ACP Internist

I'm learning to like weekends

noreply@blogger.com (Peter A. Lipson, MD) — Fri, 25 May 2012 15:00:00 +0000

This was a well-earned weekend for the Pal Family, and what a day! It's back in the 60′s (which, for my Canadian readers, is like minus 13 or something). Our local gopher is nibbling on walnuts out back, and I just deleted my bookmark for my board review questions. And I'm pretty sure I fartleked today. Afterward, I drove the car to meet the family for lunch, windows down, and caught the last two movements of a live performance Beethoven's Fifth on CBC.

There were lots of folks out on the trail today, and I'm sure that tomorrow there will be plenty in the office, so it seems a good time to go over a spring ailment. This time of year the poison ivy is just starting to leaf out, and with people getting back into their yards, I start to see a lot of intensely itchy rashes.

Poison ivy leaves a rash typical of an "outside job"; often you can tell the eruption was caused by an external agent just by the pattern. There tends to be small blisters, many of which occur in distinct lines where the plant brushed across the skin. It's a pretty benign rash, but horribly uncomfortable. Occasionally, people can develop a secondary immune reaction, or the rash can become infected with bacteria, creating a honey-colored crust on top.

The best treatment is avoidance. Learn where the poison ivy is in your area, and stay the hell away from it. My daughter has been able to recognize it since she was three; I don't want her to associate hiking with itching.

The rash is caused by oils secreted by the plant. Once you have showered in soap and water, you cannot spread it or give it to others. People will erroneously believe they have spread it because the rash can develop more or less rapidly and intensely in different areas, but these are areas that were usually exposed at the same time. Once you realize you've been exposed, the best you can do is take a hot, soapy shower, and put all of the exposed clothes into a hot, soapy wash.

Berry brambles and other benign plants often grow in the same areas as poison ivy. If you're not absolutely sure, don't touch it. If you do get the rash, your doctor will probably prescribe an antihistamine such as oral Benadryl for mild cases. Benadryl and calamine creams are usually not helpful.

There was plenty of the stuff growing along the rail trail this morning, something to distract me on my run. Running sometimes scares the hell out of me. I think it's the fear of discomfort or the fear of not being able to do it. Last weekend I hit the trail and after about 100 meters, I was done. I just. Couldn't. Move. Today was much nicer. As I mentioned, I tried the whole fartlek thing, and while I only did about two miles (for our neighbors to the north, about 1,200 centimeters or something); the variation made it much more interesting and much more comfortable.

I suspect this fear is what keeps a lot of people away from exercise, especially those who have been away from it for a while. I try to encourage my patients to get back into exercise slowly, to remind them that any physical activity is better than none. We tend to be wired to fall back on old and easy habits and when we don't exercise for a week, or we don't lose 20 pounds, we give up because we all know it's much easier to sit on the couch eating Mallomars.

So put down the cookies. Get out there, hit the trail, even if it's only a few hundred yards (or for our Canadian neighbors, three Imperial gallons or something).

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.

Mentoring in medical education takes its cue from the movies

noreply@blogger.com (Vineet Arora, MD) — Fri, 25 May 2012 13:00:00 +0000

A big part of medical education is mentoring. The term mentor originates from Homer's the Odyssey and refers to an advisor. The role of mentors vary, but generally serve to guide mentees through work, support them during the process, keep them grounded and focused on the task at hand, and provide general moral support.

Over the weekend, at the Pritzker Revisit session on Scholarship and Discovery, our own students stated the number one thing to consider when finding a project was finding a great mentor.

How does one find a great mentor? Well, our students are encouraged to seek "CAPE" mentors; think superhero mentors. The mentor should be Capable, Available, have a Project that is of interest to the student, and Easy to get along with.

Capable means that the mentor has the skills to not only be a good mentor, but also to carry out the task or project at hand. This may sound like odd, but sometimes faculty are so excited to have a medical student work for them, they may make the false assumption that the medical student will help them with tasks (i.e. statistics) that they themselves don't know.

Availability is especially important as it is the number one reason our students state they had a less than optimal experience in the summer doing scholarly work is that their mentor was not available. While availability of all doctors is an issue, the question is often whether faculty make themselves available when they can (i.e. answer student email, take phone calls, meetings). Setting expectations for when and how to meet can be very important.

Ideally, the mentor has a project that is interesting to the student since if the work is not interesting, it will be even harder to make progress.

Last but not least, the mentor has to be easy to get along with, meaning that their style meshes well with their mentees. Some people simply do not work well together do to different personality types. So, I often tell our students to consider that when meeting potential mentors or deciding between two mentors.

As I was thinking about ways to highlight effective mentors, I recalled some classic movies with mentoring relationship. In relooking at these scenes this weekend, it struck me that there are some interesting reasons why they are good mentors that correlate with our model. Some of them are a stretch but they are still fun to watch!

Yoda in Empire Strike Back encourages Luke Skywalker to not just try, but do. When Luke fails to resurrect the wing fighter, he does not allow Luke to make excuses but instead demonstrates that he can do it, showing that he is CAPABLE.

Mr. Miyagi with the Karate Kid mentors through teaching small movements related to everyday house chores, "wax on, wax off." While he is certainly gruff and challenges Daniel, Mr. Miyagi also makes himself AVAILABLE to Daniel at that moment and in the future by saying at the end "Come back tomorrow" to continue the training.

Remus Lupin goes so far to use a simulated Death Eater to challenge Harry Potter to learn the patronus charm (and making all standardized patient experiences seem like a cake walk). When Harry fails at first, he is patient and nurturing, stating that he did not expect Harry to get it on the first try. He also makes suggestions to the technique which turn out to be the key. Since Harry really needs this charm, this is a PROJECT THAT IS OF INTEREST and Harry ultimately succeeds in casting the spell.

Gandalf in Lord of the Rings provides consolation to Frodo during a moment of despair by highlighting that it his job and also showing that Gandalf is sensitive to Frodo's needs and EASY TO GET ALONG WITH.

In addition to these highly acclaimed superhero and superstar CAPE mentors, let me know if you know of other model mentors from the movies.

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

QD: News Every Day--Sodas, whether regular or diet, associated with hypertension

noreply@blogger.com (Ryan DuBosar) — Fri, 25 May 2012 11:00:00 +0000

Sugar-sweetened and artificially sweetened beverages are independently associated with an increased risk of incident hypertension, but it may not be the fructose that's responsible, a study found.

To examine the associations between sugar-sweetened and artificially sweetened beverages with incident hypertension, researchers conducted a prospective analysis of three large, prospective cohorts, the Nurses' Health Studies I (n=88,540 women) and II (n=97,991 women) and the Health Professionals' Follow-Up Study (n=37,360 men).

Results appeared online the Journal of General Internal Medicine.

Both types of sweetened drinks were associated with an increased risk of developing hypertension. Those who drank one or more sugar-sweetened drink a day had an adjusted hazard ratio for incident hypertension of 1.13 (95 % confidence interval [CI], 1.09 to 1.17) compared with those who did not.

Those who drank one or more artificially sweetened beverage a day had an HR of 1.14 (95 % CI, 1.09 to 1.18). The association between sweetened beverage intake and hypertension was stronger for carbonated beverages versus non-carbonated beverages, and for cola-containing versus non-cola beverages in the NHS cohorts only.

Higher fructose intake from sugar-sweetened drinks as a percentage of daily calories was associated with increased hypertension risk in the NHS studies (P for trend=0.001 in both groups), while higher fructose intake from sources other than sugary drinks was associated with a decrease in hypertension risk in NHS II participants (P for trend=0.006).

"These observations raise the possibility that a common element in sugar-sweetened and diet soft drinks is at least in part responsible for the abnormalities associated with the metabolic syndrome, and in particular blood pressure," the authors wrote. With sugar ruled out by the study of diet sodas, other suspects might include caramel coloring, carbonation of the beverages, or the amount of sodium they have, which is tough to measure from questionnaires.

Learning the best way to assess jugular venous pressure

noreply@blogger.com (Justin Penn, MD) — Thu, 24 May 2012 15:00:00 +0000

Of all of the physical exam findings that are often taught in medical training, I think one of the most important is the ability to judge volume status from examining neck veins. It's a skill that a lot of medical students and residents strive to become competent in; often many trainees will ask their attendings to verify their findings from their morning rounds.

Finding the level of the jugular venous pressure is hard, but I think it's something that's really worth mastering as it will inform your decision making more so than many other aspects of a daily exam.

To prove my point I ask you, does the quality or quantity of bowel sounds matter in a patient without bowel complaints? Is there any part of the head exam that would change in the course of an inpatient admission? The lung exam may change in a case of pneumonia but isn't the fever curve and the general appearance of the patient better and more important to note? The rales of heart failure may improve in a case of congestive heart failure, but I'd say that when your patient is sleeping flat, no longer dyspneic, and no longer tripoding, the pulmonary finding of rales is irrelevant.

Here is a great website about jugular venous pressure from the University of Washington School of Medicine. Where I got the information at the bottom of this post.

Here is a classic film about the JVP:

I think all of us as internists, hospital and ambulatory, nephrologists and cardiologists should have a good sense of how to find and measure the top of the jugular venous pressure in order to monitor the volume status of our patients on a day-to-day basis. The great challenge in interpreting neck veins, the expert clinician, is to be able to perform wave analysis as Dr. Wood does in this video.

