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Understanding the genetic predisposition to myocardial infarctions Gene is linked to heart attacks
While preliminary data, this research suggests that our thoughts about a cardiac inflammatory response make sense. As we better understand this response, and associated factors, so might we better screen and prevent coronary artery disease manifestations.
Do statins decrease post-surgical mortality Surgery carries many risks. One is the risk of inducing a cardiac event (probable stimulated by stress). We know that beta blockers decrease the risk of post-surgical mortality (especially in patients at high risk for coronary artery disease). Now we have epidemiologic data suggesting that statins may also offer some protection. Lipid-Lowering Therapy May Reduce Mortality After Major Surgery
Thus, we have interesting data founded in solid theory. But, as the investigator cautions, we still need a prospective study prior to widespread adoption of this new strategy. Posted byNail and hammer I always wondered where this quote originated. "If the only tool you have is a hammer, you tend to see every problem as a nail." -- Abraham Maslow (1908-70), American psychologist, founder humanistic psychology We generalists often use this quotation to describe subspecialty behavior. Sometimes we are right! Rethinking cardiac risk factors Many patients who develop coronary artery disease have well known major risk factors. These include smoking, family history, high LDL cholesterol, diabetes mellitus, low HDL and hypertension. However, these risk factors do not explain all coronary artery disease. Recent research has expanded our ideas about etiology and risk. This Washington Post article does a nice job summarizing our emerging understanding of risk factors. Not Your Father's Heart Attack
I recommend this article as a nice summary of an important topic. Posted byCreatine - apparently safe With all the furor over anabolic steroids and ephedrine, creatine remains the leading supplement for weight training. I hesitate to label creatine a supplement, but it actually fits the title very well. We all make creatine naturally. Extra creatine (whether dietary or in supplementation) seems to allow weight lifters to lift heavier weights. This leads to increased muscle growth, because the creatine allows the athlete to handle increased loads - leading to more growth. Numerous studies show creatine safe and effective. This article summarizes the data well - The creatine edge I have chosen to not take creatine myself, because I do not see a reason to supplement my muscle growth. I cannot criticize those who use it, as this supplement does have good safety data. However, like all supplements, bioavailability and consistent dosing are problematic - because the industry is not well regulated. Posted byViewing fat through historical and cultural eys Demonizing Fat in the War on Weight
A great example of this "movement" - The big fat con story
His book - The Obesity Myth - represents his treatise on this issue. The article summarizes his argument. Several important points need addressing. We can ignore the argument about BMI. Yes, many healthy athletes have elevated BMI. We should focus our definition more on fat percentage or waist circumference. Second, when we do that, we find that as fat increases, so does the risk of type II diabetes mellitus (and therefore atherosclerotic complications) and obstructive sleep apnea. Anyone you makes rounds with me for a month would see the devastation that those disease cause. Physicians are not making a moral argument, rather we are focusing on prevention. When we have patients exercise and lose fat, their outcomes improve. Admittedly, we need a new method to achieve that goal. Posted byOn vaccination Recently, a reader wrote to ask if I allowed "guest rants". The reader wanted to rant against vaccinations. I do not allow guest rants, this page is my ranting place. You can comment, but I chose the rants. I had not thought much about the request until I came across this article - Anti-Vaccination Fever. The author relates the story of pertussis (whooping cough) and how the anti-vaccination lobby has allowed this disease to make a comeback.
Read this fascinating, albeit technical, exposition. Posted byAn important surgical study Too often, new surgical techniques do not receive a careful analysis. The VA came through to answer an important question - what is the best approach to hernia repair - Open Mesh Better Than Laparoscopic Mesh Inguinal Herniorrhaphy
Surgical studies are always difficult. This study does remind us that we can not randomize surgical skill. Some surgeons obtain better results than others. The wise generalist figures out which surgeons to whom he/she should refer. If patients need major surgery, they should try to find outcomes if at all possible. At least use a surgeon with significant experience doing that procedure. Posted byAnd we all know these patients? Answer, but No Cure, for a Social Disorder That Isolates Many Posted byGeneral internal medicine - the domain Task Force Redefines the Domain of General Internal Medicine
I had the opportunity to read and comment on this report during its construction. Like any such report I can find areas which I dislike. On balance though, SGIM has taken an important initiative to address the important question of how to reinvigorate general internal medicine. A careful reading will reveal many issues that we discuss in this blog. I always try to take such reports in context of the old Southern saying: "If it ain't broke, don't fix it!" Well, generalist care is broken, and thus requires remedies. I certainly hope that this report focuses the debate. We need a healthy discussion to develop more functional solutions to generalism. Posted byA case to read for your medical enjoyment I like this case a great deal. Read it carefully, and see how quickly you can make the diagnosis. Tunnel Vision, Cramped Hands, Nausea Posted byStatins for diabetes As we discuss type II diabetic patients, we generally assume that they have coronary artery disease unless we have proven that they do not. Atherosclerotic complications occur very frequently in patients having type II diabetes. Current guidelines also make this assumption. Now we have a strong recommendation concerning statins in these patients. Treatments: Statins and Diabetes: New Advice
I believe that this guideline makes sense in lieu of the mounting data. Posted byThey are right, but ... Amazing! I just ranted about this issue yesterday. This article bemoans our expenditures on hypertension management - Following Evidence-Based Hypertension Guidelines Could Save Billions. Great! We can do a better job! As they say on the Guiness commercial (I only wish that I could get some royalties here) - BRILLIANT! . Quit bemoaning, and develop strategies to fix the problem. Identifying the problem is not enough. These researchers (who are excellent and well regarded) must address solutions. If they do that, then it really will be BRILLIANT! . Posted byThe challenge and importance of being a generalist I love General Internal Medicine - both outpatient and inpatient. The intellectual and patient interaction challenges never diminish. We must maintain broad knowledge and develop the skills to apply that knowledge to our patients. Unfortunately, most physicians can improve their performance. However, I am often frustrated by the repeated complaints about generalist performance. Here are the two most recent examples: CDC: Fewer doctors urge weight loss and Statins Underused in High-Risk Elderly Patients These two examples represent an entire class of such articles. What do these articles tell us? How should we interpret the articles? What should we (the medical community) do with this information? Using the medical paradigm, one should seek more than making a diagnosis. One should consider the possibilities of treatment. Moreover, we should not stop at making a diagnosis. We must understand what causes the problem. Consider outpatient medical practice. Each day we see multiple patients with multiple medical problems. Each patient requires attention to a variety of medical problems, including the interaction of those problems. In addition to those problems, we must consider a variety of preventive measures. Careful consideration of all issues might take as long as 30-40 minutes for some patients. But our current reimbursement system dictates shorter visits. Our current reimbursement system dictates seeing too many patients. Any interest group (and yes the CDC report on obesity represents an interest group) can seek and find deficiencies. However, I do not see much work on helping diagnose and treat the problem. We focus on symptoms, but do not understand the disease. Thus, I decry these articles. They are no longer constructive, rather they are destructive. We need a new attitude amongst the health services research community. Quit looking for deficiencies, rather focus on diagnosing and improving health care provision. We need constructive approaches to outpatient and inpatient care. We need to improve. If I am slicing my drives, I go to my golf pro to diagnose why, and then work on techniques to improve my drives. If the pro just tells my that I have a lousy swing, but does not teach me how to improve, I would likely look for another pro (I say likely, because some golfers are not willing to really try to improve). Our research group has a committment to understanding medical practice and the barriers to meeting guidelines. We hope to find solutions. I believe that rather than moan about errors and deficiencies, we should champion successes. We can learn more from the positives than the negatives. Physicians will strive towards excellence. Show us how! Posted byMaking oral narcotics non-abusable Physicians are damned if we underprescribe narcotics to pain patients, and damned if we prescribe to those who abuse drugs. Some pharmaceutical companies are trying to make oral narcotics effective, yet not abusable. Drug Makers Hope to Kill the Kick in Pain Relief
So we may soon see effective oral pain control without the option of using the pills in alternate ways. This is good news for pain control. We need the ability to prescribe without worrying about the possibility that we are contributing to drug abuse. These pills will help those patients who really need pain relief. Posted byCan primary care survive?
So one can certainly lay some blame on the insurance companies for perverting the primary care concept. However, we must take blame ourselves. We did not think through the "unintended consequences" of the gatekeeper model. Can we save primary care? Should we save primary care? I believe that the answer to both questions is yes. Patients need generalist physicians. We need physicians who care for the entire patient. I suspect that most of our patients understand this. Several movements bode well. Retainer medicine speaks to the concept loudly. While some argue that retainer medicine is just a money ploy, I would argue that some patients are willing to pay to have one intelligent caring physician available, knowledgeable and capable. Similarly, the cash only practice movement shows that patients will pay for good service. Thus, I expect primary care to transform (albeit slowly and begrudgingly). The change will take time, because few adults embrace change. But the change will help our health care. Posted byGood news - ephedra ban upheld Ephedra ban takes effect nationwide after judge rejects supplement makers' request. The supplement makers' lawyers tried!
I guess this judge is not impressed with sophistry. Posted byWhy paternalism does not die Ordering Treatments à la Carte
Paternalism is not dead. Nor should we kill it. Perhaps we should develop a new category, patient directed paternalism! Posted byGood news from Medicare Medicare Web Site to Provide Comparative Data on Prescription Medicines Posted byChallenges with the ACGME work guidelines Residencies pinpoint work-hour hurdles
Those who have not gone through residencies (non-physicians) have a difficult time understanding the difficulties that these new regulations bring. The regulations conflict with long traditions. I still do not understand how and why new, seemingly arbitrary regulations were adopted without testing. Perhaps residencies will improve. Perhaps our trainees will become better doctors. But we do not know what the long term effect of these rules. We continue to work to improve our residency while meeting the regulations. We hope for positive results. Posted byA Medicare alert on concierge practice Alert warns of Medicare conflict for concierge practices Those who start concierge practices (I prefer the term retainer practice) must carefully examine Medicare billing rules. One can still bill Medicare, however, one must be very careful not to claim that the retainer fee covers any service for which the provider also bills Medicare. Posted byNot a free market Our buddy Trent McBride has stirred up a great controversy. So When Are We Going To Get That Free-Market Health Care Everyone's Complaining About? . If you find that interesting, he has 2 follow-up posts. His rant explains (and I agree here) that we do not have a free market health care system. We have an almost nationalized health care system. Government payments and regulations prevent any free market influence (in general). He has created quite a stir in the blogosphere. I believe that this stir shows a general misunderstanding of medical practice. The biggest influence on medical reimbursement is Medicare (unless you do pediatrics). When they develop reimbursement, the insurers quickly follow. When they develop regulations, physicians pay. He rightly comments on various governmental regulations which increase overhead without allowing a way to recoup those costs. Government (i.e., Congress) influences physicians and hospitals in ways which negate any free market forces. Medicine has some exceptions - cash payments for some plastic surgeries, cosmetic dermatology, etc. However, generally, we work in a highly regulated environment. Kudos to the Proximal Tubule for starting the debate. We here at the Countercurrent Mechanism applaud his efforts. Posted byRaising HDL Test Drug Said to Increase Good Cholesterol and Torcetrapib Significantly Increases HDL Cholesterol Levels. Epidemiologic data indicate that low HDL cholesterol levels put patients at a significant risk for atherosclerotic complications - coronary artery disease, stroke, peripheral vascular disease. We assume that raising the HDL would therefore decrease the risk of these conditions. Until now, the only drug which consistently raised HDL was niacin. A new study shows that (at least under experimental conditions) one can increase HDL with a new drug.
Remember that this drug is still experimental. We must wait to learn two major things. First, how safe is this drug when taken over time. Second, does this drug improve patient outcomes. One must always take these preliminary articles as just that - preliminary. The concept has promise. Now we must wait a few years until the appropriate studies are done. Posted byThe match I have received a few important comments about the match. The wife of an incoming intern wrote:
First, please read very carefully Save the Match. Second, imagine the world without a match. Who would suffer? I proposed this question to some residents while supervising in clinic a couple of days ago. To paraphrase one, "obviously the critics have not participated in a non-match fellowship search". She shared with me her initial concerns about the match as a 4th year student. However, having just finished the interviews and acceptance of a non-match fellowship, she lamented the lack of a match in her fellowship! The match uses the game theory which John Nash (he of a Beautiful Mind) developed. The current algorithm helps students get the highest choice which has an opening for them. It is student biased rather than hospital biased (go to the web site for links to the studies). The match does not drive wages, or working conditions. Medicare reimbursement drives wages. ACGME and residency review committees drive working conditions. Working conditions have improved dramatically since I graduated in 1975. I see excellent progress regularly. I could develop a thought experiment in which working conditions might worsen at some highly desirable residencies! However, the working conditions depend more on regulatory bodies, and how the students "vote" during their match. Programs which treat their residents better tend to have better matches. The anarchy of life without a match would (according to the web site) disadvantage couples (over 500 couples matched last year) and minorities. This protest and lawsuit are (in my opinion) poorly considered. Few would benefit from the unintended but predictable consequences of the lawsuit's success. Posted byMore on the match A Job or More School? Young Doctors Take On 'The Match'
So why have a match? Why not have a free market for residencies? We believe (the great majority of attendings and residents) that the match protects both applicants and programs. It allows us to go through a careful process of evaluating the many applicants to our programs and choose interns/residents in a standard way. What would happen if we had no match? (my speculation follows)
If the courts rule against the current situation, we will have increased chaos. I would suspect that most students would then ask for a match. I am certain that most programs would. This suit might sound good to some who are not part of residency training. The destructiveness of this suit's possible success scares me greatly. Posted byCash on the barrel Most outpatient physicians hate insurance companies (including Medicare). Their pay scales are insulting, and the necessary overhead makes seeing patients minimally profitable. Some physicians have decided to go "old school" and eliminate the insurance companies. Some Doctors Choosing Cash Over Insurance
Cash visits make great sense for patients and physicians.
I love ideas that make sense. Read more about this movement - SimpleCare. This movement runs parallel to the retainer medicine movement. Both movements are suceeding due to patient and physician dissatisfaction with insurance and outpatient medicine. I would still advocate for "big ticket item" insurance. But perhaps this simple concept should become the norm. Posted byA new weight loss operation (or rather two) Double surgery for obese 'safer'
Interesting, but one must wonder about the side effects of the intestinal bypass. But then drastic situations sometimes require drastic solutions. Posted byUnderstanding the effects of leptin Animal research is starting to suggest some clues as to why weight loss is so difficult. Studies on a Mouse Hormone Bear on Fatness in Humans
Very interesting stuff, which may eventually help us better understand weight control. Posted byMaybe my last post on paternalism and prescription drugs I have read the comments. I have reconsidered the radical libertarian stand. As I absorb the hyperbole, sophistry and especially obfuscation which my debating opponents utilize, I will try to return to first principles. Primum, non nocere. - First, do no harm. In this context, I believe that many medications, if sold over the counter, could do great harm. I am also certain that improper dosing and improper combinations of medications can do great harm. Of course, we have pharmacists to help us prevent dangerous drug interactions - but would the libertarian position end the licensing of pharmacists. Why not sell HIV meds at the grocery store? As I read the arguments for ending FDA controls and required physician prescribing, I see many straw men. I do not believe that one can extrapolate from many of the examples. But I will use this retort? Should the government require a licensed engineering firm to design a bridge? Why not just let the construction company build the bridge from their experience? Many drugs can reasonably make the transition to OTC. Many do. We better make those decisions once we have enough experience to know the safety profile of the drug. Many prescription drugs do cause problems, and are removed from the market. We certainly can (and should) loosen restrictions on some drug classes. Other drug classes and diseases should require medical care and decision making. I do not worry about the compulsive intelligent consumer who might research his/her problem extensively and do self-dosing (although I have seen physicians cause harm to themselves with self prescribing). Those patients will at least think through the pros and cons of treating themselves (perhaps). I worry about the many patients who get advice from friends - oh, you must have CHF - try an ACE inhibitor - it worked for me. Remember Primum non nocere should guide us. Following the radical libertarian approach would do harm to many, some of whom cannot understand the risks. Posted byThe link between alcohol and nicotine We all really know this. Talk to any smoker, and he/she will tell you that they always drink more in a bar. The physiology makes sense. Habits: A Smoke Much Sweeter
If researchers can better decipher this interaction, we might gain some treatment ideas. It does explain an interesting phenomenon, and provide some useful information for counseling patients. Posted byPhysicians, prescription drugs and a libertarian philosophy As one commenter suggested, I have really enjoyed the comments on my paternalism rants. They have help inform my conceptualization about this subject. If one takes a libertarian viewpoint in our society one must still understand that the limits of ones freedom end when another is harmed. The common shorthand expression - The freedom of your fist ends just short of my nose. So the first test for restricting a medication must involve potential costs to society of improper use. Certainly all antimicrobials fit into that paradigm. The huge problem of MDR-TB (multidrug resistant tuberculosis) stems from unrestricted access and distribution of TB drugs. You may want to take your medications as you choose (or even think you have researched). However, your knowledge lack can lead to my worse illness. In fact, we take a very paternalistic view of TB in this country requiring DOT (directly observed therapy) give through public health departments. One can certainly extend this concept to all antimicrobials - the good of many others should outweigh your desire to buy antibiotics without seeing a physician. Admittedly, the philosophical position gets more complex when discussing cardiac medications. However, your illness improperly treated (because you chose your meds rather than having a trained physician choose those meds) costs society significant dollars - from hospitalizations, lost productivity, etc. That decision also has a significant impact on your loved ones. Critics argue against licensing physicians and requiring proper training. I have a difficult time understanding that position. Medical care has advanced dramatically over the past 50 years. This care advances because of our training and research. We do need standards for the public good. You can choose care from a non-physician - e.g. chiropractic care. That certainly gives you freedom. You can go to a health food store and self treat with supplements and herbs. That gives you freedom. In my opinion that also gives you substandard care. Like many such arguments, one can take a highly controversial position and incite everyone. However, as I read the comments, that highly controversial position does not withstand careful scrutiny for our society. Our current medical system is not perfect, but it is very good. We do improve the quality of lives. We do lengthen life spans. We cure many infections. I cannot believe that a call for anarchy will help society. Thus, your freedom to buy any medication that you desire without medical consultation could lead to societal harm. And that should be the main concern. Posted byMore on Paternalism EKR at Educated Guesswork writes about my paternalism rant - When is paternalism justified?
