The ACGME report on the new standards for resident work hours raises many interesting questions. We must examine ourselves as a profession. Attendings should consider themselves role models, and reflect on that role. How should a physician balance work and life outside work? How do we keep our moral contract with patients, while maintain our humanity and our personal lives?

I believe that many programs and attendings have lost their way. They mean well, but they haven't considered carefully how changes in health care should change our residencies. My cohort remembers working every third night. When residents work every fourth they assume it is easier. We often forget the many changes which have occurred on the inpatient wards - all make residency more challenging.

The average length of stay during my residency was longer than a week. We admitted less patients per night, and the patients were not as sick. Occasionally we would "get slammed" and get 6 or more admissions, but at least in my program that was unusual. We had time to develop a management plan, and to view the outcome of that plan.

Attending physicians made teaching rounds during the week, but the resident was king (or queen). The attending taught, but didn't direct care. Soon after I first became an attending, we had to start writing very brief notes. As the documentation requirements have increased, so has the attending input on rounds. The challenge we face today is that of balance - how do balance our clinical documentation responsibility with our teaching function. Attendings differ in their approach, not all taking the resident's circumstances into their equation.

Much of the distress in housestaff training comes from how their attendings treat them. As an attending I have to balance the resident's situation and patient care. Teaching becomes secondary to the situation. Or at least it should. We should rethink how we do rounds, when we teach, and how we transmit our expectations. Neverending rounds aren't consistent with housestaff mental health. At the risk of becoming pedantic let me make some modest suggestions:

• Daily rounds need an announced ending time. The housestaff have much to do, as an attending I should give them the certainty of when they can do their work. If I drone on and on, I selfishly impinge on their time.
• Post-call rounds should take into consideration how difficult the night call treated the housestaff. If you come in and they look haggard and tired, then adjust. I call such rounds - "survival rounds". On those days we have minimal teaching, and no longer have complete presentations on each patient. I may have to spend a little extra time after rounds, but the housestaff need time to stabilize the service.
• We should be role models of healthy lives. Let the housestaff know that you have hobbies. Discuss your life with them. Get to know them - what they enjoy - what they do on their days off. I've seen too many physicians burn out; I hope that I can prevent a few from that self-destructive life style.
Be their advocates, not their enemies.

I stumbled onto these. They might help you. Covert Bailey’s Fit or Fat: TOP 25 FITNESS TIPS. I particularly like -

• Exercise. If exercise were a pill, it would be the most widely prescribed medicine in the world.
• If spot reducing worked, people who chew gum would have skinny faces.
• More muscle equals less workout time.
• Throw away your scales. Measuring your body fat is a better indicator of health than your weight.

Very interesting analysis from the New York Times - Despite Impasse on Medicare, Elderly Will Get Something. Much of the debate comes from defining the government's role in supervising the benefit.

The House Republican bill says the government may not set drug prices or "interfere in any way with negotiations" between insurers and drug manufacturers or suppliers. That ban could fade with time, just like a section of the original 1965 Medicare law, which said the federal government must not "exercise any supervision or control over the practice of medicine or the manner in which medical services are provided."

Democrats and some Republicans say it is absurd for the government to establish a program of benefits without taking steps to limit drug costs. Without such limits, they say, the program will be unsustainable.

Senate Democrats will push two plans House Republican leaders avoided. One would alter patent laws, making it easier for low-cost generic drugs to compete with brand-name medicines. The other would allow pharmacists and wholesalers to import drugs from Canada and Europe, where prices are held down by government regulation. Both ideas are anathema to brand-name drug makers.

So much medical press derives from leaders and celebrities. If the President gets a colonscopy, we get colonscopy articles. Bush Procedure Is Routine for Age and History

Once again the President is setting a good health example. He apparently has had a benign polyp in the past, thus he needs a repeat colonoscopy. When will insurers universally pay for screening colonoscopy. I know that some states require colonoscopy as a covered item. Medicare covers screening colonoscopy. We need to provide for 50 year old patients. I assume we are on the verge of a break through here. Here's the Bush story - Bush to have colonoscopy under anesthesia

This article reports an important, although unusual, risk of tamoxifen use. Breast Cancer Drug Is a Uterus Cancer Risk - describes an increase in uterine sarcoma in women who take tamoxifen.

Started ward attending yesterday. I attend at a VA hospital with a senior resident and 2 interns. The interns just started - a little green but very enthusiastic. We get brand new 3rd year students next week. As I've stated earlier, I'll be working on meeting the proposed ACGME guidelines on resident work hours this month. We will try to get the housestaff out by 2 p.m. on their post-call day. One method we are going to try is no intern post-call day notes. We hope this will save a couple of hours at least. I write a good note on the post-call day. The interns will write short notes if there are major status changes. I'll report back periodically on our progress - the plusses and minuses.

If you are interested in our educational agenda, I've started another blog - Ward Attending. I plan to post most days on relevant clinical topics.

Interesting news piece in today's Lancet. You can read this for free, but you do have to register. I can't link to the article, as the Lancet uses an web page method that doesn't give precise links.

A team of Japanese and Danish researchers have found that a hormone secreted in the small intestine plays an important role in determining whether dietary fat is stored in adipose tissue or consumed as fuel. The finding, the researchers suggest, may point the way to a drug therapy for the treatment of obesity.

Secretion of the hormone, gastric inhibitory polypeptide (GIP), is triggered by the absorption of fat or glucose by the intestine. The research team showed that GIP-receptor knockout mice fed a high-fat diet were less likely to gain weight than wildtype mice on the same diet. Furthermore, the knockout mice were less likely to develop insulin resistance.

But on a recent Tuesday morning, approximately two hundred polite and well-dressed health professionals, senior citizens and community activists gathered at the Zeum Theater in downtown San Francisco for a "town hall meeting" to rail mercilessly against the high price of prescription drugs and the tactics that pharmaceutical companies use to market their products.

