondria: Studies of the Escalation of Medical Concerns in Web Search. This academic paper, published in 2009, reviews the history of cyberchondria and results of a survey on Internet searches and anxiety.

It's interesting that the term--coined in a newspaper story and evaluated largely by IT experts--has entered the medical lexicon. I wonder how the American Psychiatry Association will handle cyberchondria in the upcoming DSM-5.

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--End-of-life discussions happen far too late

noreply@blogger.com (Ryan DuBosar) — Wed, 08 Feb 2012 12:00:00 +0000

Most patients with stage IV lung or colorectal cancer discuss end-of-life care planning with physicians before death, but most often, the talks happen much too late.

Many end-of-life discussions occur during acute hospital care, with the median happening a month before death, researchers reported. National guidelines recommend that physicians discuss end-of-life care planning with patients with cancer whose life expectancy is less than one year.

To evaluate the incidence of end-of-life care discussions for 2,155 patients with stage IV lung or colorectal cancer, researchers designed a prospective cohort study of patients from the Cancer Outcomes Research and Surveillance Consortium (CanCORS), a group of patients diagnosed with lung or colorectal cancer from 2003 to 2005 from five large health maintenance organization insurance plans or 15 Veterans Health Administration sites in Northern California, Los Angeles County, North Carolina, Iowa, or Alabama.

Results appeared in the Feb. 7 issue of Annals of Internal Medicine.

In the study, 73% of patients had end-of-life care discussions. Among the 1,470 patients who died during follow-up, 87% had end-of-life care discussions, compared with 41% of the 685 patients who were alive at the end of follow-up.

For the 1,569 patients with end-of-life care discussions, topics included resuscitation (46%) and hospice care (82%). Other topics noted in medical records included palliative care (13%) and venues for dying other than hospice (3%). Of the 1,081 first end-of-life care discussions for which information was available, 55% occurred in the inpatient hospital setting.

Of the 806 first end-of-life care discussions documented in medical records for which provider type was known, participating providers included medical oncologists (49%), general medical physicians (36%), palliative care physicians (6%), other medical specialists (7%), radiation oncologists (4%), surgeons (3%), and other providers (0.5%).

Discussions with oncologists were divided evenly between inpatient and outpatient settings, but discussions with general medical physicians tended to take place in the inpatient setting (73%). Abstracted medical record data were available from visits with medical oncologists for 85% (1,823 of 2,155) of patients, with a median of 6 visits (interquartile range, 2 to 10). However, medical oncologists documented end-of-life care discussions with only 27% of their patients (493 of 1823).

"This finding suggests that acute medical deterioration, and not the diagnosis of incurable cancer, triggers physicians to talk about end-of-life care. The literature has also shown that physicians who have close long-term relationships with patients often wish to avoid end-of-life care discussions," the authors wrote. "Primary care physicians may also have important roles in end-of-life care decision making, but most discussions with general medicine physicians occurred in the inpatient setting, suggesting that these were hospital-based physicians and not those providing longitudinal primary care. Physicians involved in longitudinal care, however, may be best informed about the patient's prognosis and disease trajectory and best equipped to have meaningful discussions about the patient's values and goals."

Don't reach for the pills when you tweak your neck

noreply@blogger.com (Albert Fuchs, MD) — Wed, 08 Feb 2012 12:00:00 +0000

Neck pain is a very common problem. Many of us have woken up with a painful neck and found that we couldn't turn our head because of painful muscle spasm. Doctors use various treatments for neck pain. Pain medication, spinal manipulation by a chiropractor, and physical therapy for stretching exercises are all popular remedies, but there is very little scientific evidence to support any of them. I frequently used to prescribe anti-inflammatory pain medications as an initial treatment, but not anymore.

Annals of Internal Medicine published a study that sheds some light on the issue. Researchers recruited 272 patients suffering from neck pain for at least two weeks. They were randomized to three groups, each of which were assigned a different treatment for 12 weeks.

One group was prescribed medication by a physician. Medications included anti-inflammatory pain medicines (like ibuprofen or naproxen), acetaminophen (Tylenol), muscle relaxants, and even narcotics if the doctor thought they were indicated. The second group saw a chiropractor once or twice per week for spinal manipulation. The third group met twice with physical therapists who taught them to do home exercises. They were asked to continue the exercises for the 12 weeks of treatment.

All patients were followed for a year after the start of the study to periodically measure their pain and range of motion.

Surprisingly, both the home exercise group and the chiropractic spinal manipulation group did much better than the medication group. And there was not a significant difference in outcomes between the home exercise group and the chiropractor group.

So the next time you get a crick in your neck, check out the home exercises in the supplement to the Annals study. If you can't figure them out yourself, get a physical therapist to teach them to you. Or see a chiropractor. And I'll still prescribe pain medicine if pressed but first I'll recommend the more effective treatments.

Learn more:
For Neck Pain, Chiropractic and Exercise Are Better Than Drugs (NY Times, Well column)
Neck Pain? Skip the Pills, Just Stretch Like a Chicken (Wall Street Journal, Health & Wellness)
Is Spinal Manipulation an Effective Treatment for Neck Pain? (Annals of Internal Medicine, Summaries for Patients)
Neck exercises (Annals of Internal Medicine, supplement)
Spinal Manipulation, Medication, or Home Exercise With Advice for Acute and Subacute Neck Pain (Annals of Internal Medicine article)
Pain in the Neck: Many (Marginally Different) Treatment Choices (Annals of Internal Medicine editorial)

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.

Think like a doctor, part I

noreply@blogger.com (Peter A. Lipson, MD) — Tue, 07 Feb 2012 16:00:00 +0000

For nearly five years, I've been writing about medicine. One of the questions I hear the most is, "When it comes to my health, who do I believe?"

Anyone who's read my writing knows I'm critical of so-called alternative medical practices. I'm also critical of the abuse of mainstream medical practices. I've had years of education devoted to studying human medicine. How is a layperson to know what works and what doesn't, what is real medicine and what is hucksterism disguised as medicine? And, how can physicians explain this to their patients? In my mind, I've subtitled this series, "An Introduction to Medical Skepticism."