Let me try again. Many patients make their own decisions regardless of our recommendations (and remember, we prescribe we do not force feed medications). I guess a well educated patient might be able to figure out a complex medication regimen. But it really is unlikely. I guess I could treat myself - but we do have a saying about that - "The doctor who treats himself has a fool for patient". So I must endorse this form of paternalism. Physicians have the training and experience to juggle the multiple conditions and disease manifestations. We should include the patient in our decision making - but we should recommend and recommend strongly a treatment course that best fits the available evidence. For that I do not apologize! Posted byThe Proximal Tubule on Paternalism in Medicine Paternalism In Medicine - Part II: Gatekeepers Trent McBride writes a long rant about the influence of prescription drugs on the doctor patient relationship. First, I love the blog's title - I love renal physiology. Maybe I should rename my blog the Countercurrent Mechanism. Or that could be a great name for an alternative band! Trent hypothesizes that making patients come to the doctor for prescriptions represents the ultimate form of paternalism. I will disagree to some extent on his proposed solutions. Yes, prescribing medications is paternalistic. But then I do not assume that all medical paternalism is bad. If you have congestive heart failure, I have a complex drug regimen to prescribe. Adjusting these medications requires repeated visits. I must understand the side-effects of each medicine, alone and in combination. I must consider your renal function, and your electrolytes. Finally, I must prescribe the medications with an understanding of your other medical problems (and few patients have CHF alone). So to provide the highest quality care, I believe that I must be paternalistic. In that sense paternalism is not a bad attribute. Narcotics might be the exception. I do not really know how much pain a patient suffers. How can I judge the best method for treating that pain? Should I worry about narcotic abuse? Wouldn't we be better off if we just let patients buy their own pain meds and suffer their own consequences? Trent does mention antibiotics - and he is correct. But I will gladly argue that many conditions which I treat require complex decision making and adjusting of multiple medications. I accept that paternalism and I believe the great majority (>90%) of patients want that paternalism. Caveat ahead - even when one must take a paternalistic stance, one should still discuss the rationale for each medication with the interested patient. When choices are available for treatment, we can and should discuss those choices with the patient. So as usual, I am a bit wishy washy. I agree with some of the Tubule's argument. But I believe he goes overboard. But after all, that is what blogs are for - to stimulate our thinking and challenge accepted thinking. And therefore he succeeds. Posted byOn hypochondria (or somatization disorder) A New Era in Treating Imaginary Ills
If these patients do not induce "heart sink" then you are a different physician than me. These patient's name on your daily list causes anxiety, depression and thoughts of illness. The biggest challenge is sorting out their hypochondriacal complaints from real disease, because even a hypochondriac can get sick. I once had a patient who came to me after having 17 negative HIV tests. He had not had any sexual relations in over 6 months, yet thought he needed another test. I saw this patient for around 9 months. My greatest feat was getting him back to see his psychiatrist, as he also had major depression. Over time with reassurance, calm, scheduled appoints and medication he was able to regain a productive life. As I read the article this morning, I saw most of his personality and problems. We (physicians) would all like a consultant who wanted to see these patients, as most physicians and psychiatrists shun them. I certainly hope that these initial positive reports are confirmed. Posted byNY Times comments on coronary artery disease The Limits of Opening Arteries
What follows represents the implications of this essay and the accumulated data that I teach on rounds. I have tried to interpret the original data and read about the theories. Procedures - CABG and stenting - are still very important in 2 scenarios. First, patients who have just had an acute coronary syndrome, especially a small heart attack (which we call either NSTEMI or non-Q wave MI), clearly benefit from immediate intervention. Second, patients who have extensive disease (usually 2 or 3 vessels with severe narrowing) and problematic symptoms have their symptoms improved with interventions. Choosing an intervention must take into account the lesions, their location and availability of good artery past the obstruction. One must also consider current cardiac function (e.g., 3 vessel disease with a decreased ejection fraction has better results from surgery). One should not go looking for disease to "repair" in asymptomatic patients. One might want to diagnose disease in patients with mild or equivocal symptoms - but not to "repair" the disease. Regardless of whether patients do need a procedure, they need good medical management. I have written often about this issue. To reiterate: We clearly know that coronary artery disease patients benefit from 4 drug classes
So the article and this editorial describe the current thinking of coronary artery plaques as fragile changing lesions. Understanding the dynamic nature of plaques gives us a broader understanding. This concept explains much current clinical trial and epidemiologic data. It drives current therapy. Most important it should give hope to patients. As patients we can take some responsibility for our hearts. Exercise, weight control, and - when indicated - medications can modify coronary artery plaques, leading to regression and stabilization. Patients can often prevent coronary artery disease, but when they cannot (bad genetics especially), physicians can help greatly by prescribing the right drugs. Of course, the responsibility quickly reverts to the patient who then must take those medications. Posted byOn listening to tape about Nietzsche and considering yesterday's rant Listening to philosophy tapes certainly gives me a different perspective on medicine. Currently I am listening to Will to Power: The Philosophy of Friedrich Nietzsche. This morning on the way to working out and then to work I was lietening in particular to: Lecture 11: Nietzsche on Truth and Interpretation. This lecture expands on the quote you see on the right of this blog: There are no facts, only interpretations. - Nietzsche . As the lecturer expands on this discussion, I started to understand why yesterday's rant created such interest (8 comments by this morning). As I personally rate my rants, the number of comments provides me a good indicator of their effectiveness in stimulating thinking and interest. Reading the comments, and then rereading Sydney's column, I realize that I am working from a different context. Nietzsche would argue (or at least the lecturer is arguing for him) that we only have interpretation in our attempts at truth. All interpretations depend on the context in which one views the data. Our friend and frequent poster Bernie lives in a different contextual framework than I do. Thus, he views the same data but interprets it differently. Now unlike many politically correctness advocates today, Nietzsche does not assume that all viewpoints have equal value (of course, he is judging from his own context). I believe that the bio-medical model is the superior model for judging medical data. (Bernie might disagree - but then I should not speak for Bernie). As I read Sydney's column, she alludes to an important point. We must take all new data and put those data into our underlying context. What do we already know? Can we reconcile these new data with previous data? I believe that the best way to interpret new data uses the principles of evidence based medicine. One should not discount previous knowledge or expert opinion (I am a Bayesian, and therefore adjust my probabilities based on prior information). However, we should not ignore new data just because it does not fit current expert opinion. When the major study examining anti-arrhythmic therapy after MI came out - we all changed our context and practice - FINAL REPORT FROM THE CAST STUDY . The study results were unexpected and counter to expert opinion. The study had such compelling results that it overcame previous expert opinion and changed expert opinion. As one studies the precepts of evidence based medicine, one first learns the hierarchy of research designs. The randomized double blind controlled clinical trial is the epitome of research. Epidemiologic studies represent an excellent method for generating hypotheses. Perhaps my disagreement over Sydney's column involve shades of interpretation. I know many physicians who teach and practice evidence based medicine. They strive to interpret data in the context of previous knowledge and the quality of the new data. I agree that often the popular press does not hold the same high standard. Autism and MMR attracts headlines, and headlines sell papers. Even if most medical reporters understand the evidence and avoid the article, some other reporter will see this as a quick easy controversial piece to publish. So I would probably have written a similar article, but shaded it differently. In my mind we must remain skeptical of all new data and wait for the accumulation of supporting data prior to changing our contextual model. As a physician and scientist this seems natural. Perhaps Sydney's underlying message is that patients should remain just as skeptical. On Sydney Smith's Tech Central column Medpundit (Sydney Smith) and I often disagree on issues. We have communicated and agree that our public disagreements (on our respective blogs) advance thinking. Only when we have polite yet spirited debate can our readers be stimulated to think carefully about issues. In this spirit I wish to disagree with her latest Tech Central column - Medical "Truths"
Sydney does a nice job in this article of creating a straw man argument. She reasons that when she can show examples of incorrect analyses, that we can discard all analyses. She argues (I believe) that evidence-based medicine is futile because the studies are so often flawed.
She makes an interesting point about the article which supposedly linked MMR and autism. However, I believe that she targets the wrong group with her criticism. Certainly the Lancet editors made a mistake here. However, I am not aware of physician groups who endorsed this study as "evidence based medicine". Rather, "advocacy" groups of parents made this study a reason to avoid MMR. Most experts disagreed with the study at the time of publication. Sydney finishes with:
Wow! This sentence insults the entire field of evidence based medicine and medical research. What a powerful sentence! But the sentence is incorrect and an example of hyperbole. Those of us who try to practice evidence based medicine (and we freely admit when the evidence is not satisfactory to use) work hard to carefully evaluate the data. We rarely change our practice on a single study, unless it is a large, carefully done randomized controlled trial. One great web site for evidenced based medicine: Bandolier. The Cochrance collaboration provides outstanding reviews (requires a subscription). The advances in medical treatment over the past 25 years are incredible. 25 years ago we had no way to modify lifespan in CHF. Now we can greatly increase life expectancy for those patients. Similar stories exist in diabetes mellitus, coronary artery disease and many cancers. One should never regard a single study as the answer to our questions. However, as data accumulate we often can provide better care to our patients. We need more critical inquiry concerning published articles. We must put each new piece of information into context. If we do not do that, then we resemble ostriches. We have made much progress both in scientific inquiry and the careful criticism of published articles. Medicine progresses not in a straight line, but rather through fits and starts, in a jagged line. But it does progress, and our patients benefit regularly from that progress.
More on alcohol and heart disease The data continue to support moderate alcohol as cardioprotective. Study: Drinking May Help Heart Patients
Each study continues the general support for a drink or two each day. Clearly alcohol has a dose response curve. No alcohol or too much alcohol can harm us in different ways. I continue to favor moderate alcohol unless the patient has a known alcohol problem. Posted byWill Congress do the right thing? Congress to look at Medicare pay formula
This intention is a "no brainer". Everyone knows that the current formula has major flaws. We need to fix the formula, not the payments.
I certainly hope that Congress can pass a small bill to address this problem. But knowing Congress, they cannot think about one seemingly small problem at a time. Their effectiveness would increase if they did. Posted byRethinking our understanding of coronary artery disease New Studies Cast Doubt on Artery-Opening Operations. This important article does a very nice job of explaining our evolving understanding of CAD. Let me try to summarize the concepts - then go read the article. CAD has two components, first the deposition of lipid laden atherosclerotic plaques. We used to think that these plaques were static, and grew over time. As they grew into the lumen, they eventually obstructed arteries leading to symptoms. However, several observations over the past 10-20 years have changed that thinking. We now believe that plaques exist in a dynamic endothelium. Acute coronary syndromes occur when plaques rupture and release platelet aggregating factors. These PAFs attract first platelets - leading to the eventual development of clots - which cause acute vessel obstruction presenting as acute coronary syndromes. This current theory (with much convincing data) stresses inflammation leading to plaque instability and the coagulation system. We know that in acute coronary syndromes, opening the vessel helps in the short run. We also know that medication treatment remains very important. "Fixing the obstruction" does not cure the underlying disease. We now have increasing evidence that patients with stable CAD need not have obstructions "fixed" with surgery or stents. Rather we should stress aggressive medical management with platelet inhibitors (esp aspirin), beta blockers, ACE inhibitors and statins. This theory, which follows from available data, treats CAD as a dynamic disease which we can modify at the endothelial level. Now for a few quotes from this well researched article:
So for all those at risk for CAD and heart attack, we should follow a fundamental health prescription. Do not smoke. Keep our weight reasonable and exercise. Address hypercholesterolemia, especially with either a family history or diabetes mellitus. Treat hypertension. Posted byWarning on tuna Many experts worry about chronic mercury poisoning. An advisory panel has published new recommendations, with specific reference to albacore tuna. U.S. Issues Guidelines on Eating of Some Tuna
As the article states, the recommendations differ according to the type of tuna, with light tuna having less mercury.
CT colon studies Colon cancer screening works, but many patients reject current screening tests for a variety of reasons. "Virtual" colonoscopy sounds like a nice alternative. The prep is just as unpleasant, but the risks are significantly less. Gastroenterologists will support this technology, as it will increase their interventional colonoscopy business. Moreover, we do not have enough gastroenterologists to perform all the needed screening colonoscopies. Here is another study reporting on the diagnostic test performance of CT colonoscopy. CT Colonography Helpful in Cancer Screening
Not an overwhelming study, but another piece of data in the continuing story. Posted byWhat would Joe Friday say? There are no facts, only interpretations. Good news on alendronate (Fosamax) I rarely rant about osteoporosis, yet I probably should. Osteoporosis remains a major cause of morbidity and mortality, especially in post-menopausal women, but also in older men and especially those men and women who take corticosteroids. Thus, this report is very encouraging. Osteoporosis Drug Found Safe to Take for 10 Years
Yes this is important good news. One always worries about long term effectiveness. This study documents the answer to an important clinical question. Posted byChecking home BP - a better prognostic test Home BP Measurement More Useful Than Office Measurement
This study does make sense. We all know about white coat hypertension. When I was seeing private outpatients, I generally involved them in their hypertensive management by having them check their BP several times each week. We would use those measurements (taken at home, at a pharmacy or at the fire station) as the data that we used to adjust their BP meds. I always believed that this method had two positive outcomes. First, it helped the patient understand that BP control was their job, not my job. I can only help patients; I cannot take their medications, do their exercise or modify their diet. Second, the measured BP gave more and accurate data on their BP average (which isolated office BP did not do). This article reinforces my belief that the office BP can be spurious.
Worth reading
I have ranted concerning this general issue in the past. Science demands that we test and revise hypotheses. As a physician we must search for the best data and make decisions based on those data, understanding that we may change as new data appear. Read the long article for an update on a wide variety of interesting dietary, exercise, and even some medication issues. Posted byThis should scare you Around the Globe, Drug-Resistant TB Is Rampant. TB was once known as the white plague or consumption. Literature abounds with characters who died of this scourge. During my medical career, we have had great drugs to treat TB. Most patients have a quick and successful cure. However, due to a variety of factors, we now must once again worry about TB.
One of my colleagues studies this problem. Most strains are susceptible to more expensive medications. Someone must find the money to treat these patients properly. We in the US do a particularly good job at treating TB through our public health departments. For this disease we have model programs. As this epidemic spreads, it may well once again become a major health problem. Some would argue that it already is. Posted byOn fatty food, trial lawyers, and tort issues Congress is trying to take preemptive action against obesity-food lawsuits (like the poorly conceived McDonald's lawsuits. The trial lawyers are screaming foul! Fast food and fat lawsuits
Huh? This proposed law is necessary to prevent a series of lawsuits, spending the courts money unnessarily. But then the trial lawyers would like to argue about everything. Perhaps this law, and the movement behind it will start to help us develop a real sense of personal responsibility. Our country needs more personal responsibility and less blame. But perhaps the existentialism speaking. But probably that is me speaking! On HDL Is a high HDL really protective? This article discusses the controversy about HDL - Scientists Begin to Question Benefit of 'Good' Cholesterol
Medical advances occur because we (physicians and scientists) willingly challenge current dogma. We never assume that we know truth, but just that we function on our current best approximation. Fortunately, we generally make most decisions based on LDL levels anyway. HDL has functioned as a minor issue for most physicians. It may decrease from mino. Posted byMore on HSAs One of my loyal readers writes:
And that is the same plan that I currently have. The article is referring to the new law. This creates an entirely new option. I suspect that more companies and even the public sector will start to offer these new plans. The rollover benefit makes them a wonderful choice. They do require insurance with larger deductibles - thus you are expected to pay for the initial costs from your HSAs. I like the idea. Reread the money management article about them to pick up the nuances. Posted byHealth Savings Accounts - some details A Follow-Up on Health Savings Accounts
Hopefully, this explanation will help clear some misconceptions about these accounts. I love the control that these accounts provide. They make sense financially. They should also make many people think carefully about their health care expenditures. As I have said repeatedly, this thought process should lead to less demand for high cost procedures and medications. If that is true, we might actually get physicians and patients to become more cost effective. Posted byImplementing guidelines matters after MI Implementation of Guidelines Sharply Reduces Post-MI Mortality
Just another piece to the implementation puzzle. We know what to do for many conditions and many patients. Now we need to continue to study how to make certain that we give the most appropriate care to the most patients.
A breast cancer treatment advance This study suggests a strongly positive result - good news for postmenopausal breast cancer patients. Research: Breast cancer drug switch cuts recurrence
This study does give great promise to the majority of breast cancer patients. As scientists learn more about the biology of breast cancer, we may see even more advances. Great news! Sartre on freedom Yes I continue to listen to my tapes on existentialism. Currently, the lecturer is focusing on Sartre. Sartre's philosophy is quite complicated, but does include the concept of no excuses. I found this quotation particularly interesting.
Posted by NY Times editorial on PROVE-IT
The NY Times has a few issues right, and one or two that may not be right. Clearly, this study does make us reconsider how we treat coronary artery disease patients. The study does show that. My blogging colleague, Sydney Smith, disagrees - The Love Affair Continues. She and I have previously agreed that we can and should disagree on issues. I believe she is wrong on this one. She minimizes the benefit
Sorry Sydney, but Kaplan-Meier event rates are actual event rates. Kaplan-Meier curves allow one to evaluate the entire curve over time, rather than just comparing rates at one arbitrary endpoint. Therefore they are much more informative. If anyone wants to read the nitty-gritty on this subject - Survival Curves: Accrual and The Kaplan-Meier Estimate. As I read this study, the results are dramatic (and just in the first 2.5 years). As I wrote yesterday, the curves suggest that the results would become even more dramatic over longer time frames. The NY Times has no reason to suggest using higher doses as primary prevention. Primary prevention really is a different problem than secondary prevention. Extrapolating these data to the primary prevention problem does not make sense in 2004. The NY Times suggests that the cost of the higher dose (a difference of ~$600/year) would "drive up the use of high-cost drugs in a nation that is already struggling to pay its medical bills". They should consider the possibility that the decrease in mortality and hospitalizations could overcome the medication costs. We err when we look at medication costs without analyzing the benefits of decreased hospitalizations, decreased development of congestive heart failure, decreased bypass surgery, and decreased mortality. These costs are all important. Finally the NY Times is correct to point out the importance of head-to-head drug trials (a process which I have championed here over the past 2 years). Interestingly, and supportive of the results:
Yes, Bristol-Myers makes Pravachol - not Lipitor. Kudos to Bristol-Myers for sponsoring this important study!!