"Health care is in crisis, and we think the pharmaceutical industry contributes to that crisis," said meeting host Tim Fuller, executive director of the senior-advocacy group the Gray Panthers, during opening remarks. "Drug prices are rising, as you know; in general terms, last year 17 percent, this year almost 19 percent

If you want the strongest opinions on this issue - No Free Lunch: Homepage Posted by at 04:26 AM | Comments (0) | TrackBack (0)

The jockeying has started. The first votes are counted. The Republicans passed their first Medicare drug benefit plan.

Under the plan, the government would pay 80 percent of the first $1,000 of drug costs after seniors met a $250 deductible. Seniors would pick up the remaining 20 percent. From $1,001 to $2,000 seniors would split the cost of drugs with the government 50-50. From $2,000 to $4,500 seniors would pay 100 percent of the drug costs, and above that catastrophic protection would be triggered and the government would cover all of the costs.
Seniors would pay monthly premiums of about $35.

Today's entry will focus on troponin. I'm leaving the world of insurance, politics, and pharmaceuticals to discuss a purely medical subject. Today's NEJM has an article - Troponin T Levels in Patients with Acute Coronary Syndromes, with or without Renal Dysfunction and accompanying editorial Decision Making with Cardiac Troponin Tests. Troponin T Levels in Patients with Acute Coronary Syndromes, with or without Renal Dysfunction ( available only to subscribers). This article advances our knowledge of this important diagnostic test. I will summarize my understanding of Troponin T measurements.

Cardiac troponin measurements test for the release of intracellular macromolecules (cardiac biologic markers), which enter the blood are loss of cardiac myocyte integrity. This measurement came into clinical use in the late 90s, and has rapidly become a standard for diagnosing myocardial damage. Troponin measurements have led to a redefination of myocardial infarction. Patients with no ST changes or CK-MD elevations who have symptoms consistent with unstable angina, yet have a troponin elevation are now diagnosed with NSTEMI (non-ST elevation myocardial infarction). The diagnosis changed because troponin has greater sensitivity as a measure of myocardial damage. While the "cut-offs" are controversial, almost all experts agree that a level > 1 signifies increased risk. Thus we treat such patients more aggressively than those with normal troponin. The gray zone between 0.3 and 1.0 calls for further consideration and testing.

Since troponin clears the body renally, renal insufficiency can mildly elevate troponin levels. This new article shows that cardiac troponin aids decision making even in those with decreased creatinine clearance.

Let me summarize how I use troponin in 2002. We will assume a good history, normal EKG, normal CK-MB.

You know this already. Patients come to the office having researched their symptoms or their disease on the internet. Unfortunately the web doesn't distinguish between solid advice and junk. What's the physician to do? Try an Ix - Rx for the Future: Get an Ix: 'Info Therapy' Seeks Role in Health Care

My mantra continues. I'm a fitness nut. So this blog will always highlight potential benefits of fitness. Couch potatoes court cancer

This article seems astonishing. We aren't talking about new drugs here. Study says prices of 50 most prescribed drugs for seniors tripled inflation rate last year . Of course the industry disputes the finding. I don't really want to get angry with them, but they do such stupid things.

The report used data from Pennsylvania's state-run prescription drug program for the elderly, those 65 and older, to develop the list of the 50 top-selling drugs. Price histories were then obtained from a database published by Medi-Span/Facts and Comparisons.

The rate of inflation used in the report, 2.7 percent, is for January 2001 to January 2002 and excludes highly volatile energy and food prices.

"There is no reasonable basis for these alarming price increases, which continue to make prescription drugs unaffordable for too many seniors," Pollack said.

The study found that 10 of the 50 most-prescribed drugs for seniors are generics. The average annual price for those drugs was $375. Nine of those drugs did not increase in price at all.

The other 40 most prescribed drugs are brand-name medications with an average annual price of $1,106. Only three of the brand-name drugs did not increase in price last year.

Statins help before, after angioplasty

While I understand the desire for a "one payor" health system in the US, I also work for the government part time at the VA, and take care of Medicare patients. I fear bureacracy more than I fear the problems of our current system. Apparently GPs in Great Britain feel the bureaucracy crunch - Red tape clampdown 'could free GPs'

As many as 3.2 million appointments with family doctors could be saved if ministers were to strip away unnecessary work, say experts.

Fascinating article from the Boston Globe - Report raps drug firms' 'post-approval' studies. These studies were initially meant to monitor safety after FDA approval. Many companies have figured out that they can help with marketting.

Drug manufacturers spent $1.5 billion in 2000 to test medicines already approved by the Food and Drug Administration primarily so they could make new marketing claims to sell their products, industry specialists said this week. Critics say the trend inflates health care costs while undercutting the integrity of research.

These studies can yield important new information on safety and uses of drugs, such as a 2000 study that found the hypertension drug Ramipril could reduce the risk of heart attacks. But regulators and consumer advocates say the studies are helping increase health care costs, can put some patients at risk, and may taint the public's view of safety testing necessary to get new drugs on the market.

The New York Times has a very nice piece today on this subject - Familiar Blood Pressure Drugs Find an Array of Novel Uses. They refer to important articles which I often cite on rounds. Probably not news to readers of this blog, but still a worthwhile review. The million dollar question that they pose at the end

Already, many cardiologists are expanding their use of ACE inhibitors and A.R.B.'s, but Dr. Sidney C. Smith, a professor of medicine at the University of North Carolina and the chief science officer of the American Heart Association, said not everyone had gotten the message.

"I think the HOPE trial has had a major impact on physicians' decisions to use ACE inhibitors," he said. "Yet still more than a third of patients who might be candidates for ACE inhibitor therapy after a heart attack do not receive the medications at the time of discharge from the hospital."