The "a" wave represents the atrial contraction, the x decent represents atrial relaxation, the "v" wave represents ventricular contraction, and the "y" descent represents ventricular diastole.

The most prominent aspects of the neck waves are not the contractions or waves themselves but their troughs: the x and y descent.

Timing of the descents can be done while palpating the carotid or when listening to the heart. The x descent falls into the dub of S2. Lub-clap-dub. The y descent falls during ventricular diastole so it comes after S2. Lub-dub-clap.

Alternatively if you can time the carotid pulse with the x descent by saying C every time you feel the carotid pulse. Then start staying down quickly after every C; C-down, C-down. The x-descent will be occurring as you say down.

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

The lunacy of weight loss by nasogastric feeding

noreply@blogger.com (David L. Katz, MD) — Thu, 24 May 2012 13:00:00 +0000

I have previously expressed my concerns that weight loss and common sense have trouble co-habitating, and might even be at war. The discord is understandable: Desperation breeds gullibility, and wishful thinking. People with more than ample common sense are lulled into a state of hypnotized bemusement by magical claims of effortless weight loss. Again, and again, and again.

Certainly nothing else accounts for the popularity of such patent nonsense as the HCG diet. The diet gained fame by combining a 500 calorie/day meal plan with injections of a pregnancy hormone. The pregnancy hormone, essentially, Dumbo's feather, has induced legions of people to pay a fortune to lose weight by starving themselves. If they were to starve themselves at no extra charge, they would lose weight just as fast.

Leaving aside the fact that clinical trials robustly debunk HCG diet claims, there is the simple expediency of common sense. Anyone who has ever had anything to do with pregnancy knows that those hormones are NOT turning off appetite or inducing weight loss! I have plenty of firsthand experience, and not just as a doctor; my wife and I have five kids. There were times in any of my wife's third trimesters when if food was not readily at hand, I feared she would eat my arm! And absent the influence of those pregnancy hormones, my wife, who happens to be French, is a very thoughtful, moderate eater.

I thought common sense couldn't go any deeper into a coma than believing that pregnancy hormones were the reason a 500 kcal diet was causing weight loss. But I was wrong. Common sense, it seems, along with medical ethics, has come off life support altogether with the advent of the "K-E diet."

"K-E" stands for ketogenic enteral nutrition. "Ketogenic" may sound familiar, because it refers to the burning of ketone bodies that occurs with a very low intake of carbohydrates. It figured in the original Atkins diet, and more recently in the Atkins diet with a French accent, the Dukan diet. Another example of dietary common sense lapsing into unconsciousness, by the way, but we've got bigger fish to fry.

"Enteral" is a medical term that refers to putting food into the gastrointestinal system. In contrast, "parenteral" feeding bypasses the GI tract altogether by putting nutrients directly into the bloodstream.

A better, more descriptive term for the new diet is the nasogastric tube diet. The K-E diet involves inserting a feeding tube into the nose, down the esophagus, through the stomach, and into the duodenum, and then infusing a feeding solution continuously.

This is done in the hospital routinely for people who can't eat. But that's not what the K-E diet is about. It's about brides-to-be who want to lose 10 pounds or so in a hurry to look good in a wedding dress.

This "diet" is little short of lunacy on the part of any such bride-to-be, colossally misplaced priorities on the part of any groom-to-be watching it happen, and as profound an abrogation of professional ethics on the part of doctors peddling it (for $1,500) as I have ever seen.

Everything about this is appalling. Not so much because of the risk of metabolic complications from a ketogenic diet over a period of just 10 days. These are real, and include stresses on the liver, kidneys, and skeleton, but for people healthy at the start, such concerns are both minor and remote. Bone loss will occur, but will be inconsequential if limited to a 10-day span. Constipation is the one complication that will occur almost without fail. A ketogenic diet is used in medical practice to treat intractable seizures, but that's a case where the inconvenience and adverse effects of the diet are the lesser of two evils, because the alternative is uncontrollable epilepsy.

What makes the K-E diet truly appalling is that it transforms a medical therapy into the indulgence of a short-term, short-sighted, vanity-driven whim. It opens up a whole new world of shockingly bad ideas:

Why not chemotherapy-induced nausea and anorexia for weight loss? If you don't need a medical condition for a nasogastric tube, why should cancer be required for chemotherapy? Why not a medically-induced coma/anesthesia for weight loss? Or perhaps a serious metabolic stress to melt off the pounds, such as, why not medically-controlled anaphylaxis?

If self-induced vomiting after meals constitutes an eating disorder, what, exactly, is infusing liquid formula through a tube into the duodenum without medical indication? If the K-E diet survives a while, and I sure hope it doesn't, I bet it will come to be defined as an eating disorder in its own right. I fully appreciate the frustration many people feel when trying to lose weight, but if bulimia is not the right answer for that problem, neither is this!

A nasogastric tube is an unpleasant, undesirable medical procedure we impose on sick patients who can't eat. It carries with it a risk of aspiration pneumonia, which can be fatal. Ladies, not to put too fine a point on it, but: do you really want to marry a guy who stands by while you risk your life to lose 10 pounds? If my then-wife-to-be had proposed any such thing (not that she would have), my answer would have been equally emphatic and immediate: over my dead body!

In terms of quick weight loss, this dangerous nonsense is a guarantee of quick rebound with interest, since it involves no useful behavior change whatsoever. It has nothing at all to do with health, and basically endorses the notion that weight loss by any means is acceptable. If that is so, why not a 10-day pre-nuptial cocaine binge? It will work as well or better, and almost certainly be more fun, than a nasogastric tube.

As for the doctors involved in peddling this travesty, I condemn their actions. The job of physicians is not to come up with any way to satisfy a patient's whim, no matter how fundamentally at odds with health.

Our professional mission is to promote and protect health, and to serve the patient in that context. In that context, the patient is the boss, and we are, or should be, at their service. But we are abdicating our profound responsibilities and most sacred pledges when we renounce a commitment to health, and adopt an "oh, what the hell" approach to make some extra money by exploiting a patient's faith in us, and their desperation. On behalf of my profession, I am ashamed.

This is weight loss lunacy. Resuscitate your common sense while there's still time. Love the skin you're in, 10 extra pounds and all, and marry a guy who does, too!

Step away from the nasogastric tube, and one less person will get hurt.

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--Diabetes kills far fewer as treatments improve

noreply@blogger.com (Ryan DuBosar) — Thu, 24 May 2012 11:00:00 +0000

Death rates among diabetic mean and women declined substantially between 1997 and 2006, particularly among excess death due to the disease, a study found.

To determine whether all-cause and cardiovascular disease mortality declined between 1997 and 2006, researchers from the Centers of Disease Control and Prevention compared 3-year death rates of four consecutive nationally representative samples (1997–1998, 1999–2000, 2001–2002, and 2003–2004) of U.S. adults using data from the National Health Interview Surveys linked to National Death Index.

Results appeared in the June issue of Diabetes Care.

Among diabetic adults, the cardiovascular disease mortality declined by 40% (95% confidence interval [CI], 23% to 54%) and all-cause mortality declined by 23% (95% CI, 10% to 35%) between the earliest and latest samples.

Men and women shared the benefits of declining mortality rates, the study noted.

The excess cardiovascular disease mortality rate associated with diabetes compared with nondiabetic adults decreased by 60% (from 5.8 to 2.3 cardiovascular disease deaths per 1,000) while the excess all-cause mortality rate declined by 44% (from 10.8 to 6.1 deaths per 1,000).

Authors noted that, while results of the study are encouraging, diabetes prevalence is likely to rise in the future if diabetes incidence is not curtailed.

The authors wrote, "Although excess mortality risk remains high--about 2 deaths per 1,000 due to CVD and about 6 all-cause deaths--this excess risk is now considerably lower than previous reports and consistent with improvements in several risk factors, complications, and indicators of medical care and representative of gradual, ongoing improvement in health for people with diagnosed diabetes."

But the gains are fragile, the authors noted. As fewer people die from diabetes, it will become more prevalent overall, requiring physicians to diagnose and treat its vascular and neuropathic effects.

Slow medicine

noreply@blogger.com (Danielle Ofri, MD, PhD, FACP) — Wed, 23 May 2012 17:00:00 +0000

I can't tell you exactly when it happened, but sometime in the past two decades, the practice of medicine was insidiously morphed into the delivery of health care. If you aren't sure of the difference between the two, then "God's Hotel" is the book for you. It's an engaging book that chronicles this fin-de-siecle phenomenon from the perspective of San Francisco's Laguna Honda Hospital, the last almshouse in the United States.

Dr. Victoria Sweet, a general internist, came to Laguna Honda for a two-month stint more than 20 years ago and ended up staying. Laguna Honda was home to the patients who had nowhere else to go, who were too sick, too poor, too disenfranchised to make it on their own. The vast open wards housed more than a thousand patients, some for years. Laguna Honda was off the grid, and this, Dr. Sweet discovered, was to the benefit of the patients.

