ACP Internist

Time to redesign residencies

noreply@blogger.com (Robert Centor, MD) — Thu, 23 May 2013 13:00:00 +0000

Once upon a time (actually when I did my residency), we worked long hours, were taught well and learned from our patients. Residency training had minimal rules. When we looked for a residency we took work load into consideration. Some residencies were more challenging than others. I choose a busy residency because I thought (back then) that I needed to see sufficient numbers of patients to become a good internist.

Our progress over the subsequent 35 years (since I finished my residency) is dubious. Pauline Chen, MD's wonderful article in the New York Times today, "The Impossible Workload for Doctors in Training," tells part of the story--no adjustment of work load as work hours have changed.

What does not make this article is the never ending paper work that program directors must document. What does not make this article is a reluctance to reconsider call schedules.

When the rules change, then the system must change. We have to adjust call schedules for the benefit of continuity. We need call schedules that value "ownership" and patient responsibility. We have to help our residents function as a team, with different members of the team working different shifts.

We who work in residency programs can do a better job at designing the residencies.

This will not solve the ACGME problems and will not solve the major problem of not enough funding to expand residency training slots. CMS has fixed the number of residency positions. Private insurers up to now have not made contributions to training--yet they benefit from well-trained physicians.

Residency is hard. It has always been hard. It is necessary if we want well trained physicians. But it does cost money. We do not have enough residency slots and that is a major societal problem. And no one is really addressing that problem.

For those who want to blame the AMA, the AAMC is responsible for medical student numbers, and they continue to increase quickly. They have increased so much that many U.S. graduates did not find an internship that past year (I have heard numbers ranging from 500-800). This does not count DO graduates, off shore graduates or IMGs. Can you find a new doctor? If you cannot, do not blame the AMA or the AAMC. Blame those who fund residency positions.

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

QD: News Every Day--Dextrose injections for knee osteoarthritis aids pain, function

noreply@blogger.com (Ryan DuBosar) — Thu, 23 May 2013 11:00:00 +0000

Prolotherapy injections of dextrose for knee osteoarthritis resulted in clinically meaningful sustained improvement of pain, function and stiffness scores compared with blinded saline injections and at-home exercises, a study found.

Researchers randomly assigned 90 adults with at least 3 months of painful knee osteoarthritis to blinded injection with dextrose prolotherapy or saline, or to at-home exercise. Extra- and intra-articular injections were done at 1, 5, and 9 weeks with as-needed treatments at weeks 13 and 17.

Outcome measures included knee pain, post-procedure opioid use for injection-related pain, and patient satisfaction. Results appeared in the May/June issue of Annals of Family Medicine.

No baseline differences existed between groups. All groups reported improved for a composite score on the Western Ontario McMaster University Osteoarthritis Index (WOMAC; 100 points) scores compared with baseline status (P less than <.01) at 52 weeks. WOMAC scores for patients receiving dextrose prolotherapy improved more (P less than .05) at 52 weeks than did scores for patients receiving saline and exercise (score change: 15.3 +/- 3.5 vs. 7.6 +/- 3.4, and 8.2 +/- 3.3 points, respectively) and exceeded the WOMAC-based minimal clinically important difference.

Individual knee pain scores also improved more in the prolotherapy group (P=.05).

Postprocedure opioid medication addressed injection-related pain, satisfaction with the procedure was high and there were no adverse events, researchers noted.

Researchers wrote, "Its use in clinical practice is relatively uncomplicated; prolotherapy is performed in the outpatient setting without ultrasound guidance using inexpensive solutions. The knee protocol is easy to learn and requires less than 15 minutes to perform; continuing medical education is provided in major university and national physician organizations settings."

How to learn bedside (point of care) ultrasound: tips for the interested internist

noreply@blogger.com (Janice Boughton) — Wed, 22 May 2013 15:00:00 +0000

I first picked up an ultrasound transducer 17 months ago, at Vicki Noble, MD's emergency medicine ultrasound course at Harvard University. I had just barely heard about using ultrasound as a clinical tool and was vaguely interested. The course was three days long and cost a little under $700 and changed my life forever and made me a better doctor.

Emergency physicians have embraced the use of ultrasound at the bedside for many years and the vast majority of physicians who complete emergency medicine residencies are competent in using ultrasound for procedures and diagnosis. In bedside ultrasound, the doctor who examines the patient also does the ultrasound, often with a small portable machine, checking out the heart, lungs and other internal organs as part of the physical exam.

Internal medicine physicians have been very slow to pick up this technology, probably mostly because the equipment has been a little too large to be convenient and training to wield the probe and interpret the images takes time and is inaccessible. The American Academy of Chest Physicians (ACCP) is the professional organization that represents critical care and pulmonary doctors, and their journal, Chest, has recently adopted ultrasound education via an online section called the Ultrasound Corner. The editorial by Seth Koenig, MD, accurately describes the power of the technique in critically ill patients, and the educational offerings of the ACCP for intensivists.

So, first of all, why might an internist want to learn bedside ultrasound and how might it be merged effortlessly into patient care? When I see a patient now, instead of taking their pulse and placing my stethoscope on their chest and back, hearing the vague taps and clunks and bubbles and whooshes of the internal organs I have come to trust are in there, I open the ultrasound machine that lives in my white coat, squeeze a little gel from a tube I keep warm in my pocket, and the patient and I look at heart, lungs, liver, spleen, kidneys and bladder. Most of them, those not blind or in a coma, think this is incredibly cool.

At the end of this exam, which takes all of 5 minutes if I am thorough, I know whether their heart squeezes normally, whether there is excess fluid in the lungs or pericardial sack, whether there is fluid in the belly, whether the kidneys are blocked and whether the bladder is emptying normally. Sometimes I also see things like gallstones or tumors or blood clots. I can often evaluate whether the patient is dehydrated by looking at the inferior vena cava, the vein that returns blood from the lower body to the heart.

If a patient loses consciousness, like one of them just did today, I can quickly rule out a major heart attack as the cause of the problem. My little machine is not quite as sensitive as the huge expensive ultrasound machines, but it is pretty good and I can usually be sure about the answers to the questions that are most vital to treating my patients immediately. If a patient has chest pain and my ultrasound of their heart is good, I can be much more confident about whether the chest pain is due to a heart attack.

Several times since I have been doing this, I have found an unexpectedly poorly functioning heart in a patient whose story of chest pain was not particularly convincing for coronary artery disease and was able to advocate for quick or aggressive treatment which expedited treatment and saved heart muscle. The ability to evaluate bladder size is powerful. The ability to rule out hydronephrosis (urine backed up in the kidneys) allows me to avoid excessive imaging in patients who have a change in their kidney function. We often see patients with big bellies who may or may not have excess fluid due to cancer or liver failure or heart failure, and it is so very convenient to be able to make the distinction between fat and fluid without waiting for an imaging procedure to be done.

But how does a person learn how? I took three emergency ultrasound CME classes with live models and hands on instruction, one on line ACCP class in critical care ultrasound and bought the pocket Vscan ultrasound from GE, which I use at least once on just about every patient, friend and family member. The dog has barely escaped due to excess fur. I then took a mini ultrasound fellowship with the department of emergency ultrasound at UC Irvine under the direction of Chris Fox, MD. This involved 4 weeks of scanning in the ER, going over saved scans, teaching medical students and studying online material.

It was kind of expensive: $5,000 for the fellowship and 4 weeks off of work in a place where I had to stay at a hotel. But I am way better at it than I was, I know what the protocols are and can do ultrasound of things that internists don't usually examine that way, including eyeballs and uteruses and testicles and thyroids and skin structures. My Vscan doesn't have a linear transducer, so I haven't been able to improve as fast at procedures that need shallow scanning, such as blood vessels, muscles and joints. I'm thinking that I will need to have access to a machine that I can use whenever I want, so I will probably buy an ultrasound machine with a linear transducer from China where the technology costs about 1/10th what it does here.