More on PROVE-IT Since posting last night, I have had a couple of interesting questions concerning this article. I would also like to link on today's news stories concerning this article. Finally, I would like to more explicitly give my own interpretation. Who should receive the high dose strategy? Why not just use pravastatin (Pravachol) at a higher dose? We must always remember that the patients in this study already had known, active coronary artery disease. This is a secondary prevention study. That being said, if one carefully reads the NCEP guidelines - Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) you will note that patients with adult onset diabetes mellitus are treated as if they already have coronary artery disease. One can (in my opinion) extrapolate the data to diabetic patients, but not patients with pure primary prevention (and no other major risk factors). Reading the study carefully, they used the highest dosage of each medicine which currently has FDA approval. Certainly, pravastatin at 80 mg might work, but we have no data, either on efficacy or safety. Today's news stories: New Conclusions on Cholesterol from the NY Times and Striking Benefits Found In Ultra-Low Cholesterol from the Washington Post. My interpretation of the data at this time:
Posted by PROVE-IT Study: Lower Cholesterol Helps Save Lives
For those who want to read the article from the NEJM - Comparison of Intensive and Moderate Lipid Lowering with Statins after Acute Coronary Syndromes and the editorial - Intensive Statin Therapy -- A Sea Change in Cardiovascular Prevention Several caveats for everyone. First, they did use a higher dose in the Lipitor group - the group that we call intensive (rather than standard) therapy. Second, all patients had acute coronary syndrome. We should not extrapolate the use of intensive therapy to primary prevention. Third, we must understand cost (sentence quoted from the Wall Street Journal) -
Given all these caveats, I would take the higher Lipitor dose (@$4/day) if I had an acute coronary syndrome. A Nietzsche Quote relevant to our malpractice web site discussion Whoever fights monsters should see to it that in the process he doesn't become a monster. Friedrich Nietzsche Posted byThe primary care problem While most watchers have not picked this up on their radar, I have been ranting about this issue for months. We do not have enough physicians going into primary care - because primary care physicians are treated poorly, both financially and with relationship to worklife balance. Apparently DO students are figuring that out also. Fewer new DOs picking primary care Posted byMore on autopsies My colleague, Stef, wrote this important comment concerning my post on autopsies:
These comments, while true, imply that we can extrapolate from these studies to all hospital deaths. That implicit assumption (which some may make explicitly) does not work. We must remember that those patients who have autopsies are not representative of all hospital deaths. Most physicians push harder for autopsies when they do not really understand what happened to the patient. Thus, the probability of finding new information is enriched in the autopsied patients. I favor autopsies in many patients. Usually I do not push for an autopsy in a patient who was terminal (i.e., receiving comfort care, managed by the hospice service). As this represents a large percentage of deaths on our services these days, we will have a lower autopsy rate than 50 years ago. I believe that many patients who had autopsies in the past do not receive them because we make more pre-mortem diagnoses, and thus treat patients appropriately, obviating the need for an autopsy. But then, I cannot prove that. Posted byOn the pneumonia severity index We have had excellent information on the pneumonia severity index in the past. This report re-emphasizes its usefulness. Tool Accurately Assesses Pneumonia Severity. If you want to use the index online, go here - Pneumonia Severity Index Calculator Another rant on the autopsy story Go read our favorite surgeon (Bard Parker) - No Black Crow Award Here. I like his rant - of course we agree! Posted byCOPD mortality risk index Interesting and well done study in today's NEJM. This report from Medscape describes the findings of a new COPD mortality risk index - Simple Grading System Predicts Mortality Risk in COPD On the autopsy rate The NY Times has, in my opinion, used their editorial page irresponsibly (once again).
When our patients die, we frequently request autopsies, but rarely will the patient's family approve. I am probably naive or just not smart enough to consider that I could avoid malpractice through the deceit of not asking for an autopsy. Most hospital deaths in 2004 are expected. Most dying patients are terminally ill. Autopsies can give valuable information, but they are not as important an information source as they were in the 70s when I started training (nor as important then as they were in the 30s). I suspect that the NY Times editor has watched one too many episodes of CSI. Most autopsies show a few surprises, but rarely many that would change outcomes. I favor getting more autopsies. They are instructive and help us understand medicine. They offer new important information less frequently than in the past. The NY Times editors have, as I said before, overhyped this issue. But I must give them credit, they have taken a bold stance. Perhaps they understand our motivations better than we do. Thus I will finish this rant with an existential thought (yes I am still listening to the tapes) - does anyone really know our motivations for our actions - even ourselves? The NY Times editors have attacked the medical community because they believe that they can attribute motivation to us. I find that assumption arrogant. Posted byMore on MRSA Given the number of comments related to the MRSA article, I thought that I would provide a few thoughts. MRSA refers to methicillin resistant staphylococcus aureus. For the non-physicians, that means that the old penicillin variants that we once use for staph infections (oxacillin, dicloxacillin, nafcillin) do no work to kill these staph. Staph infections commonly cause skin infections, like boils, but may cause even more serious infections. Where did MRSA come from? Bacteria develop resistance by natural selection and mutation (the purest form of evolution). Bacteria naturally mutate. When we use antibiotics, we always have a probability that a mutant strain (starting with only 1 bacteria) will occur. If that mutant has resistance to the antibiotic, then it will multiply and become the prodominant infecting bacterial strain. This process fits our understanding of natural selection perfectly. Unfortunately, staph infections spread easily between patients. Thus, once a mutant is selected and grows, it becomes capable of infecting other patients. Some bacteria more often develop resistant strains (i.e., they mutate more often). Staph does mutate often. Even with appropriate antibiotic use, the biology almost insures that resistance will develop. Over the past decade MRSA first became a problem in intensive care units, then hospital wards, and now the general community. The cow is out of the barn. We now assume that staph are resistant (unless we prove otherwise with cultures and sensitivity testing). Understanding how staph became methicillin resistant reemphasizes our need to use antibiotics prudently. They are great and powerful aids to treating serious infections. Whenever possible we need to use the most specific antibiotics possible. However, even with perfect antibiotic usage, we will still develop resistance organisms - genetics and evolution drive the development. Continued research into the mechanisms of resistance will enable us to "defeat" the resistance - at least for a period of time. We can blame the emergence of resistance on many people and antibiotic uses. Our obligation though is to use antibiotics intelligently for clear indications. This will slow the emergence (not stop the emergence) of resistance and give research the opportunity to develop the next generations of antibiotics. We have an ongoing struggle against bacterial, viral and fungal infections. We can win battles, but will always lose some battles also. Posted byMore on HSAs This comment is placed with the wrong rant. Therefore I will quote the entire comment and respond.
First I must defend AHRQ. AHRQ (Agency for Healthcare Research and Quality) is an important research agency. They have a meager budget (relatively) and deserve a larger budget since they fund studies which actually help us understand what works and what does not work in health care. The article quoted an individual from AHRQ. He has an opinion with which I disagree. That does not invalidate the agency. However, the commentor makes a very insightful point. We have advanced in medicine to patient focused decision making. Back in the 70s when I trained we generally functioned paternalistically. We rarely sought patient input into our decision making. Rather we told patients what to do. Sharing decision making represents a major advance in health care. If we follow that logic, then HSAs extend that concept. We who favor HSAs see them as a way for patients to more actively participate in their medical care. These plans increase patient's responsibility for their health care. As a physician I expect that patients will expect me to understand costs and explain advantages and disadvantages of differing strategies. As a patient, I should make medication decisions based upon knowledge of alternatives - especially generic alternatives. Economically these plans should do much to control health care costs. They do require a belief in patients. That is a very libertarian concept. Posted byOn MRSA Methicillin resistant staph will soon be the only staph that we see. Routine antibiotics just will not work against many minor abscesses anymore. Bacteria Run Wild, Defying Antibiotics
Clearly, we treat all suspected staph infections as MRSA until culture results prove otherwise. This has become the most prevalent and therefore the most important resistance problem. Posted bySome hospitals understand downstream revenue Hospitals hang on to money-losing medical practices A major problem in medicine stems from who gets paid and how much. Currently, the front line physicians (family docs, general internists) are struggling financially. They make significant money for everyone else in the health system. Some hospitals understand economics enough to support these groups.
Would it not make more sense for our system to reward these important physicians financially? We all know the answer to that rhetorical question. So why do we pretend that we cannot afford to pay these physicians? Posted byComments on the ACGME's new rules Beat the clock: The new challenges to residents
Here in our program, we are doing quite well. I have had to insist that interns leave a few times. They have a difficult dilemma. After admitting for 24 hours, then rounding for 3 hours, they only have 3 more allowed hours. If a patient has an interesting study scheduled, they really hate leaving until they know the results. They rarely want to stay for patient care (our system manages that quite nicely) but rather for their own education. So we have to say, sorry you must go home. In talking with attendings at other institutions, they express the opposite problem. They have told me that their residents do not seem to take as much responsibility for their patients as residents formerly did. The 24 + 6 rule is so arbitrary and without supporting data as to engender scorn from almost all of our residents and interns. How can we teach evidence based practice when our accredition body makes decisions without evidence? But these are the rules and we do the best we can. I am proud of our residents who remain committed to outstanding patient care. They have developed a system which adheres to the most important principle - outstanding patient care - yet allows reasonable work hours. They are not always happy about the rules (and some will ignore the rules regardless of what the attendings say). Most important, our residents worry about the patients first, and the rules second. I think that should be the focus of ACGME evaluations. Posted byThe debate over HSAs HSAs (Health Savings Accounts) immediately push observers into one of two camps. Libertarians and free market economists believe that they will lead to better rationing of care - patient directed rationing. Others argue that patient care will suffer because patients do not understand enough to ration logically. Consumer-driven health care: Bush, GOP back HSA expansion
That is the argument in favor of HSAs. Others remain skeptical.
People make bad economic decisions daily. This occurs through our economy. Those who favor HSAs (including this ranter) believe that patients will change their focus when asking for health care options. Most patients will listen to recommendations and be more likely to accept less expensive medications, rather than the newest medication advertised on television. Our current system clearly does not work. We should collect data to understand the impact of HSAs. I have had them for several years - and am a major proponent. Posted byTalk time to listen Common knowledge asserts that physicians often do not let patients tell their story prior to interruption. Many physicians apparently feel that patients will just talk forever, and that they (the physician) will not have time to ask their important questions. This research shows that we can let patients have their say. Length of patient's monologue, rate of completion, and relation to other components of the clinical encounter: observational intervention study in primary care Just go read the article - it is short and makes an important point. Posted byMore on cardiovascular effectiveness For those who have access to Circulation - this perspective on the effectiveness article that I cited last week hits the mark - We Must Use the Knowledge That We Have to Treat Patients With Acute Coronary Syndromes I will quote a couple of relevant paragraphs.
Our research group spends much energy trying to understand the best ways to help physicians do this. While it does seem simple to non-phyisician observers, the problem really has great complexity. We can easily write about acute coronary syndrome care, but physicians care for patients with many problems. How can we help physicians keep up with knowledge and practice changes for all the problems that their patients have? This commentary reemphasizes what our research group knows. Knowledge and efficacy studies are not enough. We must continue to study the problem of translating our knowledge into better practice. Posted byOn existentialism I have a hobby - I listen to books and courses as I drive. Currently I am listening to a college course on existentialism - No Excuses: Existentialism and the Meaning of Life . Several comments follow from this. First, if you are interested in lifelong learning about various topics, you should explore the Teaching Company. Second, as I listen to this course, I am finding much in existentialism that reflects my own personal philosophy. This interesting web page - Existentialism: A Primer - has this interesting quote as the author discusses existentialism.
While this philosophy (at least this abridgement) does not describe the philosophical underpinnings of this blog completely, it does come close. I particular respond to the free will, choice and personal responsibility concept. Since I will be listening to these tapes for the next few weeks, you may see several more rants on existentialism. I believe that philosophy has great relevance to medicine and the politics of health care. Having strong philosophic underpinnings allows one to develop a more consistent decision making process. As I learn more about existentialism, I will try to share my thoughts on this subject. On a light note, you might find this excerpt from one of Woody Allen's early movies thought provoking (or even funny) - Existentialism
Posted by Medicare and quality Many critics assert that we (the medical profession) should work harder on quality. This concept now carries great political weight. Here is what several critics say - The quality challenge: How best to raise the bar for medical care
But practicing physicians point out that measuring quality is much more complex than just examining a scorecard -
So we have tension. Should we measure and score quality? Should we ignore this movement because we believe it too philosophically difficulty to find good measures of quality? I sit on the side of starting to measure quality - as long as the quality measures predict outcomes. One would have a difficult time arguing that the quality measures used in this study (that I ranted about last week) were unimportant - Proper care of Acute Coronary Syndrome - effectiveness data. With this (and other studies) as landmarks, I believe that we can develop measurable quality indicators which lead to observably better outcomes. As long as we stick to that standard, then I favor the quality movement. Posted byA sad story, a happy story, an important message A Healthy Sense Of Urgency. (registration required) This article should help everyone reevaluate their priorities. Posted byOn breast cancer and antibiotics Several readers have written asking for my opinion on the antibiotic breast cancer link. Here is the Washington Post article about the study - Antibiotics May Raise Risk for Breast Cancer
My thoughts:
Overall, this article is interesting, but should not be over interpreted. We do not know that antibiotics cause breast cancer. We only know that one epidemiologic study found an association. Posted byWhether to prescribe antibiotics for bronchitis Antibiotic resistance represents a significant threat now, and in the future. Giving antibiotics for non-bacterial infections causes much of the problem. Physicians have a dilemma when patients have bronchitis. We just do not know whether whether we should prescribe antibiotics. A new study suggests that we may be able to use a blood test to help with that decision. New test shows promise at reducing unnecessary antibiotic use
Interesting! I hope we do see more studies on this test. Posted byMore data on the cardiac risk associated with the metabolic syndrome Posted by Proper care of Acute Coronary Syndrome - effectiveness data Many commentors (and this author) wave the flag of evidence based medicine to marshall arguments. Often we wave this flag without really understanding what the phrase means. We have 2 levels of evidence - efficacy and effectiveness.
- RE-AIM Framework: Efficacy/Effectiveness of Health Behavior Interventionsl In that context, investigators performed an important effectiveness study on the importance of following guidelines in ACS which derive from efficacy studies. Combined Medical Therapy Improves Survival After Acute Coronary Syndromes. This study is very important because sometimes efficacy does not translate to effectiveness. In this study it does!
This is certainly an important study. As I have written previously, our research group is focusing on methods to help physicians adhere to well accepted guidelines. This article reinforces the importance of our research. When we see such dramatic effectiveness results, it emphasizes the importance of helping physicians follow rational guidelines. Posted byMore on salt, water and potassium Must I Have Another Glass of Water? Maybe Not, a New Report Says We have previously discussed this issue, but this report does a nice job of putting the recommendations into perspective. Posted byWashington Post on why we do not need drug price controls
Drug pricing remains an easy target for politicians. I agree that many drugs carry prices that I consider outrageous. When we prescribe drugs for patients in our clinics, I generally consider price as part of the decision making. Several examples are relevant here:
We are handicapped often by inadequate information. The Washington Post understands!
Posted by A great quote This is a great quote. The reference is tangential - I was just reading a review of a book on greatness. But I love this quote, and will add it to my quote section.
Posted by Our neverending focus on narcotics I rant so often about this topic. But it is important, and a great dilemma. U.S. Is Working to Make Painkillers Harder to Obtain
This issue has no easy solution. Patients will suffer under the new rules. Abusers will figure out ways to obtain drugs. Physicians will get caught in the middle. But you know the story. The entire article is well done, and describes both sides of the issue. I particularly like this quote:
And rarely are these decisions based solely on science. Posted bySalmon - good for you or not?
Sometimes scientists perform solid studies but have unreasonable extrapolations of the data. From this report, we can surmise that to be the case here. I will not stop eating salmon! Posted byUsing BNP Peptide May Help Predict Heart Diseases. Two articles appear in today's NEJM which further our knowledge of B-natriuretic peptide as a diagnostic and prognostic blood test. My experience thus far (our VA starting doing them a few months ago) agrees with these articles. BNP is now part of my diagnostic and prognostic toolbox.
Posted by IOM nutrient recommendations Very interesting report - Institute of Medicine Advises on Water, Salt, Potassium Intake. The short summary: drink fluids moderately, water is no better than other fluids, eat less salt, eat more potassium containing foods. Posted byHIV in college students New H.I.V. Test Identifies Cases in College Students This is a sad and tragic story. The new HIV test, which diagnoses infection soon after exposure is very interesting. Posted byWHO on herbals WHO Issues Guidelines on Herbal Medicines
This is a huge problem. When will our Congress step up to the plate? Posted byThings Bernie writes Our frequent commentor, Bernie, often causes controversy. I am delighted with controversy. Often I just ignore his arguments, but today I will share some of comments and give me interpretation.