Unencumbered by HMOs and insurance companies, the doctors and nurses practiced a very old-fashioned type of medicine, "slow medicine," as Dr. Sweet terms it. There was ample time for doctors and nurses to get to know their patients, and ample time for patients to convalesce. Many a written-off patient recovered within the comforting, unhurried arms of Laguna Honda.

Sweet realizes that the inefficiencies of this old-fashioned hospital, from the doctors who had time to fully research their patients' complicated histories, to the nurse who knitted a handmade blanket for every charge on her ward, to the chicken that wandered regularly through the AIDS ward, bringing a spark of life to even the most demented patients, were actually its secret weapon. The inefficiencies were actually quite efficient, if your metric was healing patients.

Then arrived the consulting firm of "Dee and Tee, Health-Care Efficiency Experts." Horrified by the rambling open wards and the old-school style of medicine, never mind the chicken, Dee and Tee quickly cut out excessive head nurses, consolidated departments, speeded up discharges and created committees, PowerPoint presentations and forms with 1,100 boxes. The consulting firm never consulted with any staff members who actually took care of patients, but they did stand to earn 10% of any savings engendered.

Thus Laguna Honda was rapidly schooled in the inefficiencies of efficiency, as patients without nurses grew sicker, and enthusiastically discharged patients spiraled downward, had multiple ER visits and were eventually readmitted to the hospital. Dee and Tee, of course, did not have to pony up for any additional costs the consultancy caused.

Over the course of Dr. Sweet's 20 years as a staff physician, Laguna Honda made this painful transition from the practice of medicine to the delivery of health care, and it was the patients who suffered most, followed by their caregivers.

During this period, Dr. Sweet found solace in her doctoral studies of Hildegard of Bingen, the medieval healer, nun, mystic and composer. Hildegard's pragmatic and thoughtful approach to medicine appealed to Dr. Sweet and even informed her own practice of medicine. Stymied by an oddly agitated patient who'd already been given a full diagnostic workup, Dr. Sweet had a What-Would-Hildegard-Do moment, and decided to simply sit with the patient.

She sat with the patient for a good long time, watching her, thinking about her, being in the moment with her. There was something frankly medieval about the patient's twisting and writhing, as though she were trying to expel something, as though she were poisoned.

Reviewing the chart, Dr. Sweet realized the woman was indeed being poisoned, by her own medications. A toxic brew of antidepressants, antipsychotics, pain meds and sedatives had led to serotonin syndrome. Dr. Sweet decreased the patient's medications, and within hours the patient improved. She eventually stopped nearly all the medications, and the patient became well enough to go home.

Untangling the mass of medications that most patients arrived with became Dr. Sweet's hallmark. She found that nearly all her patients could be relieved of a portion of their accrued medications. But this could only work in the setting of "slow medicine," of having time to watch patients carefully over an extended period, of digging deep into the convoluted lives of these patients, of having time to "just sit" with each patient.

This, of course, is highly inefficient, if you are Dee and Tee. But it's remarkably efficient if you are a patient and are interested in being cured, cared for and comforted.

You might not expect a book about San Francisco's most downtrodden patients to be a page-turner, but it is. With its colorful cast of characters battling the tide of history, "God's Hotel" is a remarkable journey into the essence of medicine.

In 1925, Dr. Francis Peabody told a graduating class of medical students that, "the secret of the care of the patient is in caring for the patient." Simple, eh? If Dr. Peabody were practicing medicine today, he'd surely be consolidated with a midlevel provider to deliver health care with maximal quality indicators and operational excellence. Sigh ...

(from The San Francisco Chronicle, April 22, 2012)

Danielle Ofri, MD, PhD, FACP, is the author of three books, including "Medicine in Translation: Journeys with My Patients," which is about learning the individual stories of patients. She is an Associate Professor of Medicine at New York University School of Medicine and editor-in-chief of the Bellevue Literary Review. She is currently writing a book about the emotional life of doctors. This post originally appeared at her blog.

My love-hate relationship with early clinical exposure

noreply@blogger.com (Amanda Xi) — Wed, 23 May 2012 17:00:00 +0000

Last semester when I saw an in-patient for the first time, the overall experience was exceedingly positive. I didn't have any confidence in my ability to diagnose anything, but that wasn't the purpose of the encounter. Furthermore, it was still my first semester of medical school; no one expected me to be able to integrate the patient's symptoms with a clinical diagnosis and course of treatment. There was nothing to lose.

My first experience left me wishing for more time with the patient and a sense of purpose when I returned to my textbooks. It reminded me that medical school wasn't only comprised of hours of time with my head spinning; there was a light at the end of the tunnel called third-year clerkships, and with each passing day I came closer and closer to being able to practice medicine.

However, during our most recent clinical experience, I walked away conflicted. The premise of the exercise wasn't too different from the first, but we were responsible for doing a bit more with the physical examination. And with an OSCE looming on the horizon, I was happy to have an excuse to practice.

After we met our preceptor for the day, we headed to a different unit to see our patients. This time, we had two different patients to interview and do a pertinent physical examination on. Prior to walking into the patient's room, the preceptor told us the chief complaint so I felt prepared to solicit more information. We walked into the room and following a brief introduction, I sprang into action.

Our patient's story tumbled out without any resistance; it caught me off-guard how easily pertinent facts could be collected from her responses. After collecting what I needed, I moved on to an abridged physical examination and wrapped up my encounter with that. We thanked the patient and left the room to discuss the encounter.

My preceptor's feedback was mainly positive, but he noted that I was a bit nervous [Well, yeah!]. There were a couple of things that I failed to obtain, but it was a learning experience so these things are to be expected.

We then moved on to our second patient, and my partner conducted the interview and physical examination while I took notes. He finished promptly and we moved outside to wrap up the experience.

It was as I was walking out of the long hallway of the hospital when a wave of dissatisfaction and frustrated rolled in. As one of the patients listed medications, I recognized a couple of them but ended up misclassifying one of the drugs. Even though I am still a first-year student, I am just about halfway done with my preclinical years. Shouldn't I at least be proficient in recognizing and identifying basic information that I already learned? How will I be comfortable with all of this knowledge for the boards and clerkships if I cannot keep simple material I learned a month ago in my head?

I know that I still have time. I know that it's still early. But I am disappointed that the medicine I keep learning seems to slip away so quickly. My knowledge feels transient and fleeting. I just want to be able to feel just slightly confident in my ability in something but it seems that I am far from it.

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

How history taking and a Toyota mechanic beat a diagnostic computer

noreply@blogger.com (Neil Mehta, MD) — Wed, 23 May 2012 17:00:00 +0000

If you give enough time to an experienced clinician working in an ambulatory setting, what percentage of acute complaints would s/he be able to diagnose correctly with just taking a good history? What about with history plus physical examination?

The answer is about 50% with history alone and about 80% with history and exam. Yes, s/he would probably order some confirmatory tests or try some medications as empiric treatment but the above numbers would hold up.

The importance of history taken by an experienced diagnostician was borne out recently. A warning to regular readers of my blog, this is another car story. Don't tell me I did not warn you!

I have a 1999 RX300 which was bought mainly to combat the snowy northeast Ohio winters. It has been a reliable vehicle and I fully intend to keep on driving it until it falls apart. You will probably accuse me of being an emotional fuddy-duddy, but it holds a special sentimental value for the family. So it was particularly upsetting when last year, early in winter it started to have all kinds of problems.

I took it in to the place where I get the oil changed and they are really nice folks, polite and accommodating. The check engine light was on, and they queried the car computer, read the code, looked up the computer and told me that some sensors needed to be changed. We did that but within a day the engine light came on again. This time the mechanic told me that the transmission was gone and it would cost more than the resale value of the car to fix it. I was crushed but appreciated the fact that he did not make me spend a ton of money before telling me this. I began to look for someone who would buy it.

Then a friend of mine recommended that I speak to this guy who works at a Toyota dealership. The Toyota Highlander is almost exactly the same vehicle as the RX300. So he might be able to tell me more. So I gave him a call. I fully expected him to read him the codes from the computer readout. Imagine my surprise when he asked me to describe what the car was doing!

I told him how I had gone abroad (a workshop I did for physicians in Singapore in October) for about 2 weeks. Right after I came back the car started misbehaving. It would work fine for the first 10 minutes or so and then when I tried to accelerate beyond 40 mph it would start revving up like it was stuck in a lower gear. I could not go on a freeway for fear of this. He started laughing and asked me if we had seen any rodents in the garage. I felt like I was talking to Sherlock Holmes! My wife had told me that she had seen a rodent near where we kept the dog food bags.

So he explained. The Highlander and the RX300 have an engine intake area that rodents love to nest in. If the car is not used for a while they start nesting there. This is particularly true of the fall season as they prepare to hibernate. The intake area is close to the wires that run to the knock sensors. The rodents eat the rubber on the wires and this shorts out the sensors (or something like that). The guy to whom I took the car to first read the computer code for the knock sensors being faulty and changed them without realizing that the problem was caused by the wires. Thus he replaced the sensors but did not fix the cause.

Long story short, (well not really but it was a pretty cool story) the Toyota mechanic changed the wires and the sensors and the car now drives like new. The key portion of history was that I did not use the car for a while during the nesting season, that we had rodents, that the problem was same as that caused when a knock sensor is faulty. His experience with having seen this before due to working on similar cars in northeast Ohio for years helped him recognize the problem.