There are other ways to learn bedside ultrasound, including year-long fellowships, which are usually based in emergency rooms. There is a program at Harvard that lasts 5 or 10 days that involves participating in scanning at the radiology department, and reviewing many scans every day. I would love to do that. The limitation of learning ultrasound techniques from real ultrasonographers and radiologists is that they do a more thorough exam than we usually have time for, and the perfect protocol for quickly determining relevant information in an internal medicine patient is not the same as what an ultrasonographer does when we order specific tests.

The ACCP has excellent courses with live patient scanning, which are apparently quite expensive. I would also love to take one of these. There are many for-profit groups that offer training as well. It's not hard to find a course that will get a person started, but it does take many hours of practice and the ability to review scans with experts in order to feel comfortable. If our hospitals or clinics decided to embrace bedside ultrasound, and radiologists bought into it (and I actually think they would) we could really benefit from the teaching of our radiology technicians and MD radiologists.

It continues to astonish me how much more effective I am as a doctor with an ultrasound than I was as a doctor without one. I make diagnoses I wouldn't have thought of, save patients radiation and hospital days and quickly have information I need to focus treatment. I understand why my busy colleagues haven't embraced this technology yet, but when they do they are going to love it!

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health care so expensive?, where this post originally appeared.

Uncomplicating matters on the way to health

noreply@blogger.com (David L. Katz, MD) — Wed, 22 May 2013 13:00:00 +0000

On Monday of this week, my staff and I at the Yale-Griffin Prevention Research Center entertained a visiting delegation of colleagues from Korea. The visit was first proposed by a preventive medicine specialist there in an email to me some months back. Somehow, in the time since, the visit grew to a group of roughly 25, most working for public health agencies.

We were of course honored and delighted that a group would travel so far to learn about our health promotion programs. And we were also eager to explore the opportunities for translating programs that have proven effective here for application in another language and culture.

Translation, however, proved to have more general relevance to the meeting. Of the group, only three members spoke English. Thanks to years of Tae Kwon Do, I can count to 10 in Korean, but that was the extent of our group's collective vocabulary. So the day's discussions, which spanned some hours, required frequent pauses for translation from English to Korean (for the most part), or Korean to English.

So, there we were, a large group from the Prevention Center, Griffin Hospital, some of our partner agencies, and our guests, gathered around a big boardroom table for hours, wrestling with the challenges of health promotion in two languages.

A group this size, talking at length about how best to implement health promotion programming, might well have sucked all of the oxygen out of the room even without the language barrier. But with that additional encumbrance, and despite my frequent recourse to standing and walking around the perimeter of the room--by mid-afternoon I was feeling increasingly prone to a sudden onset coma.

So around that time, while we were discussing programs to promote physical activity as our rear ends molded to our chairs, I asked my staff to pick out and project one of our ABE for Fitness videos for the group. We did so, choosing from the library of roughly 60 videos one made for the office setting, lasting about four minutes, and providing a total body workout in the standing position.

We all followed along, and suddenly there were smiles on faces that appeared all but unconscious a moment before. Suddenly, we had oxygen in our lungs again, and it was actually reaching our brains! And suddenly, following the on-screen guide through the exercises, there was no language barrier, and no real cultural barrier, either. We were all just moving, together, and feeling a whole lot better for it.

There's no question that activity burst rejuvenated our meeting, but its ramifications went far beyond that. It illustrated how readily we can turn a simple action into a complex idea, when what we really want is to turn ideas into actions.

We could have talked for hours about the challenges of fitting physical activity into people's days while failing to fit any into ours. Or, we could have put our feet where our mouths were and, stood up and said, how about this? Which, thankfully, is what we did.

I am by no means suggesting that ABE for Fitness, or any one program, suffices to reverse all of the forces of modern living that conspire against physical activity or health in general. I am, however, saying that getting up and moving isn't very complicated. And it isn't even very hard.

And while eating better may be a bit more complicated than being active, I think that, too, can be fairly simple. Eat close to nature. Learn enough about nutrition and food labels so you can trade up your choices. Control your own food choices rather than letting others do it for you. And by getting used to better foods, come to love the foods that love you back. Admittedly, there is some effort here, but it's not a space mission.

I believe that many of the best defenses of the human body reside with the body politic. And consequently, I support an array of programs and policies that would help pave the way to health and place it along a path of lesser resistance for us all. Exploring just such opportunities was why our Korean colleagues traveled so far to confer.

But I also believe that most of us are quite capable of acquiring new skills we deem important and applying that skill-power to good effect. I believe that people who manage mortgages, student loans, tax forms, and 401(k)s can figure out how to have a healthy dinner if it matters to them. I believe people who can navigate across the country through a maze of airports can, if so inclined, acquire the skills to fit some fitness into their daily routines.

Sometimes we mistake hard for complex. Lifting a rock, for instance, can be hard if the rock is heavy, but it's not complicated. A deliberating committee is unlikely to help.

And sometimes we get carried away with how hard something might be, instead of just doing it -- and discovering it's actually fairly easy. That activity burst was easy. One of those every hour, and we could all have gotten that recommended 30 minutes of physical activity without ever leaving the board room.

Getting to health doesn't need to be all that complicated. And it also doesn't need to be about "should." Don't pursue health because it's an obligation, or because someone says you should. Pursue health because health is a currency you can spend on living better. Pursue health because healthy people have more fun. Pursue health if it matters to you, because it matters to you.

I genuinely believe that most of us can get to health in the pursuit of pleasure and get more pleasure in the pursuit of health. I believe that making substantially better use of our feet and our forks every day need not be very complicated, might not even need to be hard, and can even be fun.

I believe we can uncomplicate getting to health. All we really need to do is decide that health truly matters, and start acting accordingly.

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--Patient education materials written above nation's average reading level

noreply@blogger.com (Ryan DuBosar) — Wed, 22 May 2013 11:00:00 +0000

Patient education materials are written for grade levels higher than the average American can read, a study found, and may require medical specialty societies to reconsider how they draft and present such handouts.

The average American adult reads at approximately a seventh to eighth grade level, prompting government and medical societies to call for patient education materials to be written at a fourth to sixth grade reading level

Researchers downloaded the body text of online patient education materials from 16 medical specialties into Microsoft Word and performed readability statistics on them. ACP materials were included in the analysis.

Results appeared online May 20 at JAMA Internal Medicine.

After using the many tools available in Word to analyze the readability of text, patient education materials from all 16 medical specialties were too complex for a sixth grade reading level. Among the specialties near the recommended grade level when measured by New Fog Count were: dermatology, 4.3; obstetrics and gynecology, 6.0; plastic surgery, 6.1; and family medicine, 6.6.

New Dale-Chall readability formula test showed that dermatology, family medicine, and obstetrics and gynecology met the average American adult reading level. Flesch Reading Ease readability analysis showed that patient resources were considered to be "difficult." The Flesch-Kincaid grade level readability test showed that family medicine was the only specialty satisfying the average adult reading ability. Fry graphical analysis test results ranged from the eighth grade level in family medicine to unclassifiable in dermatology because materials were beyond the 17th grade level.

Researchers wrote, "One simple adjustment is to write more clearly, which may increase comprehension regardless of the reader's health literacy capabilities. The use of pictures and videos may also be an effective way of increasing a patient's comprehension of health information that is too complex to fully explain through pure text."

Medical office efficiency - the times they are a wastin'

noreply@blogger.com (Michael Kirsch, MD) — Tue, 21 May 2013 13:00:00 +0000

Medical practices, particularly private businesses like mine, strive for efficiency. This has become more necessary as medical reimbursements inexorably decline while overhead and other expenses rise. This may be the point in this post when a reader will jump to the comment section below and carp how I and every other doctor are only in it for the money. Not so fast here. Yes, I would like to make a living and I believe that I deserve a decent one. In my case, I do not seek, and have never sought wealth. For small private medical groups, particularly in northeast Ohio, we are aiming to survive more than to thrive.

These days wasted time during the work week can be the tipping point that buries a private practice.

Where are the time sinkholes in medical practice?

No show patients. This is the Wonder Bread of medical practices. It torments doctors in 12 different ways. Younger readers may need to Google to get this reference.