Bernie - please show some consistency. The malpractice crisis helps cause the financial crisis. It contributes to the increasing cost of health care. Those unnecessary tests cost money. And their results often lead to more tests - and yes iatrogenic illness. Sometimes doing an extra test leads to more testing and those tests can cause complications. Physicians are generally scared to discuss errors as they worry about liability. Everyone tries to avoid being sued. The malpractice crisis paralyzes change. Until we modify our tort system, we will not have the resources or energy to address iatrogenic disease. You also overhype this problem. It pales next to self-inflicted disease. And another great non sequitor from Bernie:
What a wonderful lack of connection! We have no idea what the danger of supplements is - because we have no required testing in the USA. That is the problem! We know the risks of prescribed drugs. We have reporting mechanisms, and physicians are alert to new dangers. With the supplement industry we have 2 problems: inadequate testing prior to selling supplements and inadequate standardization of ingredients. Without these two necessities, why would someone ingest these so-called remedies. I drink herbal tea - for the taste. I do not take supplements from health food stores, because they just might hurt me. I want data that they help and do not hurt. I want to know that if a patient is taking a supplement - I can look up the ingredients and understand what he/she is taking. I want to understand how the supplements might interact with medications that I prescribe. I do not think that my desires to help the patient should be trumped by a dangerous law. Patients need to know what they are taking. Is that such an unreasonable request? Posted byOn auto safety Perhaps this is a stretch, but one can argue that we should provide safety advice. If that argument does not convince you, then just read the article anyway. I admire Malcolm Gladwell and wait eagerly for his New Yorker pieces, which I consider the best medical/science reporting that I read. Big and Bad: How the S.U.V. ran over automotive safety. That SUV is more dangerous than your smaller cars! Posted byOn teaching hospitals I recently blogged about academic medicine - stimulated by our favorite surgeon blogger, Bard Parker. He has pointed out this important article concerning academic teaching hospitals - Multiple Missions Put Teaching Hospitals at Risk
The academic medical center is big business. Because it is big business, we often have mission confusion. At times the medical school and the hospital administrations are at war. So what should the priorities be? Are academic medical centers chiefly about education, or research, or patient care? Given current finances how many academic medical centers will remain "triple threats"?
So we have these large businesses that care for complex patients, perform major research projects and, oh by the way, train our future physicians (both students and residents). With these multiple missions, few centers do all well. And too often the education piece suffers. Posted byThe supplement industry redux Oh, but this reminds me of the famous tale - The Emperor’s New Suit. There is nothing there (speaking of the industry) and yet many Americans spend large amounts of money on supplements. At the risk of offending a reader, I will quote from his diatribe concerning Sunday's rant:
So he uses sophistry (see yesterday's rant) to argue for alternative therapies. I am a simple minded physician. I need data. I want to see what happens to patients who receive a therapy - do they improve or do they get worse or does nothing happen. Clearly, I try not to prescribe medications that have no effect. The commentor urges us to allow patients to make their own educated decision. Unfortunately, many patients cannot make an educated decision about their medical care. This argument stems from the general argument between science and belief. As a scientist, I want evidence that a therapy both will increase the probability of helping me and have a limited probability of hurting me. I certainly do not want to spend large amounts of money on placebos. The commentor argues that patients know. Of course, in the land of believers the anecdote is king.
This is a simply classic diatribe against medical statistics. We should not trust statistics - because they define outcomes precisely . With no apologies, this reasoning leads to many patients down the wrong roads. Many patients are not smart about their health. If they were they would not smoke, drink to excess, have multiple sexual partners, use IV drugs, or become obese. But they do!!! People often do not know what is best for them. Ephedra "helped" many patients - but at the risk of death! Patients died because of a bad law. Perhaps they should sue Congress (oops - you cannot really do that). We need a better law. We need to advance evidence as the determinant of medical decision making. When we have no evidence and someone wants to try either an off-label drug or a dietary approach - I have no objection, if, and only if, the patient fully understands the lack of data and the potential risks. The dietary and supplement industry presents themselves as authoritative. They are not, and they hurt many patients. Fortunately, they mostly just bilk naive believers out of their money. That is bad enough.
The New Yorker on the dietary supplement industry I will probably go buy this issue to have a better, more readable copy of this article. The author has done outstanding research and puts the entire industry into both historical and current perspective. I hope this link lasts (not sure about the New Yorker's links) - MIRACLE IN A BOTTLE I will quote a few key paragraphs to make some points and highlight the issue:
Those two paragraphs nicely summarize the effects of the DSHEA.
Obviously the key here is the advertising. You can obviously sell almost anything to some people with good enough advertising. Data are irrelevant.
I hope that these excerpts have whet your appetite to read the best single overview of the dietary and supplement industry that I have yet read. DSHEA respresents the worst of our political process. The government has put the citizenry at both health and financial disadvantage. I hope that common sense and good science can prevail. Unfortunately, I am skeptical. Posted byOn pain control I often rant about the dilemma of pain control. We (physicians) often receive criticism for inadequate pain control. We clearly have risk for overprescribing narcotics. This article discusses hospitalized patients and pain control - Pain Common and Often Undertreated in Hospitalized Patients
I find this difficult research to interpret. As an inpatient attending, I often ask patients about pain on rounds. The problem that we have is interpreting their answers and deciding how to treat. Treating pain requires some art. One never really knows how much pain a patient is suffering. This survey methodology obtains subjective data. Patient's recall of their hospital stay gives us some clues, however, we really need prospective data. Nonetheless, the message the we who care for hospitalized patients should attend to pain issues is an important one. Even more difficult is deciding on discharge pain meds. Posted byOn academic salaries Our favorite surgeon - Bard Parker (A chance to cut is a chance to cure) - blogs on this subject (unfortunately his links do not take you right to the story - therefore, scroll down to Thursday, Jan 29 and read - Those that can, do). Here is the question - Do academicians get paid for sitting around and contemplating their navels? Ok, that was sarcastic, let's quote Bard Parker's original post from January 24 (actually talking about Dr. Dean and his wife)
Sorry Bard you obviously do not understand how academic medical centers work. As a division chief, I am responsible for the budget for approximately 20 physicians. One can imagine the division as a medium sized business. Like any business, the moneys in must equal the moneys out. We have multiple sources of income, only one of which is "the university". According to a formula developed in our department, we receive a sum of money calculated from our teaching activities (fortunately we are paid for teaching - not true at all medical schools). We get moneys for clinical activites (after paying an exorbitant overhead). We pay our own malpractice (just like all physicians) and get no allowance for practicing less than full time. We get moneys from research grants - some of which pay faculty salaries. Some of faculty have paid administrative positions; some work part-time at the VA (which lowers their university and practice plan salaries). When you add up all of our sources of income they must equal or exceed the expenses. We pay the secretaries salaries. All the supplies, copy machines and computers come from our budget. Academic salaries are competitive only if the moneys are earned (and our faculty certainly earn their salaries). I find it interesting that you would publish some surgeon's salaries. Faculty salaries are (unfortunately) public record - regardless of how the money is earned. I have never seen private physician's salaries published. The university does not pay the salaries. The salaries are earned. Often academic physicians (especially surgeons) can operate more for two reasons - specialty referrals and housestaff who help care for the increased patient load. So I find the common perception of academic salaries from many practicing physicians inaccurate. We are paid just like all others. We earn money, pay overhead, and then distribute the "profits" as salary. We are not very different from private practice, except we have more diverse income sources. We still must meet a bottom line. Posted byHow dangerous is cannabis? Long time readers know that I favor legalizing drugs, especially marijuana. As penalties for marijuana decrease in GB, they are having a heated debate about the wisdom of that policy. Is cannabis a risk to health?
Cannabis is not benign. Nor is alcohol, nor are cigarettes. We must change the tenor of this debate. The question which I believe should drive our decision making is: Do our current laws benefit society and individuals? I believe that they do not. They criminalize a drug which many enjoy. By making marijuana illegal with (at times) several penalties, we might well cause a disrepect for the law. Many students develop a cognitive dissonance between what the see and what the law says. It would be difficult to make the argument that alcohol is less dangerous than marijuana - in fact I could easily make the counter argument. By having marijuana illegal, we make its use part of a "drug culture" that may well lead many to try other drugs. I feel strongly that we must rethink our approach. We must understand the risks and benefits of making marijuana illegal. Primum non nocere. Posted byInflammatory markers and coronary artery disease About 15 years ago, I first heard that we would focus CHF treatment on the neurohormonal response. The first time I heard this concept, I had a paradigm shift which has continued to this day. We improve quantity and quality of life now that we understand how decreased ejection fractions lead to progressive heart failure (it is not simply hemodynamics). A similar paradigm shift is occurring in coronary artery disease. Multiple studies point to the inflammatory response as a major risk factor in which patients with strutural disease have the dynamic problem of intimal rupture, release of platelet activation, and clots leading to myocardial infarctions. While we have focused primarily on C reactive protein, several studies have pointed to other inflammatory proteins as potential markers. Today's JAMA has an important study concerning another such protein. Here are two links about that article - Study Links Heart Attacks, Protein and Placental Growth Factor Helps Determine Prognosis in Acute Coronary Syndromes. This article adds to a growing literature which focuses on both predicting the risk of MI and on understanding the pathophysiology involved. How do we put this article into perspective?
The article's authors speculate further:
This study adds to a growing body of knowledge. While these studies do not yet effect therapy (and some of our current therapies probably work to decrease the inflammatory triggers), I suspect that we will have new exciting treatment avenues over the next 5-10 years. We should watch this story unfold. Posted byOn panic attacks True panic attacks are hard for us to understand. I found this description on a web site:
Having made this diagnosis several times - with excellent treatment success each time - I have taken an interest in learning more about the disorder. Today's NY Times has an interesting article about panic attacks - Panic Spells Are Traced to Chemical in the Brain
Rangel wrote about panic attacks recently, with reference to another blogger who criticized Dean for having a history of panic attacks. Read Rangel's assessment - Howard Dean has suffered from anxiety attacks and remember that we are considering a disease not a human frailty. Posted byACE-I preferred over Calcium Channel Blockers I preach this, but until this review I did not have a great reference. Now I do - The Differences Between ACE Inhibitor-Treated and Calcium Channel Blocker-Treated Hypertensive Patients
Posted by An interesting study Tennessee doctors to get paid for "doing the right thing"
What a great project! I certainly hope that they can do the study properly, and that the results fit our preconceived notions of what we should do. Hopefully more groups will take this challenge. Positive results could fundamentally change how we practice. And that would help everyone. Posted byWhat does being a physician require? Generation gripe: Young doctors less dedicated, hardworking?
Can we have our cake and eat it too? Can we function as excellent physicians and yet still have time for a full and rich personal life? The younger generation has, in my opinion, a more complete perspective. Too many physicians have worked so hard, that their personal life and personal growth have suffered. Medicine is a great profession, but it need not devour ones entire life. Being a physician did and does require great dedication. However, if one functions in that role 24/7 then he/she will likely burn out at some point. The burn out is evident in broken marriages, drug addiction and depression. Most physicians my age have doubts about their career choice.
These answers tell me that the old ways no longer make sense. We can take great care of our patients and balance that with a full and rich personal life. Our patient care will benefit. Our families will benefit. And we will benefit. Posted byHSAs continued My frequent commentor, Fakeo Nameo, writes:
Fakeo develops a strawman which stands tangential to the main issue. HSAs would encourage you to consider Prilosec OTC rather than insist on Nexium. They would encourage you to ask your physician to develop a lower cost regimen for your antihypertensives. They may even discourage your insistence on having a CT scan when none is indicated. They will not effect big ticket expenses - nor should they. Rangel has continued his discussion - A small example of how HSAs might work with a nice relevant discussion. Robert Goldberg in the Washington Times pens this heartfelt opinion - When family matters most
HSAs will increase patient autonomy and make the costs involved in quality health care more explicit. I do not understand how that can be anything but a major improvement. Posted byNY Times dislikes HSAs
I believe that this benefit will help the middle class a great deal. Higher deductible insurance should save money. Putting money into a tax-free savings account makes sense to prudent people of many economic strata. Their accusations sound like economic class warfare to me. This editorial takes a cheap shot at Bush. I would expect more from the Times. Time out. Maybe I should not expect more. Posted byObesity costs us money Study: Taxes Pay for Most Obesity Costs
Obesity is everyones problem. Obese patients cause health care costs to increase (in a disproportionate fashion). Therefore the increasing obesity burden raises my insurance costs. And the obese raise our Medicare expenditures. That we must as a society address obesity is not a new thought. Placing this battle into an economic perspective makes sense. I still believe that the obese should have to pay higher insurance premiums. You should be rewarded for a healthy lifestyle. A move to HSAs would place the burden of obesity on the obese. Maybe that would change behaviors. Medpundit has a different take on this issue - Wages of Sin:
More on Edwards As usual, Rangel is all over this issue with a long, well considered post - Democratic candidate John Edwards and how he got rich Posted byEven more on HSAs Rangel is doing a great job! He started discussing HSAs recently and continues with this outstanding piece - Health Savings Accounts (HSAs); The most important legislation of 2003! Please read his entire rant, but if you would rather just read my excerpts, here goes:
The economic underpinnings of HSAs makes so much sense that I cannot understand why the Democrats oppose them so much. I have had an old fashioned Medical Savings Account for several years. The tax savings has made this worthwhile. I no longer buy dental insurance, because I figured out that I saved money using MSA moneys for all my dental care. Rangel has nailed the insurance industry. We should always understand our expected gain (or loss) prior to choosing a plan. If you are healthy, the gamble (albeit a relatively small one) on high deductible health insurance is a smart one. But then you will not hear this in New Hampshire this week.
On Health Savings Accounts Read Rangel and his link to the NY Times article - More ideas on HSAs His article and the NY Times article lays out the debate over whether HSAs will decrease health care costs. This interesting perspective from the NEJM (subscription required) - "Me-Too" Products — Friend or Foe? - addresses this issue, albeit indirectly.
While the article discusses much more, that one paragraph cogently summarizes one of the major financial problems of our health care system. HSAs could address this issue. Posted bySupersizing I have no comment as I have commented excessively on this issue. But read it anyway - The Widening of America, or How Size 4 Became a Size 0 Perhaps my last post on "great cases" I appreciate the many comments on my two previous posts. One struck me
This is a very interesting and cogent point, however, this is tangential to the point of the rant. My concern is in how we as physicians talk to each other. If my words are accurate then as a teaching attending I convey important meanings to my trainees. We strive to teach professionalism in training (it is actually explicit in Internal Medicine training these days). One method for teaching professionalism is role modeling professionalism. To me that was the point of the resident's post which started the entire discussion. When we forget to respect patients such as the one which started this discussion, then we have lost part of our professionalism (in my opinion). How we act at the bedside is an entirely different discussion which we may have another time. Posted byMore on great cases! Well that post got some attention. I wrote the post from the perspective of a teaching attending. Words are important. I pride myself in semantics. We should say exactly what we mean. Our words in medicine should convey our meaning explicitly. As a teaching attending, I have a responsibility to be a role model (Unlike Charles Barkley). My words must convey meanings and feelings. Thus I disagree with a couple of commenters. I should remind the students and houseofficers that we are taking care of people, not diseases. Each time I uttered the words sad case, I reemphasize that point. Each time we use the term great case in a matter other than I proposed, we are forgetting the patients. We need some emotional detachment - just not too much. We need to learn to compartmentalize our feelings and not take our work home too often. Nonetheless, if we lose our empathy than we start to lose our humanity. Medicine is based on science, but it requires art. When we focus excessively on the science, our patients eventually suffer. And, I believe, we do also. So I will stick with my strict definition of great case. Students, interns and residents have complemented me when I make that explicit distinction on rounds. And I feel better about myself. Posted byGreat cases, interesting cases and sad cases Rangel has blogged eloquently about this subject - The humanistic paradox of the study of medicine. In this rant he cites A Great Case. I will not repeat these excellent posts, but will offer my personal definition of how I encourage the use of these phrases.
I submit that all medical educators, housestaff and students should adopt this classification system. The meanings are clear and convey the right messages. As physicians we can find a patient's illness intellectually stimulating and yet unfortunate. That circumstand is not a contradiction. However, we should reserve great case for those patients who stimulate our intellectual needs and that we help dramatically. I (and all physicians) long for the truly great cases! Posted byThe difficulty of practice One of the problems that I have with our current malpractice system is the artificiality of the process. Malpractice lawyers use a bag of tricks to make a complex decision seem like a straightforward one. One cannot easily convey the context of the decision either on paper or in testimony. This essay from the LA Times does convey many features of the complexity and number of decisions that one physician is making with just one patient. A doctor's daily round of judgment calls
I recommend the entire article. It reminds us the medicine is practiced much more easily through the retrospectoscope than in real time. We all second guess our decisions at times. All bad outcomes lead to introspection. What could we have done differently? What clue did we miss? Should I have gotten a different consultant? Medicine is a challenging and wonderful profession. I love the intellectual stimulation. I thrive on the complexity. If my patient has a bad outcome, when is it inevitable, and when is it my fault? And who should judge? Posted byWhen the flu vaccine contains the wrong strains Posted by A poorly thought op-ed by Maureen Dowd Medpundit addressed this issue yesterday - Defending Dean. Today Maureen Dowd attacks Dean's wife because she continues to practice rather than campaign with her husband. The Doctor Is Out The NY Times (who ran an article yesterday and the op-ed today) and their ilk apparently do not understand. Medicine is an important profession. Many who choose medicine feel that what we do transends politics. Dean's wife - Dr. Judith Steinberg Dean - practices medicine. She is apparently dedicated to her chosen profession. Why would anyone expect her to sublimate her career for her husband's? Working with many medical couples in training, I see separate physicians, each working on their chosen avocation. Why should his aspirations impact her career? What do I not understand? Bravo to Dr. Judith Steinberg Dean! She likes seeing patients - so that is what she will continue to do. The heck with this political stuff. BTW, this does not change my opinion of Dean. Nor should it. Posted byResident work hours redux I try to write clear paragraphs. Please read this one carefully.
