Med-Peds Hospital Medicine

Musings on the current COVID-19 pandemic

2020-09-14T13:29:00.003-04:00

I want to share the perspective I have on the impressive enthusiasm to use unproven treatments for the SARS-CoV-2 infection (COVID-19).

In many countries, including the USA, lots of unproven therapies have been proposed as treatment for COVID-19; the lack of randomized clinical trials has been the constant. Many colleagues, medical centers and even national organizations in different countries have proposed treatment algoriths, with no evidence to support such.

The appeal as to being ethically questionnable "not to do anything" has spearheaded such behaviors. And time has proven the inefficacy and dangerous consequences of such treatments.

Doctors aim to offer the best for their patients. We are not used to a pandemic, and certainly is morally devastating to see the impressive mortality that this viral infection has brought along. Yet, when we reflect on the 1918 Influenza pandemic, the mortality rate was of millions of people worldwide. And the basic hygiene and isolation measures were key for its control. And nowadays it is no different than then.

I wrote along with a colleague from Mexico a perspective on the use of unproven treatments for COVID-19 in ACP Hospitalist (a publication from the American College of Physicians). We titled it "Primum non nocere: Two hospitalists muse on the current pandemic". I hope this reading provoke thought and reflection.

Basic supportive care is the cornerstone of our clinical success in our organization. Both in the regular nursing floor and the ICU. The medications are adjuncts to oxygen and good airway clearance.

In my search for the source of the coining of the phrase primum non nocere, the esteemed professor and world renowned bronchologist Dr. Atul Mehta shared with me that it was Auguste Francois Chomel (1788-1858). Certainly Hippocrates work and philosophy is fundamental for this thought.

Clinical reasoning - the continuous reflection on our own decisions

2020-09-14T13:09:00.001-04:00

Recently I had the privilage to write a blog post in OSLER, a fantastic academic and humanistic forum created by Johns Hopkins colleagues aiming to rescue Medicine from being purely technical into a more intellectual and clinically relevant field. It helps to reengage us as physicians end enhance our best qualities as humans.

One of the sections in CLOSLER is about Clinical Reasoning. This is very dear to our heart as clinician-educators; and to me personally, because as a Quality and Patient Safety Officer for a large academic institution, my responsibility it to promote a culture of safety and zero harm. I engage in a high reliability organization aiming to acknowledge that this is a complex system environment and we want to eliminate the chance of clinical and diagnostic errors.

In clinical reasoning we always step back - do not assume things; if a diagosis was made in the ED or the ICU before the patient arriving to our service, we must have a healthy skepticism; avoid anchoring, availability, recall, commission or omission, etc. We need to have awarenes of our cognitive process and bias. Understand whether we are appraising these bias and aim to mitigate them. You can read a further commentary based on a clinical case in my CLOSLER post.

As I always conclude my blog posts - physicians aim for the patients' best outcomes. First principle is do not harm.

Physicians as leaders - a reality

2020-09-14T12:45:00.004-04:00

As physicians (especially Hospitalists) gain more clinical experience and maturity, a presumably inherent expectation is the engagement in leadership responsibilities within the heathcare system. However this also depends on the individual desire to do so. Althouh I believe that experience is very relevant, an inherent flaw of the system is the natural lack of mentorship and coaching in leadership.

The engagement in leadership roles with no formal training, "learning on the fly" - can be risky nowadays given the enormous complexity of the healthcare systems. However, the key to anything is the ability to communicate effectively, understand the situation, engage and inspire a team and find solutions that were not clearly outlined before tasking the problem. This is how a lot of physicians in leadership positions have gained experience.

Regardless of the individual level of experience, training in leadership is important; there are many styles and many publications on the topic - but the most relevant aspect is to engage this knowledge along with the real life solution of problems. Many colleagues are doing now MBA's, MMM's, MHA's, etc. Some becoming Fellows of healthcare administration societies, etc. And of course, the personal experience contributes to more meaningful engagement in these academic developments.

Along with other colleagues nationally, I have multiple discussions on their own leadership development and tasking unexpected complex challenges. We ended up discussing and outlining what we considered key aspects for leadership development. I want to invite you to read two blog posts that I wrote in Doximity with musings about this training, focusing on two national workshops that have been presented at the Society of Hospital Medicine 2018 and 2019 meetings. A third iteration of the leadership development series will be presented in Las Vegas in 2021 if we are allowed to travel and pending the pandemic behavior. 1) 3 Leadership Essentials for Success in Hospital Medicine: 2) What Does a Leader Need to Survive a Complex Environment?

Leadership development is fundamental but also is the development of a culture based on values of respect, teamwork, excellence and tolerance. I have recently enjoyed a book that actually emphasizes on these topics and focuses on 7 virtues – trust, compassion, courage, justice, wisdom, temperance and hope. This is the book "Exception to the Rule" written by Drs. Peter Rhea, Jamie Stoller and Alan Kolp. A terrific resource which along with emotional intelligence development, provides tremendous assets for a compassionate and effective servant leadership.

I would also like to share a reflection; in leadership in healthcare, the ultimate focus is enhancing clinical outcomes for our patients as well as to promote enhanced population health. A robust healthcare system can have tremendous impact on the financial success and the health of the community it serves to. And this starts with each individual leader. Having the vision of best patient and community outcomes help to outline and support the engagement in personal and professional development to serve in a more effective way.

Reinforcing a parsimonious approach toward blood transfusion

2017-02-24T21:59:00.000-05:00

Blood transfusion as a treatment modality became a prominent resource throughout the last century. However, in the late 1980’s an analysis of the high volume of blood transfusions associated with its inherent cost and risks, raised concern and skepticism regarding the arbitrary hemoglobin and hematocrit cut-offs of “10/30” which were followed since the 1940 following the recommendations by Adams and Lundy. ¹ The NIH consensus statement on blood transfusions published in 1988 brought into question the previous practice and propose more parsimonious thresholds of transfusion (Hb 7 g/dL).²

The evidence that supports the safety of parsimonious approach to blood utilization was built over the decades of 1990 and 2000 with very robust and compelling results. The hemodilution studies demonstrated that the human body could tolerate lower hemoglobin values, and subsequently, clinical comparison of restrictive versus liberal transfusional approaches demonstrated the safety of restrictive transfusional approach in different clinical scenarios such as critical care, high cardiovascular risk surgical patients, sepsis, etc. ³

In this decade, the AABB has published 2 guidelines (2012 and 2016) which are robustly supported by evidence with recommendations for consideration (not an immediately actionable item) of blood transfusion when the hemoglobin reaches a value of less than 7 g/dL in non-cardiac patients, or 8 g/dL in cardiac patients.⁴ More importantly, the guideline also demystified a current practice that has increased the costs of blood management - which was avoiding the use of blood older than 14 days; the evidence that “old” blood is not associated with worse outcomes is extremely compelling.⁴

The current practices of Medicine are substantially different from 10 years ago - at least from blood utilization - not only it is a lower transfusional threshold being utilized, but also there is a decrease in the number of units of blood transfused at a given time. In addition, the clinicians are increasingly mindful of addressing the primary etiology of anemia with focus on hematinic replacement. Also, the behavior has gradually shifted toward mitigating the risk of iatrogenic blood loss by means of decreasing the routine ancillary diagnostic blood tests, which may not necessarily change management.

There are multiple venues which have adopted the recommendations of parsimonious approach to blood utilization such as the ABIM Foundation Choosing Wisely. And it is highly likely that newer organizations aimed to pursue high value and low cost medical care, will adopt the recommendations of restrictive transfusional thresholds to mitigate excess blood use with its associated inherent risks.

Less is more - the increased focus on enhancing patient outcomes and minimizing the risk associated with excessive diagnostic and therapeutic approaches, will yield in a safer, more effective and less costly practice of Medicine, pursuing the most elemental principle of medicine...primum non nocere.

References

1. Adams RC, Lundy JS. Anesthesia in cases of poor surgical risk: Some suggestions for decreasing the risk. Surg Gynecol Obstet.1942;74:1011-1119.

2. Consensus Conference. Perioperative red blood cell transfusion. JAMA, 1988; 260: 2700-2703.

3. Auron M, Duran-Castillo MY, Kumar A. Parsimonious blood utilization and transfusion triggers. Clev Clin J Med. 2017;84(1):43-51.

4. Carson JL, Guyatt G, Heddle NM, et al. Clinical practice guidelines from the AABB: red blood cell transfusion thresholds and storage. JAMA. 2016;316:2025-35.

Readmissions, quality and medical education

2016-04-15T09:50:00.001-04:00

Finding the way through understanding quality improvement, and most importantly to hardwire the concepts and best practices can appear difficult and cumbersome to the novice.

But it is not.

Quality improvement is, as a matter of fact, a fascinating field where you can gain insight and perspective on your own performance and opportunities to improve. In addition, this has been the reason behind the expansion and growth of all the industrial and technological movement in the past century.

From Taylor to Deming to the creation of the IHI, and now with well established quality health research institutions like Intermountain, Dartmouth, Harvard, etc. we now have formal training and education of a whole generation of health care scientist and providers. This has rapidly changed the culture, and all new trainees and students are intensely getting exposed to terminologies and practices that I barely had any during medical school and my first residency.

I had the honor an privilege to write this guest blog post at the SHM Blog "The Hospital Leader". I had the opportunity of having direct mentorship from Dr. Brad Flansbaum who helped me tremendously to put the ideas together to obtain the final published piece.

I hope you are able to read the guest post and more importantly that it yields into motivating curiosity to explore the fascinating world of quality improvement and patient safety. Remember, primum non nocere...

Musings of a Medical Educator - Reflections of the Philosophy of Teaching

2016-02-26T12:12:00.001-05:00

I love medical education and teaching in general. Now that I've been a father for 2.5 years, I have appreciated the incredible beauty of curiosity, of the genuine motivation to know and learn - witnessing it on my son. This has been very refreshing - and has made me a better person and professional.

I was appointed as an Associate Professor in July 2014. Yet I submit my application in 2012. I had now a recent conversation with a colleague about applying for academic promotion. He asked me for the statement I wrote.

Reflecting on this - the request from my friend, and the everyday fascination I feel from seeing my son growing and learning, I decided to delve into my archives and search for the statement I wrote for my academic advancement regarding my philosophy of teaching. I wrote and signed in August, 2012. Here it is and I'm happy to share:

PHILOSOPHY OF TEACHING / PERSONAL DEVELOPMENT

As an adult learner myself, involved in the complex world of medical education, I have a strong awareness of the different ways of learning that people use. People use the senses in different ways: some individuals require a persistent memorization effort and may appear bright in terms of factual information recall yet may be unable to develop a critical and analytical perspective of things. Others may have a more practical way of learning by solving problems and putting analysis and reflection into practice yet may not have the ability to retain factual data. Yet others may need to visually appreciate a concept or idea in order to create a visuospatial relationship with previous concepts. And finally, some individuals achieve better understanding by listening on a repetitive basis.

The most important consideration is that the educator be aware of the different methods of learning people have and is creative enough to be able to deliver the information or ideas in an efficient way to each individual learner. Creating an environment that fosters learning is essential so that the learner feels motivated – this is done by matching the teaching technique with the learner’s own best learning style.

First of all, I’m a clinician – a hospitalist – I work in the inpatient wards, where seeing acute patients is the norm. Patients are very sick, families are distressed, and most health-caregivers are under significant emotional and professional pressure. My teaching scenario is the patient bedside. I need to teach medical students, residents and fellows. Each of them has a different level of training in addition to their own learning style. Although the most experienced learners have had more exposure, may not necessarily have more plasticity toward different learning methodologies.

My responsibility as an educator is to ensure all my trainees feel motivated, inspired, and committed to provide excellent patient care. They must come every morning with a great desire to be here. This is done by fostering a team spirit – we all together as a team see all the patients, and the patients belong to all of us. We all know about each patient, we all discuss about and learn from each individual patient, we all enjoy taking care of patients. The second thing I do is to have the learners acknowledge their own knowledge gap – they shall not feel embarrassed about it, but rather feel a compelling need to close the gap – I make them read about it and give the team a concise and brief presentation usually accompanied by a handout and /or a journal article. This allows me to understand: 1) the ability of the learner to review and synthesize the literature, 2) the ability to frame and write his/her ideas in the handout, 3) the ability to orally deliver a presentation (clarity, structure, length, sequence, etc.), 4) the creativity involved in putting ideas together (presenting the information in a test format, in a clinical vignette format, in a slide presentation, etc.), 5) the interaction with the other learners answering their questions and delivering the information.