There is no deep meaning here - just laugh - Medical Pot-Shots

Medicare physician payment: Time to act on E&M mess: The Centers for Medicare & Medicaid Services needs to scrap its evaluation and management documentation guidelines.

Almost all rural areas in this country have a physician shortage. Many factors contribute to this problem. California and perhaps Federal legislation are taking aim - States seek more doctors for rural areas: Two proposed legislative measures aim to bring physicians to needy communities.

In another article from the AMA news, the Robert Graham center states that Title VII increased the percentage of family physicians.

The study examined data on all U.S. graduating classes of medical students from 1981 to 1993 and compared those attending schools that received grants from Title VII with those attending schools that did not.

Bush sets running example for national fitness

We cannot talk about obesity too much. President Bush has this one right. Most physicians have this one right. Do you practice what you preach? This physician's column lays out the problem beautifully - Super Size It, Part I . I look forward to Part II.

Approximately 15 years ago, I was playing basketball in a 35 and older league. One of our best players died on the court. He was in his 30s; played basketball at least 3 times a week; and ate right. I went to his autopsy (after having a reaction similar to the Cardinals, magnified only by participating in his code). He had a 95% LAD lesion. I didn't know him very well other than basketball. The story came out that he had a very strong family history of coronary artery disease.

Most people believe that their health actions control their outcomes. While our actions are very important, sometimes genetics are stronger than our actions. They were for Darryl Kile. In matters of the heart, family history is crucial . Remember this story today, as you may get some new requests for evaluation.

Given the relative dearth of news on Sunday, I've decided to pick an issue each Sunday and share my thoughts. These past 2 weeks the key issue comes from the ACGME and the AMA. First the ACGME published their proposed new guidelines on resident work hours Click on ' ACGME Approves New Common Requirements for Resident Duty Hours'. Later in the week the AMA endorsed those limits AMA endorses limit on residents' hours . Let's revisit the proposed new requirements and try to understand their impact.

All these requirements work on 4 week averages.

• 80 hour limit per week


• 1 full day off each week


• No more than 24 hours on call with up to 6 additional hours to insure patient care continuity


• Call no more frequent than every 3rd night


• Complex moonlighting recommendations

Now let's assume an every 4th day cycle. We have 7 call days in our 4 weeks. Thus, we have 210 hours for those 14 days (7 on call/post call combos) - with 110 hours remaining on the remaining 10 days (assuming 4 full days off). This allows for 11 hour days. In our program, weekend days often take no more than 5 -6 hours.

Putting this into perspective, the residents will have to become more time efficient and more willing to give tasks to the on call team (because they will have to leave at a reasonable time). This requires a culture change amongst many residents. Residents have their own macho culture of taking care of everything prior to leaving. We will now have to force this culture change.

So these rules will put some pressure on residents. Likewise attendings will have pressure to reconsider postcall rounds. At our institution many of us have learned that post call rounds are often "survival rounds". We come in at 7:00 a.m. post call to make certain that significant patient care issues have attending input very early in the day. I've learned that post call days cannot involve extensive teaching (unless it happens to follow a very light call day). Attendings will have to make adjustments for the residents.

Are these rules good or necessary? I'm not certain that these are the right limits. As I referenced on Tuesday, Sleep Won May Come at a Price. Sometimes patient care does require longer hours. Most residents know this and respond appropriately. By strictly limiting hours to 80, sometimes patient care could suffer. Residency training now enters a major transition. Residents and attendings will have to work hard together to make these limits work both for education and patient care.

Bisphosphonates must have very interesting pharmacologic properties. You can apparently give a new bisphosphonate once yearly and get the same benefit as weekly olendronate (Fosamax). I wonder how long until we have this available in the U.S. - Once-yearly brittle bone treatment

Heartburn Drug May Be Over the Counter This is a difficult one for me. Prilosec OTC will cost $1 as opposed to $4 per pill by prescription. This is the same company - AstraZeneca - with the Nexium controversy. My patients will financially benefit - and that's the main issue.

The money advantage aside, I do have some reservations. While patients will avoid many unnecessary office visits, unfortunately they will also avoid some necessary visits. Patients aren't perfect at diagnosing heartburn. Sometimes a good history will reveal a different diagnosis (including coronary artery disease). How long will patients delay seeking medical care? Regardless this is a very interesting development which I will continue to follow. Another good story about OTC Prilosec - Nonprescription Prilosec Backed

Health care costs continue to increase. The leading offenders are prescription drug costs and insurance costs. In my opinion, our last foray into trying to decrease costs gave us Managed Care. We held the line briefly, but we no longer save much money with this new bureaucracy. Health care costs more; physicians get paid less; administrative costs soar. Unfortunately, we are unlikely to have a reasonable debate. The issues have too much complexity for sound bites. Health concerns blossoming for voters

This article brings no surprises. Programs are getting ready. I'll be ward attending next month and plan to try to achieve the new limits with my team. The challenge will come in trying to get our new interns out of the hospital at 2:00 p.m. on post-call days. AMA endorses limit on residents' hours

We have an obvious theme developing. Our first line physicians are not given the time to do their jobs properly. The insurers, whether private or government, demand unreasonable volume of both patients and paper work. 'We need a new NHS contract' say England's general practitioners.

Thanks to the Bloviator for this link - Man interrupted in sex act assaults passerby with pipe. Rather incredible story which ends with this memorable line:

"Spontaneous interruption of a public sex act to engage in an aggravated assault should be considered as a strong indication of a seriously unaddressed anger management problem," the complaint states.