The study of human medicine goes back, presumably, to the beginning. Gods, spirits and ill-winds have always been invoked to explain illness. "Malaria" means "bad airs," even though we now know it's caused by a small organism transmitted by mosquitoes. As humanity became literate, human illness was studied and observations recorded systematically. Hippocrates of Cos, who probably lived and practiced around the 4th century BCE, wrote excellent observations on the natural history of many common illnesses, descriptions that modern doctors easily recognize.

In the 15th century, Andreas Vesalius dissected cadavers, recording his findings in beautiful and mostly accurate drawings. While human anatomy was probably well known to agrarians who slaughtered animals, and warriors, who slaughtered people, Vesalius' writings and pictures provided one of the most accurate catalogs to date of gross (non-microscopic) human anatomy. A century later, William Harvey gave the first complete description of the circulation of blood through the human body (probably; Ibn al-Nafis gave a partial description a couple of centuries earlier, while Europe was still immersed in the Dark Ages).

Through this time, as the anatomy and some basic physiology of the body was being described, real understanding of how the body works still eluded physicians. Doctors, such as they were, still held to ancient beliefs on cause and effect, mostly described using the "humors" or "temperaments" model, attributing disease to imbalances of "black bile," "blood" or other important substances. A disease believe to be caused by excess blood could be treated by bleeding, for example.

It wasn't until the 19th century that any real understanding of what we now call physiology began to appear. This is when medicine began to become more frankly materialistic (in the sense of "not supernatural"). At the time, it was widely believed that life was fundamentally different than non-life in that it was imbued with some sort of vital principle.

In 1828, chemist Friedrich Wohler synthesized urea, the first documented synthesis of an organic compound--compounds found in living things--from inorganic materials. This was thought to be impossible, as organic chemicals were supposedly fundamentally different from inorganic ones, imbued somehow with a "life force."

Wohler and his contemporaries showed that life is made of the same chemicals as everything else. Scientists began to believe that the human body must act by the same laws and processes as everything else in nature (though many still held on to an idea of a "soul" or something like it). Once it was realized that human beings were no different from any other part of the natural world, they could be studied without referencing ill humors or vital principles. Scientists and doctors began to study the function of the human body and how we might use this new understanding to help people.

The 20th century birthed the practice of scientific medicine. The Flexner report attempted to standardize medical education, something that could be done because of the shared understanding that medicine was now a science rather than a branch of religion. Deborah Blum's The Poisoner's Handbook follows doctors and chemists who use this new knowledge. Her narrative takes place in the early 20th century, when doctors and chemists struggled to understand illness and death caused by poison. Without an understanding of biology, chemistry and physiology, these breakthroughs could never have taken place. There was nothing easy and nothing supernatural about the discovery of how poisons worked and could be detected. It took hard work and a thorough understanding of science. From studying the damage done by poisons, they helped advance the science of how the human machine works.

Every advance we have made in preventing and treating disease is based on our understanding of the science of the human body. This combined with the use of statistical analysis has allowed us to live longer and healthier than our ancestors could have imagined.

In part II, I'll examine the piece that makes medical practice whole.

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.

Freebies leave one internist wanting something more--the truth

noreply@blogger.com (Peter A. Lipson, MD) — Tue, 07 Feb 2012 16:00:00 +0000

Once upon a time we used to let drug reps feed us, bring us tchotchkes, and generally use our time. The staff liked the free food, and our patients liked the free drug samples. But we didn't like how it made us feel. The pharmaceutical companies have stopped giving out pens and such, and we have stopped allowing them to bring us lunches. There are a few samples which are still useful, especially respiratory drugs that aren't available as generics. To this, we give in, and we do allow reps to stop by the office with samples, occasionally taking a bit of our time.

Studies show that these interactions affect prescribing patterns. I'm not happy about it, but it's hard to get some drugs for my patients. The reps know me well enough to know that I don't like to be detailed and that I'm pretty easily annoyed. They're tenacious beasts though. A new one stopped by today.

She was trying to get me to prescribe a drug called Glumetza (Santarus, Inc.). It's a diabetes drug. In fact, it's a really good diabetes drug. Not only is it a good diabetes drug, but it's laughably cheap, although not under that name.

Glumetza is metformin, a drug also branded as Glucophage, in an extended release form. Metformin costs about $4 per month. The extended release version costs about $10 to $15 per month. Glumetza costs about $250 per month. This must be some sort of uber-metformin, right? At that price it better lower your sugar and wipe your ass for you.

And that's basically what it claims to do. One of the problems with metformin is that it can cause some stomach upset, especially diarrhea. In nearly all patients, this wears off in a few days, and when it doesn't, changing to the extended release form ($10 to $15 per month, remember?) usually does the trick. What does Glumetza claim? "Unlike immediate-release metformin, GLUMETZA uses a special advanced polymer technology that delivers the medicine slowly and steadily over several hours.⁵ This delay in the release of the medicine may result in fewer stomach-related side effects, such as nausea, in the 1st week of taking the medication.⁴"

I don't doubt that the company has a proprietary drug delivery system. But what about the other claims?

The footnotes point to:
1. The Glumetza package insert
2. An inaccurate citation, but allows me to track down a journal article about extended-release metformin, not Glumetza specifically
3. A patent summary
4. A study that compared Glumetza, extended-release metformin, and immediate release metformin. What did it find? We'll get to that.
5. A footnote leading nowhere.

Footnote 4′s study found that: "Even with a 1,000-mg q.d. starting dose, the overall incidence of gastrointestinal adverse events during the 1st week of dosing was low and comparable among treatment groups (Table 3). There was a higher incidence of nausea in the immediate-release metformin group than in the extended-release metformin groups (P=0.05). In addition, there were more adverse events of nausea and diarrhea causing treatment discontinuation in the immediate-release metformin group than in the extended-release metformin groups. The overall incidence of adverse events considered possibly or probably related to the study drug was similar for all treatment groups; the only such events reported for greater than 5% of patients in any treatment group were gastrointestinal events."