Late patients. While these folks are less sinful than Wonder Bread patients, they mangle the schedule and suck up physician and staff time. Should these patients be told that they need to reschedule? How late does a patient have to be before he is ejected from the office? Should he be told to sit tight in the waiting room until all of the on-time patients have been seen? Are we comfortable playing hardball with a 90-year-old woman who hobbles in on her walker 20 minutes late?

Delays in receiving requested medical records. Even in the electronic era, it can be mind boggling how much work is required to get a few papers faxed over. For doctors, this task becomes a competition where we gird our loins to beat the system.

Patient paperwork. Our new patients fill out medical surveys that our staff then uploads manually into our EMR (electronic medical record) system. Although these folks are told to arrive early, it never seems to be early enough. I often find myself in solitude in the exam room while the expected patient is in the waiting room pushing paper. In time, this clumsy process will be compressed and expedited, but our practice is not there yet.

Down on the Pharma. This is the improvised explosive device of medical practices. I cannot calculate how much time is vaporized re-prescribing medications that are not, or no longer on, the preferred list. If we guess the right medication, then we err on the number of pills permitted. If we opt for the mail order pharmacy, we learn that the local drug store was the proper destination. And, of course, if we were insane enough to memorize a particular patient's proton pump inhibitor prescription pathway, it changes at year's end.

There may be other reasons that challenge medical office efficiency. Perhaps, for instance, there is the rare instance when a physician is late. In this instance, any of my patients who are reading this post are invited not to comment.

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

How red meat leads to heart disease

noreply@blogger.com (Toni Brayer, MD) — Tue, 21 May 2013 13:00:00 +0000

We have known for decades about heart disease and the effects of red meat and saturated fats being a cause of elevated cholesterol. But we've also known that is not the whole story and now surprising new research is pointing to gut bacteria and the actual chemical that is produced by meat as the culprit for heart disease.

Carnitine is found in red meat and is also used by body builders as a supplement for energy. Researchers have found that in the intestinal tract, bacteria convert carnitine into a metabolite called TMAO and TMAO promotes thickening of the arteries. Steak consumption caused subjects in the study to immediately produce large amounts of TMAO. Vegetarians did not produce the chemical.

Many people who become vegetarian say that they can no longer digest red meat. It turns out that they actually lose the ability to metabolize carnitine over time because they do not develop the gut bacteria that meat eaters have.

How did the researchers know it was the gut bacteria? They gave the study participants large doses of antibiotics to wipe out the normal flora in the intestinal tract and then none of the meat eaters or vegetarians produced TMAO after eating steak or taking carnitine pills.

The researchers from Cleveland Clinic, examined record of 2,595 patients who had undergone cardiac evaluations and found that patients with high levels of TMAO and carnitine were the most likely to develop heart disease, heart attacks, strokes and death within the next three years.

"Cholesterol is still needed to clog the arteries, but TMAO changes how cholesterol is metabolized-like the dimmer on a light switch," said lead author Stanley Hazen. "This may explain why two people can have the same LDL level, but one develops cardiovascular disease and the other doesn't."

It would appear that carnitine alone is not the problem but a regular diet of meat creates the gut bacteria that break carnitine down into TMAO. Vegetarians and meat eaters have very different gut bacteria. TMAO may be a waste product but it is significantly affecting cholesterol metabolism and deposition into arteries.

What should you take from this study?
--The Mediterranean diet is still the most heart healthy diet. (Small amounts of meat and red wine; grains and vegetables in large amounts. Avoid processed foods.)
--Try to eat only organic local farmed meat and chicken. It takes an effort but is worth the time and money to avoid antibiotics, growth hormones and horrible animal conditions.
-- Never take carnitine supplements or energy drinks.
--Small amounts of meat means no more than 4-6 oz. Think about that the next time you think about steak.

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

QD: News Every Day--Wording change affects surrogates' end-of-life choices for loved ones

noreply@blogger.com (Ryan DuBosar) — Tue, 21 May 2013 11:00:00 +0000

Small wording changes made big differences in end-of-life decisions for surrogates of critically ill patients, a study found.

Researchers conducted a web-based simulated meeting to discuss code status using 256 volunteers randomly assigned to consider a hypothetical scenario in which their spouse or parent was receiving life-sustaining treatment in an intensive care unit. An actor portrayed an intensivist, who at the end of the interview discloses a 10% likelihood of survival in the event of cardiac arrest requiring cardiopulmonary resuscitation (CPR). The actor then asked surrogates to decide the patient's code status.

Results of the study, co-authored by Robert M. Arnold, MD, FACP, appeared online at Critical Care Medicine.

While emotional triggers didn't influence the outcomes, researchers noted that three framing manipulations that mattered included implying the social norm was not to choose CPR, phrasing that the decision was the patient's vs. the surrogate's, and describing the alternative to CPR as "allow natural death" vs. "do not resuscitate [DNR]."

Emotional triggers--seeing pictures and scenarios with the loved one as opposed to seeing neutral scenes before making the choice about CPR--did not impact CPR choice. But framing the social norm as not choosing, rather than choosing, CPR resulted in fewer decisions to resuscitate (48% vs 64%; odds ratio [OR], 0.52; 95% confidence interval [CI], 0.32 to 0.87), as did framing the alternative to CPR as "allow natural death" rather than DNR (49% vs 61%; OR, 0.58; 95% CI, 0.35 to 0.96).

Researchers wrote, "[W]e provide the first empiric evidence that this phrase, which has been integrated into the language of several health systems, may directly influence code status decisions."

Angelo Volandes, MD, ACP Member, tells The Atlantic that unwanted end-of-life treatments are "wrongful care." He describes a project that will teach patients and surrogates How Not to Die.

An experience he had as a medical resident showed him that patients needed to see examples of end-of-life care--what a CPR attempt is really like--for them to understand what's involved in that decision. He and Aretha Delight Davis, MD, ACP Associate Member, are now creating videos to show surrogates who may face such decisions.

Dr. Volandes told The Atlantic, "Videos communicate better than just a stand-alone conversation. And when people get good communication and understand what's involved, many, if not most, tend not to want a lot of the aggressive stuff that they're getting."

Is your doctor relying on bad information?

noreply@blogger.com (Peter A. Lipson, MD) — Mon, 20 May 2013 15:00:00 +0000

When I was a medical student, my friends and I wore white coats so stuffed with reference books we could barely move. When we were taking care of patients, a trip to the library simply wasn't practical, and that whole internet thing wasn't really up and running yet. Now my pocket contains only my smart phone.

Sure, I know more than I did then, but I also know that I am fallible. I like to look things up, and from my phone I can access a world of medical information. Certain resources have become more popular than others, but there is no way to gauge the quality of these resources other than relying on my opinions and those of my colleagues. Online references are a tempting but risky resource for doctors.

Two of the more widely-used resources are UpToDate and eMedicine. UpToDate is just that: a resource of practical medical knowledge that is updated frequently by experts. It's also very expensive (about $500/year last time I checked). eMedicine from Medscape is free, and usually quite reliable. Last week, though, I stumbled upon a something disturbing.

Moraxella catarrhalis is a common bacterium causing disease in humans. It causes sinus infections, bronchitis, ear infections, especially in children, but in adults it can be quite deadly. It's a serious bug. Thankfully, it's usually pretty responsive to antibiotics. But here's were eMedicine loses me:

Numerous different antimicrobials have been employed to treat M catarrhalis infection (see below). In addition, among the medicinal plants, garlic, cinnamon, and avocado leaves have all been found to be antagonistic to M catarrhalis.

This makes it seem as if antibiotics and medicinal plants are on equal footing here: They are not. M. catarrhalis can cause serious, life-threatening illness. There is no reason to think that avocado, garlic, or any other plant can be used in place of or even as an adjunct to antibiotics.

Most doctors know this. Many patients who stumble upon this information may not, leading to delay of therapy. I'm going to be keeping an eye on Medscape products looking for similar problems, but the real lesson here is that even with the entirety of medical knowledge in the palm of your hand, the guidance of a professional is important in interpreting and using this knowledge.