Note that I have not attacked the 80 hour rule. In fact, we try to get our residents at 70 hours or less. My only angst is the 24 + 6 rule. Let me reiterate the problem. An intern comes to work at 7 a.m. to preround. She admits all day (maximum of 5 patients). She likely gets a few hours sleep. This next morning we make rounds from 7-10 a.m. Under the rules she has 3 hours left to get all her work done. Several patients have diagnostic studies done. She would like to see the imaging studies and discuss them with the radiologist. She would like to go to noon conference (it is on a topic that she is very interested in). But the ACGME insists that she leaves by 1 p.m. She hardly has time to check out her patients. Perhaps she has the next day off. By the time she returns in 2 days, her chance to review the imaging studies loses its urgency. She looks at the films, but the educational impact is decreased. I am not saying that she should . Rather I am saying that she should have the option of staying. Posted byTreating h pylori to prevent cancer I ranted on this subject in November 2002 - Screening for h.pylori. A recent study adds more support to empirically treating patients who are h pylori positive - Antibiotics May Help Stop Stomach Cancer This study is not definitive. Given the lower rate of h pylori positivity in the US, we will not yet advocate general screening. However, the data and concept should continue to receive attention. Posted byResident work hours - still a cause of angst Our favorite surgeon - Bard Parker - first alerted me to this story. His post - More 80 hour work week stuff - does a nice job of outlining the problem. Rangel has a relevant post also - Apparently some residency programs are still overworking their residents. Long time readers will remember that I have ranted often about this issue (just use the handy dandy search function to find my previous rantings). I will start with my conclusion, then share my angst. Generally the new rules are working. They have improved the quality of life of many houseofficers. I still worry about patient care. I still worry about education. Most programs have made significant modifications to meet the ACGME requirements. I have written in the past about our adjustments. These adjustments give us houseofficers who are better rested. When they are available they are easier to teach (because they are awake!). You do have to work harder to insure continuity of care. Pass offs are difficult. In our system care becomes a team phenomenon - we (the attending, resident and both interns) must really know all the patients. Someone (other than the attending) is gone most days, thus we are consistently picking up "the slack". My angst relates to the interns. Internship is an important stressful year. During that year you learn the fundamentals of patient care. Hopefully you learn the difference between sick and very sick. You hone your clinical instincts. The great majority of interns with whom I work are very dedicated to their patients. They do not want to leave the hospital because it is time to punch their time card (we do not yet have a time card system - but I believe other programs do). Sometimes in medicine you should stay. This is why the main objection that I have to the new regulations is the 24+6 rule. Interns have the most angst post call. They want to get everything done right. Sometimes that takes 8 hours rather than 6 hours. Many residents have concerns about patient care related to the new system. Residency is a time to develop an ethic about patient care. Do these new rules send the right message? So I was conflicted prior to adoption, and I remain conflicted. On the whole we have a better training program. I am greatly in favor of the 4 days off each month (and sometimes have been able to give housestaff an extra day during the month). The 80 hour rule is important. The 24 + 6 rule still gives my angst. Rangel has a link to the book - House of God. Hopefully all medical students and residents do read this book. Then I hope that they put the book into perspective. Students and houseofficers, unlike their age matched education match peers, deal daily with death, self-induced morbidity and the horrors of illness. We all need some humor to deal with these stresses. The House of God uses exaggeration to make those points. Unfortunately, I disagree with the protagonist's final decision. Many of us lived that book, and matured into caring dedicated physicians. I wish the ACGME was less draconian in their regulations. Since I resent all bureaucracies, I find this particular one no better than others. We need some common sense in interpreting these rules. Else, our next generation of physicians just may not learn the "right stuff". Posted byWhy the flu vaccine is less effective this year This story explains the problem of choosing the right strains of influenza to develop a vaccine against. For Health Officials, Flu Shot Is an Annual Gamble Posted byOn crystal meth A scary story - The Beast in the Bathhouse
Geek humor This really has nothing to do with medicine, but I found it drop dead funny. But then, I guess I am a geek. When the universe is expanding it can make you late for work - By Woody Allen And it is great to see that Woody Allen still is capable of creating funny pieces. Posted byA contest to improve our health care system Patient-centered model offered as road to reform
So what did the winner propose:
Hmm, we would pay for a primary care physician (I have reinterpreted coach to physician). We would have a personal savings account (sounds a lot like a health savings account). I wish the article had more details on the winning plan. I am glad to see it was not universal health! Posted byRising health care costs - Rangel knows why If you do not read Rangel regularly then you should start. He absolutely nails this topic - Health care costs continue to increase (and I think I know why)
Rangel bolded that last sentence. He is correct. Online consultations medmusings gets most of this right - The Online Doctor Visit Will Become Common When Patients Insist on it I would only suggest that some reasonable modification of retainer medicine will speed up acceptance of online medicine. Our billing systems, i.e., having to bill for each separate portion of care, really make no sense. We could either bill for time spent (but this would be a record keeping nightmare) or go to a flat monthly (yearly) fee. This would cover telephone access, internet access, filling out forms, office visits and hospital visits. The idea is really not that outrageous once you consider it carefully. Afterall, surgeons get paid for the operation and not the visits before and after - they get one all inclusive fee. You could make this more complex by charging different fees for different diseases (or more for several diseases). My main point - our reimbursement system is the biggest problem we have in providing the proper care for our patients. The incentives are malaligned for the physician to provide the most reasonable and complete care for patients. Patients should complain about our insurance system. It is the reason they have a difficult time finding a good doctor - one who will spend adequate time with them; one who will answer their telephone calls; and one who will gladly communicate with them by email. And patients would benefit!!! Posted byTime and primary care I rant incessantly on this topic - on December 31st I ranked time as the number 1 story of 2003 (for this blog). I said:
Family Medicine Notes says it better - Rectal Exams
And patients appreciate it. And patients expect it. Yet no one really pays for it. Posted byNot news - dermatology is hot! This trend started when I was in medical school. It has increased as the percentage of female medical students has increased. Young Doctors and Wish Lists: No Weekend Calls, No Beepers For me the shame here is that the best and brightest no longer clamor for internal medicine slots. This rant comes from my heart as an academic internist. I apologize if I insult anyone. Internal medicine is the cornerstone of adult medicine. We encompass a wide variety of complaints, and excel as diagnosticians. More recently, we have acquired the expertise to juggle the many medications that our sickest patients take. Internal medicine is the common ground for all patients. We care for the complex with the aid of other specialists. In medical schools, internal medicine generally represents the key rotation of the 3rd year. We win the teaching awards. We use physiology, pharmacology, biochemistry and anatomy daily. In the old days, the best and brightest aspired to become internists. We all wanted to be Sir William Osler. But times have changed.
For me internal medicine represents the pinnacle of science and human interactions. I see too many students who like internal medicine but elect other specialties for "lifestyle" reasons. I guess we need to fix the internal medicine lifestyle. But then I rant about that incessantly. Our payment system influences lifestyle. As usual follow the money if you want to know the real issues. Lifestyle is chic to blame. But it requires excellent reimbursement to adequately control lifestyle. Posted byClinical trials do change our behavior Prescribing Patterns Respond to "Bad News" Findings of Clinical Trials
Now we just need to control the media!!!!! We can get our message out to all physicians if we just controlled the media. What a thought! The above paragraph is meant to be sarcastic. I hope readers understand this meager attempt at humor. Posted byCardiac risk factors in chronic kidney disease While cardiac prevention gets most of the publicity, increasingly we should become aware of preventing heart disease in chronic kidney disease patients. Nontraditional Cardiac Risk Factors Prevalent in Kidney Disease Patients Posted byMore on CRP as a risk factor Print out this article as a handout for patients who have questions about CRP. Hunt for Heart Disease Tracks a New Suspect
Certainly food for thought! Posted byMore on stereotyping physicians Rangel weighs in - What's Dean’s problem? . . He's a doctor! Let me respond a bit to Rangel. I dislike Dean as a presidential candidate. He changes positions too often, and has too many misstatements for my comfort. I disagree with him strongly on foreign policy. However, none of those criticisms has (or should have) anything to do with his medical training. My objections to his candidacy are based on his platform and his campaigning. But medicine has nothing to do with it. I suspect that if Medpundit reconsiders her original post on this topic, she will withdraw some of the hyperbole she employed. Posted byAn endorsement of the Medicare Bill Medicare reform helps doctors and patients
So the short run news is good. Could Congress possibly have the common sense to treat the disease rather than the symptoms? Even this Pollyanna remains a skeptic. On Dean as a stereotypical doctor I must differ with Sydney Smith on this one - The Doctor Factor
I either grew up in a time warp or my medical school and residency were just much more humane. I have no recollection of such treatment. As a teaching attending I hope (and believe) that I have never treated students or residents like that. Now I must admit that some doctors fit the description.
I see less of this all the time. Such personality flaws are certainly not limited to medicine. Many lawyers fit this profile. Many businessmen (and businesswomen) fit this profile. Famous sports figures fit this profile. While the original author backtracks a bit and admits using sarcasm, still I find the writing of this opinion piece, even if meant to be humor, as a personal insult. We should not attribute characteristics of a group to an individual, whether race, gender, location (Southerners), vocation or avocation. I write in defense of physicians, who happen to span the breadth of human frailities and goodness. I see no truth in the essay, and cannot do anything but condemn such writing. db steps gingerly off of his soapbox, somewhat angry but feeling better after venting! Posted byMore on ephedra My frequent commenter - Bernie - believes so strongly in "natural" remedies that he ignores the data. He uses a variety of strategies to make his points. A recent comment:
Another commenter responds accurately:
One of my greatest objections to the dietary and supplement law is the lack of information on what you are ingesting. These products do not have dosage standards. Ephedrine and pseudoephedrine (two of the active ingredients in ephedra) come in known precise dosing. We have carefully designed studies to define safe dosing. We (the concerned medical community) are asking for the same standards on the dietary and supplement market. Patients (and their physicians) should know what they are taking. Supplements should pass safety standards (at least). We need precise information on risks. And who can really argue that those desires are unreasonable? Posted byA psychiatrist learning about side effects
This article tells an important story. As physicians we must understand side effects, explain them to patients, elicit them from patients, and document our discussions. Posted byHospitals rebel against nursing staff requirement
This is a good law and a good interpretation. As often seems to happen, the hospitals worry more about the cost than the outcome. Nursing staff ratios are important for patient care. Posted byIt is the portion size Researcher Links Obesity, Food Portions
Hmm. I have ranted about this concept in the past. How many of you complain about small portion sizes at restaurants? How many of you choose a restaurant because they have "generous" portions? Posted byOn vascular surgery I blogged on this story a few days ago. Our favorite blogging surgeon provides a more complete rant today - Practice Makes Perfect III Posted byPossible new antihypertensive class New Renin Inhibitor Curbs Essential Hypertension A very interesting development that we need to follow.
Posted by Washington Post on the ephedra ban
I rant about this issue incessantly. I will continue to rant about this law. This is a huge public health issue. Posted byOn mercury and health Friends often ask me about the risk of mercury from eating certain fish. This commentary gives one answer - Fishy warning about mercury Posted byFood recommendations My family will love this article, as these are foods we all love. And they seem healthy! Simple choices can boost nutrition in 2004 Posted byMore women in medical school Less than 10% of the students in my entering class were women (1971). Even that was considered a major step forward. The profession is changing. For first time, more women apply to med school
This is great, but ... We must reconsider all our projections on numbers of physicians needed in this country. Women (in general) have a better sense of balance and just will not work the ridiculous hours that many men worked in the past. This means that we will need more physicians for the same number of patients. Posted bydb's top ten medical stories of 2003 This list represents my arbitrary ranking of the top ten stories covered which I covered this year. Factors which I used to develop the ranking concern the health of patients and the medical community. Limiting and ranking the list proved much more difficult than I first thought. Readers will disagree with my list, and I invite you to submit your own. I ranked stories higher that I thought had "legs", i.e., we would continue to rant about this story in 2004. Honorable mention Increasing HIV in young gay males in the US - this story should scare all The pharmaceutical industry - it was very difficult to leave this issue of the list, however, many stories on the list relate to the pharmaceutical industry The COMET trial - very important, but also fairly specialized information Quality assessment - I had some interesting rants on this issue and it may emerge as even more important over the next few years Alternate payment structures for outpatient practice - these include a return to fee for service with no insurance billings and retainer medicine And now for my list: 10. The influenza epidemic - this story shows the challenge of prevention. The CDC had to guess on the strains to include in the influenza vaccine. They guessed wrong, but seemingly made the best guess possible given the data they had. 9. SARS - this story reminds us once again how vulnerable we are to infectious diseases. We are unlikely to consistently defeat infections. The potential infecting agents are too numerous, and therefore we become susceptible to mutations that naturally occur - some of which are deadly. 8. ALLHAT - I ranted extensively on this subject. This study asked a the wrong question. The principle investigators overhyped the results. The study certainly reminds us to include a diuretic as the first or second line drug. It also reminds us that the most important variable is hypertensive control. Finally, it demonstrates that we should not take results at face value. 7. Preventing type II diabetes mellitus - this should rapidly become a major focus for preventive health. We have three major avenues - weight loss, exercise and medications. Future studies will help us learn how to approach "prediabetics" and how aggressively to screen for "prediabetes". This story gain improtance due to the epidemic numbers of affected patients. 6. Obesity - this is a curse of Western civilization. We must develop positive programs to decrease obesity. Obesity puts patients at great risk for many problems, including type II diabetes mellitus. This story will not shrink anytime soon. 5. Medical marijuana - one could argue that I ranked this story too high. However, I believe that the intrusion of government into palliation represents a serious dilemma. The story about pain control that I ranted about yesterday represents the corollary issue. We must be able to better study and understand the benefits of marijuana in patients. Many citizens agree, and have voted in favor of these laws. 4. Dietary supplements - we have an illogical law pertaining to supplements. The ephedra fiasco represents the tip of the iceberg. Too many patients take too many supplements without any understanding of how they may effect their bodies, interact with pharmaceuticals, and even interact with each other. 3. The Medicare Bill - we are just starting to understand this bill, its strengths and weaknesses. Regardless of ones opinion, we all recognize this bill as a sea change. Future Congresses will likely modify features of the bill. I expect to rant often in 2004 on the bill's effects 2. Medical Malpractice - we need true tort reform. We need a totally different system for insuring high quality care. We need a system which does not resemble a lottery. We need a system that protects patients and physicians alike. Our current system is broke - therefore we must fix it. 1. The time pressures on outpatient generalist practice - this is my number one story because I consider myself an advocate for generalist physicians. We ask our generalists to do more each year, and then structure a reimbursement system that pays them a fixed amount for a visit - regardless of the time necessary. It takes time to follow guidelines for prevention. It takes time to explain disease and management to patients. We must fix this problem to provide better quality care. Many non-physicians think we can fix this with midlevel providers. To that I say "balderdash"! As we learn better how to care for patients the complexities of patient care increase exponentially. It does take a physician to do it right - and a physician with enough time. Not solving this problem will continue to have a major impact on overall patient care. This is our true health care crisis. ================================ Thank you for reading my blog. The readers continually stimulate me. I hope that I give you food for thought. I hope that medical blogging will eventually provide the grassroots for improving the medical care system. But then I am eternally optimistic. Happy New Year's to all. May the coming year bring you health and happiness. Posted byNeed abdominal aortic aneurysm surgery - find a vascular surgeon The surgery your doctor shouldn't perform
This article makes some very important points. As a generalist, I know that one of my obligations to patients is to understand the limits of my expertise. If I rarely take care of a problem, then I need a consultant (SLE, interstitial lung disease, inflammatory bowel disease are but a few examples). General surgeons should understand their limitations. As I read the article, apparently many surgeons do not understand. Caveat emptor!! Posted byDamned if you do, damned if you don't (or how to get caught between a rock and a hard place) Worried Pain Doctors Decry Prosecutions
On the one hand we (physicians) are urged to attend to pain. To not address a patient's pain issue leaves us open to intense criticism. This guideline addresses the issue - MODEL GUIDELINES FOR THE USE OF CONTROLLED SUBSTANCES FOR THE TREATMENT OF PAIN
We have adopted pain as the 5th vital sign. This VA document discusses the importance of attending to pain - Pain as the 5th Vital Sign: Take 5. Pain control challenges us daily. We have no great objective quantification of pain. Patients can fool us. Thus we are damned if we ignore and damned if we treat too aggressively. This story is scary. We need a better method for controlling physicians who overprescribe pain medications. DEA arrests are not the answer. Back to our article -
Amen! Posted byEphedra - banned! Bush Administration to Ban Ephedra I have ranted extensively about ephedra - just go and search for multiple rants (22).
And if ever a law needed rewriting - this law does!!!!!! Posted byInfant formula companies and breastfeeding Just go read it. You will be amazed. Or you might not be. The Milky Way of Doing Business by Katie Allison Granju Posted byOne of the unintended consequences Sometimes I feel like a broken record. I rant about the working conditions for physicians. I rail about the bureaucracy which now increasingly surrounds medicine. Mostly I complain about a reimbursement system which makes no sense. The outcome of this and other problems is a growing physician shortage. Physician shortage predicted to spread
If we had a reimbursement system that reflected supply and demand, then we would have less problems. When bureaucratic decisions determine fees, then we have the consequence of winners and losers - independent of needs. When malpractice awards run amuck in some states, then those states will have some physicians leave and less enter. It only makes economic sense. So as I rant repeatedly, we have a growing health care crisis, only it is not the one that the politicians yet understand. But if we do not correct current trends it will worsen. And as usual the patients will suffer with less adequate care. Posted byOn bureaucracy Does bureaucracy drive you crazy? Most physicians rail against bureaucracy. I found this page with great quotes about bureaucracy. First a couple of gems:
Now the link - Bureaucracy Quotes I also found this great page - Quotations on Bureaucracy and Public Administration A few more gems:
Both pages have many more chuckles (albeit bittersweet chuckles). Posted byOn the psychology of pharmaceutical trade names The Science of Naming Drugs (Sorry, 'Z' Is Already Taken)
And I just hate that he is correct. But he is correct. And that says something about marketing to physicians and patients. And it just should not matter. But it does. Posted byThe top ranting subjects of 2003 I started thinking recently about the major impact medical stories of 2003. This is a work in progress, and I need your help. This rant will just list (in no particular order) stories which captivated me and the commenters this year. I plan to consider them all week, and elicit your opinions. On New Year's I will put them in order with some comments.