The Secretary of HHS released this report today - HHS REPORT HIGHLIGHTS BENEFITS OF PHYSICAL ACTIVITY FOR DISEASE PREVENTION

President Bush walks the walk - actually he runs the run. He is in shape, and as I've previously documented, more of his staff are getting in shape. He appropriately wants to influence our citizens to do a better job of diet and physical fitness. Good for him!!! - Bush leads physical fitness initiative. Check out the government's new web page devoted to this initiative - Healthier US.Gov

Two Harvard researchers have reviewed the literature and recommend that all adults take a daily multivitamin. Your patients might ask you about this one - Multivitamins should be daily habit for adults

Read this very nice discussion of the placebo effect (mostly with treatment of depression) - Make-believe medicine

Very interesting link from the Boston Globe tells the story of patients who develop hyponatremia from replacing sweat with water. I like this reporting for its clarity. If you have exercising patients, this link could be valuable. Have your patients read it prior to long bike rides or long runs - When drinking too much water means disaster

This take from the San Francisco Chronicle - Doctors see loopholes in limits on workweek: Residents say medical culture of long hours hard to change . This remains a difficult question. Can you work long hours and retain your balance and humanity? I believe that educational leadership can help. We, as attendings, need to work as housestaff allies. We must modify our expectations to their circumstances. By recognizing their difficult nights and modifying rounds appropriately, we can help them. Housestaff need respect more than they need rules. I read this article and see housestaff who don't have the respect of their attendings or their hospital. Maybe that's the biggest problem.

With a resounding duh, we have this article published in JAMA - Variation of Mood and Empathy During Internship . All internal medicine attendings know this. All who have done an internal medicine internship know this.

Conclusions We found that, in this sample, enthusiasm at the beginning of internship soon gave way to depression, anger, and fatigue. Future research should be aimed at determining whether these changes persist beyond internship.

One of the joys and challenges of medicine involves the constant influx of new information. How we practice, and how we should practice is an evolving matter. A new analysis suggests that we still have many questions to ask and answer concerning statins and coronary artery disease - Timing the use of cholesterol drugs gets second look. If you like to read the original article, it's in JAMA - if you have a subscription you can view this online - Early Statin Initiation and Outcomes in Patients With Acute Coronary Syndromes

Unfortunately, having bills introduced in Congress does not lead to intelligent discourse. My greatest disappoint in democracy involves the level of spin. This article predicts the response to the Republican bill to provide a Medicare benefit. I'm not certain how I feel about the bill, but I'm certain that I won't hear a reasoned analysis from either the Republicans or the Democrats - A Health Care War Is Raging in the House

We didn't really need this study to tell us what we see in our offices and hospitals or even shopping malls. More Americans are obese than ever before - Obesity may be beginning earlier.

I generally don't rant on malpractice - I just read Medpundit. Since she is on vacation, I provide this link - AMA supports a cap on malpractice awards

Uplifting story from the LA Times which discusses the benefits of fitness training for older patients - In Their Iron Years.

Sleep Won May Come at a Price tells the story of mismanagement from the "passing off" of patients from one resident to another. The new regulations shouldn't lead to this conclusion. However, the story, as all stories, has value in keeping our focus on what our real goals are.

Fit to Govern, And Then Some

Interesting reference from Medscape - When Managing Diabetes, Good Glycemic Control Is Not Enough. You may have to register to view articles from Medscape, but it is free, and a good site. For those who don't want to register, let me excerpt the highlights.

When it comes to managing diabetes, doctors may achieve good glycemic control but have a lower priority for controlling or treating other cardiovascular risk factors, according to two presentations June 15 at the annual American Diabetic Association meeting.

"An opportunity exists to improve treatment rates and goal attainment for glycemic, lipid, and blood pressure control among patients with diabetes," write Richard Bergenstal, from the International Diabetes Center in Minneapolis, Minnesota, and colleagues. "Only by understanding how physicians prioritize and address these risk factors will we be able to develop more effective strategies to reach goals and reduce the burden of cardiovascular disease in diabetes."

• Feet


• Lipids


• Eyes


• Control


• Kidneys

Not much to add here, the article says a lot - Young type 2 diabetics face severe problems.

Type 2 diabetes is the most common form of the disease, affecting at least 90% of the more than 17 million Americans with diabetes. It is associated with obesity, lack of exercise and genetics, and until about 20 years ago, almost never occurred in teens or children.

Unlike type 1 or juvenile diabetes, type 2 is most often detected in middle age or older, but is increasingly being found in children, especially among ethnic minorities, a "dramatic and very alarming fact of our lives," says Eugene Barrett of the University of Virginia, vice president of the diabetes association.

For many physicians, the AMA seems irrelevant. If organized medicine has importance, then it should lobby for our crucial issues. Physicians feel under attack from malpractice, Medicare, managed care and hospitals.

This year's agenda also includes reports suggesting the AMA needs to heal itself to retain influence over shaping medical issues. The organization lost more than 12,000 members last year, one of its steepest recent declines and a continuation of a nearly 20-year exodus.

AMA leaders' average age is nearly 60, a decade older than that of doctors they claim to represent. Many younger physicians choose instead to join specialty medical societies if they want any part of what the AMA calls "organized medicine."

The latest figures show 278,302 AMA members, fewer than one-third of the 928,036 U.S. physicians and medical students.

AMA delegates from Texas are proposing action to address that. In a resolution, the delegates warn that the AMA "will not be able to sustain its viability if it continues to function as a 'status-quo' organization, poorly positioned for success in the future."

The resolution says the AMA should spend less time tackling social issues indirectly related to medicine and refocus on core values such as malpractice reform, doctors' reimbursements and issues directly affecting the doctor-patient relationship.

I plan to follow news from the meeting carefully this week, and will link to relevant stories.

Drug costs represent a recurring rant subject. I can't resist articles which discuss this problem. Today's NY Times discusses the Republican proposal for a drug benefit - Experts Wary of G.O.P. Drug Plan. I'm probably wary also.