In other words, all forms of metformin were well-tolerated. Even so, there was a measurable difference between the immediate release form and the extended release forms. There was no convincing evidence that Glumetza was better than the cheaper, generic extended release metformin. The discussion tries to be convincing, but the data don't back any other conclusion: Glumetza is different than generic metformin--it costs more money.

The lesson here isn't that medicine is bad. Metformin is a terrific drug, and cheap. But the marketing of predictable and high-priced knock-off drugs does nothing to contribute to our health. And plenty of physicians and patients fall for the not-so-cheap marketing.

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.

'Cancer survivorship' and the search for higher meaning

noreply@blogger.com (Ryan DuBosar) — Tue, 07 Feb 2012 14:00:00 +0000

The fact that the term "cancer survivorship" is now part of our vocabulary is a testimony to advances made in management of these diseases. Most cancer survivors, however, are not unscathed by the experience. As I tell my patients, they won't be entirely as they were before treatment. How these issues are dealt with varies from person to person. But, awareness that chronic problems may persist long after treatments end signals that even though we've won the battle, the war is not necessarily over. We may need to address problems in the physical, mental/emotional and/or spiritual spheres. After all, quality is as important as quantity.

Certainly, health care professionals are well trained to deal with physical issues. Attempting to address the totality of needs in an organized manner is a recent phenomenon. Certainly, in thinking about programs that have been successful in supporting people mentally, emotionally and spiritually, 12-Step Programs come to mind. The Steps are compelling as they are for anyone affected by the disease alcoholism, including the alcoholic (A.A.) and the "caregiver" (Al-Anon).

Substitute "cancer" for "alcoholism." The value of The Steps is that they provide a guideline through the process of recovery. In fact, I prefer the designation "recovery" over "survivorship" as it implies an ongoing process with relapses and remissions along the way.

At first glance, the verbiage doesn't seem to be appropriate. But, The Steps suggest four primary ideas.

We Are Powerless Over the Problem of Alcoholism. This notion of powerlessness is difficult for healthcare professionals, especially physicians, to accept. The intention is that we as individuals have no ability to change attitudes and behaviors of others, but we do have control over ourselves.

Think of the Serenity Prayer: "God, grant me the serenity to accept the things I cannot change, courage to change the things I can, and the wisdom to know the difference."

In fact, this is a very empowering concept that releases each of us from worrying about issues that don't concern us and address our energies to our own lives.

We Can Turn Our Lives Over to a Power Greater than Ourselves. Many find the idea of a Higher Power difficult to embrace, while others already believe in a Power greater than themselves, but feel that "God has deserted" them. Both viewpoints hinder recovery as they tend to foster a victim mentality.

Personally, I dislike the designation "cancer victim" for this reason. The slogan: "Let Go and Let God" can also be very liberating, recognizing that The Higher Power is in charge of our lives and we are not victims. The 11th Step provides details: "Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out."

We Need to Change Both Our Attitude and Our Actions. Both the cancer and its treatments can result in distorted thinking. Some are left with severe fatigue and pain; others with long-lasting memory deficits called chemobrain. Anxiety and depression are not uncommon. The possibility of recurrence is always present. Some become angry and blame their situation on others.

Obviously, these behaviors can be self-destructive and ruin relationships. In these difficult situations, a useful tool in 12-Step programs is sponsorship. Having someone who has lived through similar circumstances and recovered always there for support and guidance is crucial for recovery.

We Keep the Gifts We've Received by Sharing Them with Others. Probably the most important concept. Several studies have shown that participation in cancer support groups improves outcomes. But many patients still are reticent to join. Some prefer the privacy of one-on-one sessions with a therapist.

On the other hand, they lose the personal experiences of people who have experienced what they're experiencing. One compromise is to have a mentor or sponsor who has personal knowledge of the treatment guide the patient and family through the process.

For this reason, 12-Step programs rigidly subscribe to anonymity to encourage participation in meetings and sharing experiences with others. The most important item in the success of these programs has not been identified, but several reports have suggested sharing at meetings as the major one.

I'm thrilled that we're talking about Cancer Survivorship these days. The fact that more people are living longer is very gratifying. Therefore, formally addressing quality of life issues is the logical next step. Incorporating 12-Step program concepts into Cancer Survivorship Programs, proven successful in other diseases, merits serious consideration.

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.

QD: News Every Day--Doctors stick with a few favorite drugs, but still willing to vary

noreply@blogger.com (Ryan DuBosar) — Tue, 07 Feb 2012 12:00:00 +0000

Most doctors stick with a few favorite prescriptions, but are willing to vary their habits to meet their patients' conditions and comply with the formularies of patients' insurers, researchers found.

While a single drug accounts for 40% to 70% percent of most doctors' new prescriptions in a drug class, comorbidities and the multitude of health insurers have prompted physicians to adopt broader prescribing habits.

The study examined the 10 most widely used classes of therapeutic drugs in the U.S. from 2005 to 2007, based on medical and pharmaceutical claims from 29 large U.S. employers. Starting in 2005, all pharmacy claims identified prescribers by a masked Drug Enforcement Administration number, allowing researchers to track prescriptions from the same physician to different patients in different insurance plans. Results appeared in The American Journal of Managed Care.

When examining brand versus generic drugs, the authors noted that nearly half of the physicians prescribing angiotensin-converting enzyme (ACE) inhibitors and nonsteroidal anti-inflammatory drugs prescribed only generics. Also, 90% of physicians prescribing opiates did so, while less than 1% of physicians prescribed only generic statins or proton pump inhibitors.

In drug classes where there are more generics, naturally more generics were prescribed. In the five drug classes where the generic share is closest to one-half (38%-61%), between 80% and 89% of physicians prescribed both brand and generic medications as initial prescriptions, the authors wrote.