This is a story I will tell all my trainees, that a well-directed history taken by an experienced clinician can beat multiple tests and technology!

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

A JAMA briefing on comparative effectiveness and helicopters that allows time for questions

noreply@blogger.com (Elaine Schattner, MD) — Wed, 23 May 2012 15:00:00 +0000

The Journal of the American Medical Association held a media briefing on its Comparative Effectiveness Research (CER) theme issue. The event took place in the National Press Club. A doctor, upon entering that building, might do a double-take waiting for the elevator, curious that the journalists occupy the 13^th floor--what's absent in some hospitals.

CER is a big deal in medicine now. Dry as it is, it's an investigative method that any doctor or health care maven, politician contemplating reform or, maybe, a patient would want to know.

The gist of CER is that it exploits large data sets, like SEER data or Medicare billing records, to examine outcomes in huge numbers of people who've had one or another intervention. An advantage of CER is that results are more likely generalizable, i.e. applicable in the "real world." A long-standing criticism of randomized trials held by most doctors and the FDA as the gold standard for establishing efficacy of a drug or procedure, is that patients in research studies tend to get better, or at least more meticulous, clinical care.

The JAMA program began with an intro by Dr. Phil Fontanarosa, a senior editor and author of an editorial on CER, followed by 4 presentations. The subjects were, on paper, shockingly dull: on carboplatin and paclitaxel w/ and w/out bevacizumab (Avastin) in older patients with lung cancer; on survival in adults who receive helicopter vs. ground-based EMS service after major trauma; a comparison of side effects and mortality after prostate cancer treatment by 1 of 3 forms of radiation (conformal, IMRT, or proton therapy); and, to cap it off, a presentation on PCORI's priorities and research agenda.

I learned from each speaker. They brought life to the topics! Seriously, and the scene made me realize the value of meeting and hearing from the researchers, directly, in person. But, we'll skip over the oncologist's detailed report to the second story:

Dr. Adil Haider, a trauma surgeon at Johns Hopkins, spoke on helicopter-mediated saves of trauma patients. Totally cool stuff; I'd rate his talk "exotic." This was as far removed from the kind of work I did on molecular receptors in cancer cells as I've ever heard at a medical or journalism meeting of any sort.

Dr. Haider indulged the audience, and grabbed my attention, with a bit of history: HEMS, which stands for helicopter-EMS, goes back to the Korean War, like in M*A*S*H. The real-life surgeon-speaker at the JAMA news briefing played a music-replete video showing a person hit by a car and rescued by helicopter.

While he and other trauma surgeons see value in HEMS, it's costly and not necessarily better than GEMS (Ground-EMS). Helicopters tend to draw top nurses, and they deliver patients to Level I or II trauma centers, he said, all of which may favor survival and other, better outcomes after serious injury. Accidents happen; previous studies have questioned the helicopters' benefit.

The problem is, there's been no solid randomized trial of HEMS vs. GEMS, nor could there be. (Who'd want to get the slow pick-up with a lesser crew to a local trauma center?) So these investigators did a retrospective cohort study to see what happens when trauma victims 15 years and older are delivered by HEMS or GEMS. They used data from the National Trauma Data Bank (NTDB), which includes nearly 62,000 patients transported by helicopter and over 161,000 patients transported by ground between 2007 and 2009. They selected patients with ISS (injury severity scores) above 15. They used a "clustering" method to control for differences among trauma centers, and otherwise adjusted for degrees of injury and other confounding variables.

"It's interesting," Dr. Haider said. "If you look at the unadjusted mortality, the HEMS patients do worse." But when you control for ISS, you get a 16% increase in odds of survival if you're taken by helicopter to a Level I trauma center. He referred to Table 3 in the paper. This, indeed, shows a big difference between the "raw" and adjusted data.

In a supplemental video provided by JAMA (starting at 60 seconds in): "When you first look, across the board, you'll see that actually more patients transported by helicopter, in terms of just the raw percentages, actually die." – Dr. Samuel Galvagno (DO, PhD), the study's first author.

The video immediately cuts to the senior author, Dr. Haider, who continues: "But when you do an analysis controlling for how severely these patients were injured, the chance of survival improves by about 30 percent, for those patients who are brought by helicopter ..."

—

Big picture:

What's clear is that how investigators adjust or manipulate or clarify or frame or present data--you choose the verb--yields differing results. This capability doesn't just pertain to data on trauma and helicopters. In many Big Data situations, researchers can cut information to impress whatever point they choose.

The report offers a case study of how researchers can use elaborate statistical methods to support a clinical decision in a way that few doctors who read the results are in a position to grasp, to know if the conclusions are valid, or not.

A concluding note:

I appreciated the time allotted for Q&A after the first 3 research presentations. There's been recent, legitimate questioning of the value of medical conferences. This week's session, sponsored by JAMA, reinforced to me the value of meeting study authors in person, and having the opportunity to question them about their findings. This is crucial, I know this from my prior experience in cancer research, when I didn't ask enough hard questions of some colleagues, in public. For the future, at places like TEDMED, where I've heard there was no attempt to allow for Q&A, the audience's concerns can reveal problems in theories, published data and, constructively, help researchers fill in those gaps, ultimately to bring better-quality information, from any sort of study, to light.

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.

Twitter 101 for aspiring SoMe physicians

noreply@blogger.com (Ryan D. Madanick, MD) — Wed, 23 May 2012 13:00:00 +0000

So you've decided to take the plunge (or at least, dip your toes) into the Twitterverse. Congratulations! Welcome to a vibrant interactive community. You'll find plenty of different personalities here and lots of opinions. But if you are like I was back in January 2011, you currently have no idea how to actually use Twitter, let alone how a physician might want to use it.

There are plenty of places to find information about how to start a Twitter account, (for example here), so I am going to take a leap of faith and say that if you are reading this, you have already set one up. If not, check out some online resources regarding starting your account and come back to this blog so you can figure out what you might want to do after the basic infrastructure is laid down (or, if you are just relatively adventurous, just head to Twitter and start your account without listening to any of the "pundits").

This post is not meant to give you the ins-and-outs about Twitter. I think they do a pretty good job explaining the basics on their help center. There, you'll find the "how's" of Twitter, like how to post a tweet or how to follow others.

Instead, this post contains some of my basic recommendations about how you might first want to get involved in Twitter a professional manner. As .I have said before, getting involved means starting small. I think you will quickly see why many people have stayed involved.

Consider starting with a private account. If you are still treading the water about getting involved for one reason or another, remember that you can have a private account. No one can follow you unless you let them. This means that your posts (or "tweets") will be hidden from view of everyone except those whom you permit. I suggest using this feature really only as a place to test the waters to get the hang of writing in 140 characters and see if Twitter is for you. Be aware that with a private account, your voice will not be heard. You are not really contributing your expertise; you can still listen to and follow anyone with a public account, but you limit your prospective audience. You can always change from private to public once you've established your account, so this is often a good way to test the platform, but I do not recommend maintaining a private account unless you want to remain silent or limited in your interactions.

Start following some accounts. This is the key to finding out the power of Twitter. The majority of the time, you will end up listening (i.e., reading) more than speaking (i.e., posting). Let me spend a few extra moments answering: Who should I follow and how do I find them?

Specialty societies and journals: By now almost all major societies and journals have Twitter accounts. These are generally staffed by communications professionals who often tweet recent articles or news items you might find of interest. You can try doing a search on Twitter for their accounts, or go to the societies'/journals' home pages and find the place on the website where you can "Follow Them". If you are logged in to Twitter, you can usually just click that link or icon, and you will be taken right to their Twitter account where you can choose to follow them. Once you're there, check out who they are following. Chances are, they follow accounts or people with whom you may have some common professional interests.

Let Twitter suggest some accounts: This tool might not give you the most interactive accounts, but at least you can continue to explore accounts that you may be interested in.

Search for accounts with similar interests: Do you have a particular area of interest? Maybe a disease or subspecialty? Do a search on Twitter to find people to see what people are saying about your area of interest.

Listen to what others are saying. Are you surprised I said this before I talked about what to tweet? For everyday folk (and by everyday folk, I mean those of us who aren't "follower millionaires"), Twitter is often more about listening than anything else. By listening, you will get the feel of how people tweet, what people tweet, the format of a tweet, etc. Believe it or not, listening to the voices might lead you to the next step.

Decide what to tweet. This is probably the most common question I get asked about Twitter. There are lots of people on Twitter saying many, many things all the time, but Twitter is not just about tweeting what you are just about to eat at the local diner. Being on Twitter in a professional manner means you are starting to define your own digital footprint and your voice. Did you read a tweet that you liked? Retweet it. That is one easy way to tweet, but that doesn't create any new content of your own. Are you an expert in one particular area? Start tweeting about it. I strongly recommend avoiding tweets relating to patients directly. Use common sense when creating original tweets; remember that patient privacy is paramount. However, you might find it easier though to get started by another common type of tweet. Find an article or a news item about an important health issue or topic in your field and tweet it (or comment on it). Any webpage can easily be tweeted nowadays with one of a number of tools that will shorten the web address to easily fit into the 140 characters of a tweet, like Tiny or bitly. Once you've shortened the link, you can import that into any tweet you'd like. For an example, see the Twitter stream of Dr. Orlowski (@Myeloma_Doc), who tweets virtually exclusively about multiple myeloma.