Addendum

A reader pointed me to the study that was likely the source of the claims about treating M. cat with avocado, etc. As expected, it is an in vitro look at the effect of these substances on the bacteria. In my into to microbiology course, we would often grow out cultures of various bacteria, setting, for example, a slice of garlic on the medium to see if it would inhibit growth (we also did much more sophisticated versions of this experiment. While interesting, these studies say nothing about the clinical utility of these substances. The human body is very different from a Petri dish. For these plants to be used as treatments, they would have to be "weaponized," creating a way to deliver useful doses of the plant without, for example, having the putative active ingredients destroyed in the acidic environment of the stomach.

When researching antibiotics, candidate substances are identified either by computer modeling or good old-fashioned trial and error in the lab. After that comes years of testing to see if there is a way to make it useful in human beings. The study authors' conclude that (emphasis mine): "Garlic, cinnamon and avocado leaves extracts represents alternative source of natural antimicrobial substances for use in clinical practice for the treatment of cases of M. cattarhalis."

This is irresponsible and just plain wrong. The study doesn't lead us to conclude anything about clinical practice and to claim otherwise is bad science and bad medicine.

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 at Forbes. His 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.

Why surgical complications may actually hurt hospital profits, despite what you've read

noreply@blogger.com (Eli Perencevich) — Mon, 20 May 2013 13:00:00 +0000

If there is no financial incentive to reduce excess length of stay, why has every hospital spent the past 20 years trying to reduce it?

There's a high-profile and important paper in JAMA this week by Sunil Eappen and colleagues. The study looked at surgical discharges during 2010 from a single 12-hospital system and determined that admissions that included a surgical complication were associated with a higher profit (defined as the contribution margin) than admissions without complications. The authors concluded that this creates a disincentive for hospitals to prevent surgical complications since they might see reduced profits as a result.

This is a very provocative finding and it's getting a lot of well-placed media attention, as you might expect. However, there is an important caveat with the study that I would like to highlight.

In the study the authors report that admissions with surgical complications result in $39,000 higher "profits" if the care is reimbursed via a private payer and $1,800 if Medicare is the payer. However, as Dr. Reinhardt correctly noted in the editorial, "Allocating profit and loss is exquisitely sensitive to the many assumptions made in economic modeling and must be performed carefully to provide useful evidence about the financial ramifications of surgical complications and other services." His concern dealt mostly with how the authors allocated fixed costs in their calculations. My concern has to do with what the authors assumed happens to an empty bed once a patient is discharged in a U.S. hospital.

This is what the authors assumed (and mentioned as a limitation): "We did not estimate the effect of 3 potential factors that could affect the hospital economics of surgical complications. First, the shorter lengths of stay of procedures without complications could benefit the small percentage of hospitals operating at full capacity because they might be able to admit additional patients with favorable insurance who were 'crowded out'" What this means is that they didn't include any profits that might be generated by an empty bed filled with a second (or third or fourth) patient. In the study, around 5% of patients developed a complication and stayed an excess of 11 days (at the median)--the mean would be higher.

Note: Based on recommendations of Johns Hopkins professor and retired CFO, Bill Ward, we focused on estimating the costs of HAI using return-on-investment calculations from filling empty beds that manifest through HAIs avoided in the Business-Case SHEA Guideline. In discussions he suggested that excess bed capacity is quickly taken off line and therefore doesn't impact economic evaluation to a large degree. If there is no financial incentive to reduce excess length of stay, why has every hospital spent the past 20 years trying to reduce length of stay?

The big question: Do you believe that 5% of beds in hospitals with high surgical volumes sit completely empty for almost two weeks? Of course, there is excess capacity in the US system, but the amount of excess capacity is most important here, not that it exists. You can't completely ignore profits from increased admissions. For example, if only one patient was admitted into a bed vacated by a "healthy" patient discharged at day three that would have otherwise been occupied by a patient with a surgical complication discharged at day 14, the results of the study would be have been negated--i.e., it would have been a negative study. If more than one patient was admitted into an empty bed over 11 days, which seems likely at most high-volume hospitals, admissions with surgical patients with complications would result in reduced profits compared with admissions without complications. It would have been nice to see estimates of the excess capacity at the 12 hospitals under study.

A provocative study and wonderful analysis. However, as Dr. Reinhardt states, the study "provides important data on a pressing clinical and financial problem affecting hospitals" yet "much of this represents a shell game of how costs are allocated." I would add, and which profits are included or excluded.

Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands). This post originally appeared at the blog Controversies in Hospital Infection Prevention.

QD: News Every Day--Simvastatin may blunt exercise's impact in overweight people

noreply@blogger.com (Ryan DuBosar) — Mon, 20 May 2013 11:00:00 +0000

Simvastatin may blunt the impact of aerobic exercise in overweight or obese patients at risk of the metabolic syndrome, a small study found.

Researchers looked at the effects of simvastatin on changes in cardiorespiratory fitness and skeletal muscle mitochondrial content in sedentary overweight or obese adults with at least two of the five metabolic syndrome risk factors from the National Cholesterol Education Panel Adult Treatment Panel III criteria.

Thirty-seven people (18 exercise plus statins; 19 exercise only) were randomized to 12 weeks of aerobic exercise training or to exercise in combination with 40 mg per day of simvastatin. Exercise consisted of staff-monitored sessions at the university's gym while attached to a monitor, with 30 minutes of treadmill walking or jogging at 60-75% of heart rate reserve on 3 days during the first week, 5 days during the second week, then 45 minutes of treadmill walking or jogging at 60-75% of heart rate reserve 5 days per week.

Results appeared at the Journal of the American College of Cardiology.
At 12 weeks, body weight decreased significantly in the exercise group (P<0.01 for change within group) but not the exercise plus statin group (P<0.01 for between group difference in change from baseline), as did fat mass in the exercise group (P<0.05) compared to the exercise plus statin group, (P=0.056). Lean body mass increased significantly in the exercise plus statin group only (P<0.05 for with-in group change from baseline; P<0.05 for difference in between-group change from baseline).

Cardiorespiratory fitness increased by 10% (P<0.05) in response to exercise training alone, in line with what would be expected, but was simvastatin patients achieved only a 1.5% increase (P<0.005 for group by time interaction). Similarly, skeletal muscle citrate synthase activity increased by 13% in the exercise only group (P <0.05), but decreased by 4.5% in the simvastatin plus exercise group (P<0.05 for group by time interaction).

"Therapeutic options which minimize the adverse effects of LDL lowering therapies on adaptions to exercise training are warranted," researchers wrote.

QD: News Every Day--Doctors, nurse practitioners work together as they fight over scope of practice

noreply@blogger.com (Ryan DuBosar) — Fri, 17 May 2013 15:54:00 +0000

Physicians and nurse practitioners may frequently work together, but they don't get along when it comes to scope of practice issues. The long-simmering feud now has some data meant to fuel discussion rather than inflame rhetoric, study authors concluded.

Researchers conducted mailed survey of 505 physicians and 467 nurse practitioners in primary care from November 2011 to April 2012, (response rate, 61.2%) asking about scope of work, practice characteristics, and attitudes about expanding the role of nurse practitioners. Results appeared in the May 16 issue of the New England Journal of Medicine

In describing their clinical practices, physicians reported working longer hours, seeing more patients, and earning higher incomes than nurse practitioners. A total of 80.9% of nurse practitioners reported working in a practice with a physician, compared to 41.4% of physicians who reported working with a nurse practitioner.

Further highlighting the gap in proper scope of practice, nurse practitioners were more likely than physicians to believe that they should lead medical homes(17.2% of physicians vs. 82.2% of nurse practitioners) or should be paid equally for providing the same services (3.8% of physicians vs. 64.3% of nurse practitioners).

When asked whether they agreed that physicians provide a higher-quality examination and consultation than do nurse practitioners, 66.1% of physicians agreed and 75.3% of nurse practitioners disagreed. Another difference: 88.9% of physicians in collaborative practice agreed that "nurse practitioners typically defer certain types of patient care services and procedures to the primary care physician," compared to 61.3% of nurse practitioners (P less than 0.001).