Bush calls for safety review of ephedra . This story brings out another principle (I feel very principled this morning). Don't get health advice from health food stores, advertisements on the radio or magazine ads. We should not use the phrase alternative medicine. All that stuff must have the same rigorous testing as medications we prescribe. When anyone takes "supplements", they are playing Russian roulette. They could be taking something dangerous. And who's there to advise them - not a health professional.

Read this story about an overmedicated elderly lady - Abundance of 'Cures' Brings Ills. Thats the story, what's the principle? Whenever you see a patient with 5 or more medications, ask yourself whether they are all really necessary. I've helped many patients by discontinuing medications. Long med lists are clues, we should be detectives.

NIH panel give hepatitis C report - Panel: Treat more hepatitis C victims: Drug users, kids, AIDS patients should no longer be excluded

Acarbose can delay the development of diabetes according to a randomized controlled trial published in today's Lancet. But I find one section of this report - Study: Pill Could Delay Diabetes - depressing.

Experts estimate more than 200 million people worldwide -- including nearly 16 million Americans -- are pre-diabetic and half will develop diabetes within 10 years. They predict a worldwide explosion by 2025 and say the disease is likely to become the biggest epidemic in history.

Although exercise and healthier eating can delay or prevent diabetes for most people, some experts believe that because many people won't heed advice about healthier lifestyles, drugs will be necessary.

One pill makes you larger
And one pill makes you small,
And the ones that mother gives you
Don't do anything at all.
Go ask Alice

In Alabama, we call malpractice suits the state lottery (we keep voting against the real lottery). Patients and trial lawyers try to hit the jackpot. The trial lawyers can get obscene settlements. Given their excess cash, they contribute greatly to many state campaigns, no wonder they control many legislatures. Well it is starting to hit the fan. Sounds like New Jersey is worse than Alabama - In Mass Trenton Rally, Doctors Protest Malpractice Insurance Costs

You could predict that the whining would come. The hospitals are complaining about the cost of the new rules. I expected that, and I have no sympathy for the hopsital admiinstrators who generally take Medicare direct and indirect medical education money and don't apply those moneys to the educational program. Now they will be spending the money that they should have been spending. The NY Times has this article on the hospitals complaints - Limits on Residents' Hours Worry Teaching Hospitals. The one quote I don't understand is from an internal medicine program director.

Even specialities like internal medicine that already adhere to 80-hour workweek will have to adjust. At the University of Chicago hospitals many residents work 36 or 38 hours at a time to be able to provide follow-up care and attend educational programs, said Dr. Holly Humphrey, who oversees the residents in internal medicine. The 24-hour limit, even with a possible additional six hours for handing off patients or attending lectures, "is a big, big change," Dr. Humphrey said.

She is concerned that residency programs will "take on a mentality of shift work," she said.

Well, I have printed, read and digested the new ACGME rules. As usual the newspaper reports are superficial, perhaps correct in concept but missing critical details. As an active participant in our housestaff program, the details have great importance.

Duty Hours
-Residents must not be scheduled for more than 80 duty hours per week, averaged over a four-week period, with the provision that individual programs may apply to their sponsoring institution’s Graduate Medical Education Committee (GMEC) for an increase in this limit of up to 10 percent, if they can provide a sound educational rationale ;
-One day in seven free of patient care responsibilities, averaged over a four-week period;
-Call no more frequently than every third night, averaged over a four-week period;
-A 24-hour limit on on-call duty, with an added period of up to 6 hours for continuity and transfer of care, educational debriefing and didactic activities; no new patients may be accepted after 24 hours;
-A 10-hour minimum rest period should be provided between duty periods; and
-When residents take call from home and are called into the hospital, the time spent in the hospital must be counted toward the weekly duty hour limit.

I will comment on these articles sometime today. Briefly, the rules are not as onerous as the articles make them sound. They will require some minor changes to some programs, but major changes to others. First the NY Times version - Hospital Accreditor Will Strictly Limit Hours of Residents. For the original source go the ACGME home page - Click on ' ACGME Approves New Common Requirements for Resident Duty Hours'

The New York Times has this release from the AP - Work Rules Set for Medical Residents

Hot off the web, the ACGME has announced new work rules starting next June - Doctors-in-training get a break. I will comment on these rules later today.

If you don't check out Medpundit every day, you should. She writes eloquently today about pharmaceutical reps - check it out - Pharmaceutical Pique:

Interesting study in the CMAJ used focus groups to understand the daily use of evidence.

Two major themes emerged: evidence in the clinical encounter and the culture of evidence. The family physicians reported thinking about evidence during the clinical encounter but still situated that evidence within the specific context of their patients and their communities. They appreciated evidence that had been appraised, summarized and published as a guideline by an independent national organization. Evidence remained in the forefront of consciousness for a limited time frame. Local specialists, trusted because of their previous successes with shared patient care, were important sources and interpreters of evidence.

I can't let this issue go unnoticed. The case of the reluctant residents

I read yesterday that pharmaceutical stocks are slumping - Big pharmaceutical stocks have been hammered, but are they now bargains?. Many interest groups have new found anger against these companies. Vermont legislatures have decided representatives shouldn't give "freebies" valued at greater than $25.

Critics of the pharmaceutical industry charge that the use of freebies by sales representatives to promote products drives up medical costs by encouraging doctors to prescribe new, more expensive brand-name drugs.

"This disclosure should embarrass this greedy industry into playing fair," said state Senate President Pro Tempore Peter Shumlin, a Democrat.

The industry argues that doctors are not unduly influenced by the freebies and that the law is unnecessary. The pharmaceutical companies say that they are merely educating health care professionals about new products, not trying to promote more expensive drugs over cheaper, equally effective alternatives.

How much sleep is enough? Are you tired most days? Does sleep influence your health?