Find a hashtag. OK, now we're starting to get to "Twitter 102 for Docs". But if you've come this far and you're ready to explore a bit, you might want to head over to symplur.com's Healthcare Hashtag Project to see what they've created. Let me give you an example. In the tweet below, "#GERD" acts as a tag for the tweet. You can search for tweets by including the hashtag to increase the likelihood you'll find something directly related to your topic of interest.

Well, I hope these hints help you get started navigating your way through Twitter as a medical professional. Please feel free to comment and add your own suggestions or feedback.

In an upcoming post, we'll delve a little bit more into "Twitter 102 for Docs", where I'll discuss some ways to enhance your professional community.

Special thanks to Natasha Burgert (@DoctorNatasha) for helpful hints!

Ryan Madanick, MD, is an ACP Member, a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain. This post originally appeared at his blog, Gut Check.

QD: News Every Day--Teen diabetes rate more than doubles in a decade

noreply@blogger.com (Ryan DuBosar) — Wed, 23 May 2012 11:00:00 +0000

Prediabetes/diabetes rates in teenagers increased from 9% to 23% in the past decade, researchers reported in a study.

Researchers looked cardiovascular risk data from the National Health and Nutrition Examination Survey, which included 3,383 participants aged 12 to 19 years from the 1999 through 2008. Results appeared in Pediatrics.

There was a 15% prevalence rate for prediabetes (from a single blood draw, fasting plasma glucose level more than 99 mg/dL to 125 mg/dL) and diabetes (more than 126 mg/dL).

Prevalence rates were 14% for prehypertension/hypertension, 22% for borderline-high/high low-density lipoprotein cholesterol, 6% for low high-density lipoprotein cholesterol (less than 35 mg/dL). No significant change in the prevalence of prehypertension/hypertension (17% and 13%) and borderline-high/high low-density lipoprotein cholesterol (23% and 19%) occurred from 1999-2000 to 2007–2008.

There was a dose-response increase in the prevalence of each risk factor by weight category. An estimated 37%, 49%, and 61% of overweight, obese, and normal-weight adolescents, respectively, had at least one risk factor.

The authors wrote, "Our findings are concerning given growing evidence demonstrating that CVD risk factors present during childhood may persist into adulthood. Moreover, atherosclerosis, a complex, multifactorial disease that affects millions of adults, may be first observed in childhood as atherosclerotic changes on the arterial wall."

Lifestyle changes offer hope, they continued. Awareness of the rising obesity rates, screening of children 6 years and older and better diet and exercise all show signs of stemming the tide.

Measles rates highest in 15 years

noreply@blogger.com (Albert Fuchs, MD) — Wed, 23 May 2012 01:00:00 +0000

Three years ago I wrote a post alarmed that measles was on the rise in the U.S. Little did I know then that this was only going to get worse.

This week the CDC released data in its Morbidity and Mortality Weekly Report and in a telebriefing for the media reviewing the measles statistics for 2011. The numbers are worrisome. (The picture shows the typical rash caused by measles.)

There were 222 cases of measles in the U.S. in 2011, the highest number since 1996, and much higher than the average annual case count in the last decade, 60. This may not sound like a big deal, since most cases of measles are mild, but a third of the patients with measles are hospitalized. Fortunately, there were no deaths in the last year.

Because the U.S. population vaccination rate for measles is very high, most of these cases (200 of the 222) were linked to importations of measles from abroad, either due to a US traveler being infected while outside the country, or a foreigner traveling to the US while contagious. Half the cases from abroad were from Europe, primarily France, Italy and Spain. (This proves that despite their fiscal challenges the European Union can still export something.) Unlike the US, Europe has never eradicated year-round person-to-person transmission of measles, so it continues to act as a reservoir of disease. In fact, last year, over 37,000 cases of measles were reported in Europe.

So the CDC is stressing two points. The first is that the MMR (measles, mumps, rubella) vaccine is effective and safe, and all children should have two doses of it. Some of the measles cases last year were among patients who could have received the vaccine but claimed exemptions due to philosophical or personal beliefs. Unvaccinated people don't only run the risk of being infected with measles themselves; they also risk infecting those around them, particularly infants too young to have been vaccinated.

The second message promoted by the CDC is that travelers abroad should make sure they're immune to measles. Those born before 1957 are presumed to be immune because that was before the vaccine was widely used and everyone was exposed. Everyone born since 1957, however, should be sure they've had two doses of MMR. For those who are not sure, the CDC simply recommends revaccinating. An additional MMR is safe even if unnecessary and is more reliable than checking a blood test to determine immunity.

So when you go to the London Olympics this summer, keep in mind that the adorable Parisian child in the next seat might be a biohazard. Defend yourself.

Learn more:
In 2011, U.S. logged the most measles cases it's had in 15 years (Los Angeles Times Booster Shots)
CDC Telebriefing on Measles – United States, 2011
Measles — United States, 2011 (Morbidity and Mortality Weekly Report)
WHO issues Europe measles warning (BBC News, December 2011)
My previous posts on measles and vaccinations

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.

10 bad assumptions that patients make

noreply@blogger.com (Rob Lamberts, MD) — Tue, 22 May 2012 15:00:00 +0000

Don't assume anything. Ok, I guess there is one thing you can safely assume in our health care system: the crash position.

Sorry. Unfortunately, it is more true than I wish.

Assumptions can kill. Assuming something regarding your own health care can cost you money, cause you pain, and kill you Here's my list of potentially harmful assumptions:

1. Standard care is the right care.

Much of what doctors do is based on, or at least consistent with science; but a lot of care goes on despite that science says otherwise. A group of physician organizations recently banded together and published the Choosing Wisely campaign, a set of "things patients and physicians should question." The groups urge doctors and patients to choose care that is:

--supported by evidence,
--not duplicative of other tests or procedures already received,
--free from harm, and
--truly necessary.

Here's a sample of things done frequently that the Choosing Wisely campaign suggests questioning:

--getting an X-ray for people with uncomplicated back pain,
--using antibiotics for sinusitis lasting less than 7 days,
--routine EKG's on average (lower-risk) people,
--routine screening stress-tests, and
--use of anti-inflammatory drugs (NSAIDs) in people with high blood pressure, heart disease, kidney problems, or diabetes.

There are many more recommendations on the site, but the reason this campaign was launched was because of how often these rules are broken. I must admit, I have had to change my habits in the light of some of these recommendations.

2. My doctors communicate

I am a primary care doctor, so I am supposed to be the hub of a patient's care. If a patient of mine goes in the hospital, has surgery, sees a specialist, or goes to the emergency room, I am supposed to be notified. Unfortunately, this is probably not even true in of 50% of these situations. Even when patients ask specifically to have records sent to me, they often aren't there.

Specialists also have this problem, often getting consults without a clear reason. Often this is a problem at the referring physician's end, but we have had numerous specialists turn down offers to access our records. We have also offered access to our records by hospitalists and ER doctors, only to be been turned down. Many doctors prefer to give care with only information they gather. It is rare that any doctor has all of the information that may be helpful.

An exception to this is the integrated care system run by a hospital (usually), in which doctors all share medical records. Clearly the sharing of information in that setting is better than in my world, but being under the care of a hospital gives other disadvantages I will discuss later.

3. My doctor has accurate records

Not only do I not have much of the information that comes from other doctors, but the information I do have in my records are not always accurate. The biggest culprit in our office is old information that doesn't get taken off. It takes a large amount of time to make sure a person's records are accurate, and there are no insurance companies willing to pay for improved accuracy. So accuracy only happens when doctors take time away from reimbursed patient care and work to organize the records. Again, our office makes a valiant effort at keeping things accurate, but I have found that it takes a huge amount of time, planning, and energy to keep records updated.

I personally don't think this will change until the patient becomes responsible to keep their own records. Nobody will ever care about a patient's records as much as the patient does. In the meantime, I recommend that you keep an updated list of your medications, surgeries, probles, and even your family/home situation and bring it with you to visits.

4. No news is good news

If you have a test done and don't hear anything about the result, do not assume it is fine. This assumption kills people. I have too many patients with too much information flying at me every day for me to catch every important detail. Sometimes things are missed, but sometimes the results don't come to our office. We have trained our patients to expect an e-mail or letter with their results within a certain amount of time, so they sometimes call when the test results don't come in. I tell them to do so in the clinical summary sheet I hand out at the end of each visit, but the assumption remains.

Always know what tests are being run, and always get the results of those tests (in writing, if possible).

5. I will be notified when things are due

Are you due for a colonoscopy, thyroid lab tests, a follow-up CT scan, or a diabetic eye exam? Most people don't know exactly when things are due, and many assume they will be notified when this is the case. Gastroenterologists do often call when the follow-up colonoscopy is due, and mammography facilities sometimes call for a follow-up, but these are exceptions to this rule.

Doctors often say "repeat test in six months," and then expect the patient to call to schedule after six months. Even patients coming into the office may not be reminded of overdue tests, mainly due to the disorganization of medical records (#3 above). If you think you might be due for something, ask. Even asking the question, "Are there any tests or labs I am due to get done?" can help remind providers to check for these things. Remember, it is incredibly hard to keep records organize, so don't assume your doctor's office will act anything like Jiffy-Lube.