Researchers noted that primary care physicians are unlikely to embrace expanding the role of nurse practitioners for fears of health care quality. This stems in part because "nurse practitioners and physicians come from very different cultures of professional education, are guided by different theoretical perspectives, and often develop their clinical skills in different practice environments."

Authors wrote, "Both physicians and nurse practitioners will be needed to address the many challenges of developing a workforce that is adequate to meet the need for primary care services. It is our hope that the stark contrasts in attitudes that this survey reveals will not further inflame the rhetoric that has been offered by some leaders of the two professions but rather will contribute to thoughtful solutions for health care workforce planning and policy."

In an editorial, David Blumenthal, MD, FACP, president of The Commonwealth Fund, wrote that the feuding comes amid an increasing primary care shortage. Nurse practitioner provider the same quality of care with better scores on patient communication, yet complex-disease care remains unanswered and patient preferences about who provides care need to be considered.

Dr. Blumenthal highlighted four points to consider in future policy talks:
--Objectively interpreted data on the differing competencies of these two types of clinicians should guide policy, "not rigid, often antiquated state laws";
--Policy should be flexible as studies increase understanding of physicians and nurse practitioners' roles;
--Patients should have a larger say in who provides their care; and
--There must be higher priority given to developing the primary care workforce.

He wrote, "[U]nless physicians and nurse practitioners collaborate to improve primary care, neither will be happy with the outcome. We urgently need a facilitated, open dialogue about the roles of physicians and nurse practitioners that includes representatives of the public."

Nosocomial listeriosis

noreply@blogger.com (Michael Edmond) — Fri, 17 May 2013 13:00:00 +0000

The Sydney Morning Herald is reporting that three patients in two Sydney hospitals have developed listeriosis after consuming profiteroles served to patients at the hospitals. The infecting strain in all patients was identical. One of the patients has died from an apparently unrelated cause.

Nosocomial foodborne illnesses, particularly those of bacterial origin, are seemingly uncommon. I suspect this is likely due to a lack of appetite in many hospitalized patients, and the highly processed nature of hospital foods. (Sometimes I'm not sure it's actually food).

A few weeks ago, while making morning rounds on the inpatient infectious diseases consult service, I went to see an immunosuppressed patient with pneumonia. As I was about to leave his room, I noted a clear plastic container of macaroni salad on his overbed table that had been served the evening before. My paranoia of foodborne infections must have been palpable. He thought it was quite funny that I alarmingly said, "Don't eat that!" While laughing at me, he said, "That's old Doc, I'm not gonna eat that." Just to be sure, I threw it in the garbage, which made him laugh all the more.

Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. This post originally appeared at the blog Controversies in Hospital Infection Prevention.

Means, at the ends of ethics

noreply@blogger.com (David L. Katz, MD) — Thu, 16 May 2013 15:00:00 +0000

Doctors, psychologists, ethicists and others, along with our society at large, debate whether "the ends justify the means." But nobody debates whether "the means justify the ends." There is no point even looking for an answer to a question that is patently silly. For now, just hold that thought, please.

Medical ethics can be very challenging. There are the difficulties of interpreting "do everything" in desperate situations where heroic effort is on one side of a line, and futility on the other. There are the challenges of doing "no harm," while taking great risks. There are challenges of optimal resource allocations for the greater good. There are challenges related to tradeoffs between beneficial and adverse effects, particularly with high-risk surgical and critical care procedures. In this context, the question of ends justifying means comes up routinely.

Perhaps the most vivid and obvious illustration is any variation on the theme of euthanasia. Those who believe it is the work of medical practice to protect life view all such variants as wrong, if not anathema. If, however, the work of medicine is to preserve dignity, and autonomy -- the case for assisted dying can be made, at least under narrowly-defined circumstances. It can be a case where the ends--relief from suffering, death with dignity--might justify the means.

The question has far-ranging implications for the whole field of ethics. One school of thought, for example, is that whatever achieves the greatest good for the greatest number is "right." This is referred to as utilitarianism, and while few real-world ethicists espouse it in pure form, they do invoke its principles.

The extreme contrary view, deontology, stipulates that some things are wrong just because they are wrong, no matter what effects they exert. Again, the pure practice of this probably doesn't exist, but it informs the "do ends justify the means" debate.

Psychology experiments famously reframe the "ends versus means" debate by presenting a scenario where a great deal of good can be done, such as saving a whole group of people, but only by doing intentional harm, such as killing an individual.

There are good reasons why the debate endures, and is to some extent insoluble. There may be no single right answer.

But again, no one wrestles with the reciprocal question, "Do the means justify the ends," and with good reason. If you are getting bad outcomes, what point could there possibly be in "justifying" the means that lead to the ends you don't want?

In a world where means are used to justify ends, there might be means to treat the nausea of pregnancy. For those affected by it, those would be welcome means, indeed. And for those with more severe forms of pregnancy-related nausea and vomiting, they might even be truly important means.

But, as has in fact proven true in the past, those means might produce serious unintended consequences, in the form of birth defects. In a world that sensibly asks "do ends justify means?" while just as sensibly avoiding "do means justify ends?" the response to this is rather obvious. Doing what seems like a good idea stops being a good idea when it produces bad outcomes. A treatment for pregnancy-related nausea that produces common, serious birth defects would not be justifiable. The abandonment of thalidomide for this purpose demonstrates that this is not just hypothetical. In the real world, bad ends unjustify well-intended means.

And now we come to the reason for this ramble. My hope, if not quite my belief, is that we might constructively look at the vexing issue of gun control through this same lens. We do so, of course, in the immediate aftermath of background checks failing to make it through the Senate.

The roiling debate about the Second Amendment seems to hinge on where one places one's semantic emphasis. Those opposed to any regulation of gun sales emphasize "shall not be infringed." Proponents of gun control emphasize the subordination of that clause to "a well regulated Militia."

I have opinions about this, and you may as well, but since we are unlikely to resolve any differences of opinion about the language of the amendment here and now, let's not try.

Rather, let's consider this: The language of the amendment, however it is interpreted, is about means. Some manner of access to guns for some portion of the citizenry is the means, and something like defense against tyranny and protection of liberty the presumably intended ends.

Clearly, the ends could justify the means. If more guns of all kinds freely accessible to all meant more liberty, more security, less risk of tyranny, then the means might well be justified, and the fuss would end.

But the means cannot justify bad ends. If the consequences of interpreting the Founders' means one way are ill and unintended, such as the massacre of schoolchildren without better protection of liberty of defense against tyrrany, then the means, whatever their original intentions, are subject to reconsideration, no less than thalidomide. It in no way tramples the rights of pregnant women to have their nausea treated when we abandon a drug that causes birth defects. Bad ends, however unintended, unjustify means, however well-intended.

We might better confront the gun control debate with data, gathered in a non-partisan manner, about the ends we are getting. We could make a systematic effort to look for all potential good, and all potential bad, ensuing from the status quo just propagated on the floors of the U.S. Senate. If we don't even look for such data, it implies someone doesn't want to know the ends we are getting, and that is an always ominous sign of ulterior motives and cowardice. We must know the effects of our actions to be qualified judges of our conduct.

Whether ends justify means will remain, in particular contexts, a legitimate and challenging debate for the foreseeable future. But in a world where means justify ends, and unintended consequences don't matter, the very concept of ethics has met a very mean end already.

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.

Influenza at the human-animal interface

noreply@blogger.com (Daniel Diekema) — Thu, 16 May 2013 13:00:00 +0000

The first three novel avian influenza A (H7N9) viruses have been sequenced, and the sequences uploaded to the Global Initiative on Sharing All Influenza Data (GISAID). Not surprisingly, there were genetic changes found that have been associated with increased transmissibility of other avian flu strains to mammals.