Which stories do you find most interesting and important? Thanks in advance for your opinions! db Prather on health savings accounts As we start to digest the monstrous Medicare bill, we find the good, bad and the ugly. HSAa are in the good category. Robert Prather has championed this idea on his excellent blog for the past year at least. He addresses the issue once again with reference to the bill - Maybe I (Mis)Underestimated The Reforms In The Medicare Bill I have nothing substantial to add. He has nailed it. A surgeon's take on the appendectomy issue Posted by Laparoscopic appendectomy They work better than traditional appendectomy. Less invasive appendix surgery means faster recovery Posted byA good article on Type II Diabetes Mellitus Stampede of Diabetes as U.S. Races to Obesity
We as a society need to aggressively address this epidemic. We need to make exercise easy, safe and inexpensive. We need to all learn how to eat less and better. We must make personal committments to care for our bodies. And it will not be easy! Posted byGabapentin (Neurontin) works for chronic daily headaches I posted 3 rants on Neurontin in May and July - The whistle blower and Warner-Lambert, The Neurontin story, and More on Neurontin. These rants received many comments from angry users (who blame many side effects on these drugs. One of my guiding principles is to carefully look at the data rather than anecdotes. Thus, this article caught my eye - Gabapentin Safe, Effective for Chronic Daily Headache. CDH patients challenge the best physicians. You know something is wrong, but you do not know what, nor how to help. You would like to avoid chronic narcotics, but does anything else help?
So do these results make trying this high dose of gabapentin worthwhile? I guess I will consider offering the option (with a full disclosure of known side effects) and let the patient decide. These results do not appear outstanding and as the editorialist points out, they are modest. But sometimes modest is all we can hope for. Posted byWhat drugs should be OTC? There's a Blurry Line Between Rx and O.T.C.
This article focuses on the "morning after" pill, but we could write similar pieces on Prilosec or Claritin. Each of these decisions brings mixed feelings. On the one hand, many drugs are safe enough and beneficial enough that patients should not need my permission to take them. However, self medication does carry dangers. Patients do not always understand warning signs. We see patients who self medicate for longer than is prudent. I suspect we will continue to have angst over each of these decisions. Just to complicate matters, patient insurance muddies the waters. Many patients only have prescription drugs covered. Thus, rather than take Prilosec OTC (for 70 cents a day) they want the little purple abomination (at over $4 a day). But then they do not pay.
Maybe we need to restructure how we think about OTC and prescription drugs. Maybe we need less dichotomy here. But I cannot figure out how to modify the current structure. Posted byInfluenza - when to seek care Most influenza does not need a physician visit. This article makes clear the signs that should lead to physician care. U.S. Offers Advice on When to Seek Flu Care
Some humor at the expense of academicians and the pharmaceutical industry Often I have seen David Sackett introduce himself at medical meetings. He generally uses the pseudonym - Kilgore Trout. Of all my heroes (and yes he is clearly one of my heroes) he has the best sense of humor. This piece from the BMJ uses humor in hopes of making us think about the insidious relationship of academic researchers and the pharmaceutical industry. HARLOT plc: an amalgamation of the world's two oldest professions Hopefully a couple of excerpts will whet your appetite to read the entire piece.
And
The entire piece represents much too much effort for these intellects. However, I suspect that this farce is and was a labor of love. So enough of my ranting, read the article and enjoy a good laugh. Then remember the serious issues that stimulated this piece. Then laugh again. Posted byThoughts from the BMJ Richard Smith, editor at the BMJ, recently spoke to a group of new medical students. He asked many physicians for advice. His remarks appear in today's BMJ - Thoughts for new medical students at a new medical school While these thoughts are originally meant for new medical students, I would argue that all physicians should read this article regularly. The article contains much wisdom. Many non-physicians will want to read this article, and I hope they will comment here. The author does a nice job of capturing the tensions of being a physician. Enough of my ranting - go clickity click and read and consider. Posted byMore on atrial fibrillation I ranted earlier this week on the new atrial fibrillation guidelines. Medscape does an excellent job of developing selected articles for in depth coverage. Here is the link for those who want to learn more about this issue - ACP/AAFP Issues Guidelines for Management of Atrial Fibrillation Posted byTreating BPH Virtually all men eventually develop benign prostatic hypertrophy (BPH). Our goals of therapy are twofold, improve quality of life and prevent surgery. Today's NEJM has an important article - summarized in this story - Drug Combo Can Fight Enlarged Prostate
For those who subscribe to NEJM - The Long-Term Effect of Doxazosin, Finasteride, and Combination Therapy on the Clinical Progression of Benign Prostatic Hyperplasia. The accompanying editorial puts the issue into proper perspective.
This study should change practice. If (or rather when) I develop symptomatic BPH I have a study to guide my treatment. If any readers are wondering whether they have clinical significant BPH, the AUA symptom score can help. All patients in the study had a score of at least 8. CHECK YOUR AUA SYMPTOM SCORE Posted byNew guidelines for atrial fibrillation The American College of Physicians and the American Academy of Family Physicians have jointly released new guidelines for atrial fibrillation management. I am providing the link for those who have access to the Annals of Internal Medicine and for my own future use - Management of Newly Detected Atrial Fibrillation: A Clinical Practice Guideline from the American Academy of Family Physicians and the American College of Physicians The guideline has 6 recommendations.
I agree wholeheartedly with these new guidelines. Interestingly, we just discussed this issue on rounds over the past 2 days. Time to make copies of this guideline for the students, interns and resident! Appeals court on medical marijuana My previous rants on medical marijuana are just a search away. This particular story deserves wider coverage. Federal appeals court OKs medical marijuana in some cases
An excellent, albeit too technical for me, blog summation from a Boston University professor is here - VICTORY IN 9th CIRCUIT MEDICAL CANNABIS CASE! It will be interesting to see how this ruling is handled. I suspect that the Justice Department will appeal to the Supreme Court. Doesn't the Justice Department have much more important issues to worry about? Why do we spend so much money to prevent marijuana use in this country? (especially medical marijuana use) Posted byThe danger of decreasing antibiotic use Infectious disease experts worry about antibiotic resistance. Generally they err on the side of underusing antibiotics. The National Health Service in Great Britain now wonders whether this movement leads to difficulties. UK considers antibiotic policy
This study raises the interesting question of errors of comission versus errors of omission. Have we become so worried about antibiotic overuse that patient care is suffering? These findings are worrisome and deserve careful validation. We have been quick to criticize primary care physicians for dispensing antibiotics too quickly. Maybe they were smarter than we thought!!! Posted byAre you worried about the flu? We were sitting in clinic yesterday afternoon with some residents. One had a documented exposure to influenza. He had taken the vaccine last month but was trying to decide whether or not to take Tamiflu as prophylaxis. Our opinion was that given the imperfect coverage of this vaccine this year, we would take 75 mg daily for 7 days. This article answers a number of questions about this flu epidemic. What to Do About The Flu? Health Savings Accounts and the new Medicare bill Our colleague, Robert Prather at Insults Unpunished, has long championed health savings accounts. The new Medicare bill encourages them - Medicare reform opens up health savings accounts to all
Clearly the Democrats abhor free market solutions to our health care crisis. I believe that free market solutions can work well. HSAs would encourage patients to participate in economic decision making. And as I and Robert Prather say repeatedly, the lack of participation may well be a driving force in overutilization of health care. Posted byAnother plus for the new Medicare bill New Medicare Law Boosts to Chronic Care
While as always, the devil is in the details, this benefit seems quite promising. I have used disease management with CHF and believe that it provides an outstanding addition to care. Posted byMore on quality I love the intellectual interchange between blogs. Matthew Holt has stimulated my thinking, and hopefully I have reciprocated. As he has updated his entry (with reference to yesterday's rant), I will respond specifically to a couple of his points. His permalink is working now - QUALITY: Why doesn't evidence-based medicine happen in practice? Now with UPDATE
Oh but that we could fit medicine into databases with such immediate feedback. Unfortunately, we have two problems - cost and the extent of the task. The cost problem has two parts - the program and data entry. Having physicians enter data on their patients is not an intelligent use of their skills and time. In order to understand quality we would need such a large and broad database that data entry would take longer than patient encounters. The extent of the task seems even more daunting. We can measure (and expect quality on multiple issues). Each quality measure has provisos which require additional information. I understand the desire for real time feedback, but fear that the task remains beyond any reasonable solution.
Many physicians (and non-physicians) throw out the term evidence based guidelines as if one can develop a clear solution to medical issues. Oh but that it was that easy. Let me give an example that is close to my own interest - the management of adult sore throats. Two organizations - the Infectious Disease Society of America and the American College of Physicians - have published "evidence based guidelines" on the diagnosis and management of adult sore throats over the past 3 years. These guidelines disagree in major ways. Unfortunately, many issues in medicine depend on one's perspective. In the sore throat example, the answer depends on how one values symptom resolution as opposed to minimizing overuse of antibiotics. These viewpoints and their resulting guidelines both have merit. But which would we choose for our computer program? While it is easy to criticize anecdotal information and experience, many medical situations do require judgements for which the data are either unclear or absent. We (physicians) must have the experience and skills to make reasonable decisions with patients. This requires more than formulaic care. Medicare and many managed care companies do have programs which are encouraging physicians to provide higher quality medical care. Our research group studies different techniques for influencing care. Fixing a single deficiency will remain easier than remedying broad practice. We can (over time) teach physicians to prescribe beta blockers after all MIs (although we do not know how to insure that patients take their medications). But most patients are complex and many have multiple problems. How do we influence physicians to care for those complex patients and address all the indicated quality issues? And remember time is limited both in the US and in Great Britain. Maybe we could make generalist care financially stable, encouraging physicians to spend enough time with patients to address the broad scope of issues. But then I digress and start dreaming. But a man can dream! The British NHS Many physicians still clamor for universal health care in the US. We must look at international models to better guess what such a system would do to our health care. Perhaps we would still have an active private medical care system. Great Britain does. Private health: bigger than NHS!
Thanks to the blog author for the "heads up".
Holt on quality Matthew Holt of The Health Care Blog fame partially nails this issue - QUALITY: Why doesn't evidence-based medicine happen in practice? (permalinks do not work, so scroll to Thursday, Dec. 11).
So he gets right the parts about the difficulty in applying evidence-based guidelines to individual patients. As we (and I am part of a research group that studies such issues) study these issues, one of our greatest challenges comes in defining "ideal" candidates for a drug. For example, we all know that ACE inhibitors decrease mortality in CHF caused by systolic dysfunction. However, ACE inhibitors do have side effects and contraindications to use. Our challenge (and the challenge of any report card study) is to accurately define the denominator which we use to calculate the percentage of patients who achieve the guideline. Now Matthew is mistaken in thinking that we do not study this in the US. Medicare sponsors many such studies, giving feedback to physicians. We have learned several things about quality. Quality (as measured by percent compliance with a guideline) varies across indicators. Quality changes across time. More post myocardial infarction patients take a beta blocker now than 5 years ago. Physicians do learn and do adopt changes in practice. However, changing ones practice occurs for physicians at different speeds. As we get older, we become wary of the latest and greatest. We have seen too many new drugs have major side effects discovered within 2 years after release. We need excellent data to change from therapy that has worked. I have written about this several times in the past - these two rants are a good start -
My point remains that these issues are more complex than simple sound bites make them appear. We are striving to teach physicians to optimize their practice, however they know that optimal practice in 2003 may change in 2005 (e.g.,hormone replacement therapy for preventing coronary artery disease). Posted byAn article on health care blogs Health 'blogs' are multiplying - thanks to Matthew Holt at the Health Care Blog for the link. And yes I am included, along with one of my more erudite comparisons! Posted byPhysicians and diabetes management I received this question today:
Well I cannot speak for all physicians. Therefore my rant will only provide opinions and controversy. Nonetheless, that has never slowed me down in the past, so here goes! Diabetes (especially type II) provides a special challenge for physicians. The disease is extremely common, yet very difficult to treat well. Excellent treatment requires a motivated patient and a motivated physician. Many physicians find few motivated patients. We plead with patients to achieve excellent control. We would like them to test their sugar regularly. As I have blogged previously, quality diabetes care requires that one touch all the FLECKS. (Feet, Lipids, Eyes, Control, Kidneys and Shots). Diabetic patients have many issues to address. Our reimbursement system penalizes us for spending adequate time with patients. Let me repeat that sentence (it is not a mistake). Our reimbursement system penalizes us for spending adequate time with patients. Doing the right thing takes time. And time is money. Many physicians try hard. They encourage patients to develop tight control. Yet most patients show little interest. One would hope that patients could find a physician who matches their desires. We must accept the blame, even when we can explain why. Providing quality care is difficult. Yet it should always be our goal. I apologize for talking around the question. However, I do not think the question is directly answerable. Most physicians just have no pump experience, therefore, they use the tools with which they are experienced. But again that represents and insufficient excuse. We should refer motivated patients to the appropriate experts. On the economy class syndrome Studies confirm risks of 'economy class syndrome' This report refers to 3 studies. Those studies show the following risk factors - longer than 6 hour flights, increased age, being overweight, birth control pills. The risk is very low, however, I would recommend (and when I fly I do this) getting out of your seat every couple of hours to walk and stretch. Posted byA conservative view on the Medicare bill While many conservatives have criticized the Medicare bill as being too costly, others have supported it. This columnist does a nice job of emphasizing his positive opinion. Making Medicare Reform Work
And that is the reality that physicians understand. We all know that we really do have major financial problems with drugs that could benefit patients significantly.
As I have blogged previously, one feature of this bill that I like is that those with greater need get the greater benefit. Many seniors will not like these adjustments. However, given the huge cost of Medicare, it seems only fair that those with get less help than those without. As we continue to digest this huge bill (knowing that it will require tweaking each year), we should read various supporters and critics to better understand our positions. More on virtual colonoscopy I blogged on this story last week. This article adds important information to the discussion. I was at a birthday party over the weekend (for a 50 year old), and had several people ask me about virtual colonoscopy. I suspect most physicians are getting these questions. Not quite in a comfort zone
This assessment seems quite similar to my interpretation last week.
So as I said last week, we have promising results, but not definitive results. I would not "settle" for virtual colonoscopy yet. I will follow the literature for further developments. Posted byThe wait for colonoscopies Apparently, many 50 year olds want a colonoscopy. 50 and Ready for a Colonoscopy? Doctors Say Wait Is Often Long
Given the numbers crunch (and the cost) we need very careful analyses to understand the cost benefit relationship. Hopefully more studies of virtual colonoscopy will confirm that it would make an adequate screening test. Perhaps we would combine flexible sigmoidoscopy with virtual colonoscopy (on the same day) and have a superior test to colonoscopy. This is a good problem. Having patients interested in screening shows progress. Now we must develop creative solutions. Posted byBig pharmacy and medical research A reader provided this link. Here is a public thanks! Stealth Merger: Drug Companies and Government Medical Research
Now I believe Relman guilty of hyperbole. Most scientists do not think that explicitly about these relationships. Rather I believe the influence more subtle. What the pharmaceutical industry buys is influence. They do not often get an explicit quid pro quo . Rather they work to influence ones perception of the company and by extension the products that they produce. I have referenced Cialdini's work on influence in the past, but will provide a link once again - INFLUENCE by Robert B. Cialdini I have chosen this link (from amongst many candidates) because it gives a nice overview of the conceptual framework which Cialdini has developed. If this seems intriguing, I can highly recommend the book. Considering his work, and this story, I would reinterpret the trap that the investigators have accepted. Medical researchers (not unlike most humans) like the ability to make extra money. Being a paid consultant has the veneer of appropriateness and respectability. The researchers easily delude themselves that as scientists they are immune from influence. Unfortunately, this naivety allows them to unknowingly make mistakes. They justify their actions as necessary to support their overall research. They truly mean well. However, much like Dr. Faustus they are selling their souls. This is the dirty secret of much medical research. We need a new ethical standard. We need to understand why we engage in this dance. We need to stop. Posted byPrimum non nocere Study Questions Some PSA Prostate Tests Remember this important principle. Preventive medicine works best for those with longer life spans. At some point (difficult to assess admittedly), the potential for gain from prevention may no longer exist. Obviously, it depends on the type of prevention. Flu vaccines are likely to help almost anyone and especially the older elderly. Cancer screening diminishes in value above a certain age. As you read this article, remember that it refers only to screening - not evaluation. The article argues against random screening of those older than 75 for prostate cancer. However, PSA testing may have indications as a diagnostic and prognostic test rather than a screening test in these patients. The results make sense when you consider the limited potential value of pure screening in this group of men. On Canadian drugs Today's NEJM has a nice summary of the Canadian drug issue (for subscribers) - Canadian Drugs
Posted by A cardiologist talks about primary care That Ounce of Prevention Grew Too Big
He makes my point better than I make it! As I wrote earlier this week, our current reimbursement system does not reward excellence in primary care. It penalizes you for spending more time. Until we develop a better reimbursement system, patients will suffer. As an example:
This is our health care crisis!!! Posted by On virtual colonoscopy On the road at a retreat, so I have not had a chance to read the NEJM article. The NY Times review makes sense and puts the issue into perspective - A Gentler Type of Colonoscopy Proves Effective
While the results are very encouraging, we need more validation of the technique. It looks promising, but I wonder how radiologist dependent the reading is. Sometimes with newer radiologic procedures, those on the cutting edge who develop the procedure get better results than those who follow. I am not ready to have virtual colonoscopy rather than the standard at this time (and yes I have already had a colonoscopy). We should follow this literature closely. This is a great first step. Please change our coding and reimbursement system!!!!!! Primary care troubled by coding errors: Medicare officials suggest doctors may have trouble deciphering evaluation and management guidelines in billing. Doctors may have trouble deciphering - Medicare officials use understatement to negligible effect.