My particular method is to teach while rounding and seeing patients – make them observe carefully the patient at the bedside, and first of all, understand that the patient is in a delicate situation and maybe be suffering – have them empathize and be compassionate; know to talk to the patient, provide comfort and hope. This is perhaps the single best teaching we can do at the bedside: good bedside manners. Everything else follows naturally. The next thing while providing comfort is to enhance the awareness of clinical signs and symptoms: have the trainees to use their senses and enhance their observation and auscultatory skills; then we discuss a differential diagnosis. I put in play the Bayesian approach using pre-test probability of disease and we define a diagnostic and therapeutic approach based on the likelihood of a given pathology. I use the electronic health record as a teaching tool as well. We review the bloodwork and analyze the abnormalities with immediate “on the fly” teaching, associating given laboratory values with the patient’s clinical diagnosis or physiologic condition. This allows the visual learner to make a visuospatial relationship; my explanation allows the auditory learner to understand the process; the whole clinical experience (seeing the patient, reviewing the labwork and imaging, discussing the case) allows the analytical learner to understand the process of disease. In addition, we have the fortune of being in a technology rich environment – this allows me to do literature searches in PubMed at the bedside and look at the literature in the point of care to help facilitate the medical decision making. I show them how to download podcasts especially for the auditory learners.

Once my trainees have written their clinical documentation, another opportunity arises to help them further reflect into the process of disease as well as medical decision making by reviewing their “Assessment and Plans” and discussing with them about the reason for adjusting or changing it allows them to obtain further feedback and reinforce previously taught concepts or as well identify new teaching opportunities.

In addition, at the end of the day, it is important for them to realize how much they need to know and how much they have already learned but perhaps not been quite aware of it. I send them links to articles based on our patient’s diagnosis, diagnostic pathway or treatment, then ask them to choose one article each to present later on the week. I send these emails on a routine basis – almost daily throughout the rotation – to foster the need to read and appraise the literature in order to provide the best patient care; in addition motivates them to search for the literature on their own sharing their readings with the rest of the team. The advantage of this is that at the end of the day, the learners not only get “live” teaching during rounds, and close their knowledge gaps on their own, but they learn to become self sufficient to search the literature and start building their core of knowledge.

My main satisfaction comes at the end of a rotation when I witness an impressive learning curve, as well as an enhanced level of comfort and ease for medical decision making. My patients express satisfaction with the degree of thoroughness my learners put in every morning during rounds for both assessing the patients as well as explaining to them the results of the diagnostic pathways. I enjoy seeing the degree of satisfaction that my learners show when we are able to successfully discharge a patient who came very ill and is able to look into the future with hope, renewed strengths and desire for recovery. Most importantly I enjoy when my learners actively demonstrate that critical directive, primum, non nocere.

M.A.

Cleveland, OH, August 2012.

Choosing wisely - the saga continues

2015-02-27T10:44:00.000-05:00

Today, the ABIM Foundation published a nice blog post on the choosing Wisely campaign - which they launched several years ago. It can be read here.

This week, this was the topic of my institution Department of Hospital Medicine Grand Rounds. We reviewed the current state of healthcare in USA - and the disproportionate ratio between healthcare expenditure and outcomes. Then we discussed the 5 SHM recommendations. 1) Don't use routine antacid prophylaxis out of ICU, 2) Don't place routinely urinary catheters, 3) Don't get daily labs in the setting of clinical stability, 4) Don't routinely transfuse unless clinically unstable and Hb < 7 (and we emphasized the word "consider" transfusion instead of "just go ahead and transfuse"), 5) Don't use telemetry routinely.

Interestingly, there was a lot of controversy around each topics - why so far, we still have gaps in performance? - why so far is so difficult to hardwire change?.

Let's just focus on the urine catheter use.

Regarding urinary catheters, we have an overall low DUR (Device Utilization Ratio) - meaning the number of "Foley-days" divided by the total number of patient days. We have a low rate of CA-UTI - still it is not zero. Why?

In most cases, the CA-UTI was linked to urine cultures obtained by trainees at the middle of the night in patients with fever as part of a pan-culture approach. Yet, these patients were: 1) not neutropenic, 2) didn't have urinary malformations, 3) didn't have a renal transplant, 4) did not have any clinical evidence of cystitis or pyelonephritis, 5) were not hemodynamically stable. Still - it is very difficult for a trainee to simply withhold a urine culture in a patient with a Foley catheter. In addition, these positive cultures had no translation whatsoever into any kind of clinical meaning. They become a statistic without clinical relevance, yet with impact in the overall institutional quality metrics.

The question needs to go further and beyond - does the patient still needs the Foley catheter?

My question to my trainees is - instead of just performing a urine culture in this patient, which most likely will have no real clinical meaning, why don't we just consider having the urine catheter removed?

We reviewed the other organizations Choosing Wisely recommendations - and the ACEP also recommends against routine placement of urinary catheters - therefore, hopefully, the story of "the patient already came with a Foley when admitted from the ED" will be a goner.

We had implemented in 2013-2014 an enterprise-wide Nursing driven protocol for Foley removal - which has impacted in a 30% decrease in CA-UTI rate. The current utilization of the protocol ranges in the 80%. Interestingly is that in quality improvement, it is not only the implementation of a new protocol or change which creates impact, but also the adherence and compliance with it.

Nowadays an interesting phenomenon, is the engagement of patients in the decision making process, which by the way is a principle objective of Choosing Wisely. When a catheter is placed - for instance to "monitor diuresis in a patient who is getting IV diuretics" - I have now patients asking if the catheter is strictly necessary, as they can use a urinal for quantification of urinary output. Still, I've witnessed resistance from providers regarding the "need for an accurate output measurement" and accepting not placing the catheter in a "lost battle mood". And this is because we were hardwired to use catheters in an indiscriminate way - and now are swinging the balance to the opposite side.

The times are changing and we all need to ensure there is engagement, especially from our young trainees. We need to hardwire best practices early enough. Teach them the words of Henry Ford "Quality is doing the right thing when nobody is watching".

Rescuing my blog from the oblivion. Musings on the transformation of our millennial trainees into patient-centered professionals.

2014-08-05T00:24:00.001-04:00

It is interesting to see the excitement with which lots of people (including yours truly) starts blogging, using Twitter, etc. and how the energy and effort into it appears to slowly getting diluted within the incredibly intense day to day activites, responsibilities, anxiety, etc.

In my case, I started blogging for a variety of reasons - it is my own forum to express ideas and thoughts that happens in my everyday busy clinical life. We as hospitalists (in my case, Med-Peds), get exposed to an incredibly wide array of different clinical situations from childbirth until caring for a century age patient; these situations can vary from very complex disease presentations with highly complex comorbid conditions, to witnessing very difficult social situations that impedes treatment compliance.

On top of the daily clinical experience, there is the exposure to academic activity, where we are role models and teachers for medical students and residents to train them to become specialists. It is our role to teach them to become patient-centered, rather than self-centered. With this, I mean to change the importance trainees give to their own "presentation" or the feedback/evaluation they receive into focusing in the aspect that they are part of a team privileged in taking care of patients. We have the compromise to provide optimal and evidence-based patient centered medical care - emphasizing in excellent communication and patient experience.

Nowadays, I try to ensure that my residents appreciate teaching through rounds - not necessarily classic Socratic teaching - but the teaching that emanates from actively discussing medical decision making; the dissertation of the different outcomes that can occur, etc. We may complement with additional reading material, and perhaps some protected time for board teaching. Yet, the most important thing to me, is to ignite in them the spark that will trigger their behavior as adult learners to pursue self study and close their own knowledge gaps.

We are training a new generation of medical students and residents - the millennials - self-driven, hi-tech adults. We need to adjust to a different perspective of doing things and approach knowledge. It is cool to have an app for everything you want to teach - but most importantly, this generation does not learn dogmatic concepts by default. I love when they challenge the concepts and try to reason about the rationale for specific outcomes or medical decisions.

However, even if they are self learners, we need to strive in helping them find their own knowledge gaps - and use toward our own advantage their self-learning behavior to go and close it on their own. In my case, I ask them to give a small 3-5 minutes presentation to the team on a specific concept that they have just read upon and learned.

We must create academic momentum within a strongly humanistic, empathetic and compassionate care. I want to appreciate the enthusiasm, interest, motivation, energy, desire to learn and excel, and overall, the most incredible passion for patient care. They are learning to become good doctors and to broaden their knowledge - but most importantly, because they want to provide safe medical care to our patients. I cannot divorce compassionate medical care from excellent medical decision making. What distinguishes the good physician from a mere human being technical expert is the blend of outstanding medical knowledge with genuine compassion and empathy.

When the medical student or resident is compassionate, and feels the compelling need and desire to excel, and master the knowledge as much as possible, it is because wants to provide the best care for their patients - they know the patient well; they have read about their medications; explored in depth the details discussed during rounds - and all this effort is targeted toward providing outstanding medical care. Then the rounds are about presenting to the team the most relevant aspects of the patient medical status, current state of the diagnostic and treatment phase, provide focused teaching to the team, etc. But rounds are not anymore about "my presentation". They are now genuinly engaging in the care delivery as very valuable team members and their work is centered around the patient.

This is the transformation we desire. They can accompany it by all the issues of the New England Journal, most recent Up To Date articles, McGee's physical diagnosis evidence based information, etc. But this knowledge is parallel to their genuine desire to help the patient thrive through his/her experience in the hospital and receive the most compassionate and empathetic care as possible.

For the trainees, the situation becomes a very different one - the patient experience has becomes a paramount composite not only of the medical care, but is even embedded in the CMS payment models. No matter how technically beautiful a brain aneurysm surgery went - if the patient experience in the hospital is bad, then the technical aspects become secondary. And the trainees as a part of a medical team have a shared responsibility in ensuring the best experience for the patients.

Being a doctor is a tremendous privilege - we get the confidence and trust of our patients. We became doctors to provide healing, relief, and alleviate suffering. I hope that most people who became doctors did it for this sake, and not just to pursue a necessary pathway to become a specialist in refractive surgery, or joint replacement surgery, or cosmetic surgery, etc.

When a trainee is under our supervision, we can't really change what motivated them to become a medical student or now as a doctor, to pursue a residency training, but we can certainly demonstrate a role model for humanistic and compassionate medical care, and teach how to conduct their bedside manners in the most respectful and excellent way as possible. And then, blend this behavior with their own acknowledgment of necessity of self boost of their medical education in order to safely take care of patients. If this combination is successful (learners acknowledgment of their own knowledge gaps with subsequent gap closure, blended with a genuine compassionate behavior and understanding that all we do is patient-centered), then we can take pride on our modest yet valuable contribution to medical education.

Our journey toward crossing the quality chasm - musings from the Intermountain ATP course

2013-02-03T18:14:00.002-05:00

I spent all last week in Salt Lake City, Utah, at one of the worldwide recognized most prestigious academic activities in quality and patient safety - the Intermountain Advanced Training Program in Healthcare Delivery Improvement, which is taught by a veritable pantheon of healthcare quality improvement colossus leaded by Dr. Brent James.

This course is a 20 days course, taught over 4 weeks (one week each month for 4 months), and the attendees are the quality leaders in different institutions - all really smart and engaged individuals with a substantial amount of experience and knowledge in the field - several with 2 or 3 master degrees (MMM or MMA or MBA plus a MS or MPH). However, despite their knowledge and training, still something is missing. It is a fascinating experience to network with such a phenomenal group of professionals with a common goal - provide the best medical care in the world.

This course helps to fill the gap - Dr. James has taken all the teachings from the gurus in quality, Dr. Deming and Dr. Shewhart and translated into healthcare. Essentially they teach how to understand that healthcare delivery is as well as in manufacturing, a series of processes which receive different inputs in order to have a final output or outcome, and its quality will depend whether it meets or not required specifications. Quality is defined by our own set of values, expectations, cultural beliefs, etc. and good quality is when the output meet specifications (which are defined expectations). The FOCUS-PDSA strategy allows to identify opportunities and implement quality improvement processes in small scales and translate subsequently toward a larger scale. It is very relevant to understand how the industry has improved and how certain industries achieve incredible safety records - e.g. aviation, car manufacturing, etc. - and how the application of Deming's philosophy has been instrumental in this incredible safety record.

It is important to understand the history of healthcare delivery in America - how its philosophy has changed - after world war 2, there was an emphasis in ensuring access to healthcare to all the population; however after the costs started to rise and the insurance companies started to take control, the shift focused toward cost control and maximizing hospital reimbursement - this was sub-optimal as opportunities to care may have been missed by patients as insurance companies controlled the medical decision making not emphasizing at all in quality of care but just cost of healthcare delivery. However, quality of care was less than optimal and medical errors were the 6th cause of mortality in the US. This was highlighted in an publication by the Institute of Medicine called "To Err is Human" and subsequently by "Crossing the Quality Chasm". This has shifted equation of healthcare delivery toward "value" of care - which meant increasing the quality of healthcare delivery while minimizing unnecessary costs. This is the current philosophy that allows us to design the healthcare processes.