I have no deep thoughts on this--it is what influenza does, after all, with avian and other non-human strains occasionally making the leap to humans. The few things we know about this particular strain, as of late yesterday, can be found at the CDC and WHO websites, and include the following:
--A total of 21 cases have been laboratory confirmed in China, including six deaths, 12 severe cases and three mild cases.
--More than 530 close contacts of the confirmed cases are being closely monitored.
--The viruses isolated to this point appear to be susceptible to neuraminidase inhibitors (e.g. oseltamivir) but resistant to adamantanes (e.g. amantidine, rimantadine).
--There is no current evidence of "ongoing human-to-human transmission."
--The virus should be detectable with existing PCR methods as an "unsubtypeable" influenza A virus (the CDC is working on adding this strain to their testing approach so that it can be more quickly subtyped if it spreads outside of China).

The most recent interim guidance for case investigation, testing, infection control and treatment are here.

Finally, for those interested in a regular update on the threat of non-human flu strains, the WHO publishes monthly updates on influenza at the human-animal interface. (Wait, aren't Homo sapiens also animals? Maybe it should be, "influenza at the human-nonhuman interface" ...)

Daniel J. Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. This post originally appeared at the blog Controversies in Hospital Infection Prevention.

QD: News Every Day--iPads susceptible to hype in medical education

noreply@blogger.com (Ryan DuBosar) — Thu, 16 May 2013 11:00:00 +0000

Taper hopes of using iPads in medical education, said one study.

Residents generally love using their tablet technologies, but high initial expectations sometimes resulted in residents reverting to traditional ways of doing things when faced with a technologically difficult or time-consuming task.

In October 2010, 115 internal medicine residents received Apple iPads as a personal gift from Steve Jobs. Residents completed surveys on anticipated usage and perceptions 1 month before and 4 months after receiving them.

Results of the study, which was conducted by numerous ACP members and fellows at the Internal Medicine Residency of the University of Chicago, appeared in the Journal of Medical Internet Research.

All but one of the 115 of residents responded. Before getting them, most residents believed that the iPad would improve patient care and efficiency on the wards. However, fewer residents "strongly agreed" after deployment (34% vs 15% for patient care, P less than .001; 41% vs 24% for efficiency, P=.005).

Residents with higher expectations were more likely to report using the iPad for placing orders post call and during admission (71% vs 44% post call, P=.01, and 16% vs 0% admission, P=.04). One of the strongest predictors of using the iPad was already owning an Apple product.

In all, 84% of residents thought the iPad was a good investment for the residency program, and 58% reported that patients commented on the iPad in a positive way.

Researchers noted that simple tasks such as reviewing labs, paging and answering clinical questions are inherently easier to learn than entering orders post call and placing admission orders through the iPad.

"Because these tasks are inherently more complex, it may be that residents who showed more excitement were more willing to expend the effort necessary to use their iPads in situations that required more time investment and effort," researchers wrote. "On the other hand, residents who did not report hype may have been more likely to revert to traditional methods when faced with technically complex tasks."

Hospital readmissions: What exactly is the deal with this?

noreply@blogger.com (Janice Boughton) — Wed, 15 May 2013 15:00:00 +0000

Medicare has been costing the government a scary amount of money for many years, and the very popular program, established in 1965 under President Lyndon Johnson to pay for health care for seniors, has undergone many changes since its inception. Because the government funded program was a very deep pocket from which the sick could pay hospitals and doctors, it influenced the cost of medicine and the volume of health care in a pretty profound way.

In 1983, Medicare began to pay hospitals for care of patients in a way that was felt to be likely to reduce unnecessary and expensive care. This was the Inpatient Prospective Payment System, the IPPS. Instead of paying a hospital for everything that was done to a particular patient, which would potentially encourage higher costs and higher utilization of services, Medicare began to pay hospitals a certain amount for each kind of sickness. These categories of sickness were called Diagnostic Related Groups (DRGs). If a patient had a particularly bad pneumonia, the hospital would get a certain amount of money, encouraging them to treat the patient as quickly and cheaply as possible. Doctors were still paid according to how much they did, but hospitals received a bundled payment for stuff such as bags of IV fluid and antibiotics and CT scans. Many hospitals closed, and the ones that survived learned to discharge patients earlier, use less expensive resources, use the DRGs that paid the most (as much as they could without defrauding the government) and also shifted some of the costs to patients who were insured by private companies.

There was concern that hospitals could game the system by discharging a patient, potentially too early for the patient to really make it at home, and then readmit the patient to the hospital and get paid again. And, indeed, that does happen. As physicians we were (and are) strongly encouraged to get our patients out of the hospital at the first reasonable moment, and the constant nagging and puppy eyes of the discharge planners would often make us send patients home before we felt it was wise to do so.

In 2011, Medicare announced that it would pay hospitals less for taking care of patients if records showed that the hospitals had too many readmissions of Medicare insured patients within 30 days of discharge. This is really quite a random number, based loosely on how long it takes the moon to orbit the earth (actually 27.3 days.) It was thought that, if a patient came into a hospital, got fixed up properly and was discharged, that patient should stay well for slightly longer than it takes the moon to go around the earth. So if that patient came back to the hospital before the moon made it entirely around the earth, it was likely that some mistake or carelessness had been committed. Equally randomly, it seems to me, they decided to look at just three diagnoses, heart failure, myocardial infarction and pneumonia, to start with.

I'm all for punishing hospitals for convincing me to discharge patients early against my better judgment, but that is not what is happening, in my recent experience.

I have taken care of several patients, readmitted before 30 days had passed, in the last few weeks. Their stories are varied, but don't really represent poor care. The Journal of the American Medical Association has occasionally visited the concept of hospital readmissions, and some of the articles are excellent, exploring the idea that readmissions don't necessarily represent dangerous care and that they are indicative of a population of patients who don't have adequate access to good medical care outside of the hospital (look at this article for a good discussion, though you only get the first page because JAMA is proprietary.)

So I'd like to look at some of the examples to see if there is a pattern.

1. 50-year-old man with alcoholic cirrhosis who lives on the street and has just recently been diagnosed. He has no insurance and no regular doctor, and though we give him an appointment to see a doctor after each discharge, he never makes it to these appointments, sometimes because he gets sick with massive ascites before he can get there.

2. 88-year-old woman, discharged after a long battle with pneumonia to her home and pets, returns to the hospital weak and short of breath. She appears to have worsening chronic lung disease on further evaluation and be too weak to return home. It was still worth a try!

3. 29-year-old woman, uninsured and with very bad luck and two forms of cancer, discharged to assisted living, returns in a day, short of breath and anxious. She has been too anxious to actually take her anxiety medications, and hasn't yet seen her oncologist back for treatment of both cancers which are still quite active.

4. 60-year-old man with dialysis-dependent kidney disease who was very grouchy and obstructive in the hospital, returns after a day in a nursing home because he is grouchy and obstructive.

5. 87-year-old woman with end-stage kidney disease, also on dialysis, has been in the hospital approximately once per lunar orbit for 18 months for problems such as pneumonia and urinary tract infection, admitted with shortness of breath and a large collection of fluid in both lungs.

I'm thinking that a really great and very motivated outpatient doctor who goes the distance and visits patients in their homes and treats patients for free and lets the homeless ones crash on her couch could have averted all of these readmissions. I'm also thinking that this particular doctor is not just a dying breed but virtually nonexistent.

In the absence of this doctor of whom legends are written and ballads are sung, a good hospital will continue to be a (very expensive) refuge. The costs to those patients who have no insurance in this group are huge, but they have no resources and will never pay, and the hospital knows this and stays afloat in some other way.

It's hard to know what to do with our well-established cultural belief that everyone needs dialysis at the end of life unless they vigorously oppose it, which is what results in frequent readmissions of patients with end-stage kidney disease. Clearly the fact that a hospital is usually the only place that a person with no resources whatsoever can get good medical care will continue to drive frequent readmissions of this group of people.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health care so expensive?, where this post originally appeared.

Supplementing Mediterranean diet with olive oil or nuts decreases stroke risk

noreply@blogger.com (Albert Fuchs, MD) — Wed, 15 May 2013 13:00:00 +0000

What is a Mediterranean diet? I had always believed that it involves eating shawarma three times a day while sitting on a beach in Tel Aviv, just because that's my diet when I visit the Mediterranean. I was astounded to learn that this is not the case. A Mediterranean diet includes a lot of fruits, nuts, vegetables, olive oil and cereals. It includes moderate intake of fish and poultry, and very little dairy, red meat, and sweets. Wine is included in moderation and consumed with meals.