Only a small percentage of physicians prescribed a single drug in a class, ranging from less than 1% for selective serotonin reuptake inhibitors to 15% for ACE inhibitors. In eight of the 10 classes, the median physician prescribed three or four different drugs. "This reflected broad prescribing patterns given that the median number of initial prescriptions per physician in our sample ranged from six to eight in the 10 classes," the authors wrote.

For selective serotonin reuptake inhibitors, 45% of physicians prescribed five or more different drugs in the class. Among those who prescribed as many as eight to 12 different drugs to start, 72% prescribed five or more different drugs and less than 2% prescribed only one or two drugs.

Researchers also reported that physicians prescribing one or two drugs were more likely to prescribe the leading drug in a class, "which in most cases was the most heavily promoted drug." Among physicians prescribing just one statin, 80% prescribed the market leader and most heavily promoted drug.

Proton pump inhibitors had only one generic drug during the study. Prescribers with narrow prescribing patterns in this class were split between high prescribers of the brand drug and high prescribers of the generic. "Perhaps due to the degree of similarity between these 2 products (esomeprazole, the top brand, and generic omeprazole), physicians generally prescribed one drug or the other."

In contrast, the leading brand and generic antihistamines have different active ingredients and most physicians prescribed both, the authors noted. Physicians with broader prescribing patterns leaned toward generic and/or less common brands.

There is a widespread perception that physicians prescribe a narrow range of drugs within a therapeutic class because of prior experience with the drug, and because of pharmaceutical marketing and drug detailing, the authors said.

"Despite these perceptions, we find surprisingly broad prescribing across 10 prominent classes," the authors concluded. "Physicians whose patients were covered by a wider array of health plans and formularies tended to have broader prescribing habits, as did physicians who treated patients with varying comorbidities. This suggests that attempts to match specific drugs to a patient's health condition and formulary design were important factors in deviating from their favorite drug. While physicians whose prescribing habits were narrow were more likely to prescribe highly advertised drugs, few doctors prescribed these drugs exclusively."

If exercise is the medicine, 30 minutes a day is the dose

noreply@blogger.com (John Schumann, MD) — Mon, 06 Feb 2012 16:00:00 +0000

Imagine a medicine so potent it could reduce both the absolute risk of death and treat a number of different chronic conditions with tremendous success. You'd probably want some, right?

I came across one such medicine in this video from preventive health expert (and family doctor) Mike Evans of Toronto.

I'd seen it in some "Best of 2011" health roundups. At that point, it had a couple hundred thousand views. It's shot up to over 1.5 million (and climbing) at this point.

It's doubly captivating: the animation is simple, clean, and superb. The information is deep, but the message is startlingly clear, and laid out in the fashion of an argument with irrefutable logic.

The video is only nine minutes, and well worth it. It makes you think, and makes doing the right thing sound simpler and thus more possible for all of us.

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.

Minding your second favorite organ

noreply@blogger.com (David L. Katz, MD) — Mon, 06 Feb 2012 14:00:00 +0000

As a preventive medicine physician who truly believes "if you don't have your health, you don't have anything," our prevailing behaviors have always been hard to fathom.

The parent who simply can't find time to cook a family dinner can, always, find time to take a kid to the ER or endocrinologist. People who can't afford mixed greens can afford diabetes test strips.

People who carefully and responsibly invest in the financial security of their retirement (although we know that's no guarantee of a good outcome!) routinely neglect altogether any investment in their health. If money can be put aside for future benefit, why can't time be "put aside"--invested in physical activity, eating well, getting enough sleep? It can be, of course, but our social norms don't encourage it, and it doesn't happen. Standard-issue, responsible modern adults carefully tend their money, and neglect their health. It's normal, and almost expected. But it's bizarre and often calamitously costly.

Many people reach retirement with the money they need, lacking the health they need to use that money for anything enjoyable. As a physician, it is excruciatingly painful to look into the imploring eyes of a retiree who has long anticipated their golden years--and has cultivated the bank account to underwrite it--now disabled by progressive diabetes, lung disease, brain disease or heart disease that need not have occurred.

And it is all too common. I have seen, and continue to see, many such patients. Patients who reach retirement age with robust good health and too few dollars come along, too, of course, but far less often. And here's the news flash: Those with health but not much money are clearly a happier group than those with money but not much health. I have met them on the intimate turf of clinical care, and they have told me so.

This is the backstory for a careful consideration of the Alzheimer's disease crisis we now face.

There has been enormous attention of late to the grim and genuinely frightening problem of Alzheimer's disease. The problem is grim by its very nature. There is little we contemplate with greater dread than the loss of our minds, our very selves. The problem is frightening at the personal level because we feel vulnerable to this increasingly common condition we don't know how to cure, and at the collective level, where estimates suggest it could cost the nation $1 trillion dollars annually by 2050. There is also the terrible burden on family members, who must face the high demands of care, compounded by the heart-wrenching loss of a loved one who is still there, yet already gone.

It is in this context that President Obama has declared a war of sorts on this scourge, calling for means of both prevention and treatment by 2025, or even 2020. There is lively debate about how realistic the goal is, although on that issue, I note that the best way to predict the future is to create it. You don't get to the moon without committing to the trip.

To create the president's future, it will be important to develop new treatments, as it is for obesity and diabetes. But as with obesity and diabetes, it will be important not to let the hunt for breakthrough treatments become the tail that wags the dog.

Alzheimer's is overwhelmingly a vascular disease, and thus overwhelmingly preventable. Estimates are less well established than for other chronic diseases, but it seems likely the risk can be trimmed by nearly 80% and perhaps eliminated entirely but for the extremely genetically vulnerable by minding our general health.

It is only fair and honest to concede that we do not have perfect defenses against Alzheimer's. And, to some extent, we are hoisted on our own petard, vulnerable to this condition of advancing age because we are better at living longer than ever before.