Results from two studies show that adults who get seven to eight hours of shut-eye a night live longer and are less likely to develop heart disease than people who slumber shorter or longer.
THE FINDINGS, to be presented this week at the annual meeting of the Associated Professional Sleep Societies, come on the heels of a controversial study published in February that suggested that people who sleep less than the recommended eight hours may live longer.
The new studies ? both out of Boston ? support this connection, but pinpoint seven to eight hours as the optimal amount of nightly sleep rather than the five to seven suggested by the earlier report.

Medicare isn't giving the money to physicians, so why is there a financial crunch? HHS Report: Medicare Paying Too Much: Medicare Paying Too Much for Medical Supplies

They are not certain that fat substitutes really help anything! Heart Assn. advises on fat substitutes

I've only recently become aware of glycemic index and glycemic load. There interesting concepts run rampant in the nutrition and fitness literature. Let me use some quotes to explain.

The glycemic index is a measure of how much carbohydrate-containing foods raise a person's fasting level of blood glucose and consequent need for insulin in two hours.

Others, like Dr. David S. Ludwig, director of the obesity program at Children's Hospital in Boston, maintain that the glycemic index has value in helping people choose healthful diets, but that in doing so it is important to appreciate its limits, prime among them that the index does not take into account the caloric density of a food.

A glycemic index ranking is defined as the blood glucose response after a person consumes 50 grams of available carbohydrates in a food. Depending on what else is in the food, including water, it can have more or less carbohydrate per serving than a standard reference food like white bread or sugar. Thus, even though carrots have an index number of 71 and sugar has 65, it would take six or seven servings of carrots to match the blood glucose effect of one-fourth cup of sugar. That is because measure for measure, sugar has far more carbohydrate.

A more helpful gauge is a value like the glycemic load, which refers to the blood glucose effect of a standard serving of a food rather than a fixed amount of carbohydrate. The glycemic load value for carrots puts them in a far more favorable light, on a par with milk and well below spaghetti, apples and even lentils.

Readers of this blog know that I'm somewhat obsessed with fitness. I consider this a healthy obsession, as fitness predicts better quality and quantity of life. The challenge (especially for those of us > 50) is to exercise within our capacity. Read this nice article about aging and exercise - What to Do When Age Outruns You

I was able to get a copy of the article. The article contains the crucial information. In this initial study (and remember initial studies are generally more promising than validation studies), the sensitivity for responders was 69%, the specificity was 75%, translating to a positive predictive value of 75% and a negative predictive value of 69%. Let's translate these data. You diagnosis a patient with depression and start medication (in this study fluoxetine and venlaxafine had similar response rates ~ 50%). You obtain a one week EEG. If it predicts that your patient is a responder, 75% of patients will in fact have a good 4 week response. If it predicts that your patient won't repond, 31% of patients will still have a good 4 week response. I don't understand the excitement. This is not ready for primetime. Reporters need a course in medical decision making - test characteristics!!

We know that only some depressed patients respond to medications. Since response takes as long as 4-6 weeks, we would love to predict response earlier. Brain scan may shed light on depression reports on data from a study suggesting that responders have EEG changes which differ from nonresponders.

there was a clear pattern early on in the EEGs of those who later showed clinical responses -- meaning they felt measurably better. In January the same team reported they used EEGs to show, in the same group of patients, that brain function changes when a patient responds to a placebo.

But the researchers found it took two weeks for any changes to be seen in the brains of people who responded to placebos, and when the change did come, it was characterized by an increase of activity in the prefrontal cortex, not the decrease seen with the drugs.

Testing first to see who will respond to medications may save money. A 16-week course of treatment with antidepressants can cost $2,500.

Back in medical school, who would have thought that peptic ulcer disease came from an infection. Even as the evidence mounted for helicobacter pylori causing most ulcers, many experts scoffed. Mounting evidence suggests a role for infection in coronary artery disease. This interesting summary gives a nice overview - Are most chronic illnesses really infectious diseases?

Rangel has written an excellent piece on Celebrex. His article lays out a damning indictment of the makers of this drug. What a surprise - a drug company stretching the truth! Celecoxib hits the fan! . Read this carefully as it represents a beautiful summary.

Who could imagine this? Apparently hangovers are related to alcohol metabolism, and slow metabolism is better than fast metabolism for the cardiac benefits - Hangovers are healthy.

I've previously talked about being careful about news reports of studies or technology. We need good scientific data to make good decisions. Physicians tend (appropriately) to be skeptical of claims until the data are published. Many patients though believe what they want to believe. Is this new technique the answer to GERD? First, a few quotes

Made by Curon Medical in Sunnyvale, Calif., Stretta uses a high tech balloon that emits hot radio waves. The balloon snakes down the throat and then sticks out needles that burn a series of tiny scars. The new tissue makes leaky stomach valves shrink.

"So now you have a new kind of tissue there," said Dr. Neil Stollman, who performs the procedure at the University of California at San Francisco. "When you had a more elastic tissue, you now have presumably a stiffer, thicker tissue there."

Most GERD cases respond to prescription drugs such as AstraZeneca's Nexium. Heartburn patients need to take the drugs for the rest of their lives, but they work. Skeptics such as Dr. Stuart Spechler, a gastroenterologist at the University of Texas Southwestern Medical Center in Dallas, wonder what makes 4-year-old technology a safer alternative.

"The wise physician and patient will wait a little bit," Spechler said. "I think we need a little bit more information before we start recommending it for clinical purposes."

If you are like me, you often eat too much when going out. This article documents that restaurants give ridiculously large portions - although in their defense we've all heard nice portions as a plus for a restaurant. Restaurant meals busting buttons: Meals often five times larger than healthy servings

Editorial from the Lancet on obesity Getting a handle on obesity.

Interesting article from the Boston Globe which points out positive data about sun exposure, while acknowledging the skin cancer problem - Sun exposure may be a good thing. Nice to post this article prior to playing golf.