It is important to stop practicing a highly variable "craft of Medicine" which allows for increase risk of errors and missed opportunities - it allows for an incredibly selfish and individualized practice of "what works for me". This can make a physician practice differently in a same patient/same scenario in different time periods. Patients are increasingly complex; medical knowledge is increasingly complex too - more than 10,000 different journals, it is impossible to know all the current evidence to support a safe medical practice. This is one of the reasons for having quality improvement systems in place - and to have all doctors get on board the ship of quality and safety and adopt the culture of quality as their main philosophy.

But in order to ensure adequate quality delivery, we need to know whether we are meeting the specifications! Therefore, it is fundamental to have a clear understanding of our current performance - essentially, know well the data to be able to study and appraise it. Be able to graphically show where our performance gaps are is fundamental - using time series, pareto charts, Ishikawa (fish-bone) diagrams or other cause-effect diagrams, histograms, flow charts, etc. (Now a lot of things make more sense!). Metrics should drive performance when understood within an appropriate knowledge and understanding of our own institution philosophy, vision and mission. The graphs allows to identify outliers and areas of opportunity. Errors or mistakes are horrible words - should not be used; the purpose of quality improvement is not to punish or take action toward an individual - the context of all the theory is geared toward improving the system! Rather than using these words, it should be identified as "opportunities for improvement" or "outcomes outside of specification". All individuals within the system should be accountable, but the purpose of QI is to enhance the system in a consistent form. For example - you don't ask when climbing a regional jet whether your pilot is competent - you trust the system! The same should occur in hospitals - create systems that enhance patient safety and consistent quality delivery.

For quality improvement purposes, the most important aspect that Deming taught was to decrease variation - once variation is decreased, the area under the curve decreases - the population bell shape distribution narrows and its peak is more prominent - then it is easier to identify real outliers - the causes for real "signals" and be able to help improve. In a traditional bell shape, when arbitrary cut-offs are met, these outliers can mix with the rest of the population. So it is important to standardize processes to minimize variation. In healthcare, each patient will be different, so if we standardize our processes, the only variation will come from the patient who can receive an individualized care but the overall standards of care will be met.

The leverage of all resources - technology: electronic health records, computerized-personal-order-entry systems (or CPOE), and non-technology: discharge processes, nurses/physician huddles, etc. - should be targeted toward minimizing variation and use all opportunities to meet top quality standards.

Once a process is started - a work-flow diagram that illustrates the process and subsequent steps, can be modified with constant feedback from the end-users about its performance to improve it in a continuous way - what is also called continuous improvement.

A beauty if the QI philosophy is that once specifications are being met rather than "sleeping on the fame", a constant pursuit of further enhancement and refinement in the process should be maintained - this desire for continuous improvement is what creates safer and better environments - this philosophy is what helps the world to keep advancing and be a better place for the next generations.

My responsibility will be to immediately apply all the currently acquired knowledge at my institution, as well as share this philosophy and knowledge with my peers, medical students and both Medicine and Pediatrics residents. This is important as the new generations must harbor the culture of quality and safety as their main philosophy. I'm excited as this will help to deliver a much better medical care and help to shape the Medicine of the future today.

A safe medicine with highest quality standards allows us to practice our mantra....primum non nocere.

Less is more - additional evidence against liberal blood transfusion (or in favor for parsimonious use of blood).

2013-01-02T18:31:00.001-05:00

I went last year (yes, the year that just ended 2 days ago) to Mexico City to give a lecture at the International Course of Internal Medicine sponsored by the Mexican College of Internal Medicine. My lecture was named "Blood is life: to transfuse or not" - and it was targeted toward presenting the evidence for parsimonious blood utilization. This invitation came as a result of my involvement with the preoperative anemia optimization program at the Cleveland Clinic.

At the Cleveland Clinic, a large effort was initiated about 6 years ago in order to decrease the number of transfusions, mainly red blood cells, and mostly in surgical patients. The efforts have yielded in an impressive decrease in blood utilization as well as in a more proactive behavior to optimize the patients' anemia before undergoing surgery. One of my main areas of interest is preoperative anemia optimization to minimize the risks of intra-operative or post-operative blood transfusion. We optimize the iron stores, or in special cases, use erithropoiesis stimulating agents (Jehovah's witnesses, hip and knee arthroplasties mainly).

The culture change has been slow but steady. Nowadays, nobody attempts to transfuse liberally in anybody with hemoglobin more than 7 g/dL; of course, each patients is evaluated individually and certainly you can transfuse at higher numbers in patients with other co-morbidities (for example, patients with severe chronic lung disease and active ischemic cardiomyopathy, or severe acute ischemic renal injury, etc.).

I have undergone a large review of literature which I presented in Mexico (the translated slide presentation can be seen here). The presentation raised controversy - some of my Mexican colleagues still transfuse based on "their experience" and not on the evidence; they are scared of using intravenous iron preparations; they still think an hemoglobin of 10 in a critically ill patient is an indication to transfuse. It was a big cultural shock to find out that it was in critical care patients where the evidence came from, supporting a parsimonious blood utilization. Some people advocate autologous blood donation (which we do not use here), as well as the use of perfluorocarbon blood substitutes (which as well we do not utilize here neither). A long road is to be traveled and a large educational effort is required to change long-standing practices; I was grateful by receiving the opportunity to help in the initiation of these efforts and will continue to share our experience and growing literature available.

In the past 2 weeks, two articles have come out to provide additional support to the parsimonious blood utilization - one published online in Archives of Internal Medicine which demonstrates and increased mortality in patients with acute myocardial infarction who were transfused - and the other published in tomorrow's NEJM - which fills out the missing part of the puzzle: whether pursuing a parsimonious blood utilization in active GI bleeding was a safe initiative.

The article in Archives, is a well designed metaanalysis which review 10 studies out of 729 finding interestingly a mortality risk ratio of 2.91 with a number needed to harm of 8 in patients hospitalized with myocardial infarction who were transfused. In addition, this risk was independent of the baseline hemoglobin level and to muddy the waters more, it was associated with increased risk of subsequent myocardial infarction. This is very interesting, as most guidelines recommend a higher threshold for transfusion (e.g 8 g/dL instead of 7 g/dL) in anemic patients with myocardial ischemia. I don't think clinicians should stop from transfusing patients that need blood; but I would advocate a more conservative approach looking into the causes of anemia - hematinic deficiencies (iron, vitamin B12, folate, etc.); bone marrow suppression or dysfunction; ongoing blood losses; etc. As the authors conclude a larger trial is needed and I concur; however, it is interesting to see the trend toward the worse outcomes, including reinfarction.

The article in the NEJM, comes to provide very needed information in the actively bleeding population. We tend to transfuse as in an actively bleeding patient it is unclear whether the hemoglobin will stabilize or how low it can go. In my institution, we tend to monitor the hemoglobin every 4 to 6 hours in these patients - and hold for transfusion until the hemoglobin reaches 7 g/dL or less. This behavior is supported by this article, which certainly provides a sigh of relief to all who practice a parsimonious blood management. Of course, that in addition to this, clinicians should always optimize the hematinic deficiencies (iron stores, folate, vitamin B12, etc.), in order to maintain the substrate for an adequate hematopoietic response. I'm glad this article is out in print as certainly will provide a stronger support for all blood management programs, and minimize worse outcomes in our patients.

Doctors and midlevel providers want the best for their patients. It is a matter of education and reaching a comfort level to pursue evidence based and common-sense based medicine. As always, we all strive for the best....primum non nocere.

Realizing the incredible frailty of life and the battle to avoid irrational exuberance: a journey into the NICU as a Med-Peds uncle.

2012-04-29T03:51:00.001-04:00

It was September 2003. I was a recently Board certified Internist in Mexico, now repeating the residency training in the United States in a combined Internal Medicine and Pediatrics program. I was stepping for the first time in my life in a level 3 Neonatal ICU (NICU) at Metrohealth Medical Center in Cleveland, OH; a 40 beds state-of-the-art NICU, where miracles happen. Used to examine adults; used to palpate the abdomen with two hands; now my patients were smaller than my hands. I stepped into one of the rooms to see my first patient; a 24 week gestational age patient, born a week ago at age 23 weeks! As I approached the isolette, gusts of shivering invaded my body. I was anxious and scared; I was having an incredible mixture of emotions; I felt an incredible pride of being a physician as well as I was marveled by technology; nonetheless I suddenly felt I did not belong there. I was an internist trained to see adults with cirrhosis, lupus, rheumatoid arthritis, heart failure, diabetes, hyperlipidemia, etc. And now, I was in the "darkness" of an entirely unknown yet incredibly fascinating world.

Most babies were in isolettes; however, others who required more hands-on approach were in open warmers. I came to see strange ventilators called "oscillators"; ECMO became a reality, not a fiction; and suddenly I found myself looking into numbers that were surreal....a blood pressure of 60/30???? a heart rate of 150????? that was "normal".

The most impressive thing happened when I opened the isolette and found that my patient was surrounded by a million lines and monitor cables, and his legs size were as thick as my hand ring finger and the arms were smaller than my pinkie finger and the body was thinner than my whole hand size! ....How was I supposed to examine this patient???? how was I supposed to flip him over? I was terrified of even giving my patient the slightest touch. The skin was red, transparent, I could see vessels, perhaps peristalsis. I felt inside my heart an immediate love for that baby, an immediate sense of tenderness, compassion, and acknowledge how frail, tiny and delicate my patient was. I felt an immediate commitment to be a guardian, a protector, an advocate for this tiny person's life. This challenge was as well very important...it could mean that if I didn't liked the rotation, I would switch from a Med-Peds training to just Internal Medicine.

My attending physician (the main staff who supervises the residents and fellows in an academic medical center) was one of the most important authorities in the field, Dr. Satish Kalhan. I was terrified of not giving an adequate performance after being warned who he was. I ended learning a great deal from him and finding much needed inspiration to become a Pediatrician. We became great friends with mutual respect for one another.

Time passed by, and the only way I could obtain an additional income was "moonlighting" in the NICU, so over the next 4 years, I routinely "moonlighted"; sometimes when I was in the middle of an Internal Medicine rotation, I spent a single night in the NICU - an extreme Med-Peds experience. Fortunately, I was skilled - did intubations, placed umbilical lines, PICC lines, intravenous lines, did lumbar punctures, did neonatal resuscitation, etc. I loved it, not to the point of becoming a neonatologist, but yes to the point of enjoying being a Pediatrician.

Nine years later, I found myself in the NICU, this time not in Ohio, but in Des Moines, Iowa. My brother, who is a Pediatric Nephrologist (and one of the brightest physicians I know) and his wife who is a Family Medicine specialist and a Master in Public Health, had premature babies at a gestational age of 26 weeks.
I witnessed miracles in the NICU during my residency - lots of normal patients who were very premature who developed to be children with normal intelligence and with no learning disabilities. Of course that as a Med-Peds trained person, I saw as well a lot of complex care Pediatric patients with all ranges of learning disabilities and handicaps - but these were the minority. Most patients were able to pursue a normal life.

These tiny children in Des Moines are now my blood...are my brother's offspring!, the next generation in my family!, my parents' first grandchildren!, my grandmother first great-grandchildren!. When I met them an infinite sense of pride, happiness, love and tenderness invaded my body; similar to my first experience in the NICU, I got gusts of shivering and goosebumps from the emotion. However, now I felt an immense feeling of adoration for them.

I was very worried as before I landed in Des Moines, I came to know that both of them had NEC - necrotizing enterocolitis - a potentially life threatening condition that occurs in premature babies due to immature intestinal perfusion and poor barrier for enteral bacteria. My niece was doing fine and only required a small surgery. But my nephew was very ill - he had 23 cm of his bowel resected, had acute renal failure and oliguria, had coagulopathy, developed a liver hematoma and a subdural hematoma. Due to severe hypotensive episodes likely from overwhelming sepsis due to bowel perforation he developed a watershed infarct in the brain.

My niece was in an isolette, with nasal CPAP and tolerating enteral feeding, still with total parenteral nutrition. My nephew was in an open warmer; on dopamine and dobutamine - medications to keep his cardiac output and blood pressure; morphine to keep him sedated; phenobarbital to protect his brain and to control new onset seizures. He was in the oscillator. His abdomen was enlarged, distended, blue. He received a myriad of blood products to compensate for his coagulopathy and bleeding.
I was incredibly sad and disheartened by seeing a little person with the same face as my brother's, in such a frail and incredibly life-threatening state.