But the evidence is strong, if not incontrovertible, that whatever the genetic underpinnings, the epigenetics of Alzheimer's, those exposures that influence how genes behave, are of profound importance. By and large, Alzheimer's is a vascular disease. By and large, the practices that prevent cardiovascular disease, eating well, being active, avoiding tobacco, slash the risk of Alzheimer's.

Study after study after study after study that has shown an elimination of up to 80% of all chronic disease with the application of lifestyle as medicine has NOT carved out an exception for Alzheimer's. The evidence that we can alter gene expression with the power of lifestyle almost certainly pertains to Alzheimer's as it does to cancer. By minding our bodies, we can mind our minds, too. We can best mind both, by minding the short list of what matters most to health.

Available evidence suggests that controlling cardiac risk factors can lower dementia risk specifically by 50% or more.

So see a doctor at regular intervals to have your blood pressure and cholesterol monitored. High cholesterol can contribute to dementia by accelerating the development of atherosclerosis; controlling blood lipid levels with diet or medication can protect against this. High blood pressure can damage the blood supply to the brain in several ways, and is the leading risk factor for stroke. At least one European study suggests that treatment of high blood pressure all by itself can cut dementia risk in half.

While the scientific evidence linking cigarettes to dementia per se is equivocal, the link between smoking and vascular disease is clear and strong. So avoid tobacco to protect your brain by protecting the blood vessels that nourish it.

There is some evidence to support what most of us have heard about "brain foods." Fish consumption appears to protect brain function, most likely by contributing omega-3 fatty acids to the diet. An omega-3 oil supplement, one to two grams daily, is an alternative. Antioxidants in food appear to be protective as well, contributing to the reputations of blueberries, red wine and green tea.

But while an inventory of potential brain foods can be assembled, the evidence is much stronger for the importance of the overall dietary pattern. Eating well is as important to the brain as it is to the heart. Lower your risk of Alzheimer's with plenty of vegetables and fruits, whole grains, beans and lentils, olives and avocado, nuts and seeds. Limit consumption of highly-processed foods, fast foods, sugar, salt, saturated and trans fat. Physical activity, too, nurtures the health of body and mind alike.

There is some evidence that poorly controlled stress, lack of sleep and various nutrient deficiencies, vitamin E, vitamin C, and vitamins B₁₂ and B₆ in particular, may increase the risk of dementia. Controlling stress, getting adequate sleep and a balanced diet with or without supplements may all confer protection.

Finally, population studies consistently suggest that those who exercise their brains protect their minds from dementia. Crossword puzzles and Sudoku are aerobics for your brain. Just as physical activity defends the body against aging and infirmity, mental activity seems to help preserve the vitality of the brain. The Mayo Clinic and the Alzheimer's Foundation, among others, provide nice summaries of prevention strategies online.

As we mind our mind by minding our bodies, we can mind our business into the bargain. The price tag of Alzheimer's, and chronic disease in general, threatens nothing less than our national solvency. Only prevention can solve that problem. A breakthrough drug for Alzheimer's would be wonderful, but who is naive enough to think the drug would be dispensed for free? Serious chronic disease is bad financial news when we can't treat it, and still bad financial news when we can! The financial news turns to the good only with prevention. Lifestyle is not only the best medicine we have. It is the only medicine we have already available to all, at essentially no extra cost, and without a prescription.

A healthy brain needs clear arteries, a sound heart, clear lungs, fit kidneys, a robust liver. Even if your brain is your second-favorite organ, you can tend it best by looking after all the other less-favored organs on which it is co-dependent.

Altogether too many of our loved ones have Alzheimer's already; and too many more will get it. There is no question we need the government, and big Pharma, and the biomedical community at large to wage the battle of treatment on our behalf.

But prevention is the greater prize in the long run, and is largely already within our grasp. There is no need to wait for the government, or big Pharma. Take matters into your own hands. Mind your mind and mind your body with the zeal and diligence you routinely apply to minding your own business. Because, they are.

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--Blacks have twice the rate of ESRD despite half the CKD of whites

noreply@blogger.com (Ryan DuBosar) — Mon, 06 Feb 2012 12:00:00 +0000

End stage renal disease (ESRD) is higher in blacks than in whites, despite having less chronic kidney disease (CKD), researchers concluded, a difference that is explained in part by albuminuria.

The study compared the incidence of CKD among young adults over 20 years of follow-up in the community-based Coronary Artery Risk Development in Young Adults study. CARDIA was a prospective cohort study sponsored by the National Heart, Lung, and Blood Institute that recruited patients from Birmingham, Alabama; Chicago; Minneapolis; and Oakland, California.

Participants included 4,119 adults, 18 to 30 years old, with an estimated GFR (eGFR) greater than 60 ml/min per 1.73 m² at baseline. CKD was defined as an eGFR less than 60 ml/min per 1.73 m² and more than 25% decline in eGFR at study visits conducted 10, 15, and 20 years after baseline.

Results appeared in the Clinical Journal of the American Journal of Nephrology.

43 cases of CKD developed during follow-up, 29 (1.4%) among blacks and 14 (0.7%) among whites (P=0.02). The hazard ratio (HR) for developing CKD comparing blacks to whites was 2.56 (95% confidence interval [CI], 1.35 to 5.05). After further adjustment for body-mass index (BMI), systolic blood pressure, fasting plasma glucose, and high-density lipoprotein (HDL) cholesterol, the HR was 2.51 (95% CI, 1.25 to 5.05).

At the year 10 visit, the geometric mean albuminuria level was 8.2 mg/g (95% CI, 7.8 to 8.5) and 6.6 mg/g (95% CI, 6.4 to 6.8) among blacks and whites, respectively. The age- and sex-adjusted hazard ratio for developing CKD at year 15 or 20 for blacks versus whites was 2.14 (95% CI, 1.07 to 4.25). After further adjustment for covariates from the year 10 study visit, developing CKD at year 15 or 20 had an HR of 1.50 (95% CI, 0.71 to 3.16). Further adjustment for year 10 albumin-to-creatinine ratio reduced the hazard ratio to 1.12 (95% CI, 0.52 to 2.41).