Training causes shortage of doctors, study finds

Interesting report which focuses on training and demographics. A couple of revealing quotes:

In 1993, a two-year family residency became a prerequisite for a general practitioner; before that, only one year of postgraduate study was required. Most provinces also made a deliberate decision to increase the number of specialist residency programs, reducing the number of family-medicine interns.

Many medical students went directly into a specialty area instead of doing a stint as a GP. The upshot is that by 2000, only 45 per cent of medical-school graduates worked as general practitioners, down from 80 per cent in 1993.

Dr. Chan, however, said it is unclear whether there is a shortage of GPs in Canada. "That's a societal question. What level of service do people want? What level of service are they willing to pay for? Until we answer those questions, we can't say if there is a shortage," he said.

What is clear is that the physician-population ratio has fallen steadily since 1993.

Practically speaking, there are the same number of GPs available to treat patients today as there were in 1987. But to come up with the real supply of doctors, the ICES researcher adjusted for two important factors: The influx of women GPs, and the aging of the physician population.

Dr. Chan said that women doctors work about one-fifth less than men, largely because they have more family responsibilities. Older doctors, many of whom are remaining on the job past the age of 65, also cut back on their hours.

"If you don't adjust for those factors, you might be fooled into thinking supply is rising, but it's not," Dr. Chan said.

This editorial from the Canadian Medical Association Journal pertains not just to Canada but also the US. I believe that we have a combination of many forces at work here. Among the many are work-life balance (i.e., number of hours one works each week), prestige, reimbursement (at least in this country), the inability to cope with uncertainty, and the glamour of subspecialties. Make no mistake, this is a major problem - The decline of family medicine as a career choice

Readers of this blog will recognize that I have a great interest in housestaff training. The AMA has an interesting proposal, wel worth reading. I believe that the internal medicine residency where I work would already meet these criteria, but I doubt whether many other residencies would. Internal medicine has led the way towards reforming training.

I like this proposal because it is moderate. It allows a 24 hour on call period, but pushes to get the residents out of the hospital after a total of 30 hours. Given that residents on call should start around 7-8 a.m., that would mean leaving the next afternoon right after lunch. This is a great goal, and will put pressure on attending physicians to streamline rounds. We would have to change our rounding culture a bit, but that is not necessarily bad. To read more - Resident work-hour limits to headline education debate: AMA's Council on Medical Education recommends an 84-hour-per-week limit for residents.

Now I'm on the side of lawyers against pharmaceutical companies. I'm so confused. States Accuse Bristol-Myers of Fraud

Just a quick link this time, again to Lagniappe - his take on the issues I discussed yesterday - we're not that far apart - Adam Smith Goes Pharmaceutical.

I love blogging. This morning I was struggling a bit with what to say today. As the day went by several topics struck me. I've considered adding this link for some time. If you don't know of Malcolm Gladwell, you should. He wrote the excellent book, the Tipping Point. He regularly writes for the New Yorker. This piece from August, 2000 has minimal medical relevance, yet I think you will find it fascinating - The Art of Failure: Why some people choke and others panic .

Several years ago at am AAMC (Association of American Medical Colleges) meeting, the then major of Baltimore made the argument for legalizing drugs (at least marijuana, cocaine and heroin). I believed his argument then, and believe it now. The harm that comes from our current drug laws far exceeds (in my opinion) the potential benefit. For those who are interested I recommend the following thoughtful essay on the topic - Cocaine, Marijuana, and Heroin. This well considered essay makes many important observations, and backs these with data. They don't address one additional problem with our current system. Especially with marijuana laws, we create a distrust of the legal system in most of our adolescents and college students. We spend so much money on drug enforcement that could be spent on important public health issues.

If you disagree strongly, please send me your reasoning. I will be happy to publish any thoughtful pieces, either anonymously or with attribution.

Lagniappe is a delightful weblog written by a medicinal chemist. He recently wrote this well considered piece - Innovation and Its Discontents. I still think I'm right, but I do want to share another view.

Today's Wall Street Journal has a wonderful front page article titled 'As a Patent Expires, Drug Firm Lines Up Pricey Alternative'. Since the Wall Street Journal web version requires a paid subscription I won't link to the article. Rather I will summarize the issues.

Prilosec's patent expiration date was April 2001. As of today we still have no generic competition.

The reason? Seven years of planning by a group of marketeers, lawyers and scientists within the drug's maker. The group called itself the Shark Fin project after the dismal shape the sales chart would trace if they did nothing: an inverted-V.

Beginning its work in 1995, the team came up with a list of nearly 50 possible solutions to the patent-expiration disaster facing the company. ...

This article from London breaks down how to suspect problems with press reports - Q&A: how to spot a 'misleading' health story

While I have concerns about medical education, it clearly succeeded in making me skeptical about claims and even published studies. I have taught critical appraisal of the literature for many years. JAMA confirms the need for that skepticism in a well done study described here - Medical journals
may mislead public. I have learned to take each new article in perspective, and work to dampen enthusiasm, while using the new data. This is like walking a tightrope, but that's what good physicians do.

Most of us learned about ghrelin 2 weeks ago from a New England Journal of Medicine article. This reporting gives context discussing how the history of previous discoveries like leptin should render caution about ghrelin and weight loss - Hungry? Blame a Hormone

I received this story from the GME newletter of the AMA:

The Accreditation Council for Graduate Medical Education (ACGME) has withdrawn accreditation of the Yale-New Haven Medical Center surgery residency program, effective July 1, 2003.

An ACGME site visit found the program in violation of ACGME work hour standards, including the standard limiting on-call activities to every third night and giving residents at least 1 day in 7 off.

Residents in the program reported that they routinely work more than 100 hours a week. Yale officials said that the university's teaching hospital would spend more than $1 million to hire additional physician assistants and moonlighting physicians and thereby reduce the residents' workweeks to less than 80 hours, according to an article in the May 6 Chronicle of Higher Education.