I prayed, had a lot of good thoughts, supported my brother and my sister in law. Asked to my friends in the social media to pray. Tried to bring positive energy while in the back of my head I had my medical knowledge kicking and stabbing my soul. I tried to debate between whether it was an irrational exuberance to provide all this care to this baby who had a very low birth weight and that all the scientific facts in the medical literature were against his odds of living, versus my incredible and gigantic love for him as an uncle wanting to be an advocate and steward for his life. So far, my brother, a Pediatric Nephrologist fought back the Neonatologist who wanted to withdraw support. This little kid had a big ally on his side so far!

I decided that it was not irrational exuberance, and I supported to give all to him. I told my brother..."he is tiny, yes, he has a bleeding in his brain...but Hashem makes miracles, the brain plasticity is great; let him fight and let's fight with him". The next day, my nephew urinated, his creatinine started coming down; he had a meconium string (a bowel movement - which is a sign of the bowel working); he was weaned off the oscillator to a conventional ventilator; he was weaned off dobutamine and dopamine! The power of prayer was working! We had doubts about the neurological prognosis due to the abnormal cerebral images in the head ultrasound and a presumed midline shift of his brain. However his head circumference was stable and his fontanelle soft; in addition he was grimacing and moving his four limbs symmetrically, so I thought this was reassuring.

My niece on the other hand, was tolerating trophic feeds and was now providing a lot of strength to all of us.
I left Des Moines and came back to Cleveland. I gave a lecture at a Transfusional Medicine conference in Phoenix; then came back to my regular professional duties at the Cleveland Clinic (from where I'm typing this blog post on a Sunday at 2AM, working as the Medicine Triage Officer). In Phoenix I required to call one of my Pediatric Neurology colleagues at the Cleveland Clinic to ask him for insight regarding the neurological prognosis. The CT scan of the head was very disheartening - he had either severe edema versus almost an hemispheric infarct in addition to the subdural hematoma. The prognosis was looking grim and sad, but still, with some hope for the rest of the brain to take over.

My brother called me several days ago, his voice was very "dark and sad"....he said...."the baby is having severe abdominal distention; the surgeon is not available now; he got a gastrograffin enema...and the gastrograffin came through his mouth...he is now in respiratory distress....keep him in your prayers please, we think this is it....". Immediately after he told me I felt a freezing sensation and cold in all my body. I prayed, cried silently (I have not been able to put a tear out...it has been very contained and I feel a lot of pressure in my heart).

The next day he called me...."Samuel passed away at 3:45 AM, we were at his side...he stopped suffering". I can't believe how sad, disheartened, abandoned and helpless I felt. A myriad of images started crossing my mind remembering when I met him in the NICU, seeing his face so alike to my brother's, and how he fought through those 27 days of life. I prayed to Hashem to keep him peaceful with no pain, with no suffering. I felt the most terrible pain I ever had in my heart. I adore these children. I felt terrible for my brother and his wife, for our parents, for our families....and for all the families who have lost premature babies in the NICU.

I debated on how cruel life can be...."is this fair? that I have given so much, that my brother has given so much as a Pediatric Nephrologist keeping babies alive, and we lost our child?...is this fair?....why?....why us?....". But as a non-religious but believer, I think Hashem has a reason for things to happen. Perhaps my nephew would have suffered from very debilitating disabilities from this complicated NICU course with poor neurological outcome. Perhaps this was for the best. Who knows.

How frail life is. How thin is the layer between life and death. We enjoyed him coming out to life, and so fast he went away. I realized how fascinating technology and science are, but how terrible and blinding they can be providing with false sense of hope. However...I admire the human power of having feelings and emotions....how much you can love somebody you just met, but who you know you were waiting for him or her all your life.

This is a very difficult time for us as brothers, as a father (for my brother) and as an uncle (for me). This is hard, I have a knot in my throat all the time. A squeeze feeling in my epigastric and retrosternal area is constant. My tears are contained, haven't been able to cry....feeling like so but I can't. Trying to give strength to my parents, brother and sister-in-law.

As a doctor, as a Pediatrician, as an Internist I hate futility. I believe in preserving quality of life over everything else. I believe in the most intimate respect and veneration for human dignity. I'm not sure if this NICU battle was going beyond these principles, but now this is past. Now my nephew is resting in peace and his memory will always be in my heart. I love him so much, with so much intensity, with so much appreciation for his incredible fight for life. He taught me how you can be so tiny yet so strong. He made me recall my appreciation and respect for Neonatology specialists, NICU nurses but overall, for the families and the tiny NICU patients themselves.

Now, my dear and sweet niece, so beautiful, so precious, so frail yet strong, is doing well. I keep all my feelings and prayers for her to survive the NICU and be a happy girl. I will strive to make from my standpoint what I can to make her enjoy and cherish life, have her enjoy this wonderful world full of colors, music, happiness, cultural richness and heritage. Her life is so meaningful to me as my own life. Her life represents my nephew life as well. She is living for both. She is a daughter, a granddaughter, a niece! We all love her so much. I have incredible feelings of infinite happiness for her to be alive, and a simultaneous incredible sadness for my precious nephew to having pass away.

I am experiencing very intense feelings I have shared with my friends - I am so grateful for their support and prayers, for their words. Social media is powerful. I have been able to share this important event in my family with our friends and colleagues from all the world. There are people who I may have not seen in quite a while, but whom I like and appreciate; people from whom I have learned something and shared some period of my life. People who have made me become who I am. Friends and family whom I respect and I'm infinitely grateful for their existence and for being there. I am here for them as well. In anything I can help I will always be here for them too. This is the beauty of friendship, the beauty of family, the beauty of existing - being there for the other; help each other; give a word of encouragement; and as a human being looking always to do the good and do not harm - treat others as you would treat yourself.

So much has happened lately - I realize how frail we are - we should be grateful to be alive; to have normal children; to see them grow and become independent; we should be grateful to be who we are!; to walk; to talk; to see; travel; to be able to exist for oneself and for others. My nephew didn't have that privilege. His sister will do. Now I realize once more to never take things for granted.

I found again some sentimentalism I have always had, and I strengthened my respect for life and death, for the dignity of life, for the value of family and friendship, and most importantly, my infinite respect for all those little patients who fight like champions to perhaps, one day, become the Neonatologists who will make miracles happen and give hope to other babies and their families.

Samuel Alexander Auron (3/30/2012 - 4/27/2012) Z"L. My love for you my dear is as infinite as the universe, we promise to take good care of your little sister. You have made me be a better person and I will always follow my main principle as a doctor....primum non nocere. (I hope our irrational exuberance didn't harm you).

Preoperative anemia optimization - the role of intravenous iron in the XXI century

2012-03-18T00:26:00.002-04:00

Intravenous iron was first used in the first half of the XX century until the decade of the 70's when it was essentially considered as a very dangerous drug with substantial potential for anaphylaxis.

The fear prevailed for 2 decades, until the decade of the 90's when a closer look into alternatives to blood transfusion, and a desire to provide a safer medicine yielded into exploration and revision of intravenous iron as a potential therapeutic agent. In the early years of last decade, the FDA showed that even the high molecular weight dextrans were associated with a very small risk of adverse effects as well as a substantially lower cost compared with blood transfusions.

A surge in a safer practice of Medicine has blossomed in the past decade, including the famous publication of "To Err is human" from the Institute of Medicine, as well as multiple endeavors from a variety of government and private institutions, creating a real-time awareness of the need to change our practices with a safer, conservative and parsimonious use of resources as well as attention to detail.

Among these practices, it is the practice of blood management. I won't go into deep details, however, must say that in surgical patients, it is well known that preoperative anemia is a risk factor for poor outcomes.

In this article at the ACP Hospitalist, we provide an insight on the utilization of intravenous iron as a treatment to optimize preoperative anemia and ensure that patients' preoperative hemoglobin rises enough so that after surgical blood loss, the postoperative hemoglobin levels won't reach the transfusion threshold.

We have been building experience in our institution with a substantial decrease in perioperative allogenic blood transfusion utilization, promoting patient safety and improved quality of care, obeying our medical mantra.....primum non nocere.

What is the Ashman's phenomenon

2011-12-04T21:49:00.001-05:00

One of the core competencies of hospitalists is the appropriate and accurate interpretation of electrocardiograms (ECG). Of course, we are Internal Medicine or Pediatrics (or both) specialists and not Cardiologists.

The ECG interpretation requires skill, close observation, excellent knowledge of the vectorial conduction of electricity in the heart, and most importantly, lots of practice and seeing multiple ECG's. In addition having the mentorship of senior Cardiologists with experience is paramount.

I had a case in the pre-operative clinic (IMPACT - Internal Medicine Preoperative Assessment, Consult and Treatment) at the Cleveland Clinic, and as part of the routine evaluation an ECG was obtained. She did have Atrial fibrillation , however some unexpected presumed premature ventricular contractions.

Further investigation on this electrocardiographic phenomena let us reassure our surgeons team and have the patient undergo surgery safely.

Read here our report in the Cleveland Clinic Journal of Medicine December 1 issue.

What to believe?

2011-11-18T10:02:00.001-05:00

This has been a rough week for all of us involved in Perioperative Medicine. As hospitalists in a large academic medical center we take care of a large perioperative clinic that sees 16,000 and more patients every year.

In order to ensure optimal care of the patients, we use evidence based guidelines to provide the safest medical decision making.

One of the most prolific authors in the field is Dr. Don Poldermans, a very well respected and renowned cardiologist who we had the fortune of knowing as he has visited our institution for the Perioperative Summit which is now hosted by the University of Miami.

In November 16, the University of Erasmus of Rotterdam asked Dr. Poldermans to leave. This on assumptions of misconduct in research. This is a very frail moment as for any institution to take such a decision is not easy and decisions like this are not taken lightly.

For us is very hard; I just gave a lecture in Mexico City last weekend on perioperative medication management and I cited the DECREASE studies findings supporting the current evidence to use betablockers, especially the ones recommending starting low dosing with gradual increase and preferentially within 1 to 4 weeks of surgery.

The media has been taken by assault and all of us feel like orphans. Can we trust the data? Is this a precipitated decision by Erasmus? Everybody should be cautious in times like this and careful in not destroying the prestige of somebody who has been an authority in the field and a good man.

I look forward to follow closely what happens and ensuring that the evidence we use is still valid or not. We should be careful in not labeling him until further clarification occurs either from him or Erasmus.

These are some links to these news:
http://www.anesthesiologynews.com/ViewArticle.aspx?d=Web+Exclusives&d_id=175&i=November+2011&i_id=785&a_id=19726
http://retractionwatch.wordpress.com/2011/11/17/breaking-news-prolific-dutch-heart-researcher-fired-over-misconduct-concerns/#more-5216
http://ktwop.wordpress.com/tag/don-poldermans/
http://www.erasmusmc.nl/perskamer/archief/2011/3488672/
http://www.nrc.nl/nieuws/2011/11/17/nieuw-geval-van-wetenschapsfraude-hoogleraar-erasmus-mc-ontslagen/

Sigh!.......What to believe?

Perioperative management of morbid obese children

2011-08-30T19:08:00.000-04:00

Obesity is the plague of our days. It takes years of life away in an instant. However, despite the knowledge and awareness of its terrible consequences, it seems that parents are blind to the devastating effects of it.

I presented a workshop on perioperative management of the pediatric patient in Kansas City, at the 2011 Pediatric Hospital Medicine meeting, sponsored by the American Academy of Pediatrics and the Society of Hospital Medicine.

A section I focused on, and brought special attention was the management of children with morbid obesity. You can read in further detail here.

Do hospitalists boost costs? - a reality or fiction?

2011-08-03T04:14:00.002-04:00

The Hospitalists community is shocked. Or at least I am.

Yesterday Drs. Kuo and Goodwin published a very well written study in Annals of Internal Medicine. It is in fact, an impressive study despite all its limitations. They evaluated a 5% sample of Medicare patients in 454 hospitals, comparing 36,871 patients treated by their Primary care physicians (PCP) with 21,254 patients treated by Hospitalists during a period of 2001 through 2006.

They found that although the length of stay was lower (0.64 days less) among patients treated by hospitalists, and that the inpatient charges were S282.00 lower, the Medicare costs in the 30 days after patients were discharged were in fact $332.00 higher. This translates in an additional 1.1 billion in Medicare costs per year based on the approximate 25% Medicare admission managed by hospitalists. (This is very dramatic if we take into account that the government almost shut down yesterday).