6. Hospitals care

The commercials boast of how local hospitals are "there for you when you need them most," and "your advocate for your health." This is horse hockey. The people in the hospital may be caring and kind. The doctors, nurses, and even administrators may want you to be healthy. But the hospital is a business which requires people to be sick and have lots of procedures done to be profitable.

Most health care dollars are spent in hospitals, and many times those dollars do no good to the patient. I've seen end-stage cancer patients get heart catheterization, people with dementia spend weeks in the ICU, and countless other procedures are done with no benefit (other than income to the hospital).

Don't be fooled. Your goal is to stay healthy and stay out of the hospital; your doing so is bad for the business of hospitals.

7. More is better

I have patients frequently asking for tests they don't need. Shouldn't people get yearly lab panels? Shouldn't kids get their cholesterol checked? What about those screening mobile tests for carotid artery plaques or PAD? It's hard to make my patients understand that in saying "no" to tests, I am being a better doctor.

I talked about this in an earlier post, but it bears repeating. If someone has a high chance of having a condition, screening for it is useless (doing a strep test on someone with an obvious strep throat). If someone has a very low chance of having a condition, screening for it won't reduce the risk (CA-125 screening for ovarian cancer, for example). Having more information is often not helpful, can lead to unnecessary worry or further testing, and costs a lot of money for no gain. I don't want more information, I want the right information.

8. New is better

What about that new drug advertised on TV? What about the surgery done by robots? Should I take that antidepressant for pain? Do I have low-T? Should I go to the hospital with the brand new 200 gazillion dollar heart pavilion? Always look at advertising with a skeptical eye.

The main reason businesses spend money on advertising is that they want to make more money when you use the thing they advertised. The 200 gazillion dollars for the heart pavilion has to come from somewhere. There's a reason why you first heard of "low T" on television and not from your doctor. The company who wants to fix your T wants your money. Robotic surgery is surely cool, but it is also really expensive to buy that machine, and hospitals need you to want the "cool" surgery so they can pay for those machines.

Sometimes "new and improved" is a truthful boast, but usually it is a means into your wallet.

9. The doctor will think I am stupid

I often have patients apologizing to me. They apologize when they have a "weird" symptom, when they "ask too many questions," when they stop taking a medication due to side-effects, and when they are really, really worried about something. They seem afraid that I am going to roll my eyes and think of them as "one of those patients," the kind that I complain about to my office staff.

I hate it when people apologize. Apologies assume there is some standard or expectation that a person is not meeting, and the only expectations that I have of my patients is:
a. they have or want to prevent medical problems
b. They want my help.

Why should I get mad at people for either of these things, as it is the job of a doctor to help people who need them. I know there are doctors out there who treat patients like bad kids or like they are morons, but those doctors are out of step with reality. They are the morons. I don't apologize to the barber that my hair grew. I don't apologize to my accountant for having tax questions. Understand your position as the paying customer; get what you paid for.

One warning on this one: Viewing yourself as a customer cuts both ways. If you have the right to get what you pay for, the doctor has the right to be paid for what they give you. People often think docs should do what they do out of pure charity and kindness, which is wrong. I may expect the mechanic to be kind and charitable, but I should also expect to pay them for what they do. This means that expecting your doctor to spend 30 minutes with you and only charge you for a 5-minute visit is not fair to the doctor (or his wife and kids).

10. Doctors don't want to be questioned

I hope I am not unusual in this, but I would rather have patients question what I do than to accept everything I say.

Patients' questions help me in several ways. First, they let me know what I am not explaining well enough. I think people follow instructions better when they understand them, so if you don't understand what I said, ask. Second, questions build my credibility. If I can explain the reason for my recommendations, I am more trusted. If I fear questions, then it looks like I am hiding something. Third, and most importantly, questions sometimes lead to better care. Sometimes patients ask me about something I haven't considered. Sometimes the questions make me think things through and see my faulty logic. Sometimes questions make me look for information and learn something.

Good doctoring has a whole lot of teaching in it. Teaching is not a goal in itself, however; the goal is to get the person being taught to understand. If you don't understand what's being done, why you got a prescription, or what your diagnosis is, ask. If you wonder about another possible diagnosis, ask. If your doctor doesn't like you asking questions, ask for a copy of your records and find another doctor.

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.

QD: News Every Day--Most state medical boards substandard, watchdog group says

noreply@blogger.com (Ryan DuBosar) — Tue, 22 May 2012 11:00:00 +0000

Most states don't protect patients from substandard doctors, in part because of budget cuts, according to an annual ranking of state medical boards by Public Citizen.

The annual rankings are based on the number of serious disciplinary actions taken against doctors in 2009-2011 as reported by the Federation of State Medical Boards. Public Citizen calculated the rate of serious disciplinary actions (revocations, surrenders, suspensions and probation/restrictions) per 1,000 doctors in each state averaged over three years to establish each rank.

Starting with the worst, South Carolina had 1.33 serious actions per 1,000 doctors, compared to the national average of 3.06 per 1,000.

The rest of the bottom 10 are Washington, D.C.; Minnesota; Massachusetts; Connecticut; Wisconsin; Rhode Island; Nevada; New Jersey; and Florida.

South Carolina, Minnesota and Wisconsin have consistently been among the bottom 10 states for each of the past nine Public Citizen rankings. Connecticut has been in the bottom 10 for each of the past six rankings. For the fourth time in a row, Florida is among the 10 states with the lowest rates of serious disciplinary actions even though it is beginning to improve.

Other large states, such as Texas, Pennsylvania and Michigan, have been in the bottom half of state rankings for all nine rankings and California has been in the bottom half for the past six rankings.

Tighter state budgets are the likely cause, the organization said in a press release.

The best states when it comes to doctor discipline are Wyoming (6.79 serious actions per 1,000), followed by Louisiana, Ohio, Delaware, New Mexico, Nebraska, Alaska, Oklahoma, Washington and West Virginia.

Alaska, Ohio and Oklahoma have been in the top 10 for all nine rankings. Only one of the nation's 15 most populous states, Ohio, is represented among those 10 states with the highest disciplinary rates.

Nationally, the rate at which state medical boards take serious action has declined significantly over the past seven years. The average in 2011 was up 3% from 2010 but is still down 18% from the peak rate of discipline in 2004 of 3.72 per 1,000.

The report states, "Absent any evidence that the prevalence of physicians deserving of discipline varies substantially from state to state, this variability must be considered the result of the boards' practices. Indeed, the "ability" of certain states to rapidly increase or rapidly decrease their rankings (even when these are calculated on the basis of three-year averages) can only be due to changes in practices at the board level, often related to the resources available to have adequate staffing; the prevalence of physicians eligible for discipline cannot change so rapidly."

Public Citizen said that boards are likely to do a better job disciplining physicians when they:
--are well-funded, with all license fees going to fund board activities instead of other parts of the state treasury,
--are well-staffed,
--proactively investigate rather than only respond to complaints,
--consider Medicare and Medicaid sanctions, hospital sanctions and malpractice payouts,
--are independent from state medical societies and other parts of the state government, and
--apply preponderance of the evidence rather than beyond reasonable doubt or clear and convincing evidence as the legal standard for discipline.

Wearing the white coat focuses physicians' attention

noreply@blogger.com (Toni Brayer, MD) — Mon, 21 May 2012 15:00:00 +0000

A recent study in the Journal of Experimental Social Psychology found that wearing the white coat of a doctor caused the person to focus and pay more attention. Wearing the white coat of a painter or other occupation didn't have the same effect. The scientists call this enclothed cognition: the effects of clothing on cognitive processes.

The experiment was done with 58 undergraduates who wore either a white lab coat or street clothes. Those who wore the lab coat made half as many errors on incongruity trials than those who wore regular clothes. In a second experiment, they randomly assigned 74 students to either wear a doctor's coat, wear a painter's coat or see a doctor's coat. They were given tests for sustained attention, and those who wore the doctor's coat found more differences and had more heightened attention than the other two groups. Further experiments also showed that the students who wore the doctor's coat had improvement in attention.

It appears that certain articles of clothing affect how a person behaves and what "role" they take on. Other experiments show that if you carry a heavy clipboard, you will feel more important. Dr. Adam Galinsky, a professor at the Kellogg School of Management at Northwestern University says that women who dress in a masculine fashion during a job interview are more likely to be hired and a teaching assistant who wears formal clothes is perceived as more intelligent than one who dresses more casually.

I love this experiment. There is an old saying that "clothes make the person." If you dress in old, ill-fitting, shabby clothing it is hard to feel successful and confident. This study points to the idea that it goes further than just wanting to "look nice." Perhaps clothing really does change the psychological state of the wearer in a way that affects behavior and skill.

Now if I can just get my teenager to stop wearing those saggy, butt drooping pants!