"Clearly, the RRC is on a roll about this issue, and I suspect that there are going to be a series of high-profile programs coming under the gun," Yale surgery program director John Seashore, MD, told
the Chronicle.

Yale surgery residents interviewed for a Boston Globe article ("Surgery residents' long hours draw warning for Yale," May 20) approved of the action. "I'm ecstatic," said one resident. "I love medicine. I care about medicine. But I also care about my family and friends."

I discussed this story previously - More on long hours in training. This is a very important story. Most internal medicine programs have taken the Residency Review Commission seriously; previously surgery programs have felt immune. This decision should change that greatly. As RangelMD discussed (see the link in my previous story), fixing this abuse of residents is long overdue. I do worry about the parameters of the fix. Housestaff training is hard, being a physician is hard. It does require long hours. Defining the appropriate limits is the challenge. I hope all surgical programs take note.

Over the weekend, I wrote about Dr. Reinhardt's letter to the BMJ. I quote again

Boutique medicine in the United States can be interpreted as a desperate attempt by some doctors to keep the income ratio at 5.5 or above; it is unlikely to be a genuine attempt to provide patients with health care of a higher quality. If quality of care was doctors' main concern there is so much they could do.

So I checked out the current U.S. median income - $62,228 (Median income ). By my calculations that would translate to an income of greater than $333,000 for a general internist or family physician. I stand by my critique of the letter. Many generalists make 2-3 times the median at most.

This take on weight training from the Washington Post's Lean Plate Club - Weights Can Keep Your Weight in Check . This article discusses the benefits of weight training, including burning calories after the workout, and raising basal metabolic rate.

Jane Brody, whose weekly columns are usually gems, has this excellent piece about the value of resistance training. Having personally started last August, I echo her personal comments. The data are very good also. Get those women into the gym at menopause! Push Up the Weights, and Roll Back the Years

I really have nothing to add to this well written editorial about gifts and the new policy - Pharmaceutical marketing to physicians: Free gifts carry a high price

As an addicted golfer, I had to link this article. It is mostly true - Par fore the profession: What is it about doctors and golf?

The Medicare evaluation and management codes have an ugliness that only a bureaucrat could create. I have attended numerous boring conferences trying to make me understand and accept the codes. Like most physicians, I have found them distasteful because

Douglas Wood, MD, chair of the regulatory reform panel, said the committee members felt the documentation guidelines had not achieved their goals, but had created unneeded complexity for physician practices.

"The documentation guidelines that have been used are unworkable, and I think 10 years of effort to try to find one that works is a pretty strong statement that there is something fundamentally difficult or fundamentally impossible about trying to create documentation guidelines for evaluation and management services," Dr. Wood said.

"The fact that no other commercial insurer uses them should be a pretty strong statement that they're probably not applicable anyway," he added.

Dr. Wood also said the guidelines emphasize a physician's clerical talent. "You are rewarded more for your ability to produce the perfect record than you are for your ability to make the appropriate medical decision about what is best for the patient."

Go to RangelMD (link on the left) today and read his rant on whole body scans. Well done and to the point.

Read this and smile - Solicitor General Backs Maine Law

I write often about obesity, because it is a huge health problem. The downstream effects of obesity costs the health care system billions. This interesting article presents an interesting story about a new pharmaceutical approach that wasn't planned - How a Side Effect Might Turn Into Success

There are no shortcuts to weight loss. Supplements don't work. You have to eat smart, both less and better foods, and exercise. No shortcuts - Guide to Weight Loss Supplements

So what do you do when your drug's patent runs out? You could bring out a slight modification and claim it much better. You could try to convince me that the generics are equivalent. Or you could go OTC, charge much less, but advertise like crazy. Heartburn sufferers could get OTC Prilosec relief .

I have mixed feelings about this idea. On the plus side, it would save patients a lot of money. I could just tell patients to buy OTC Prilosec rather than give them a prescription. However, I would what diseases the OTC drug will mask, preventing prompt diagnosis. The tension between the value of OTC, and the missed opportunity for a visit around a legitimate complaint is a tension that I haven't resolved. On the whole, OTC Prilosec would help more than it would hurt. Get ready for you TV ads now.

Cooper, the founder of aerobics, speaks out on this issue - More fit in less time: New twists in cardio, strength, and flexibility. As I write frequently, we don't do enough to influence our patients into a more fit life. Why not? Time constraints and lack of skills prevent our success in this and other life style areas. We aren't paid to improve health. This has to become our crusade. Another major obstacle to success involves the availability to patients of exercise. I go to gyms, many fitness enthusiasts run outside, but many patients live in neighborhoods where running outside doesn't seem an option. And they can't afford a gym. They don't know where to start. Hopefully our public health advocates are starting to work on fitness. So after you finish reading this, go do something active. I plan to hit the elliptical machine this morning - much easier on my knees and just a good a cardiovascular workout.

Well, I've been taken to task. I'm guilty. I don't like the pharmaceutical industry; I don't like how they buy influence; I don't like how they advertise directly to patients. But I am guilty of not giving the same intellectual attention to this issue as I have to retainer medicine. I'll try harder. This Washington Post article raises some interesting questions - Industry Role in Medical Meeting Decried:Symposiums Sponsored by Pharmaceutical Companies Trouble Some Psychiatrists

I am in favor of ethical advertising, however, I believe that the drug companies have crossed many lines. Everything they do is about influence. Does it change prescribing habits? It probably does or else they wouldn't spend the money. Influence peddling can be subtle. I prefer making my prescribing decisions on unbiased data, and you just won't get that from the pharmaceutical industry.

Are the COX-2 inhibitors really safer, i.e., less GI side effects? Maybe not - Study Finding Celebrex Safer Was Flawed, Journal Says Well at least the COX-2's are more expensive!