In addition, the authors found that patients cared for by hospitalists may have a decreased lenght of stay hypothesizing that this may be at expense of increased rate of discharge to skilled nursing facilities or nursing homes by almost 20% compared with primary care physicians.

As well, they found that patients cared for by hospitalist had an 18% increase in subsequent emergency department visits and 8% increased risk of readmissions.

The findings were confirmed with an impressive statistical analysis in the entire cohort study of 205,190 admissions in 4657 hospitals.

However, this study had multiple limitations including: only included patients with an identified PCP; patients admitted with medical (non-surgical) diagnoses; did not include patients cared by subspecialists who may as well be hospitalists; only studied patients with fee-for-servide Medicare coverage; it included a period of 2001-2006 which may not be representative of the current practices; they extrapolated the costs, based on total Medicare charges, but did not actually directly assessed the costs.

Their last conclusion was very interesting - given that hospitalists may have incentives based on a fixed prospective payment based on the severity of the admission (medical diagnosis-related group or DRG) shifting costs to the outpatient in a post-discharge fee-for-service model, this drive overall to increased Medicare costs. The authors proposed the increase in bundling of payments based on the episode of care to minimize these incentives. The latter translates to the current proposed model of Patient-centered Medical home in which bundled payments will cover both inpatient and outpatient care.

I'm appalled. I am a strong believer that hospitalists in fact decrease overall costs of healthcare - why - because we provide evidence based quality care. We focus on quality improvement, increased patient safety, improved patient outcomes; we are very critical of our performance and advocates of increased accountability and transparency. We advocate the model of increased quality and decreased costs.

However this incredibly large national database is in fact, proving otherwise. In addition it proves some quality metrics to be in the red numbers area - for instance, shows an increased number of ED visits and readmissions.

If we take the heart failure model, it has been shown that early outpatient follow-up decreases readmission rates; but this requires a proactive behavior from all the healthcare system (including the patients). This is a current national priority and at least in this population we most likely will be seeing soon data of current practices.

I can argue that in the period of 2001 to 2006 a flawed system with limited access to outpatient medical care may have contributed to these results, and that this has been changing with time, and at least from my personal experience, we ensure that our patients receive a soon follow up with a PCP to facilitate transitions of care.

Now, it may be true that hospitalists may discharge patients more to skilled nursing facilities - but this may be due to the increased attention to detail to the patient's ability to perform activities of daily life and provide self-care; we may have increased Physical Therapy evaluations to ensure safer transitions of care. For instance, in this cohort of patients, they averaged 77.5 years old - any patient that age who is acutely admitted to the hospital may in fact suffer from substantial deconditioning that may not facilitate a safe discharge to home.

In addition, this analysis focus on economic impact and do not include all inpatient quality metrics, such as core measures, current national patient safety goals practices, use of VTE prophylaxis, documentation practices, etc.

An additional thing that is very important to take into account is the famous cost-to-charge ratios analysis in the Medicare population as well as differences in reimbursement in both inpatient and outpatient settings. In this study, the authors state that they calculated the Medicare spending 30 days after discharge based on total charges; as well they state that charges reflect price setting rather than resource consumption and therefore may overestimate costs.

So, this is a very statistically impressive study, but that focus on economic outcomes and may not be in fact evaluating the quality of care provided by hospitalists. In addition, Hospital Medicine has gone a long road since 2006 to 2011. We are very well embarked in the journey of patient safety and quality. We are advocates of the formula improved quality/decreased costs.

I believe further analysis based on newer populations, other payors systems (private insurances, Kaiser system, etc.), including more recent data, as well as more inpatient quality metrics, as well as adjusted severity and mortality should be done.

We need to be critical of our own practices and look in detail what can we do to improve. As the healthcare system in the United States moves toward the Patient-centered Medical home with bundled payments, most likely this presumable differences in healthcare expenditure between the PCP and the hospitalists model may in fact narrow to a non-significant level.

For the time being, the hospitalists will need to take this as an opportunity for reflection, and as a source of energy to fuel new research endeavors to improve patient outcomes and decrease healthcare costs.

For us as hospitalists our principle will always be....primum non nocere.

AN INCREASED INSIGHT PERSPECTIVE INTO QUALITY AND SAFETY – MUSINGS OF A HOSPITALIST

2011-04-03T22:01:00.000-04:00

In the previous ten years, a steadily progressive increased insight into patient safety and improved quality of healthcare delivery has been promoted by famous physicians-writers and has now become a focus of federal organizations such as the Joint Commission.

If I imagine myself in the hypothetical situation of being a patient in any random hospital in the USA, I really want to get the best of the medical standard of care and have medical errors as well as communication failures avoided at all. I want to receive safe, compassionate, cutting-edge medical care, where attention to detail on the type of medication and dosages are well thought, where medical knowledge is sufficient to provide my caregivers have a broad differential in the diagnostic work-up and avoid missing any diagnostic or therapeutic opportunity. Am I asking too much? I don’t think so.

We have read scary stories of medical errors which happen on a daily basis, as the human are not infallible. However, what is scary is that some of these errors happen to be entirely preventable, only based on taking a minute to think and review the situation. For instance, medication errors secondary to having a nurse administer the wrong dose or medication to a patient – in a busy environment, where the ratio nurse to patient can escalate a risky and ridiculous high number of patients per nurse (5 or more), in the setting where our patients are becoming sicker and more complex, and where expediting the medical care is paramount to minimize length of stay, etc. – can potentially be preventable if the nurse would have more time to verify the dose, the appropriate indication of the medication, and then double check the patient’s name, DOB and medical record number.

But sometimes the system is created in such a hierarchical fashion that nurses just obey doctors’ orders. For example - perhaps in a setting where a nurse detects that the patient’s platelets are low, and the nurse is about to administer a new medication ordered by the intern (the first year of a medical or surgical specialty), she could take a glimpse to medical causes of thrombocytopenia and whether the new medication may in fact worsen the problem.

Or the case of a patient with pancreatitis, who gets for dinner macaroni and cheese and the nurse, allows the patient to eat it as “the doctor ordered a soft diet”. A hard stop could have been put in place, but if the nurse ignores that the diet in a patient recovering from acute pancreatitis should be not only soft, but low in fat, then an unsafe medical practice could be avoided.

But this is not the nurse to blame – this is a result of a very complex system – the doctors input an order; the pharmacist prepares the medications (most of the time accurately, and pick up mistakes as well, but in a busy environment where they receive multiple medical orders at the same time, there is always place for mistakes); the kitchen receive the diet orders for the patient (they are not going to glimpse in the medical record to agree whether this should be a strict low sodium diet, or a diabetic diet, or a diet for a patient with renal disease on hemodialysis, etc.); the transport service receive orders to transfer a patient to a given study (which may be the wrong patient and the wrong study), etc. There are too many different steps involved in providing care to an inpatient patient. Having too many hard stops may in fact stop the process of patient care.

So, in a busy environment, where the time is precious, but the patient safety is even more precious, how can us, the healthcare professionals give the best and safest medical care? This is a question that has driven too many research endeavors targeting safety of patient care as well as quality of care.

I have been fascinated with the subject since I was in medical school. Physicians and nurses presumably always follow the primum non nocere philosophy; however there are multiple barriers to a perfectly safe medical care. The understanding and acknowledging process of what those barriers are is fundamental to be able to humbly attempt to minimize its occurrence. This requires not only a humble perspective to Medicine itself, but a very candid approach to Medicine and to acknowledge our own knowledge and abilities limitations. A large number of mistakes happen in the setting of ignoring subtle signs. For example, when I am on my Internal Medicine inpatient service, a rule of thumb I share with my residents and which a lot of my colleagues may not necessarily agree with me is: “a code blue in the floor is an avoidable mistake”. A code blue is when the emergency medical team is called to the bedside of a patient whose vital signs are critically compromised and his/her life is at danger or in the case of a patient with cardiopulmonary arrest.

Why do I consider a code blue an avoidable mistake? For starters, patients that undergo an abrupt deterioration may have had in fact subtle signs of worsening multi-organ failure which are “ringing alarms”. It is not just about maintaining a good blood pressure; the mental status changes, the worsening of the renal function, the increased oxygen requirements, the deterioration of the liver enzymes, etc. These things happen several hours or even days before the final event. However, in certain medical institutions, the acuity and severity of patients taken care of is so immensely high that the medical personnel can “lose the floor” and get used to them and sometimes take an increasingly common brave attitude of keeping those very ill patients in a regular nursing floor, when in fact appropriate triaging would demand an escalation of the acuity of care, meaning the Intensive Care Unit (ICU). However, those medical centers have in proportion a higher acuity level as well in comparison with other ICU’s. So in proportion everything is more complex in high volume academic institutions.

If I compare the acuity and complexity of medical care when I started my first residency 12 years ago in Mexico, with my second residency 8 years ago in Cleveland, and then when I started my work as a hospitalist 4 year ago, with my current patients, I can objectively state that the patients are now older and much sicker. Sometimes the average age of the patients in my Internal Medicine inpatient service is in the mid 80’s. Not only they have multiple co-morbidities (the number of active diseases and clinical conditions), but they have advance stage of some of these conditions, in addition to the advanced age. However, they have now achieved the opportunity of developing new diseases thanks to their increased survival, which has occurred thanks to the advance of medical science which skyrocketed in the second half of last century.

These patients develop a higher level of expectation from the medical science, sometimes unrealistic, which can put them at the danger of pursuing treatments and procedures which may not necessarily extend their life expectancy, or even worse, will not improve their quality of life. This is also a barrier for patient safety. How much is sufficient? This is a difficult question to answer and brings into the conversation serious bioethical issues and dilemmas which are not the objective of this blog post. The reason of framing this clinical scenario is that increasingly complex challenges are becoming the common picture in the current healthcare environment.

So, when facing an increasingly complex clinical practice, in a world with increased liability, in a steadily progressing complexity in the healthcare system, having hard stops and ensuring adequate patient safety is paramount. High patient volumes, in an environment that can seem a factory of healthcare, where multiple patient get admitted, other so many get discharged, in an endless cycle, there should be objective measures of accountability, transparency, ensuring each patient is appropriately identified and get the correct treatment; have hard stops in the pharmacy; have hard stops in the OR to run checklists, now fortunately so popular; have hard stops in the computerized personalized order entry (CPOE) obliging the healthcare givers to think twice and avoid reflex behaviors.

Creating a system where hospitals get graded accordingly to the level of the safety they provide, ensuring the minimum standards of quality are met, seems as a burdensome and difficult system to practice with. However, if we realize that we can be the patients subject to multiple levels of opportunity to have an error in our healthcare, then we can prove that these measures of standard of care are not unreasonable. The hospital safety get graded according to multiple levels, charting, medication reconciliation, knowledge of procedures in case of emergency, safety of the physical areas in the hospital (O.R., E.R., I.C.U, inpatient floor, etc.), level of hygiene (hand washing, garbage disposal, etc.), ensuring oxygen tanks are secured, etc., etc. All these different measures allow a minimum standard of safety to obtain an accreditation from the Joint Commission. And these ensure a more homogeneous safety across the whole hospital system nationwide.

In addition, other standards of care arise – the National Hospital Quality core measures and Surgical Care Improvement Project (SCIP), which are publically, reported measures of healthcare quality. In order to appeal for transparency, accountability and ownership of success, these measures are publically reported and everybody can know how well or poorly any hospital in the US performs. For instance, if you have a heart attack, which generally is due to the rupture of a plaque of fat inside your coronary arteries, with the subsequent activation of platelets that try to “heal” the plaque, causing a blood clot which occludes the artery, you want to get an anti-platelet medication as soon as possible in order to avoid your artery to get occluded and keep the blood flow to the heart going. Well, one of the so called “core measures” is that patients with a heart attack (myocardial infarction), receive an aspirin upon arrival to the hospital. Other core measure is in patients with pneumonia, which is an infection and inflammation of the lungs generally secondary to a virus or bacteria, a way to prevent them from having invasive infections that can put them back in the hospital is to immunize them against the Influenza virus and Pneumococcus (the most common bacteria causing invasive lung infection). Immunizations are part of the secret of the current society longevity, despite whatever the detractors to vaccines can say. If patients admitted to the hospital with a heart attack do not get an aspirin, or patients with pneumonia do not get immunizations, those are signs of a deficient medical practice which is detrimental to patients. Therefore, these core measures are safety hard stops that ensure hospitals provide a safe medical care to patients.