Like the low-carbohydrate (Atkins) diet and the low-fat diet, the Mediterranean diet has passionate adherents and advocates. A debate between proponents of different diets quickly resembles one between zealots of different religions--there is much heat but little light. That's because virtually no high-quality studies have directly compared one diet to another. So in the face of weak data, each camp highlights the data that confirms their bias and disregards the rest.

A study published in this week's issue of The New England Journal of Medicine (NEJM) tried to compare a Mediterranean diet to a low-fat diet. The study took place in Spain and randomized over 7,000 people who did not have cardiovascular disease at the start of the study but had risk factors for cardiovascular disease, like diabetes or high cholesterol. The people were randomized into three groups. The first group was instructed to follow a Mediterranean diet and told to add about four tablespoons of extra-virgin olive oil (which was provided by the study) to their diet daily. The second group was also instructed to follow a Mediterranean diet. They were instructed to add about a quarter cup of mixed nuts (also provided) to their diet daily. The third group was instructed to follow a low-fat diet.

The three groups were followed for an average of 5 years. Strokes, heart attacks, and other episodes of cardiovascular badness were tallied.

The three groups had similar numbers of heart attacks, but the two groups following the Mediterranean diet had significantly fewer strokes than the group instructed to follow the low-fat diet. The statistics suggest that for every 60 people in one of the Mediterranean diet groups instead of the low-fat diet group one stroke is prevented every five years. That's pretty impressive, and is better than some medications used for stroke prevention.

So does this mean that a Mediterranean diet is better at stroke prevention than a low-fat diet? Not at all. As an accompanying editorial makes clear, what is important is what the three groups actually ate, not what they were supposed to eat. The first two groups were pretty good at keeping a Mediterranean diet, but the third group which was supposed to eat a low-fat diet, didn't Most of the people in the third group, despite being instructed to eat a low-fat diet, ate pretty close to a Mediterranean diet, which is what they were eating before the study. That makes sense. Spain is Mediterranean, and it's very hard to change people's eating habits.

So this study doesn't teach us anything about the benefits of a Mediterranean diet, but you wouldn't know that from the headlines in the popular press coverage (links below). This study taught us much more about how ineffective it is to instruct people to change what they eat, and much less about whether one kind of diet is healthier than another.

This study does suggest that in people eating a Mediterranean diet, adding olive oil or mixed nuts decreases stroke risk, which in itself is very interesting. Does that mean that olive oil and mixed nuts might prevent strokes in the rest of us? Maybe. I certainly wouldn't object to my patients adding nuts and olive oil to their diet, and I'm busily trying to figure out how to order that with my next shawarma.

Learn more:
Olive Oil Diet Curbs Strokes (Wall Street Journal)
Mediterranean Diet Shown to Ward Off Heart Attack and Stroke (New York Times)
Mediterranean diet over low fat? Well, at least it's more fun (Los Angeles Times opinion)
Primary Prevention of Cardiovascular Disease with a Mediterranean Diet (NEJM article)
Did the PREDIMED Trial Test a Mediterranean Diet? (NEJM 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--Hysterectomies may not increase cardiovascular disease risk

noreply@blogger.com (Ryan DuBosar) — Wed, 15 May 2013 11:00:00 +0000

Primary care physicians can assure women that the possibility of a hysterectomy doesn't necessarily lead to a higher risk of heart disease. It's one less thing to worry about for a procedure that's could frighten any woman.

Contrary to previous retrospective studies, this prospective analysis showed that hysterectomy with or without ovarian conservation was not a key determinant of cardiovascular disease risk.

Researchers enrolled 3,302 premenopausal women not using hormone therapy between the ages of 42 and 52 and followed them annually for over 11 years for sociodemographic, lifestyle and clinical factors.

Results appeared online at the Journal of the American College of Cardiology.

Among the women, 1,769 reached natural menopause, 77 underwent a hysterectomy with ovarian conservation, and 106 women had a hysterectomy with bilateral oophorectomy. Cardiovascular risk factors did not vary annually by group with few exceptions, and the significant group differences that did emerge did not suggest an increased cardiovascular disease risk.

These results should reassure women and clinicians that hysterectomy in mid-life is unlikely to accelerate cardiovascular risk, the authors noted.

"The influence of natural and hysterectomy with or without ovarian conservation was similar for HDL-C, LDL-C, ApoB, HOMA-IR, SBP, PAI-1, and Factor VIIc over time," the authors wrote. "Several CVD risk factor changes did differ during the intervals prior to and following hysterectomy, compared to the changes prior to and following FMP (first menstrual period), but not in a pattern suggesting increasing cardiovascular risk following hysterectomy."

Your disease, your problem

noreply@blogger.com (Peter A. Lipson, MD) — Tue, 14 May 2013 15:00:00 +0000

I get that medicine is hard; I've spent a good portion of my life studying it. Because of this, people come to me for help in maintaining their health. Today's patient tends to have access to much more information than when I started medical school. The Internet gives us all the potential to learn more about our own health.

Unfortunately, there's no quality filter on Google. That's one of the many reasons people come to see me. While I share the ambivalence of many of my colleagues about patients bringing internet printouts to the office, I generally think it's a good thing. It's a great way to open the door to educating my patients. They seem to appreciate my opinions and they feel more a part of their own health care.

Achieving and maintaining good health requires a lot more than googling, though. My biggest challenge every day is treating the Big Three: hypertension, diabetes, and nicotine dependence. These problems require a collaboration between doctor and patient. I can dispense medicines and advice, but I can't make someone change their lifestyle.

These problems are difficult because it's not just about will power. Smoking and eating cause changes in the brain that reward the behavior and punish you when you don't over-indulge. Still, will power is a good starting point.

What I get to see daily is people who come in for a check-up and nothing has changed. They swear they eat "nothing" and yet gain weight; they take all their medications as prescribed but their blood pressure is always high; cigarettes are so expensive that they can't afford the medications to help them quit.

There's a lot doctors and insurance companies can do to help patients along the path to health, including sponsoring weight control programs, gym memberships, and paying for smoking cessation.

But it still comes down to accepting that you have a disease and that managing it is your responsibility. Testing your blood sugar, taking your medicines, watching your eating are all up to you. As a society, we need to be better about supporting these behaviors. We need to make healthy behaviors affordable. If you live in a dangerous neighborhood where it's too dangerous to walk, and you can't afford diabetic supplies, we as a society have failed you.

But it's not just the poor who fail to do their part. All of us have behaviors that are bad for us, and all of us have to take steps to make ourselves better. Come by the office and ask me where to start.

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 at Forbes. His 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.

Patient safety and suppositions

noreply@blogger.com (Zackary Berger, MD) — Tue, 14 May 2013 13:00:00 +0000

Recently I went to the Maryland Patient Safety Conference as one of the Armstrong Institute clinical patient safety fellows. I missed Rudy Giuliani's keynote because I was busy taking care of patients in the hospital. Rudy, of course, is a well-known patient-safety expert. Or at least I hope so, because I doubt he spoke for free.

What I did catch, though, were two very interesting talks on aspects of safety and quality which are near and dear to me. Keith Berge, MD, of the Mayo Clinic spoke about opioid diversion. Opioids are among the most commonly prescribed medications, and they have street value. Thus they are stolen, oftentimes by health care workers. Sometimes those health care workers are our patients too.

Berge's presentation was remarkable for its unvarnished, pithy, piquant quality: stories of prostheses used to provide clean urine for witnessed drug tests; mug shots of convicted felons now serving jail time. "Some people say, you are criminalizing a medical problem [of addiction]," he said. "I say, you are medicalizing a criminal problem!"

Both are true, of course. Criminal liability must be prosecuted but does that not limit the responsibility of the provider to understand the disease of addiction. In my setting, Johns Hopkins, we need to find those who are diverting opioids but at the same time we need to (a) find help for those addicted, (b) write fewer prescriptions in cases when the medicines don't work and (c) not ignore pain treatment as we try and address substance abuse.