It is possible that African Americans have more severe kidney disease that progresses to ESRD more quickly, the authors wrote, noting that six of the seven patients with ESRD in this study were black.

"This finding provides an important contrast to cross-sectional studies reporting a higher CKD prevalence among whites compared with African Americans" the concluded. "Much of this increased risk may be explained by the higher prevalence of albuminuria among African Americans."

The Good Things in Medicine #1: The Exam Room

noreply@blogger.com (Rob Lamberts, MD) — Fri, 03 Feb 2012 16:00:00 +0000

I said I would do it and I will follow through with it: I am going to talk about good things about my job. I must confess, however, that finding 53 of them might be difficult at this moment, as I am overwhelmed with the craziness and stupidity of the system. I must also confess that I can't find a whole lot of good things to say about our system. I fight the system and its foibles all day long, and try to practice good medicine despite the way I am forced to do it; so finding good stuff about the structure of our payment system will be difficult, if not impossible.

Maybe it's just me and my current mindset. I hope so. Unfortunately, it is how good the good is that makes the bad all the worse. The fact that the system itself stands in the way of the good in medicine makes the system all the more broken.Anyhow, I do have things that I really, really like about medicine. I've got to have them, as I could not deal with these negatives if I didn't have a reason to stay that was at least as strong as my reason to leave. It's like the nucleus of an atom. We know that the forces holding the protons together is strong, because they repellant force of two positively charged particles is very strong. There must be a stronger force keeping them together.

Likewise, I am drawn to medicine in a very strong way, and nothing draws me back more than the exam room.No, I am not talking about the table that is too high for my old people to climb on, out-of-date magazines, or the smell of rubbing alcohol. I am talking about the interchange I get to have every day with people. To me, the exam room encounter is medicine. It is the Holy of Holies, the sacred part of a secular system. The practice of medicine can be boiled down to a single thing: the interchange between a person with a need and a person who tries to meet that need.

While this is actually the description of all commerce and much of human interaction, it is the nature of the interchange and needs that make it so special to me. Here are the things that make this encounter so unique and so (in my mind) sacred:

It is personal
The patient does not need an object or a luxury item. They don't want to be entertained. The things the patients need are themselves. They want to live and to be healthy. They want to have a good life and to be out of pain. Our possessions are not what define us, but to a large degree, our bodies do. We are what is confined in that package of flesh. Our time on earth is defined by what that body does, and how long it does it. So, to come asking for care for our bodies is intimately personal, a fact unfortunately forgotten by many in health care.

It is private
The door to the exam room is closed and I am committed to keeping what goes on in the room closed off to others. The more that I can assure the patient that their privacy is safe, the more they will expose their needs to me. We humans don't like to share our needs with many people, as it exposes our weakness and vulnerability. We also feel that we are intruding on others' lives when we ask them for help. So, actually asking for help is only possible when done in a situation of great trust.

The fact that people can be asked to get naked in the exam room is evidence to the degree of vulnerability they are exposing to me. The nakedness extends to the emotional realm, as boundaries that are expected on the outside are not present behind the closed door.

It is relational
The thing that is so sacred about the exam room to me is not the fact that it's private or personal, however; it is that I am asked to be with them in that vulnerable moment and hear the weaknesses. The relationship is physical: I listen to what they say, look at what they are, and feel their bodies with my hands. It is mental: I listen to them, think about them, and help them decide what to do. It is emotional: I hear their sadness, fear, and relief; I feel emotion as I hear their emotions; I try to help, heal, or comfort them. This is the sacred, as it is human relations stripped to the core, free from most of the pretense and facades that are there in nearly every other place.

It is meaningful
I take great comfort in the fact that what I do has meaning. When other parts of my life are difficult, I find refuge in the opportunity I have every day. When I am feeling sad or anxious about other things, feeling insecure in my relationships or in my future, or regretting my decisions, I heal myself in the exam room. It's not that I see that my life is good compared to my patients--that's no comfort at all--it's that I get to do and to give to other people; and while I can lose relationships and material things, nobody can take away the good I have done.

It's really an honor to be a part of the exam room encounter every day. It does take its toll on my emotions, and it is a convenient escape when I'm avoiding other areas of my life, but I know it's where I need to be. I am glad that I am a doctor. I really lucked into the profession I chose, as I didn't know most of the good things before I enrolled in medical school. It's good for me to remember this good, as I can get lost in the struggles and troubles that the other part of my job brings. Our system needs to do everything it can to enable more real exam room encounters, and remind health care providers that they do more than just work at their jobs; they heal.

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.

'I'm your cook, not your doctor'

noreply@blogger.com (Matthew Mintz, MD) — Fri, 03 Feb 2012 14:00:00 +0000

Celebrity chef Paula Deen confirmed she had type 2 diabetes. She was diagnosed three years ago, but only decided to come out recently. She also mentioned that she is a paid spokesperson for drug company Novo Nordisk, maker of several diabetes drugs. (Click here to view Al Roker's interview).

When the news started breaking earlier this week, I had mixed emotions about Deen as a spokesperson for diabetes. Blogger and health care marketer Richard Meyer at worldofdtcmarketing.com posted This is a spokesperson for Novo? Deen is of course known for her southern style of cooking, which typically involves very fattening ingredients. At one her restaurants she famously serves a hamburger with bacon and egg on a donut instead of a bun.

Rich correctly asks, "What message does this send to people ? That it's OK to eat really bad food because diabetes can be treated with Rx drugs ?"

I commented on his blog that if Deen actually changes her ways, and focuses on healthier cooking, providing healthier recipes to her fans and other diabetics, she might actually make the perfect spokesperson. Americans have not been paying attention to what we eat and obesity has now become an epidemic, leading to increasing numbers of patients with type 2 diabetes.