For those who do not have to deal with E&M coding, recall Kafka's book, the Trial
Quote link - The Trial
AMA News on Medicare Doctors get a 1.5% pay hike as Congress passes Medicare reform I will use this summary to provide my opinions on several provisions. My comments in italics. Posted by New York complaining about rural hospitals One provision of the Medicare bill that excites me is the adjustment for rural hospitals and physician payments. Apparently New Yorkers disagree. City Hospitals Reap Little in Medicare Bill Here in Alabama (and similar states) we have a huge problem providing adequate care in our rural areas. Finances play a major role. This bill corrects previous inequities. Bravo! Posted byEuropeans question their health care Posted by Younger workers satisfied with drug benefit A $400 Billion Purchase, All on Credit
Posted by The Medicare bill and cancer clinics Over the past 2 years I figured out that Medicare was overpaying for cancer chemotherapy. We had a big jump in residents choosing oncology for fellowship. (I know this is a cynical jump in logic, but it does make sense). It appears that congress has adjusted. Doctors fear lower Medicare drug payments will hurt cancer clinics: Scandal prompted bill's writers to cut reimbursements
The overall effect remains opaque, but as usual, time will tell. Posted byMore on the Medicare bill These links are provided for those who want a broad view of the new Medicare legislation. The breadth offered reflects our uncertainty concerning many provisions of the bill.
Posted by On pulmonary artery catheters from The Arc of the Pulmonary Artery Catheter (paid subscription required)
This quote comes from an editorial about the following article. Early Use of Pulmonary Artery Catheter Offers Neither Harm Nor Benefit
So back to the editorial -
I became a skeptic concerning pulmonary artery catheters from reading Dr. Connors work, and discussing his study with him. This article while not revealing any major harm, also does not give me a reason to request pulmonary artery catheterization. We must look further to understand whether this technology has any benefit.
For now I remain skeptical. Posted bySurgeons with great volume get better results Surgeon Caseload Largely Explains Hospital Volume Link to Mortality
This article argues for referring patients to surgeons who have great experience with a specific type of surgery. The data make sense, as the task is difficult, fraught with many hazards, and experience should give one a better "check list" to use during surgery. I suspect that the same is true (to a less dramatic effect) for many medical conditions. As a general internist, I would never try to give chemotherapy - I just do not have the volume to keep up with changes in the field. Studies have shown that among generalists, specialoids (those who focus on a disease or system without advanced training) have better outcomes. We suspect those better outcomes occur because volume leads to experience which leads to a better understanding of the nuances of care. These findings do not argue against the importance of generalists. Generalists can (and do) care very well for most common diseases. For example, type II diabetes mellitus is so common that we should have a large enough volume to have excellence. Similarly experience occurs with coronary artery disease, congestive heart failure, dyspepsia, chronic obstructive lung disease, hypertension as several examples. The truly excellent generalist will become an expert at caring for the most common diseases and retain expertise in diagnosing the great majority of complaints. Part of our excellence comes from knowing when we do need to refer. We must all beware the error of not referring when indicated. I find the findings of this article sobering. Perhaps we should evolve our health system in ways which take these findings into consideration. Interestingly, the durrent issue of JAMA considers this problem - Regionalization of High-Risk Surgery and Implications for Patient Travel Times (paid subscription required). The essence of the article:
These findings challenge us to consider the trade off between inconvenience and outcomes. I do not think it a difficult decision. Anecdotally, most physicians who have complex disease (especially cancers) travel almost any distance to find the specialist for that disease. What do physicians know? Posted bySurgeons with great volume get better results Surgeon Caseload Largely Explains Hospital Volume Link to Mortality
This article argues for referring patients to surgeons who have great experience with a specific type of surgery. The data make sense, as the task is difficult, fraught with many hazards, and experience should give one a better "check list" to use during surgery. I suspect that the same is true (to a less dramatic effect) for many medical conditions. As a general internist, I would never try to give chemotherapy - I just do not have the volume to keep up with changes in the field. Studies have shown that among generalists, specialoids (those who focus on a disease or system without advanced training) have better outcomes. We suspect those better outcomes occur because volume leads to experience which leads to a better understanding of the nuances of care. These findings do not argue against the importance of generalists. Generalists can (and do) care very well for most common diseases. For example, type II diabetes mellitus is so common that we should have a large enough volume to have excellence. Similarly experience occurs with coronary artery disease, congestive heart failure, dyspepsia, chronic obstructive lung disease, hypertension as several examples. The truly excellent generalist will become an expert at caring for the most common diseases and retain expertise in diagnosing the great majority of complaints. Part of our excellence comes from knowing when we do need to refer. We must all beware the error of not referring when indicated. I find the findings of this article sobering. Perhaps we should evolve our health system in ways which take these findings into consideration. Posted byThe blogging world and the Medicare bill For those who want to read a wide variety of opinions, here goes:
If you run into more reasonable links, please let me know. Posted byPrivate insurance and the elderly This is the second post on the Medicare bill. Many critics dislike the provision which allows participants to choose another insurance plan. In trying to understand this opposition, I am assuming that critics worry about a dilution of Medicare as we know it. Thus, we must ask if we would rather have a monolithic insurance, run by legislation, or free market competition. I dislike much of Medicare, and believe that a little competition could improve it. I like that there is a provision for demonstration projects. I find nothing objectionable here. Hopefully, the competition will have a desired effect. It might even eventually positively impact drug pricing. Posted byThe drug benefit This is the first in a short series of commentaries on the Medicare bill. The essence of the bill is captured in the first post today (since I post in reverse chronological order, scroll down). The drug benefit has 2 parts. For '04 and '05, seniors can buy (for $30) a discount card. This card will give an estimated 15% savings on drugs. Thus, if you spend more than $200 a year on drugs you will save some money. Low income seniors also would get a $600 subsidy. Starting in '06 the big plan takes effect. This plan has modest benefits for those with minor drug expenses (I define minor as < $2000 per year). There is then the doughnut (There would be no coverage for drug costs between $2,250 and $3,600 out of pocket -- the so-called coverage gap). Then coverage is excellent above that amount. Those with less income would get co-pays and premiums waived. The drug benefit could be called catastrophic drug insurance. The big benefit accrues to those who need multiple expensive drugs. The benefit is tied to income, those who make more, pay more. While this solution to prescription drug coverage is not ideal, it does have some pluses. The coverage helps those in the greatest need for help - those with low income/assets and those with huge drug costs. Those with more resources would pay more. Certainly this plan is better than no plan. I worry more about paying for the plan, than the true benefit to recipients. They will get some benefit (which clearly is better than they currently have). Posted byKey points of the Medicare bill
from Analysts: Seniors' drug costs to rise My commentary will start later this morning and probably continue through the holiday weekend. At a first glance I see both ponies and manure. On balance, the bill has many major pluses. The overall cost does bother me, but I will try to put even that into perspective. Posted byStarting statins while in the hospital I found this study interesting. In-Hospital Initiation of Lipid-Lowering Therapy Predicts Long-Term Use
Posted by On pain control and addiction Most blogs have recurrent themes. Excellent blogs stray occasionally, but generally have major themes that the author revisits frequently. Pain control represents one of my major themes. Physicians feel squeezed when we discuss pain. We all understand that we have a responsibility to relieve pain. However, we also feel obligated to avoid creating narcotic addiction. We also fear (as I state repeatedly) being duped into providing narcotics for addicts (and even worse for resale to addicts). This article adds to the discussion, pointing out that patients with real pain rarely develop addiction. The Delicate Balance of Pain and Addiction I highly recommend this article as giving a balanced view of the conflict that we perceive. I still do not know the answer. Posted byDedicated to my favorite lawyer Go clickity, clickity and laugh your socks off - Lawyers on medicine in the court room Posted byComments Comments greatly improve this blog. I will continue to encourage and support them. However, some old posts get too many unnecessary comments. Therefore, I have installed a plug-in which restricts comments to posts within the past 14 days. If you have an important comment on an issue older than that, please email instead. Thanks db Posted byThe clinical skills exam The AMA has this one right! Evidence doesn't support push for clinical skills exam During a time when we urge students, residents and all physicians to base their practice on evidence, the NBME has added a new expensive examination without first collecting any evidence of its importance.
Points well made!!!! Posted byAnother reason to support the bill I found another pony! Deal sets path for vote on Medicare physician pay fix
So we have an admittedly flawed bill, with several gems. The adjustment in physician payment is very important to maintain access for Medicare patients. Posted byComplex care Long time readers know that I argue often that patients need an excellent physician who has the time to provide complex care. However, complex care takes time. This article suggests that I am right. Spend the money up front, and patient care benefits. Managing multiple conditions: A challenge for Medicare: A Medicaid project in North Carolina has cut costs and improved care for patients with chronic diseases. Can Medicare do the same? Posted byWhen physicians do not have enough time Good business ideas come from spotting unmet needs. Sometimes one must convince consumers of that need (marketting), sometimes it is just so obvious that the business succeeds immediately. A middleman steps into the physician-patient relationship
And it has come to this. Physicians do not have the time to advocate for their patients. Our billing and payment systems do not handle this need. I hate this. Advocacy should be a part of regular medical care. We should have a financial system that allows this. Posted byMore on alternative stuff Nonwithstanding Bernie's comments the other day
Well Bernie, loyal reader, you happen to be missing the boat here. We need double blind trials. They are not myopic. Let me give you the classic example. In the 70s and 80s when patients had a myocardial infarction and then had premature ventricular contractions, we would prescribe an anti-arrhythmic drug. After all, when the patient has an arrhythmia, an anti-arrhythmic should decrease fatal arrythmias. However, when they finally did the study, the patients who received the anti-arrhythmic more likely died. Just another quick example. We assumed from epidemiologic studies that post-menopausal hormones would decrease heart disease in women. When they did the study, they found that the opposite was true. We need carefully collected data to help patients make difficult decisions. Apparently Bernie and those of his ilk disagree. The Ongoing Problem with the National Center for Complementary and Alternative Medicine This article is long and comprehensive. The National Center is laughable. We must study things carefully and appropriately. To not do careful studies puts patients at great risk. Just like taking herbals that have not had careful study. Posted byBariatric surgery is dangerous Surgeons tell this to patients. So do generalists. Oftentime the risk is worthwhile. However, we should never downplay the risk. Hospital stops gastric bypass surgery
I still advocate for bariatric surgery in some morbidly obese patients. We bemoan the error of commission, but must understand clearly the error of omission. The majority of patients who need this surgery have such poor projected health and survival as to make the risk worthwhile. I have written previously about the successes. This article reminds us that the decision to undergo bariatric surgery should never be taken lightly. In fact, the surgeons involved here understood those issues.
Just to reiterate, I have linked here to remind readers that the procedure carries danger. It also conveys benefits. The harm in alternative medicine My father sent me this article. I liked it, and found it online. What's the Harm?
Posted by Hooray!!! - searching works again Several weeks ago I upgraded my version of Movable Type. I was slowly able to get everything to work - even changing my database to a mysql database. However, searching did not work. I use the searching function myself to find old rants. I suspect that many of you use it also. So today I have finally fixed the problem. You (and I) can search again. Posted byThe ongoing medical weblog debate over Terri Schiavo I have not expended sufficient energy on this question. However, I do believe that Chris Rangel has. The most vociferous portion of this debate has occurred on RangelMD and Medpundit. Rangel latest rant - Terri Schiavo and patient autonomy Read his interpretation of the issues, and please click on his link to Medpundit's interpretation. These heated debates, while carried out on weblogs rather than in person, represent the strength of medical weblogs. Try to understand the arguments that each excellent blogger makes. Then you can decide your position. I side with Rangel here, but I do understand the issues and feelings that this case creates. Posted byShock waves work for calcific tendonitis Shoulder pain represents an extremely common joint complaint. I have had rotator cuff tendonitis, and can attest to the discomfort. This study demonstrates that for the subset of calcific tendonitis, we have a worthwhile therapy - Extracorporeal Shock Wave Therapy Benefits Patients With Calcific Tendonitis of the Shoulder
Posted by NY Times editorial page favors Medicare plan
I have not studied the plan carefully. I understand that this plan exists for political reasons. I suspect that you and I could develop a better plan. But we live in a political world, and as the NY Times states, this plan is likely better than no plan. Posted byOn football concussions Think Troy Aikman. Study looks at football-field concussions
Posted by An interesting proposal The Universal Cure - clearly a very interesting proposal and relevant to our previous discussions. What do you think? Posted byIf I could change everything - further thoughts on Sowell If you have not read Thomas Sowell's 3 part essay and the many outstanding comments that this post engendered, go there, read the post, Thomas Sowell and the comments. Then come back to here and I will rant. Thomas Sowell - no free lunch medicine Welcome back! We clearly have a health care crisis in this country. Let me enumerate my concerns:
That admittedly short list provides a foundation for my frustrations. Let me first state that I love medicine and being a physician. I would highly recommend this profession to any one who asks. That does not mean that we cannot improve our current crisis. Thomas Sowell argues for a free market approach to medical care. I agree. However, I probably disagree with him on this fundamental assumption - we are far from living in a free market system today. We are beset by bureaucracy and poor laws. Let me try to explicate. I favor medical savings accounts for most medical care (rather than insurance). Medical savings accounts would encourage patients to ask questions about prices. With insurance and a drug benefit, the patient might want Nexium (the evil purple pill). If that same patient were paying from a medical savings account he/she might choose Prilosec OTC (for approximately 20% of the cost). We should combine this with a new method of billing for outpatient care. We should be billing for time spent with the patient (with everyone understanding that physicians spend significant time on that patient's care while not physically in the room). Patients would know what a 10 minute appointment costs, what a 20 minute appointment costs, etc. While this billing method has some problems, having the patient actually pay the moneys would minimize abuse of the system. Patients would have an explicit expectation of service from us, and would make reasonable demands on our time (knowing the cost involved). We need to modify the pharmaceutical laws. We do not need loopholes for drug companies to block generics as their patents expire. They deserve a fair run at profits on an individual drug, then let the marketplace work. We need to fund more studies comparing 2 or more drugs of a class, and drugs of different classes. These studies (with appropriate publicity of results) would inform patients and physicians - choosing the right drug for the patient. We need even better post approval studies of side effects. We need to better know the rates of side effects for each drug. We need free market pricing. Currently we have price controls on physicians and hospitals. We a different system of paying physicians and hospitals, free market forces would control prices. We would have winners and losers. Physicians, who patients perceive provide more value, would be able to charge more. Similarly, hospitals perceived to provide better care might charge more. This system would encourage better care (and therefore more profits). We need better tax incentives for providing charity care. Many physicians willingly provide a percent of charity care (I would suggest 10 percent as a good start). They would be able to "write off" that care as a charitable donation. I believe this could become a good policy. The same process should work for hospitals. I might even go so far as to demand that all health care providers (physicians, hospitals, clinics) provide a reasonable percentage of charity care. We would also expect a usable system of providing pharmaceuticals and diagnostic testing. I do understand that I am dreaming. Developing a new system would have too many enemies - insurance companies, perhaps the pharmaceutical industry, perhaps big business. However, our current system is broken. Some might ask why not universal care? I despise bureaucracy, and bureaucratic decision making. Universal care would bring us bureaucracy. As practiced in most other countries that I have studied, it would lead to rationing. The choices that we would have to make are choices that I would rather not make. They are choices that most of our patients would not want us to make. I have thought about this issue for the past few days, reading the comments on the previous past carefully, and examining my own philosophy. This rant is not a polished proposal, however, I do stand by the concepts that I have proposed. So bring on the commentary. Attack my ideas. But always refrain from ad hominem attacks on any commentary. Posted byNo longer morbidly obese - a reporter's success From 'morbid obesity' to 'Wow!' Bravo! Posted byOn palliation My defining moment came in 1978 during my residency. I was caring for a patient who had aplastic anemia. Because of almost non-existent neutrophils, he was in the medical ICU on strict reverse isolation. We consulted hematology and they told us that we had no options for treating his neutropenia. (This story precedes bone marrow transplantation.) Hospital epidemiology insisted that he have strict reverse isolation (gowns, masks, gloves) to prevent overwhelming infection. The gentleman (in his 60s if my memory is correct) asked very politely but with great emotion if we could remove the isolation requirement. He told me that he knew that he might die a few days sooner, but he want to see faces, he wanted to hug loved ones, he wanted his last few days to have meaningful interaction with family. He said (and he was right) that the accouterments of reverse isolation decreased his quality of life. He convinced me and turned on a light bulb. Fortunately I had a wonderful attending who agreed and we overturned the hospital epidemiology decision (to their howling protests). The patient died in a few days, but he died happier and his family was greatly appreciative. The palliative care movement is (in my opinion) having a major positive impact on many patients and families. They have a new trust in our system of medical care. This piece is just one in a series that I have spotlighted. I will continue to spotlight this issue because it stimulates a positive passion about our ability (as physicians) to make a difference. Providing Care, When the Cure Is Out of Reach Posted byDoctors try, but that is not enough
Posted by Doctor heal thyself Doctors who lose gain credibility
Bravo! Thomas Sowell - no free lunch medicine Whether you agree or disagree with Thomas Sowell, one must respect his ability to explain his perspective. He is doing a series on price controls related to medical care. Here are the second installment. Free-lunch medicine, Part II You can get to the first instsallment by choosing to look at his archives (bottom of the page). If you are reading this after this weekend, you will need to explore the archives to find his writing. Here is a sample of his thinking.