There are caveats against the core measures, like anything, nothing is perfect. In order to abstract the core measures, somebody needs to review the charts and identify when the standard of care is not met. However this depends on documentation practices. Therefore, patients can in fact get the standard of care, but if it is not documented appropriately, it did not happen. So, this brings a new window of opportunity to healthcare providers that imply a minimum of extra work – document what you do, or as well, the rationale for not doing an expected behavior. However, if you realize that providers are extremely busy, seeing a lot of patients, and taking complex medical decisions in an incredibly complex patient population, then you can ask yourself…do you want a doctor that spend more time thinking to provide sound medical decision making, sometimes at expense on the time for documentation, or a doctor that writes nice novels in the chart, but who is not precisely clinically skillful. The issue is that it is not up to physicians to decide. This is a reality and documentation is paramount. You wrote it, you did it. You didn’t write it, it never happened. That’s simple.

So, in the intrinsically fascinating world of Medicine, we have now, more than ever, new challenges in order to ensure that healthcare delivery is as safe as it can be. We have federal regulations, we have wonderful checklists, we have professionals who are passionate about quality in each institution whose role is to promote the active incorporation of safety behavior and practices in each hospital. This is a fascinating opportunity to ensure today that the healthcare we’ll give tomorrow is the safest ever in the history of humankind. We all need to be on board of the train of safety and quality, as this journey will be the most exciting ever, and as a hospitalist, we are passengers in the First class coach.

As always….primum non nocere.

Targeting the inflammasome - new ventures for a hospitalist

2010-10-23T20:16:00.006-04:00

When the undefined, unclear, obscure clinical presentation makes its appearance on the hospital stage, taking the patient as a hostage, the internist will always carry the flag of the best patient's advocate and passionately fight against the darkness of uncertainty.

In the classic case of the patients with fever of unknown origin we'll attempt to elaborate a list of the most common diagnosis, and once everything else has been ruled out, we'll leave to the end the strange and uncommon diseases, which in the case one of those is attributed and descifered as as the culprit of the patient's maladie, then not only a therapeutic opportunity can be offered to the patient, but of course, the internist's personal experience will broaden and solidify, as well as his/her ego boost up.

What is a similar challenge is when patients with an established rare diagnosis appear, with exacerbations of the disease that are uncontrolled with the usual medications. Then, the main issue will be whom to ask for help especially if the potential likelihood of not having an alternative therapy arises.

Well, we had in the teaching service a patient with Familial Mediterranean Fever (FMF). Yes. This is one of those diseases that everybody can just pop out in trivia and board questions without having ever seen one in their lives. This young patient had a very prominent abdominal pain as well as severe diarrhea - this last one, worsened with colchicine, which is by the way, the standard of care in this disease. Our question was whether this patient may be refractory to colchicine, and if this would be the case, what other alternative we would be able to offer her.

As a background, the FMF is a clinical entity manifested as recurrent attacks of serositis. Attacks can last sometime up to 5 days and the recurrence is variable - some patients have recurrence every few weeks to months to every few years. Stress (physical and emotional) has been linked as a trigger. Most commonly affects the peritoneum (90% of cases), the pleura (45% of cases), scrotum (5% of cases) and pericardium (1%). Patients can as well have acute monoarticular arthritis. Some patients can develop at long term complications such as amyloidosis.

The management is generally succesful with the use of colchicine. However, 5 to 10% of patients can have persistence of FMF's symptoms despite colchicine. Available choices are Interferon alpha and methylprednisolone. It has been described as well, that dietary changes with elimination of lactose as well as gluten in some patients, may help to avoid the colchicine intolerance.

Going back to our case, she has had intolerance to both IFN-alpha as well as methylprednisolone in the past, therefore creating a therapeutic challenge; as well, her diarrhea worsened with colchicine and did not improve despite the use of anti-diarrheal medications.

After expert discussion with the Rheumatologists, which by the way included the Pediatric Rheumatologist, we decided to use one of two drugs that blocks the Interelukin 1 action - either an IL-1 trap called Rilonacept or a soluble IL-1 receptor blocker called Anakinra.

Of note, as a hospitalist, my experience with either drug was only limited to some patients with Rheumatoid Arthritis treated with Anakinra. I looked in the literature which dates back to 2007 when this drug was suggested as a therapeutic alternative to colchicine in patients with FMF; I found as well some reported cases of its use as a salvage therapy in patients refractory to conventional treatment, such as this case and this other one.

More information about the pathogenesis of chronic inflammatory diseases which for ages its pathophysiology has been an enigma to clinicians is appearing. This article explains the role of IL-1 in this chronic inflammatory diseases as well as the role of the inflammasome which is a cytosolic multi-protein complex, which regulates the caspase-1 dependent processing of inflammatory cytokines IL-1β and IL-18.

The patient received anakinra with an impressive improvement in her clinical symptoms within 24 hours. Her pain subsided as well as her fever. The caveat is that the administration of this drug requires daily injections, which the patient is willing to take in order to avoid the devastating attacks. Further discussion with the insurance company will be needed to assess whether coverage for weekly rilonacept injections can be obtained.

This case brought to me several lessons. First, this was an opportunity to review the new pathophysiologic mechanisms of recurrent febrile and inflammatory diseases as well as understand based on this, the new pharmacologic approaches to these diseases. The use of IL-1 pathway antagonists has a very broad application; for me as a hospitalist, knowing about anakinra, canakinumab or rilonacept, permits me to manage a different language and be able to sustain a different level of conversation with our Rheumatology subspecialists, as well as share my fascination with my residents and medical students.

I am very interested in following the long term outcome of this patients and hopefully the increased understanding of the mechanisms of disease may yield a really curative approach in the next 10-20 years.

An Academic Hospitalist

2010-09-27T14:06:00.001-04:00

Well. A lot of things have happened since my last post. I'm not precisely very happy with my scant productivity in this blog, and as frequent as I have ideas that I want to share, it is the same frequency I have other things to do.

I was busy in May, attending the ACP Leadership Day, advocating for Internal Medicine, attempting to minimize the Medicare cuts based on the obsolete Sustainable Growth Rate (SGR) formula; as well tried hard in advocating to ensure the perpetuation of a constant supply of Primary Care providers to ensure the future medical coverage of americans. It was exciting as well as intense and inspiring.

Then in June, I had a fantastic trip to the Far East, especifically, South Korea, where in addition to climbing the Halla-San in Jeju, we enjoyed the temples and cold water of the Sea of China in Busan, the jovial nature of the University in Gwanju, and the energetic life of Seoul. We appreciated the Korean food and hospitality, attempted to understand the Hangool symbols, and to learn some of their salutations and greetings ..."ani-aseei-yoh!, kansamnida!, etc...."as well as got inspired by their incredible and fast evolution within half a century. Understood a lot of their sentiments toward the japanese, whom essentially attempted to destroy their culture and heritage in a savage and brutal way. I'm impressed on the power of forgiveness and the intelligence of dialogue that both countries have nowadays; an example to follow in the rest of the world.

Then in July, the excitement of the new academic year brought winds of energy and passion; I attended in the Pediatric wards the first week of the month, and was happy with the new interns' performance.
Subsequently, got a sequential series of academic and curricular updates - got an accepted workshop at the 2011 Society of Hospital Medicine meeting, about Perioperative Management of the Pediatric Patient; got promoted to Full Staff; started my activity as a core faculty at the Internal Medicine residency; started a 4 weeks slam in the Internal Medicine teaching service (briefly interrupted by a family emergency that required switching my role from a physician to become a patient's relative).

Looking at the vertiginous last month, I realized how passionate I am about academic medicine, most importantly, Hospital Medicine. My accepted SHM workshop is in Pediatric Hospital Medicine and I'm giving tomorrow the Children's Hospital Grand Rounds on Pediatric Perioperative Medicine which will be a nice catalizer to find out which topics will be the best ones to present at the national meeting.

I was very fortunate, given my interest in academics, that there is an fantastic available course for thriving academic hospitalists, called the Academic Hospitalist Academy. It is sponsored by 2 of my favorite institutions, the Society of Hospital Medicine and the Society of General Internal Medicine. We flew last September 21 to Atlanta, GA. Then took a cab to the hotel in Peachtree, GA, 45 min away from downtown Atlanta, located in a picturesque town where people trasnport themselves in.....golf carts! (they have more than 9000 golf carts in this town).

This course was given over three days, covering the most important aspects that will enhance any academic physician's career. I appreciated the innovative approach to teaching medicine, such as the Clinical Coaching, where rather than filling the students and residents with a bunch of facts, we teach them how to do clinical reasoning and think in a structured way. We had a fantastic approach to the Bayesian method for problem solving, and the use of a Socratic non-threatiening questionning technique for bedside teaching, as well as classroom teaching. In this very tenure, time management is a very important element, and the way to better administrate the time was taught in a masterful way.

We rediscovered the magic of the white board and color markers, with the idea of making didactic points clear and outstanding. We gave all mini-lectures, 6 minutes each in break groups, providing afterwards a feedback based upon the content and outline, as well as delivery of the talk. We used specific feedback with the idea of strongly improving flaws such as "talking to the board", talking pace, shyness, etc. We discussed as well ways to give feedback to our students and residents, both on the fly and in a formal separate setting, with the notion that feedback is non-judgementa, targeting areas for improvement.

We discovered a new way of setting goals and expectations in a SMART way - Goals should be specific (but also systematic, synergistic and significant); measurable (and also meaningful and motivating); achievable; relevant (but also realistic, reasonable, rewarding, responsible, reliable, and remarkable); timely, tangible and thoughtful.

Fantastic lectures and workshops on career building and paths for Promotion with specific 1- and 5-Year Planning were held, and this apparently threatening activity showed how important it is to efficiently organize the academic activities; some activities can occur simultaneously; some will occur at different stages; but the most important thing is not to lose track of at what level of progress is each activity standing. The long term goal is the continuous career development and academic advancement. For instance, one of my goals is to be promoted to Associate Professor within the next 3 to 5 years.

The peer networking was fantastic, and I loved to meet so many young people from all the US, especially from the most important academic medical centers, all motivated with a single interest - become better academicians to improve medical education and patient care.

Other important skills were the Applied Principles of Quality Improvement (QI) and Change Management, as well as Patient safety and error analysis - hospitalists have a niche in QI. Most of the subspecialists will be busy enough to even attempt to stare at this. The hospitalists have become stewards of QI and patient safety, mainly through the use of IT, improved communication skills and efficient transitions of care. The systematic and critical analysis of errors, along with the proposal of corrective strategies to overcome these errors, are paramount in the establishement of QI initiatives to promote patient safety. We felt good about the importance hospitalists can achieve for their healthcare system.

Other fun activites included the teaching on how to develop a great Clinical Vignette - we had one on one teaching on pre-written Clinical Vignettes, and in a very rapid way were able to find significant flaws in the initial vignettes and correct them immediately. It was nice to see the before and after.

The creation and mainteinance of a teaching portfolio was one of the most important skills practiced, which will help find success in the academic career advancement. It was very clarifying to see the organization of the CV's according to each academic institution, which although seemed like a very though task, once accomplished, is a great stress reliever, as it is the tool required to apply for academic positions, awards, grants, etc.

Finally, the discussion of what the relationship among a mentor and a mentee should be was clarifying. I have changed my CV to my institution's characteristics and am now in search for an experienced but motivating and empowering mentor.

I found a lot of substance in this course - actually, I found that there is a lot of substance in our academic practice; a lot of raw energy and talent that appears as a brute diamond that needs to be polished. The energy needs to carefully be focused and shifted toward constructive and highly achieving goals and profiles. I think the elements we obtained from this fantastic resource will be rewarding in the near future.