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

Dangerous electrolytes, part 2

noreply@blogger.com (Robert Centor, MD) — Mon, 21 May 2012 13:00:00 +0000

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

pH=7.6
pCO₂=26
pO₂=100
HCO₃=21

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

Three respondents did a great job describing the acid-base disorder.
1) The anion gap equals 32, thereby by definition the patient has an increased anion gap metabolic acidosis.
2) The delta gap equals 21, thereby the revealed bicarbonate is 42, supporting an underlying metabolic alkalosis.
3) These two metabolic problems fit the story perfectly. The patient had both positive ketones and a mildly elevated lactic acid level. We expected a metabolic alkalosis with persistent vomiting. The hypokalemia fits the clinical picture perfectly.
4) Using the Winter's equation, one also finds a respiratory alkalosis. Clinically, we felt that the respiratory alkalosis resulted from the hypotension and alcohol withdrawal.
5) All the acid-base abnormalities resolved over the next few days.

Now the electrolytes are really the point of this presentation. The patient has hyponatremia, likely secondary to volume contraction. Her serum osm = 259 with urine osm = 411.

She had hypokalemia secondary to vomiting. We confirmed that vomiting was the cause with urine electrolytes. Urine Na less than 10, Cl less than 10, K = 45

We also checked Mg, normal at 2.5 and PO4, which was very low at 0.7.

What are the risks of the severe hypophosphatemia, and how would that abnormality impact your treatment plan? Also speculate why her initial PO4 was so low.

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--Over half of drug-related morbidities deemed preventable

noreply@blogger.com (Ryan DuBosar) — Mon, 21 May 2012 11:00:00 +0000

Two studies from Norway drug-related morbidity may affect more than half of all patients, much more than observational studies suggest might occur.

Physicians estimated that 51% of all patients outside hospitals and 54% of all hospitalized patients experience drug-related morbidity, while pharmacists estimated this to affect 61% of all patients in health care, researchers reported in two studies.

Of the affected patients, 24 to 45% were estimated to experience preventable drug-related morbidity, and the resulting costs were 730 euros to 1,645 euros per patient with drug-related morbidity.

Drug-related morbidity is defined as new medical problems, such as adverse drug reactions, drug dependence and intoxication, and as therapeutic failures, such as insufficient effects of medicine and morbidity due to untreated indications.

The two expert panels of physicians and pharmacists estimated the proportion of patients experiencing drug-related morbidity, the proportion they perceived as preventable, and the clinical consequences resulting from drug-related morbidity. Costs to the health care system were modeled based on national statistics for costs of health care consumption.

Researchers at the Nordic School of Public Health NHV noted that this method was used to estimate the costs of drug-related morbidity in the U.S.

In the first study, which appeared in the International Journal of Clinical Pharmacy, an expert panel of pharmacists determined the probabilities of therapeutic outcomes of medication therapy. The cost-of-illness analysis included direct costs from the health care perspective.

The expert panel estimated that 61% +/- 14% (mean +/- SD) of all patients attending health care suffered from drug-related morbidity, of which 29% +/- 8% suffered from new medical problems, 18% +/- 6% from therapeutic failures, and 15% +/- 7% from a combination of both.

Drug-related morbidity was considered preventable in 45% +/- 15% of the patients with drug-related morbidity. The estimated cost-of-illness was 997 euros per patient attending health care, corresponding to an annual cost of 6.6 billion euros to the Swedish health care system.

In the second study, which appeared in the European Journal of Clinical Pharmacology, a panel of 19 physicians estimated the probabilities of drug-related morbidity, preventable drug-related morbidity, and clinical outcomes of drug-related morbidity separately for outpatients and inpatients.

Physicians estimated that 51% +/- 22% of outpatients experience drug-related morbidity and 12% +/- 8% preventable drug-related morbidity. Of inpatients, 54% +/- 17% was estimated to experience drug-related morbidity and 16% +/- 7% preventable drug-related morbidity. Of outpatients with drug-related morbidity, 24% +/- 11% was estimated to experience preventable drug-related morbidity, whereas this proportion for inpatients was 31% +/- 15%. The estimated cost-of-illness was 376 euros per outpatient and 838 euros per inpatient.

Rumors of a doc's demise ...

noreply@blogger.com (John Schumann, MD) — Fri, 18 May 2012 15:00:00 +0000

A loyal reader sent me this very interesting letter.

Dr. Dowden apparently mailed it to all of his patients, current and former. [Note: This is not an April Fool's joke.]

Not a very subliminal message. Translation:

"Rumors of my retirement are greatly exaggerated. Fear not, loyal patients. Yet should you be hesitating on having me render you more beautiful, tarry no further; else you may find yourself out of luck ... "

I wonder if by this method he'll drum up business and retire in a blaze of cosmetic glory.

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

Can someone tell me why I should care about EINSTEIN-PE?

noreply@blogger.com (Justin Penn, MD) — Fri, 18 May 2012 13:00:00 +0000

EINSTEIN-PE was published in the April 5 edition of the New England Journal of Medicine, the place to find cutting edge, non-inferiority, open-label trials, written and sponsored mostly or fully by pharmaceutical companies.

What I learned from reading this article is that rivaroxaban is a great generic drug name, as I'm not sure what syl-LABUL to put the em-PHASIS on: RIVA-ro-xaban or is it riva-ROXA-ban? It really doesn't matter, but it's one reason that I'm not rushing out to find converts to its cause.

In this day in age of evidence-based medicine I'm not sure why we as internists should have to put up with an open-label non-inferiority trials to guide our prescribing habits. They might as well have glued $20 bills or coupons to a local Sushi restaurant in the journal. I've heard that there is a worldwide shortage of placebo, rising cost of sugar because of the cost of gas. It must be at the heart of this.

It turns out that rivaroxaban is not worse than enoxaparin and warfarin, which many of us are very familiar with and our clinics can easily manage. For example, look at the study's Kaplan-Meier curves minus the grossly magnified inserts that they published. Based on these curves I can safely say that I see no clinically meaningful endpoint to suggest that I should jump ship quite yet.

For the sake of argument, let's do the math. For the primary outcome of recurrent nonfatal venous thromboembolism the absolute rate reduction of rivaroxaban vs. enoxaparin/warfarin was 0.3 percentage points (based on the absolute event rate, not the hazard ratio.) The number needed to treat is 333. It appears that there is a 1.1 percentage point difference in first major or clinically relevant nonmajor bleeding episode the winner here, rivaroxaban. Number needed to prevent said bleeding episode of 91.

Maybe I'm just against these oral direct thrombin inhibitors and factor Xa inhibitors because they take all of the fun out of warfarin management.

I'll continue to prescribe rat poison. I'm good at it, it's cheap, and it works.

Addendum: Finally, in addition to actually monitoring all 4,900 patients for 6 months of therapy they just stopped when they felt (had proven statistical utility ... er, power) that enough patients had recurrent events. So we really don't know what truly happens when you put people almost 5,000 people on this med over the course of 6 months.

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

QD: News Every Day--Biggest fear of malpractice suits is the time-drain

noreply@blogger.com (Ryan DuBosar) — Fri, 18 May 2012 11:00:00 +0000

Nearly 80% of malpractice verdicts are in favor of the doctor, while less than 3% of cases against internists and medicine-based subspecialists ultimately reach a trial verdict.

A research letter published online in Archives of Internal Medicine looked at more than 10,000 cases from 2002 to 2005.

From all claims, 55.2% of all specialties resulted in litigation, while the rate among internists and medicine-based subspecialists was slightly lower, at 53.5%.

Cases were dismissed by the court 54.1% of the time across all specialties, but more often among cases against internists and medicine-based subspecialists, at 61.5%.

With the outcomes so slanted, it's more often the time tied up in litigation, the authors wrote. The mean time required to close a malpractice claim was 19 months, with the mean for litigated claims being just over 25 months.

"While most claims were ultimately decided in a physician's favor, that resolution came only after months or years," the authors wrote. "The substantial portion of litigated claims that are not dismissed in court and the length of time required to resolve litigated claims more generally may help explain why malpractice claims undergoing litigation are an important source of concern to physicians."

Board exams don't resemble real practice and waste my time

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

I took the day off today. I'm taking my recertification exam tomorrow, and I like to go into these things well-rested. I got up with PalKid, made her breakfast, had a leisurely cup of coffee and enjoyed a ride to school with a loquacious second-grader. I violated one of my primary rules for before-the-test days and did a little studying at the coffee shop. It's still hard for me to take this exam terribly seriously. I was reminded of this when I dropped by my office to get a little work done, work that bore little resemblance to what I will encounter on the board exams.

Internists trained after the 1980s are required to re-certify every 10 years. It's not a stretch to say that most internists find the process time-consuming, expensive, and largely irrelevant. As medical knowledge has expanded, the practice of medicine has become very subspecialized. There is little need for me to know the current regimen for the treatment of multiple myeloma. It's enough to know how to diagnose it and to know some of the consequences of treatment. I don't manage kidney dialysis, so the ins and outs are, to me, not terribly useful. I'm not a brain surgeon (just ask anyone) so I don't really need to know the best surgical approach for a pituitary macroadenoma.

The recertification process takes at least a year or so. One of the more useful aspects is the requirement that I do "learning modules," sets of questions that help me review important topics (but that are explicitly labeled as being NOT board review questions, wink-wink). Of course, I could do those modules in the course of my yearly continuing medical education. The most onerous bit is the "practice improvement module." I chose diabetes, a condition familiar to my practice.