After seeing the Today show video, I remain on the fence. Her interview was not the redemption story I was hoping for. Give journalistic kudos to Al Roker, who pressed Deen on whether she had changed her ways or changed her cooking. She responded essentially stating that she has always eaten (and suggested others eat) in moderation, claiming that her weekly cooking show is only 30 days out of a full year and that no one should eat that kind of food every day. According to Deen, when asked a similar line of questions from Oprah, she responded, "I'm your cook, not your doctor."

Deen did state that she and her sons would work to come up with lighter recipes (available on Novo's website) and recommended people go to their doctor, get tested and "get on a program." On the website diabetes in a new light, Deen does say that she had to give up sweet tea. In fact, rigid diet and exercise programs do not work all that well in reducing weight or improving diabetes, since patients have a hard time sticking to them, so her mantra, "I wasn't about to change my life, but I have made simple changes in my life" may have some merit.

However, I believe there is still a difference between promotion of healthy lifestyle and realistic changes in diet and exercise and "everything in moderation" and "it's OK to have that little piece of pie." Paula doesn't have to become the next Richard Simmons or Jillian Michaels, but I would have liked to seen a little more "mea culpa."

I am interested to see how this plays out in the media and in public opinion. This is a terrible disease and the prevalence is getting worse. Ms. Deen has the potential to make a major impact. I hope she takes her spokesperson role seriously.

Matthew Mintz, MD, is a Fellow of the American College of Physicians. He is board certified in internal medicine and has been practicing for more than a decade. He is also an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients. This post originally appeared at Dr. Mintz' Blog. Conflict-of-interest disclosures are available here.

QD: News Every Day--New technology takes the blame, yet gets the credit

noreply@blogger.com (Ryan DuBosar) — Fri, 03 Feb 2012 12:00:00 +0000

New technology is offering doctors in small and medium practice an easier time with practice management, according to survey results of the users of a free electronic medical record product.

Practice administration has been difficult of late, and electronic medical records have taken some of the blame. They're expensive, they're time consuming and they require at least two weeks of training to properly implement their advanced functions.

In short, new technology hasn't always been popular among physicians.

Still, Practice Fusion, a company offering a free, web-based electronic medical record, surveyed 1,000 of its users online and said in a press release technology has made things easier for physicians in private practice:
--45% of doctors report that their practice is doing better this year compared to last year while 14% report that their practice is doing worse and 33% report no change.
--26% reported that their practice was doing better than the year before, while 41% reported doing worse.
--60% of small practices report that new technology has made things easier.
--26% of practices use computers that are less than a year old. 38% report that the computers in their practice are over three years old compared to 73% the previous year. 7% of practices have computers in the five to six-year-old range, down from 21% in 2011.
--89% of doctors report being satisfied or extremely satisfied with their career despite challenges, a 20% increase from the year before.
--Top pressures on the practice as a business included insurance and reimbursement (69%), patient compliance (64%) and practice administration concerns (48%).
--Top improvements were advancements in medicine (68%), patient compliance (53%) and improvement in the health care workforce (51%).

Rising physician referrals are sometimes desperation passes

noreply@blogger.com (KevinMD.com) — Thu, 02 Feb 2012 14:00:00 +0000

According to a recent study from the Archives of Internal Medicine, primary care physicians are referring more patients to specialists than ever before. In fact, the rate almost doubled in the 10-year period between 1999 and 2009. This drives up the cost of care, as specialist consults tend to be more expensive than primary care visits. Furthermore, specialists tend to order more advanced diagnostic tests.

It's pretty easy to see why this is happening.

Back in the days of capitated care, there was pressure from HMOs to reduce the amount of referrals, as doctors were given a set fee to manage each patient. A referral meant a financial hit to the practice. But the HMO model was rejected by patients, who didn't like their choice restricted and accused doctors of holding back care.

So, fee-for-service medicine continued to grow, and there was little incentive to scale back referrals. In fact, as a New England Journal of Medicine study revealed a few years ago, the Medicare patients saw an average of seven doctors: two primary care physicians and five specialists.

According to the lead author of the Archives study, Dr. Bruce E. Landon,: ... medicine has become more complex, with specialists and subspecialists seen as expert in the latest treatments. "Medicine is becoming increasingly technologically sophisticated," he said in an interview.

But Dr. Landon also points to the "tyranny of the 15-minute visit," during which the average primary-care physician does not have the time or resources to delve into any potentially complicated medical condition.

The last point rings particularly true. As patients become more complex and time pressures grow, many doctors simply take the path of least resistance and refer out.

Sarah Kliff, who blogs at the Washington Post's progressive-leaning Wonkblog, adds that money is a factor: ... part of it likely has to do with the economics of referrals: Doctors who have an ownership stake in their practice are 50 percent more likely to refer to a specialist, which would increase the total revenue generated by a given patient.

That's dubious. I don't have a financial incentive to refer to specialists. Most of my colleagues don't either. And with more doctors exiting private practice and into salaried hospital positions, that reason will become less relevant.

I'll add one more reason that hasn't been mentioned: defensive medicine. Although the threat of a malpractice lawsuit is typically associated with ordering potentially unnecessary tests, making a specialist referral is simply another variation. When primary care doctors see "failure to refer" as one of the leading reasons why they get sued, it's no wonder why more are doing so.

Physician behavior is governed, to a large degree, by incentives. Given the incentives that doctors face in our health system today, there's little surprise why more are referring patients out to specialist care.

Kevin Pho, MD, ACP Member, is an internal medicine physician and on the Board of Contributors at USA Today. He is founder and editor of KevinMD.com, also on Facebook, Twitter, Google+, and LinkedIn. This article was originally published on KevinMD.com.

QD: News Every Day--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.

Do you really want to read what I wrote about you?

noreply@blogger.com (Albert Fuchs, MD) — Wed, 01 Feb 2012 14:00:00 +0000

All patients have a right to a copy of their medical record. In practice that right is rarely exercised. It usually means submitting a request in writing, paying a fee for photocopying, and waiting weeks for someone to copy and mail the records. The development of electronic medical records has the potential to revolutionize patients' access to their records, making it possible for patients to review their records securely whenever they want from any internet-connected computer.