Ventures of a Young Physician in Narrative Medicine

2010-05-04T21:47:00.001-04:00

I have multiple things to write about, especially from my experience in my second ABIM Foundation meeting, where we discussed the feelings elicited on all of us from the reading of an article written by a physician who died from ALS and had a terrible experience as a patient before her death. Her article was published after her death at Annals of Internal Medicine, and it is a true fountain of inspiration to recall and rescue our most intimate values as physicians and human beings. We are not health-care technicians. We are doctors and should act up as advocates of our patient's wellbeing in all spheres - bio-psycho-social. We should always ensure a warm and compassionate environment.
In the article, the doctor recalls how much she suffered when she had an EMG (electromyography) done; this is a study where needles are inserted in the muscles with electrical stimulation in order to record the nerve action potential. It is quite painful and a torture in itself. The author writes how the attending physician, who was a presumed recognized neurophysiologist, was cold and detached. He was teaching the residents while performing the EMG, and in a fascinated mood described "the typical and pathognomonic electrophysiological characteristics of ALS". ALS or Amyotrophic Lateral Sclerosis is one of the most devastating diseases the human being can face. It is one of the most frustrating diseases for any physician, given the lack of cure even in 2010. It is famously known as "Lou Gehrig's disease" as the famous ballplayer died from it. It affects both your upper and lower motor neurons, and cause a steadily progressive and devastating neurologic damage.
I was wondering how the academic environment and fascination for teaching should not detach from acknowledging the patient's suffering itself. I wonder how the physician could have been more toughttful and perhaps hold on making any "academic" comments in front of a colleague who simply suffered the invisible "saber stabs" in her soul by hearing the veredict of an unavoidable destiny.
I enjoy involving the patients in the academic discussions. Teaching them and improving their health literacy is satisfying. This week, for example, I treated a patient with severe pulmonary hypertension coming for a pre-operative evaluation; his chest roentgenogram (fancy word for chest X-ray), revealed an unsuspected pneumothorax. In the setting of pulmonary hypertension this is quite worrisome as if untreated can be fatal. The patient was upset of requiring a confirmatory chest CT-scan, as the image was not categorical at all; as well as if confirmed, may need to be admitted. By that time, I have already discussed the case with his primary pulmonologist. He couldn't understand what was the meaning of the pneumothorax. I draw in a blank piece of paper the chest anatomy, the virtual pleural cavity and the lungs, and explained how the lung compression by the pneumothorax would yield in an dramatic increase in the pulmonary hypertension in addition to the worsening of hypoxemia by the collapsed lung with a VQ mismatch. His anger faded (slightly); he accepted to be transferred to the Emergency Room and get the CT scan.
My point is that we need to understand the patient's frustration; sometimes their frustration is due to their lack of understanding and our lack of explanation. Once they are able to acquaint the rationale of our medical decision making, they can accept it in a smoother and less painful way.
We as physicians and teachers need to strive in rescuing humanism in Medicine and teach our students the value of the individual as a human being an as a member of society; the medical students should learn from early stages in their career to interact with suffering. We should not train health care technicians who will be skillful exam takers, get into fancy surgical residency programs aiming to make a lot of money from a given specialty. They should aim to be compassionate doctors who want to help their patients to achieve wellness, and a sense of well-being from all the standpoints - bio-psycho-social. They should aim to be pillars of the society and more than being recognized as doctors, be recognized as humanistic and compassionate human-beings because at the very end we aim to provide care, comfort, healing and mitigate suffering as much as we can.

Narrative Medicine, the Charter and the battle to preserve professionalism

2010-03-13T19:08:00.000-05:00

Last week I became engaged in one of the most educational programs I've ever been before - it is a project sponsored by the ABIM (American Board of Internal Medicine) Foundation to promote the use of Narrative in Medicine (reflective writing) as a vehicle to increase self-awareness, with the intention of improving empathy among physicians. Multiple institutions are participating in this project and have different goals.

We started by reviewing a classic document that I read many years ago, the Physician Charter, published in Annals of Internal Medicine as well as The Lancet. This document was created by internists worldwide with the intention of rescue professionalism in medicine which is being threatened by the new "values" in industrialized world which has prompted to changes in healthcare delivery. This document supports physicians' committment to patient welfare and social justice, which by itself is just a confirmation of the principles by which we as a profession have always abided to for ages.

I liked the document, and I think that most of my colleagues by reading it just confirm what they are already practicing, however, I do agree that in the current world - especially non-academic medical centers and practices - physicians need to reconsider whether the circumstances of practice are interfering with these principles of care.

It is interesting as I participated last week in the session of the Healthcare and Public Policy committee of my local ACP chapter and I heard interesting stories from colleagues working in non-academic practices, where the medical insurance companies essentially block them from practicing medicine, and decide in an arbitrary manner whether "the customer" (that is how insurance companies see patients) needs a study or not - for example they deny a stress test to a patient "because he can walk, so doesn't need a stress test", or a CT scan "because they should do a pelvic US first"....of course, my colleagues cry their inmense frustration as can't practice Medicine anymore without hurdles put in place by unscrupulous non-physicians. So, their internal battle arises from their frustration as they try to practice Medicine with the highest regards and respect for patient's welfare, but totally external influences - the "industry"-really threatens professionalism.

My dilemma surges from the fact that I am privileged to work in an institution that promotes an academic and humanistic environment that promotes the patient's welfare as its principle - our motto is "Patient's First" - for instance, we get the opportunity to participate in this ABIM Foundation activity - however, I feel terrified for my colleagues in non-academic environments, where they need to fight for every space they deserve in order to preserve their principles as physicians.

So, moving along the way, the Charter starts by defining Professionalism, which is "placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health." They then discuss how the role of the physician as a "healer" is being threatened by the current changes in healthcare, advancement in technology, etc.

Then they state the three Fundamental Principles of the Charter - which should not be put under pressure from the industry needs- are:

1. Principle of primacy of patient welfare: Altruism and the best interest of the patient is the driving force in medical practice.

2. Principle of patient autonomy: The patients should receive honest and clear information about their health, and should be empowered to make their very own informed decisions about their treatment. Of course, these decisions should be honored only if they are supportive of ethical practice and permits appropriate care. Essentially, respect the patient's medical decision making if they are able to acquaint and express an understanding the risks and benefits they are getting involved into.

3. Principle of social justice: All individuals belonging to society, regardless of their religious or political beliefs, gender, ethnic backroung, socioeconomic status, etc. have the same rights to healthcare.
Then they discuss the Professional Responsibilities, to which all physicians are commited to:

1. Professional competence. Physicians should be knowledgeable up-to-date. This basically supports the use of mainteinance of certification process, CME, etc. This is why physicians who don't keep their CME can be expelled from the State Medical Boards.

2. Honesty with patients. The truth is fundamental. We need to let patients know all risks and benefits of the medical care. But if we commit a mistake, we should be open about it. Is all about transparence.

3. Patient confidentiality. This is why HIPPA exists. However, if welfare of others is compromised, then this can be overruled.

4. Maintaining appropriate relations with patients. Relationship with patients are exclusively professional.
5. Improving quality of care. Will sound redundant - this is what supports all measures of quality improvement; these protocols in the medical system are designed to minimize human error with increase in patient safety, and promoting an optimal utilization of resources. All this leads to improved outcomes.

6. Improving access to care. This basically entails that we should identify and minimize all barriers to adequate health care. These barriers can be based on patient educational level, laws, economic status, geographic location, as well as social discrimination.

7. Fair distribution of finite resources. Cost-effective care should be sought at all times as this will render in enough resources for everybody.
8. Adequate scientific knowledge. Essentially - we are commited to lifelong learning and up-to-date knowledge.

9. Maintaining trust by managing conflicts of interest. Physicians should disclose their relationships with industry and pharmaceutical companies.
10. Professional responsibilities. We need to ensure that our colleagues practice within the medical and ethical standards of care as well as that they are updated in their medical knowledge. This supports the sanctioning by State Medical Boards to unethical physicians.

In summary, this Charter is a document that reinstates and brings back the principles that rules an ethical medical practice with the intention of respecting the patient's welfare to the most.

On that day, we reviewed the principles in the charter, as well as some terminologies that we need to be aware such as the difference between patient vs. customer, physician vs. provider, the hospital as a healthcare site vs. corporation, etc, etc, etc. We reviewed as well some bibliographic basis for narrative writing such as this small article by Dr. Charon, as well as other articles that discuss the conflict that physicians suffer when adapting to the new changes in healthcare after introduction of technology, cost-saving industry behaviors, etc.

Then afterwards we sit down in several groups to write down a specific time when our empathy was challenged. We all spent a good 30 minutes of writing and then heard out stories. The beauty of reflective writing, is that the patient's identity can be very well concealed and some components could be fictional. In reflective writing it is encouraged to do so freely without caring for grammatical details or vocabulary changes, as it will permit more freedom to express the physician's feelings. The fictional components won't take away the substance and power from the document; the beauty of it is that we open up to our colleagues some of the hardest and most challenging times we've had as human beings and as physicians, and we all learn from these stories. We all become better, we get to understand our colleagues in a better way. I truly admire my colleagues by the way the see life and medicine and really feel honored of being able to share my experience with them.

In my travel along the discovery of Narrative Medicine I found several excellent reources:
- Literature, Arts and Medicine Blog.
- Medical Humanities Blog.
- Medical Humanities.
- Narrative Medicine Program at Columbia University.
- Master of Science in Narrative Medicine.

I have always been interested in writing besides scientific writing; essentially writing essays and my own thoughts and feelings. Did it all the time in medical school, but never thought it was so useful and so powerful. Now I have rediscovered this great resource and will encourage my young colleagues, medical students and residents to pursue it. We may add a session on reflective writing in future meetings (such as our local chapter meeting) to provide more resources to promote empathy and professionalism.

I think that this is one of the best ways of pursuing the principle of primum non nocere...

Improving primary care conditions or increasing the number of physicians, what should be first? the egg or the chicken? - I think both!

2009-12-24T22:50:00.000-05:00

I have been following with particular interest the ongoing discussion about whether increasing the number of residency slots should be sought as a solution for the ongoing shortage in primary care physicians and general surgeons. Several excellent sources such as the direct newspapers as well as many blogs that I list at the end of this post, have been useful for giving myself a good idea of the different perspectives out there.

Many physicians and analysts have completely opposite points of view; some advocate the increase in the number of residency slots to cover the increased demand of physicians; other disagree considering that this will not resolve the problem but just increase the number of subspecialists.

What does this mean? Why is this discussion relevant?

The way Medicine has evolved in the US, has unfortunately given a dramatic importance to therapeutics and not to prevention. It is fancy to show the dramatic improvement in coronary robotic surgery, the fascinating techniques for laparoscopic bariatric surgery (although this one is moving toward the site of prevention of obesity complications), it is fancy to develop newer and more expensive drugs to treat hypertension, hyperlipidemia, as well as the complications of atherosclerosis. A fascinating story is the development of all the drugs to treat smoking; how much money does a self-destructive habit caused to be spent in an attempt to treat it.

Therapeutic medicine is a necessity, however, I believe that Preventive Medicine with a specific focus on wellness is more important. How many trillions of dollars can be saved if people don’t develop diabetes or hypertension, and myocardial ischemia and strokes could be prevented. How many trillions of dollars could be saved if people would not smoke. If people eat well, exercise, avoid drinking and smoking, and just focus on enjoying our planet with respect for humankind and the environment perhaps a lot of money would be saved, but we are not in the position of having wishful thinkings.

There is concern about spending money in medications the patients need. Unfortunately, once you have developed a chronic disease you won’t really cure it, but you can prevent the complications by means of good control and lifestyle changes. For example, if a hypertensive patient complies with the DASH diet and walks 30 minutes per day, aims to be in the ideal body weight, may need fewer medications as weight loss in addition to increased aerobic capacity and decrease in insulin resistance will be in fact therapeutic as well as prevent further complications; for instance, preventing a single stroke that can be devastating, can save millions in a single person lifetime.

But going back to the beginning of the discussion – we need more emphasis in Primary Care; we need good Family Practitioners, Pediatricians and Internists that will have the aim of educating people to prevent the development of complications of chronic diseases, or even, preventing the development of chronic diseases.
As a hospitalist; in addition to our fascination with acute medicine, we all (at least I do) emphasize in-house in teaching our patients regarding lifestyle changes and encourage the follow up with a good Primary Care Physician.

If you realize that you have spent 8 years to become an MD and 3 or four of training, your least desire is to practice a Medicine that will burn you out and crush any remaining passion for healing and helping others. If you are underpaid, focused on filling a lot of paperwork every day, having a suboptimal timeframe to see patients (10-15 minutes) like a robot, without a real possibility of even having a brief conversation that can enhance the human interaction, and as well you live in uncertainty (due to insurance issues, lack of immediate diagnostic resources, etc.), this is a real uninspiring scenario.

What if the bureaucracy that is so heavily involved in Primary Care would be diluted; what if there would be a more streamlined process to help patients and avoid the doctors filling so much useless paperwork; what if there would be more time to enjoy the interaction with the patients and the opportunity to be more careful and thorough in the patient’s assessment; what if the economic compensation would be substantially improved to enhance the fundamental activity of keeping Americans healthy. What if there would be a real focus on physicians wellness; what if there would be real chances for Primary physicians to update themselves with protected time to study (as this do not exist in a lot of practices); I guess, that would definitely be a very attractive job. But not only we need to change the way it is being done, but we need more physicians – if we’ll see less patients per day as we’ll have more time to see them, then we’ll have need for more docs – we need to increase the source of physicians, and this is done by means of training more internists, pediatricians and family doctors.