It required my patients to fill out surveys, for me to enter data from a couple of a dozen charts, go through several other bits, re-review my charts, and at the end of the month or so it took, time was taken away from my life and I learned something I already knew: It's hard to take care of diabetics when they are real people. Not every patient can reach the standards we've set, nor should they, depending on their circumstances.

Tomorrow I show up at a testing facility with two forms of photo ID and must submit to "palm vein biometric analysis." Then I have to leave everything outside the room: my two forms of photo ID, my wristwatch, my wallet, any pens or pencils, and God-knows what else. Probably my belt and shoe laces. No scratch paper for me! (Apparently they provide some sort of small dry-erase board or something to jot ideas on.)

Is this expensive, humiliating, time-consuming effort useful? Who knows? There aren't many useful outcomes measures in the literature. It's not clearly known whether the current process makes better doctors. It is clear, to those of us in daily practice, that the process was not designed by practicing internists, at least not those who work full-time in the busy primary care environment. It also fails to recognize the technology available to modern physicians. We no longer rely exclusively on our memory when evaluating patients. We have quick and easy access to web-based references and to our colleagues. The board exams reflect our ability to recall rote knowledge, something most of us are quite good at, but it encourages behavior that is not good for our patients. Our access to information helps our patients, keeps us from making mistakes based on faulty memory.

I'm not terribly concerned. I do well on standardized exams, but I realize that this little talent has little to do with my daily practice.

It's pretty embarrassing that we allow our colleagues to put us through this. The exam is the least offensive bit. The entire process is a drain on the limited time and resources of a primary care physician. The process could be simplified by having docs do question sets at home, with access to reference sources, the way we actually work in real life. Throw a dozen of those at me and I'll probably learn more medicine in two months than I have in two years of my current recertification process.

(Here's an example of more realistic questions you'll never see.)

Did I mention that we get a TSA-style wanding?

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.

Plumbers, ninjas and doctors

noreply@blogger.com (Rob Lamberts, MD) — Thu, 17 May 2012 15:00:00 +0000

When my wife told me about her encounter with the plumber, all I could think was: "What a jerk!" Then I was hit with an eerie sense of familiarity. OK, it wasn't exactly eerie, but there was some creepy music in the background.

We had a shower fixed about a year ago, costing us a bunch of money. I would do it myself, but past experience gave me frightening images of water dripping through the ceiling, and bathrooms falling in to the middle of our garage. I still awake with cold sweats from previous plumbing experiences. So we found a plumber with good recommendations on Angie's List, so we thought we were safe.

But after paying a whole lot of money, we were left with a faucet that seemed like it was made out of a plastic-metal alloy and took about half a turn to get any cold water. We were afraid to call the guy back, however, given how much he charged us for our previous encounter. Despite the cheap faucet, we had no leaks and experienced no sudden appearances of bathrooms in our garage.

Then last week my daughter told us the shower wouldn't turn off. Through the fine art of faucet jiggling I was able to get the shower to stop (and she was quite impressed by my mad skills). But another night's shower had the same complaint from my daughter, and my skills were not as mad as I was. Since it had been about a year since our last repair, and since the faucet seemed chintzy, we called back the same plumber and he came over to assess the damage. It seemed like it was his fault.

The plumber, being the trained craftsman he was, quickly found the source of the problem: us.

My wife explained what happened, as well as the elbow pain we all experience turning the cold water, and he shook his head. He noticed the caulking around the cold water faucet was missing, and told my wife that someone had "obviously" done something to that faucet. When my wife explained that my mortal fear of plumbing (and her mortal fear of my plumbing) made this an impossibility, he looked at her with a condescending skepticism. It seemed "obvious" to him that either my wife was not telling the truth, or that a plumbing ninja had infiltrated our bathroom to remove the caulk without our knowledge.

Things got worse when my wife suggested that the hardware installed wasn't very high quality. He seemed offended at the suggestion that he would use anything but the best. How could a mere mortal non-plumber suggest that the shower that she uses every single day is anything but the best? Her suggestion that it shouldn't take so much turning to get cold water was clearly a statement of ignorance, or a fabrication designed to slander this highly trained professional.

The good news was that it was just the white cartridge thingy that needed replacement and so it took only $75 to get rid of this jerk and get our shower back to its previous sorry state. I suspect that because the faucets have so much play in them, my daughter cranked them harder than she should to turn them off and so damaged the cartridge thingy. Either that, or the plumbing ninja was at doing more than going after the caulking. I shouldn't think about it too hard, though, because I've actually created leaks in pipes by prolonged contemplation.

Unfortunately, this encounter with the demigod of plumbing reminds me a lot of what my patients get when they see certain specialists. Several aspects of my wife's experience are eerily similar (there goes that music again).

The plumber's reality trumped anything my wife experienced. Despite the fact that she showers in it every day, she was not given any credit for her own experience. The plumber's self-centered view of the universe made it impossible to consider my wife may know something about the shower. In the same way, patients are treated like they simply can't be having the symptoms they are having because it doesn't make sense to the highly-trained and extremely intelligent doctor specialist.

My wife's suggestion that the plumber may be wrong was something she was made to feel guilty about. It's not just that she was wrong in her reality experience; she should feel shame for experiencing anything the plumber said wasn't true. This is exactly the same as my patients who visit doctors with the same reality-distortion field. They are bad people for experiencing what they do.

Our experience with the plumber makes us want to avoid further encounters with members of the profession, and to seek alternatives if possible. Why is it such a mystery that patients seek alternative medicine when they are made to feel stupid when they go to the doctor? Nobody wants to be made to feel guilty for symptoms they don't want in the first place.

We feel like our ignorance (and mortal fear) of plumbing is an opportunity this guy used to pass cheap material off on us for a premium price. My patients come back from specialist, ER, or hospital visits with enormous bills and often feeling they are not listened to.

I don't mean to pick on specialists, as there are plenty of primary care docs who treat patients in the same condescending way. Our profession has a bad reputation that we've been working hard to earn, so I have to share the credit with doctors of all kinds. I have patients actually tell me that I am "the first doctor who has ever listened to me." While I think that is an exaggeration, the perception is rampant: We docs are arrogant know-it-alls who charge too much.

So what next? I am going to Angie's List and am going to write a bad review of our experience with this guy. I owe it to other plumb-o-phobes so they can steer clear of this doink. I can't do this without hearing the shrill cries of doctors detesting their patients who give them bad online reviews. How can I complain about this guy? What do I know about plumbing? I should just be glad I don't have a shower in my garage!

We need to wise up. Some of this arrogance stems from a system which turns patients into E/M and ICD-9 codes, forcing doctors to pay more attention to documentation requirements and achieving "meaningful use" than to what the patient says. Doctors are sick and tired of the system, and sometimes facing a patient who blames us for the system that makes our lives hell gets under our skin. But nothing excuses arrogant reality-distortion fields like this plumber and many docs emit.

Nobody wants to see a jerk.

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.

260 words about 'eating mostly plants'

noreply@blogger.com (David L. Katz, MD) — Thu, 17 May 2012 13:00:00 +0000

The notion that eating meat might be bad for us is tough to swallow for a generation that has drunk deep of the "low carb" Kool-Aid.

Even if eating meat were good for people, too much focus on it would be ill-advised for a population of 7 billion of us. The environmental costs of eating animals are an order, or even orders, of magnitude higher than eating plants.

But can it be that eating meat is truly bad for the health of the great-great-granddaughters and sons of hunter-gatherers? Yes. Because just as we "are what we eat," so too are the animals we eat. The diets of most animals providing our meat are nothing like those of THEIR ancestors, and thus neither is their flesh. Most of our meat is higher in calories, harmful varieties of fat, and environmental contaminants that get concentrated as they move up the food chain.

Finally, what we eat more of has implications for what we eat less of. Eating "more" meat means eating a lower proportion of calories from plants, vegetables, fruits, nuts, seeds, beans, lentils, whole grains, which are decisively associated with better health. To some extent, meat consumption contributes to adverse health outcomes, to some extent it "muscles" out of the diet foods that defend against them.

Eating some meat, preferably from lean, well-fed, well-exercisedand kindly tended animals is assuredly consistent with human health. But the health of humans and the planet argue consistently for Michael Pollan's excellent and pithy advice: Eat food, not too much, mostly plants.

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--CDC says team approach better controls blood pressure

noreply@blogger.com (Ryan DuBosar) — Thu, 17 May 2012 11:00:00 +0000

Physician-led teams provide more effective care for controlling blood pressure, reports the CDC's Community Preventive Services Task Force.

About one in three adults in the United States has hypertension, and less than half have it under control.

If all hypertensive patients could reach the goals specified in current clinical guidelines, it might save 46,000 deaths each year, as well as medical costs of $131 billion and lost productivity costs of $25 billion.

The Task Force recommends team-based care based on evidence from 77 studies of nurses and pharmacists working in collaboration with primary care providers.

Each team consisted of the patient and a primary care provider, with most adding a pharmacist, nurse or both. The estimates for improved systolic and diastolic blood pressure were similar in the studies that added a nurse or a pharmacist. The estimated proportion of patients with controlled blood pressure was much higher when a pharmacist was added.

In four of the 28 studies, team-based care was implemented without a nurse or a pharmacist, but with added professionals such as community health workers and dietitians. Blood pressure improvements in these studies were small, however.