But would patients want that? Would it improve their care? Would it help or hinder their doctors' work?

An interesting study aims to answer these questions. The pilot program, called OpenNotes, approached primary care physicians working for three health care systems in Boston, Seattle, and rural Pennsylvania. These physicians were already working in organizations that used electronic health records. Some of these records already had features that allowed patients access over the internet to their medication list or to their laboratory test results, but none offered patients a chance to review doctor notes.

The study proposed to give patients access over the internet to their physician notes for one year. All the physicians in the three locations were invited to participate but had the option of declining. Only the patients of participating physicians were given access to their notes.

We won't have the actual results from the OpenNotes project for another year. Annals of Internal Medicine published the results of questionnaires completed by the physicians and the patients prior to the study. The questionnaires asked the physicians and patients about their expectations of how patient access to notes will impact care, and about the potential benefits and harms of this access.

The difference in the answers between physicians and patients was surprising. The authors of the study expected younger and more educated patients to be more optimistic about the project, since these patients would be more technologically savvy and feel they deserve greater control over their care. Actually most patients, regardless of age or education, were very optimistic that the project would be helpful to their medical care, would help them understand their care better, and would give them more control over their care.

Physicians were much more restrained in their optimism. Doctors who opted into the program were obviously more optimistic than doctors who declined to participate, but many doctors in both groups expressed concerns that access to progress notes may increase anxiety and confusion among patients.

It's easy to imagine a patient presenting with symptoms which could be due to many different diseases. Doctors routinely document the many possibilities that will be tested and excluded or confirmed. Many of those possibilities are terrible diseases that will turn out not to be present. Will patients want to know before the test results are available all the scary possibilities? Patients expressed very little concern that reviewing progress notes will make them more anxious or confused. Is that because they are psychologically sturdier than doctors fear, or because patients are naïve about what they'll be reading?

An accompanying editorial in the same issue describes the experience at M.D. Anderson which has already been offering all its patients online access to their entire medical record, including doctors notes. The editorial states that the M.D. Anderson experience has been largely positive. Patients appreciate having access to their notes, and feel better educated about their disease and treatment. They claim that impact on physician workflow has been minimal.

We'll find out the results of the OpenNotes project in a year. As healthcare in general moves away from paper records, patients and physicians will have to struggle with balancing transparency with discretion, openness with privacy, and empowerment with guidance.

Learn more:
Patients Want To Read Doctors' Notes, But Many Doctors Balk (Shots, NPR's health blog)
Do you want to see what doctors write about you? Apparently, you do (Booster Shots, LA Times health blog)
Inviting Patients to Read Their Doctors' Notes: Patients and Doctors Look Ahead (Annals of Internal Medicine article)
Access to the Medical Record for Patients and Involved Providers: Transparency Through Electronic Tools (Annals of Internal Medicine editorial)

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--Iodinated contrast media associated with thyroid dysfunction

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

Iodinated contrast media is associated with subsequent incident hyperthyroidism and incident overt hypothyroidism, a study concluded.

Use of iodinated contrast media has grown along with imaging in general, as much as an eight-fold increase in such tests in the past 20 years. A typical dose of contrast media contains about 13,500 micrograms of free iodide and 15 to 60 g of bound iodine that may become free iodide in the body. "This represents an acute iodide load of 90 to several hundred thousand times the recommended daily intake of 150 [micrograms]," the authors noted.

Researchers performed a nested case-control study of patients treated between January 1990 and June 2010, who did not have preexisting hyperthyroidism or hypothyroidism. In a parallel analyses, incident hyperthyroid or hypothyroid cases were defined by a change in thyrotropin level from normal to low or high.

Results appeared in the Jan. 23 edition of Archives of Internal Medicine.

The source cohort consisted of 4,096 patient intervals matched to 3,678 patient intervals that served as eligible controls. In total, 178 and 213 incident hyperthyroid and hypothyroid cases were matched to 655 and 779 euthyroid controls. Iodinated contrast media exposure was associated with incident hyperthyroidism (odds ratio [OR], 1.98; 95% confidence interval [CI], 1.08 to 3.60), but not with incident hypothyroidism (OR, 1.58; 95% CI, 0.95 to 2.62).

In the secondary analysis, iodinated contrast media exposure was associated with incident overt hyperthyroidism (follow-up thyrotropin level less than or equal to 0.1 mIU/L; OR, 2.50; 95% CI, 1.06 to 5.93) and with incident overt hypothyroidism (follow-up thyrotropin level greater than 10 mIU/L; OR, 3.05; 95% CI, 1.07 to 8.72).

An editorialist wrote that an association was noted when cases were restricted to those with overt hypothyroidism. There was also an association between iodinated contrast media and incident hypothyroidism when the analysis was restricted to cases that occurred within 180 days of exposure, "likely related to the transitory nature of iodine-induced hypothyroidism."

Scattered reports in the literature report an association between iodinated contrast media and hyperthyroidism, called Jod-Basedow phenomenon. This study suggests the incidence is more widespread than previously believed, the editorialist said.

In terms of practical clinical practice, the editorialist noted, "First, the ALARA ("as low as reasonably achievable") principle should always be exercised in determining the need for radiation exposure, as potential risks of iodinated contrast studies extend beyond the thyroidal risk from iodine exposure. Second, particular care should be taken in patients at high risk to develop thyroid dysfunction after the administration of iodinated contrast medium. Palpation of the neck for the detection of goiter is reasonable before ordering contrast studies, although nodular goiter may occasionally be missed even with a careful physical examination."

The editorial continued, "[P]atients who may be particularly unable to tolerate thyroid dysfunction, such as those with underlying unstable cardiovascular disease, are also good candidates for monitoring of thyroid function after iodine exposure."