Yes, the national healthcare bill is going to go up by increasing residencies, but people don’t realize that residents are in fact extremely underpaid doctors (yes, they are MD's or DO's) and even when working 60 hours, will really work hard. (I was trained in the 120+ hours/week era and regardless, I appreciate that they work very hard nowadays); these residents treat patients; these residents are a cheap source of healthcare providers and will be the future physicians. Paving the road with better work conditions that will be witnessed as an attractive choice for practice, will broaden their perspectives and increase the chances that they remain in Primary Care.

I believe that passion should be the engine behind a decision and not just the money factor. But we need to nurture that passion and changing the conditions for better is part of the process. While improving the current work conditions of Primary Care Providers, their availability should be enhanced so that patients don’t need to wait so long to have the chance of seeing their doctor - we need more docs.

Which will be the best way to improve Primary Care retention? – this is a good question – I advocate decreasing paperwork and improving salaries. Cash only practices, retainer models, are both valid choices that are well explained in Dr. Val and Dr. Centor's blogs. The main thing is to look in the first place for the well being of our patients, as our goal is a stronger America; a better world for our children. Because even in politics, the goal of physicians is always primum non nocere.

References:
http://www.medrants.com/archives/5087
http://www.kevinmd.com/blog/2009/12/adding-residency-slots-improve-primary-care-numbers.html
http://www.nytimes.com/2009/12/23/opinion/23brownlee.html?_r=2
http://www.medrants.com/archives/5104
http://getbetterhealth.com/why-concierge-medicine-is-not-the-solution-to-primary-care-woes/2009.12.12
http://online.wsj.com/article/SB125928189292865761.html
http://blogs.wsj.com/health/2009/11/27/would-adding-residency-slots-solve-the-primary-care-shortage/

The triage owl....the musings and thoughts of a night coverage triage hospitalist

2009-12-13T03:02:00.004-05:00

It is sunday, 2 AM. I'm in my office, with a cellphone directed to the admitting line, where my role is to receive the calls from any external medical center wishing to transfer a patient to our institution for evaluation and treatment. I have 2 pagers as well, and of course, my direct office extension.

This activity is called the Nocturnal Internal Medicine Triage Officer, which basically is a medical-administrative job as said above. You accept and coordinate transfers from any external medical center, and triage them to the appropriate medical subspecialty. After you accept a patient, and you consider the patient should be admitted, let's say, to Hematology, then you get connected with the Hematologist on call and give report so that the patient can be admitted under their service.

As well, you take all the calls from the Emergency Department (ED) transferring patients to Internal Medicine, where you do the same thing; help the ED staff to triage the patients to the appropriate service; help the ED residents to determine the required acuity of care (regular floor, telemetry, ICU) and as well the appropriate specialty.

You want to ensure that the patient gets the best standard of care; and even if our Internal Medicine staff are tremendously bright, knowledgeable and insightful, if a patient benefits from being on a primary subspecialty service, then that is the best; for example - a lung transplant patient or a patient with a congenital heart disease with Eisenmenger's, etc. What is most important is always to look at the situation this way: "if this patient would be me or my mother, who would I prefer her to be taken care from"....a bright internist with limited subspecialty knowledge, or a bright subspecialist that wrote the "State-of-the-art" on that very particular disease last week (which is the kind of colleagues I'm fortunate enough to interact with)", and if needed can always get an Internal Medicine consult on board.

Appropriate triaging impacts patients in many ways: they can get different standards of care depending the service where they go to; the length of stay is minimized in subspecialty services that have an increased comfort level discharging patients that based on their experience are stable enough to be followed as outpatient; the patient can get procedures done earlier; the subspecialist's experience can as well mandate an earlier work-up. Remember, your eyes can see what your brain knows. That means a lot in Medicine. We as internists know a lot of everything; but a subspecialist knows a lot of a particular thing that generally goes well on top and beyond our knowledge and that is fine; they did an additional 2-3 years of fellowship plus an extra 1-2 years of further fellowship (so in general 3-5 years more than our training). I feel very proud of being an Internist and a Pediatrician. I harbor with pride my FAAP FACP titles (which may seem pompous, selfish and arrogant, but it is not; it is important as the letters are designed to identify my area of expertise); however, I recognize that there are limitations to our knowledge, and I start a work-up, have a perspective of things, but at some point, it is the subspecialist expertise which will help the patient the most.

Of course, most patients will end up in the Internal Medicine service. The difference will be depending on their medical complexity whether will be triaged to a "teaching" service or a "non-teaching" service. This is an academic medical center, so residents will take care of patients supervised by a staff; in the non-teaching service, a hospitalist will take care alone of all the patients.

In addition, you are the staff at night to help the Internal Medicine consult resident on call with questions and see patients that need urgent evaluations, particularly pre-operative assessments. For the pre-operative evaluation we do "assessments" and "determine the medical optimization" of the patients; we "optimize" them as much as we can from the medical standpoint. We do not "clear" patients; this is a common misconception; in our large outpatient preoperative clinic (IMPACT - Internal Medicine Preoperative Assessment, Consult and Treatment) we write at the end of the note..."the patient is optimally prepared for surgery" or " not optimally prepared...".

You track all the admissions and transfers. We have organized and know all the details of each single admission - where it comes from, which service is taking care of the patient, who wrote the history and physical, what floor and bed the patient is at, which service will take care of the patient in the morning, who is the responsible staff.

Essentially, from the medical operations standpoint this is one of the finest and most sophisticated way that patient safety in transitions-of-care has evolved into.

There is variation from night to night. I have been kept awake from 5pm until 8am non-stop. Tonight, it is a quieter night. So quiet, that I decided to write a new post.

I realize that yesterday it was the most sacred day in Mexico, the Day of the Virgin of Guadalupe, or the "dark skinned lady from the Tepeyac" as people refer to her. It was as well the second night of Hannukah; the first one fell on Shabbat - so it is a special celebration. Last night (saturday night), the menorah was lighted after singing Eliyahu anavi. It is a religious weekend. I feel blessed and enlightened as I'm able to work in good health and spirit, and able to help people, both our patients (even if I'm just coordinating their transition of care, are MY patients) and my colleagues. As always....primum non nocere

Influenza in infants - oseltamivir and a daycare

2009-12-10T18:49:00.002-05:00

Well, it seems as throughout the progression of the flu season, the number of cases have been decreasing, however, the flu has taken its toll in terms of mortality, so we should be very careful and not dismiss the safety measures wisely implemented. Follow the CDC H1N1 Flu updates here.

I wish I would be able to convince many parents who adamantly refuses the influenza H1N1 vaccine given the extreme misinformation provided by the media "based" on "non-evidence-based" resources. It is frustrating as a physician it is my main interest to enhance and ensure the well being of the human-kind. But for the most part, the majority of parents have been very well compliant with the recommendations. It should be recognized the fact that immunizations are perhaps, the best discovery of the last century, and hopefully the truth will overcome the fear toward immunizations.

Today, I had a 6 months old little boy admitted with URI symptoms, with very prominent clear rinorrhea, nasal congestion, cough and concerns for bronchiolitis. As soon as he had his nose cleared with bulb syringe suctioning, his symptoms improved dramatically and did not require oxygen. As part of the admission we obtained a Respiratory Viral Panel (an example of what it detects is here). The baby had positive Influenza A, and by definition, on this season, you consider it as H1N1. His family got the influenza vaccine; his parents are extremely pleasant, but the fact is that the baby started going to daycare last week.

Fortunately for him his chest roentgenogram is normal and is not requiring oxygen, however, the question brought to the table was: it is safe to start him on antivirals?

The data on safety and dosing of oseltamivir in infants is very limited, and if used, a careful monitoring for adverse events should be pursued. FDA recommends against routine prophylactic use in infants younger that 3 months of age. Recently (October 30, 2009), the FDA released a statement about Emergency use of Tamiflu in Infants less than 1 year of age.

The recommended treatment dose for infants younger than 12 months of age is 3 mg/kg/dose twice a day. However, as it will likely happen, if weight is unknown, a dose based on age can be used: birth to 2 mo, 12 mg (1 mL) BID; 3-5 mo, 20 mg (1.6 mL) BID; 6-11 mo, 25 mg (2 mL) BID.

The recommended prophylactic dose for infants 3 mo to 1 year old is 3 mg/kg/dose once daily. For infants younger than 3 months it is not recommended.

Of note, the FDA makes it very clear that the weight-based dosing recommendations are not intended for premature infants, as given their immature renal function, they can have slower clearance and offer the potential for toxicity.

So, we started him on oseltamivir, and we had as well an immediate concern for the parents. So we gave them a prescription for prophylactic oseltamivir use. Hopefully they won't develop the symptoms. They are immunized and hopefully in the case that the flu shows up, it will be as mild as it can be.

What about the other kids in the daycare? should they receive prophylaxis? what is my role as a hospitalist? - we essentially let the parents inform the daycare about the case and the other children's parents can discuss with their pediatricians; most likely they'll get prophylaxis.

Back to the Z - the Zebras: Macrophage Activation Syndrome and Hemophagocytic Syndrome

2009-12-09T23:58:00.003-05:00

I'm finishing another week in the Pediatrics wards. It has been a truly exciting journey, and we are finishing it with cases seen more commonly in the subspecialty grounds and that my training as an internist helps me to approach it from several perspectives before having the subspecialists involved.

A fascinating case of a child admitted with intermittent fever, mild anemia and lymphopenia and generalized lymphadenopathy and hepatosplenomegaly. The most common cause of a mononucleosis like picture will be a viral disease; but this child had negative Epstein Barr, Citomegalovirus, Herpes simplex and Hepatitis serologies; his PPD is pending and has no exposure to cats suggesting an infection with Bartonella henselae which can cause bacillary angiomatosis, or an infection with Toxoplasma sp. Most likely he will benefit from an histopathologic diagnosis. However, the fascinating issue is the differential that can outsource from a patient with hepatosplenomegaly, fever, cytopenias, which includes infectious causes as above, malignancy such as lymphomas and as well systemic inflammatory diseases like Hemophagocytic lymphohistiocytosis also known as hemophagocytic syndrome as well as a subset of this disease known as Macrophage Activation Syndrome.

I brought to my resident's attention my interest in ruling out this as part of the work-up prior to obtaining a lymph node biopsy. It was interesting to find out their surprise with the unknown names and their immediate curiosity about its place in the diagnostic puzzle. I told them..."your eyes can see what your brain knows". It is my responsibility to expand my own knowledge, but to make sure I share this knowledge with other colleagues and especially the residents and medical students.

So, what are macrophage activation syndrome and hemophagocytic syndrome? these are significant inflammatory conditions, usually occurring in patients with Juvenile Rheumatoid Arthritis or Juvenile Systemic Lupus Erythematosus. Its etiology is unknown, but it has been proposed that it is due to an abnormal regulation of the macrophage-lymphocyte interaction with secondary increase of cytokines (TNF-alpha, IL-1, IL-6, IFN-gamma, soluble IL-2 receptors and soluble TNF receptor; all of these cytokines are derived from T-cells and macrophages. Both can be life threatening if unrecognized. Usually, it is clinically characterized by persistent fever, generalized lymphadenopathy, hepatosplenomegaly, a Disseminated intravascular coagulation profile with thrombocytopenia, low fibrinogen levels, and prolongation of coagulation times; secondary to coagulopathy, can manifest with hemorrhages in any part of the body. It can be associated with pancytopenia (usually bicitopenia), elevated ferritin, transaminitis, and hematophagocytic histiocytes in the bone marrow. Its mortality can reach almost 50% of the cases. An interesting confusing picture is the elevated ferritin, which can by itself be a manifestation of Still's disease and as an acute phase reactant. The treatment is aimed to control the intense inflammatory response, using systemic immunosupressants such as steroids in elevated doses, cyclosporine A, IVIG, TNF-alpha inhibitors, anakinra, etc. However, this is a competence of the Hematologist and the Rheumatologist not of the hospitalist.

In addition to the excellent reference that is UpToDate, I always aim to look into PubMed for newer and updated references (such as the ones I post almost on a daily basis in my Twitter account "medpedshosp"). This time I was lucky enough in finding a very good reference from Dr. Tristano at Med Sci Monit, 2008; 14(3): 27-36. As well a very updated reference from Dr. Karras in Nature Reviews Nephrology. Jun 2009; 5: 329-36.

My residents received today an email including these references, as well as other based on our morning discussion (utility of anti-cyclic citrullinated peptide antibodies in the diagnosis of Rheumatoid arthritis - I emailed them 3 articles - a review from the Ann NY Acad Sci, and another from The Journal of Rheumatology.).

Tomorrow will be an interesting academic round after they have reviewed this articles.