The second talk was by Jason Wolf, PhD, an organizational development specialist and a masterful user of anecdote. Patients, he claimed, are now the masters of the health care system, because they have the power of choice. Leave aside the naivete (many patients have no power to choose anything, much less health care).

Dr. Wolf's idea is that health care organizations can flourish in the market only if they provide patients with unforgettable experiences through superlative customer service. He told a couple of stories to this effect. A nurse goes out of her way to escort a patient on discharge to his car, even when the patient forgets where his car is and then the car happens to be parked in by another car. When the nurse finally returns to her unit, she is applauded for going the extra mile. Stories like these make you wonder: what about all the sick patients who need taken care of when the team is a man (or woman) down? Doesn't safety and reliability matter as much as superior service?

When you're at a big conference, you feel the crowd around you swept up by these talks, and you try to find the nuggets of useful information among the questionable suppositions.

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

QD: News Every Day--Not so fast with that fecal transplant!

noreply@blogger.com (Ryan DuBosar) — Tue, 14 May 2013 11:00:00 +0000

The FDA will require doctors to pursue an investigational new device exemption for fecal transplants, since the procedure's ... er, core ingredient ... is not approved for any use.

The American Gastroenterological Association reported on its website that it confirmed this in a letter from Karen Midthun, MD, ACP Member, the Director for the Food and Drug Administration's Center for Biologics Evaluation and Research.

Fecal transplants have captured the interest of many physicians seeking a definitive solution to recurrent Clostridium difficile infections. The procedure goes back in the literature as far as 1958. A few modern-day internists' experiences are reported here, here and here. Still want more proof? The Centers for Disease Control and Prevention are working on the issue, as well.

Finally, meet another doctor who is working on the issue, by donating the ... again, core ingredient ... to those in need who don't have family that can donate. Hunter Johnson, MD, an Emory University medical resident, describes why he likely has a high success rate for patients who use his samples for their treatments. He says the best donors are young, healthy, and at low risk for infections; don't eat exotically, travel a lot or use drugs; and essentially lead "a pretty boring life." His supervisor is working on the investigational new device exemption that would define his stool as medicine, reports NBCnews.com.

Do work hours reduce medical errors?

noreply@blogger.com (Michael Kirsch, MD) — Mon, 13 May 2013 15:00:00 +0000

One of the points I offer in this blog and elsewhere is to be skeptical to assume that something is true because we think it should be.

We've been brainwashed to believe that obesity is a killer, despite research performed this year concluding that a little more weight may add years to your life. Many argue that an assault weapons ban will save lives despite the absence of social science research that supports this. Fewer guns should save lives, right? When skeptics like me point to Chicago, which boasts extremely strict gun control legislation while being a murder theme park, we are given excuses to reject the data that contradicts gun control dogma. Isn't the term "assault weapon" itself unfairly charged and loaded?

I have supported medical education reform advocating that medical residents and interns should not be worked to exhaustion and yet be expected to administer high quality and compassionate care to ill patients. I had believed that somnambulating medical interns were more likely to harm patients with careless care. I believed that this was true because it seemed entirely self-evident.

Two recent studies published in the April 22 issue of JAMA Internal Medicine suggest that I was wrong. What should one do when a study contradicts a long held view? There are two choices to consider:
--Reflect, consider the quality of the new information and modify your view.
--Attack the study as a Big Government, Big Oil or Big Anything conspiracy and hold your ground.

The latest information suggests that interns and residents who work fewer hours commit more errors. Reasons include:
--While residents work less at the hospital, they aren't sleeping more.
--Residents are now required to do the same amount of work in fewer hours.
--Shorter shifts mean more hand-offs of patients to the next crew of eager interns.

Obviously, cramming in the same amount of high-pressure work into fewer hours invites errors, particularly with relatively inexperienced physicians who may not be adequately supervised at night. Medical handoffs are the event when interns who are leaving the hospital sign over the care of their patients to the next crew who must assume immediate responsibility for patients they may have never seen. Hospitalized patients are complex. The nuances of their condition cannot be seamlessly transmitted to doctors-in-training in a few sentences. An intern may have to assume care of 10 or so new patients as he comes on shift. Would you feel at ease if you were one of these patients? Indeed, one of the defenses of the pre-reform system when interns were real men and worked until exhaustion was that there were fewer dangerous medical handoffs.

Now, these two studies are not determinative. The increased error rates with shorter work shifts were volunteered by the doctors themselves, which is not scientifically rigorous. I'm not ready to abandon my view that interns in my day were unnecessarily overworked, but it may be that the reforms that are in place left now have left us too far from a humane end zone.

Not every hypothesis needs to be tested. Do we need a study to determine if highway driving while wearing a blindfold is dangerous? Are we still entertaining the notion that it is better for patients and young physicians to meet when the doctor is disoriented from sleep deprivation? Is there really a need to torture interns to buck them up for their later years in medical practice when they will likely sleep soundly through most nights?

I'm against torture, even though I know its definition has been a matter of public debate. Indeed, I'm pleased that my views coincide with national policy.

What if our senators and representatives had to legislate on four hours of sleep each night? Care to predict the outcome? Would the quality of legislation, comity and bipartisanship flourish? One would surmise that exhausted congressmen would commit more errors, but who knows? I say, let's try the experiment for a year to test this hypothesis which may ultimately improve the political process. I think there's a reasonable prospect that congressional sleep deprivation may improve quality, considering that these self-promoting, self-aggrandizing, self-serving and self-protective scoundrels have already hit bottom. There's only one direction they can go. No need to sleep on this one.

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

Diagnostic skills can decrease health care spending

noreply@blogger.com (Robert Centor, MD) — Mon, 13 May 2013 13:00:00 +0000

"Not everything that can be counted counts, and not everything that counts can be counted."
--Albert Einstein

When policy wonks and legislators talk about bending the health care cost curve, they often stress quality. They then assert that we can measure quality and incent that same quality, with important positive results. Too often I have listened to this mantra--control health care costs by paying for quality.

Long-time readers know that I become agitated when the wonks assert that they can measure quality (they are only measuring performance which is a small part of quality) and decrease costs with that strategy.

So I will assert that the key to decreasing health care spending involves taking care in the diagnostic arena. My observations, while anecdotal, suggest that we spend too much money on diagnosis. Too often we resort to expensive imaging; too often we start treating one diagnosis instead of carefully establishing a diagnosis. We have too many diagnostic errors, or delayed diagnoses.

Talking with a wonderful colleague while at Internal Medicine 2013 in San Francisco, he suggested that too often he sees patients who have not had a sufficient history, physical exam, or thought process. Careful and thoughtful diagnosis takes time. In too many emergency departments, a protocol exists that allows a triage nurse to order an abdominal CT prior to a careful history and exam.

Why are the suits obsessed with performance and not diagnosis?

Oh, measuring the accuracy of diagnosis is very difficult!

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

QD: News Every Day--Consider oral drops for asthma symptoms

noreply@blogger.com (Ryan DuBosar) — Mon, 13 May 2013 11:00:00 +0000

Sublingual drops for asthma work just as well as injections, a meta-analysis found.

Researchers reviewed outcomes for injections of 13 trials with 920 children and 18 studies of 1,583 children who received drops. All trials were randomized controlled trials of children with allergic asthma or rhinoconjunctivitis. Only three of the 34 studies directly compared shots and drops.

href="http://pediatrics.aappublications.org/content/early/2013/04/30/peds.2013-0343.abstract"Results appeared in the May 6 issue of Pediatrics.

There was moderate strength of evidence that injections improved asthma and rhinitis symptoms and low strength of evidence that injections improved conjunctivitis symptoms and asthma medication scores. Strength of evidence is high that drops improved asthma symptoms and moderate that they improved rhinitis and conjunctivitis symptoms and decreases medication use.

There was little evidence to support using injections over drops, the authors noted. The three studies that directly compared injections versus drops for dust mite-induced asthma and rhinitis showed no strong evidence that shots worked better than drops.