His arguments make one think. I have argued often that the percentage of GNP spent on health care is rising because we can do more. Our advances do require resources. We can return to lower cost medical care, and we can have the outcomes of old. We would rather have the better outcomes (both quality of life and quantity of life) that technology and pharmaceuticals have given us. To achieve these successes we must spend money. No rhetoric, no political speech, no wishing can make that economic fact disappear. We need a real debate on health care costs. Understand the long term impact of economic decision making on health care must underlie those debates. Unintended consequences of the DDT ban Why do we consistently ignore the consequences of our actions? This commentary argues that the ban on DDT allows the West Nile virus to infect an increasing number. Mosquitoes kill us; DDT doesn't Posted byObesity as disease Written perhaps with tongue in cheek - Hang in there, tubby America, your day in the sun will come Posted byBaseball players illegally use androgen steroids Surprise, surprise, some baseball players (in fact at least 5%) use steroids to enhance muscle mass. So now they will have to undergo mandatory testing. Results of Steroid Testing Spur Baseball to Set Tougher Rules
Posted by Canada, O Canada Many in the US either buy, or would like to buy prescription drugs from Canada. We would like to save money, and most prescription drugs have lower prices in Canada. However, our desire for a bargain may negatively impact Canada! Canada to U.S.: Don't buy drugs here
Never forget that actions generally have unintended consequences. Posted byVacation On vacation. Have web access. May blog. May not. Back to regular blogging on Monday. But may blog later today. Just depends. Posted byPreventing nose bleeds from nasal steroids Having periodic allergic rhinitis, I have used nasal steroids with good effect. However, I am one of the 15-20% who develop nose bleeds from nasal steroids (in fact the only 2 nose bleeds of my life came from nasal steroids). This study tells me that I can try them again, just change my technique!! Nasal Steroids: Contralateral Hand-Nostril Technique Curbs Epistaxis
Now I must see if I have sufficient coordination to use the technique!! Posted byThe downside of universal care Universal care has a big price: patients wait. Now I must throw in a brief rant before the commenters go crazy! The article points out that Canadians have a higher life expectancy than those in the US. This statistic may or may not have relevance. We would really like to understand the difference in demographics. We would need to know the causes of death. Unadjusted life expectancy is like unadjusted surgical mortality. Extrapolating from these data are hazardous. Posted byA potential difference between statins We know that some statins lower LDL more than others. Some raise HDL more than others. What we do not know is whether those differences matter. This study suggests that the differences may be important. Study of Two Cholesterol Drugs Finds One Halts Heart Disease
One can also read more details on this study at theheart.org (no direct linking of articles, but it appears in the November 12th entries). This important study deserves several caveats.
As most good research does, this study raises as many questions as it attempts to answer. We must always remember that we rarely have definitive answers based on a single study. Rather, we must view clinical knowledge growing in fits and starts, with data accumulating over time. If I had coronary artery disease, I would probably take atorvastatin 80 mg a day. I can afford it, and it just might help. I will finish this rant with these quotes from theheart.org.
Posted by Another reminder on drinking and marathons I know, I have beat this horse to death. However, I just might help one person but redundantly blogging about this issue. If so, I will have done something important - Too much H20 may be a no-no Posted byBusy day - here are some great reads Last week I referenced a NY Times editorial on IV HDL. Derek Lowe has nailed this one - you must read it - To The Editors of the New York Times Chris Rangel is on a roll! First read this link he gives on the "obesity is a disease" question - Is Obesity A Disease? (Rosemary), then read his analysis - Does Obesity=Disease and what are the causes? Finally, read Matthew Holt on Canadian physicians moving to the US. While I do not entirely agree, you should read his arguments - POLICY: Oh Canada. Posted byVancouver IV drug sites US slams Canada over Vancouver's new drug injection site
Bravo Jill. She understands, the White House does not. We need a fresh look at drug abuse. Prohibition does not work. Messages of fear do not work. Criminalization does not work. Much substance abuse causes health problems, but so do alcohol and tobacco. We are slowly winning battles against tobacco and alcohol. We are losing the "drug war". We are losing because the unintended consequences of that war are harmful. From my vantage point, Canada is taking a more enlightened approach. I will bet that they will have more success. Posted byARBs as effective as ACE inhibitors post-MI These results are not surprising, but they are welcome. VALIANT Results Suggest ARBs as Effective as ACE Inhibitors Post-MI
The NEJM reference for those who want the details - Valsartan, Captopril, or Both in Myocardial Infarction Complicated by Heart Failure, Left Ventricular Dysfunction, or Both and editorial - Angiotensin-Receptor Blockade in Acute Myocardial Infarction -- A Matter of Dose
In my opinion this study makes more clear our options. We continue to use ACE inhibitors first, but know that when patients do not tolerate ACE inhibitors we can use ARBs with similar results. And that information is worthwhile. Posted byFour diets work equally and not that well! Best Diet? Take Your Pick
So dieting works - but just a bit - but that bit is worthwhile.
Adhering to guidelines Compare these two headlines for the same study - Doctors fail to give basic heart care and Study Documents Large Variation in Heart Failure Care . Now read the description of the study and its results:
So which headline makes the most sense? Perhaps we should have a headline contest. What do you think would make the most balanced headline for these data? As a researcher in the area of quality improvement, I abhor the sensational headline. This study does not plow any new ground. These findings fit with many previously published studies (including our own research). One can decry the performance of some physicians, or one can try to understand the why behind these findings. Medpundit blogged about this issue yesterday (no permalinks, just scroll down). She made some very cogent points, however the problem is more complex than any one commentary can explain. Our current research focuses on the tools that physicians need to provide higher quality care. While we find "deficiencies" in quality, we focus rather on why, and how to improve care. If one studies heart failure, one becomes an expert on the nuances of CHF management. We study the literature, and understand the texture of the problem. Most physicians cannot focus on one problem alone. We must provide excellent care of CHF, COPD, diabetes,cirrhosis, headaches, sore throats, cellulities, venous thrombosis, pap smears, breast cancer screening, etc, etc. We must do this with inadequate reminder systems. We must do all these things in short time chunks. So when I read these headlines, and read the study results, I ask how we can improve medical care. I do not and will not castigate physicians. We must understand the difficulties of practice and help them provide better care. So what is your headline? I bet that the readers can develop much better headlines than the news services! Posted byMy blogging personality ![]() You are a David Weinberger. You are smart, savvy, interested in why people do what they do, enjoy questioning yourself and are not balding. Take the What Blogging Archetype Are You test at Still hanging over our shoulders Medicare formula spells pay cut of 4.5% for physicians in 2004
So once again we dance the political dance. So once again we divert our energies to fix something that should never have become a problem. If I took care of a patient this way, you would sue me for malpractice. This problem is analogous to purposely not giving aspirin, beta-blockers, ACE inhibitors or statins to a patient who just had an MI. The patient develops CHF, and we try to then treat the patient. This is why most physicians fear a health care system with political influence. This is why we dislike bureaucracy. No one thinks the cuts are appropriate but
So we wait for Congress. CMS blames the law. And guess who suffers the most?
And no one believes this would help patients. The system does not work. The problem is the political nature of the system. That must be fixed. Posted byBack to the rock and the hard place I know of no more vexing issue in medicine than pain control. Most physicians suffer great conflict when trying to balance the desire to relieve pain with the desire to avoid providing unnecessary narcotics. Painkiller phobia inflicts needless suffering
Bravo to the columnist who has done a very nice job of describing the problem. The one issue that she does not address is the fear of being duped that physicians have. I try to offer excellent palliation to all patients. This process becomes easier the longer you know the patient. However, we all have had patients (usually new patients, or a partner's patient) who have either duped us or tried to dupe us. They claim chronic pain which only Oxycontin or Lortab or (fill in you narcotic of choice) will relieve. We do not have the historical perspective, yet have to make a decision which either declares the patient a drug seeker or confirms that the patient needs narcotics for compassionate care of chronic pain. The problem has much more complexity than most short expositions will include. We (physicians) are not insensitive. We do resent having patients fool us. This fear puts legitimate needs in jeopardy. Posted byNY Times whine (er editorial) A New Way to Unclog the Arteries
Posted by How our debates effect patients and families Recently I blogged about antidepressants and adolescents. The issue of their safety in adolescents raises important questions about data, epidemiologic studies and anecdotal information. However, while we are debating, patients and families are suffering great angst. And our debating makes their decision making more difficult. The Fear of No Right Answer
Please go read the author's story about her son's depression and her own. "Gail Griffith lives in Washington. Her book, "Will's Choice: A Family's Struggle to Save Their Suicidal Son," will be published next year by HarperCollins. " An unintended consequence of medical reporting is the angst that patients and families suffer. One can argue whether knowledge expansion and open debate is worthwhile given the produced angst. I believe that we must have the discussions, but this article has made me wonder. I congratulate the author for her insight and clear definition of this problem. Posted byWe do not do a good job helping with weight loss Brief training in primary care does not lead to weight loss in obese patients - a brief synopsis of this article - Improving management of obesity in primary care: cluster randomised trial
On waist circumference As data accumulates, the importance of waist circumference as a risk factor for the metabolic syndrome becomes even more clear. Physicians Should Measure Waist Circumference
While these are very interesting and important findings, waist circumference measurement is not yet a standard of care.
So get out your tape measure. Posted byMore on the cost of courage The Bloviator references my rant on the Pittsburgh Post-Gazette series. Unfortunately, he does not provides links to individual pieces. Still his comments are worth your inconvenience. Check out the post titled - Patient Safety: Shooting the Messenger - posted Wednesday, November 5th. Rangel on Schiavo Rangel posts less frequently than many. However, when he posts, his essays (and yes they are essays) are worth our time. I have previously linked to him on the Terri Schiavo story. He returns to that story with many strong points. I cannot add to his comments - and agree wholeheartedly. A long slow death in Florida part II; Is this really a case of playing God?! . Please read it carefully. And for those who want a dissenting view. Deciding 'quality of life' Posted byMore on ALLHAT Long time readers will remember my outrage over the press coverage of ALLHAT. Moreover, I felt (and I am not alone) that the investigators overhyped their results. For those with electronic access, I highly recommend this commentary from the current Annals of Internal Medicine - ALLHAT, or the Soft Science of the Secondary End Point. I will not excerpt, because you should read the entire article. If you care for patients with hypertension, and ALLHAT has influenced your thinking, please get a copy of this article and read it. Here is the hard copy reference - Messerli, F. ALLHAT, or the Soft Science of the Secondary End Point. Ann Intern Med. 2003;139-777-780. Posted byNew hope of osteoporosis We know why we develop osteoporosis (at least we know the risk factors). We can delay the onset of osteoporosis. However, until now we could not reverse the bone loss associated with osteoporosis. Apparently a new drug can reverse the bone loss. Osteoporosis bone loss reversed
Not knowing the drugs name (I work primarily as an academic hospitalist now and am not up to snuff on the latest outpatient advances), I did a quick google. FDA APPROVES TERIPARATIDE TO TREAT OSTEOPOROSIS - dated a year ago.
Well that is my lesson for the day. Many of you already knew this, but perhaps I have reinforced some knowledge. And some of you need this knowledge injection just like me! Posted byDecreasing atherosclerotic plaque This story - reported in today's JAMA - suggests a very interesting new approach to atherosclerosis. Cholesterol Study Offers Hope for a Bold Therapy
Please note the highlighted caution. This study certainly creates a buzz. We need to know much more. Side effect studies will require many more patients. The result could possibly be a chance finding. All those precautions stated, this study is exciting and should increase our understanding of atherosclerosis. Posted byWith apologies to Paul Harvey And here ... is the rest of the story. If you did not read yesterday's case, go read it first - Sunless sunburn. Now for the denouement.
So how did this dermatologist figure out this case? He claims serendipity and explains:
So (imagine the dramatic tones of Paul Harvey) you know ......... the rest of the story. Posted byPhysicians finally become politically active Overlawyered has a great story on political battles over medical malpractice. Just go read it - Malpractice key issue in NJ, Pa. races Posted byAnother potential blow to HMOs Supreme Court to Rule on Patients' Rights
This case puts me in a quandry. I emphasize greatly with the patients and the doctors who get bullied by HMOs. I dislike opening the flood gates to lawsuits. Should I flip a coin? Naw. The HMOs are the greater evil here. They have bullied physicians and patients for too long. They need to bear responsibility for their decisions. The Supreme Court can right a wrong here. Posted byCoronary artery disease in women We generally understand coronary artery disease (CAD) in men. Read the textbooks and you quickly see classic presentations. Work on the wards and those presentations fit the textbooks. However, we seem to have more difficulty diagnosing CAD in women. This article provides some suggestions and perhaps some insights. Fatigue an early sign of heart attack?
I suspect further investigations will find the fatigue in some men. My anecdotal memory clicks with this observation. Hopefully we can get more such studies to improve our history taking and influence our index of suspicion. Posted bySunless sunburn Time for a little game. I will provide an excerpt from a case. I will not provide the link until tomorrow. You can try to figure it out. Feel free to post your guesses in the comments section. The case is quite instructive.
So that is your challenge for the next 24 hours. I would not have figured this one out! Posted byStudents continue to avoid primary care and choose subspecialties Resident match review shows subspecialties' lure
Hmmm, I think we can understand this. Primary care (or perhaps better stated the generalist professions) has increasing overhead, worsening work conditions, and decreasing revenue per patient. So now, the generalist has long work hours, a stressful job, and makes less money. Last time I checked medical students were very smart. They make decisions based on income, lifestyle and prestige. Why should they choose primary care? We must change the system. I strongly believe that patients need excellent primary care.
I would argue that our main governmental program - Medicare - should consider this social need in determining reimbursement rates. It does not. Hence we have a crisis. Posted byThe value of nitrites Study Finds That Nitrites in the Body Greatly Aid Blood Flow
This research is not yet ready for clinical application. I suspect that we will see health food stores and supplement advocates cite this research as a reason for us to add some new (or old) supplement to our regimen. I prefer to heed the investigators warnings:
Ah! A reason to eat more hot dogs (db plants tongue firmly in cheek). Posted byA contrary view on health insurance This contrarian position may make one think. Why Do Employers Pay for Health Insurance, Anyhow?
Things that make you go hmmm! Posted byBack to blogging!! I have just recovered from a weekend long Movable Type crisis - details provided to the curious. I just finished recovering from my disaster. It is good to be back!! I believe that comments did not work for the interval period. I hope all works again. Additionally, I migrated my database to SQL. Here's hoping that is a good thing. db Cardiac risk in kidney disease AHA Raises Alert on Cardiovascular Disease Risk in Kidney Disease Patients
For those who want to read the statement - Kidney Disease as a Risk Factor for Development of Cardiovascular Disease Posted byMore on the whistleblower story Earlier this morning (2 posts down) I blogged about physicians who complain about substandard care. I have read the newspaper stories now and find them chilling. These articles point out the conflict between hospital administration and physicians. Most physicians worry first, second and third about the quality of care that their patients receive. They know that good quality care requires excellent nursing care, accurate laboratory and radiological facilities, and much more. We can develop a care plan; we can write orders; but we do not provide all the care. When we complain about substandard care, we are (in my opinion) directly challenging the hospital administration. We are saying that they have not provided an environment and sufficient personnel to provide high quality care. Some administrators have the patients as their highest priority. Unfortunately, I believe that some administrators are more concerned about the "bottom line" and make staffing decisions based more on finances than quality. When physicians complain, those administrators will sometimes become defensive. This defensiveness can turn into aggressive measures against the physician whistle blower. I understand why we need hospital administrators. I understand the importance of the bottom line. What I do not understand is a lack of interest in prioritizing quality patient care. What I do not understand is an attitude that physicians who complain about documented nursing errors are trouble makers. If you have the time, read the stories. From my perspective, they make Stephen King look lame. Posted byForeign policy and the war on drugs Readers will remember that I favor legalizing drugs. I believe that the costs of the "war on drugs" greatly exceed any possible benefits. This decidely libertarian approach bothers many. One issue which I have not considered (but which bolsters my argument) appears in this op-ed piece - High politics
Points well made!! Posted byPhysicians who speak out Not much time this morning (have to go workout soon), but I plan to read this entire series later today and then comment. Thanks to a reader for pointing me to this link - The Cost of Courage: How the tables turn on doctors
This link starts a week long series. It looks most interesting. Posted byGrooving while listening to my music I guess I always knew this, but I love having the reference - Merry Melodies
And their findings:
As a non-music major, I do find that music helps me relax and work. Perhaps it has a major positive effect on my mood. Regardless, I do enjoy listening to music - and believe it rewarding for its own sake. Posted byMore on the Crestor story Medpundit clued me in to Derek Lowe's excellent analysis - Harsh Words Posted bySlowing down as we age Our athletic ability does deteriorate with age. At 54, I cannot do the same things I could do at 35. This econometrician has developed models to show the phenomenon. For Aging Runners, a Formula Makes Time Stand Still
I found this article fascinating. A quick web search found this reference to more details on his analysis - Marathon Times with link to his article "How Fast Do Old Men Slow Down," The Review of Economics and Statistics, February 1994, 103-118. Posted byEating smart while eating fast Sometimes you just want to eat fast food. Apparently the choices have increased dramatically. In the Temples of Supersizing, Eating Light Draws Converts
While I strongly disagree with the lawsuits, perhaps the attention that they attracted have encouraged people to reconsider their diets, and fast food companies to reconsider their offerings. Sometimes a bad process yields good outcomes. Still when I want fast food:
I personally like the turkey! Posted byTHG banned The FDA got this one right. Acting Quickly, U.S. Bans Newfound Steroid
I would bet that this scandal will spread. For more on this topic check my previous posts - A new steroid for elite athletes, More details on the new steroid controversy, and More on the designer steroid controversy. Posted byMore on passive euthanasia I finally did address the Florida case yesterday. One comment reads:
The reader raises an interesting point. How do we distinguish between active and passive euthanasia? I strongly disagree with the first, and accept the second. I found this commentary from a Rabbi's sermon on the High Holy Days: On euthanasia - for those interested, scroll down to the second sermon. To be the key paragraph in this intelligent sermon reads:
So we find ourselves with a complex philosophical point. Are we obliged to supply nutrients to a patient who cannot acquire them? This patient cannot feed herself in any way. Is a discontinuation of nutrition a legitimate and moral passive euthanasia? I believe that this is a moral and compassionate option. I believe in states "worse than death". I would not wish this poor woman's condition on anyone. I understand that others would disagree with this opinion. I hope you can understand the philosophical basis of this opinion. Posted byMedscape I often link to articles in Medscape. Medscape is a free service. I consider it the best single source for medical stories (article reviews, presentation reviews, news releases). If you are a physician and have not done so, I recommend registering (free), and checking out releases on your specialty daily. Medscape. Posted byCOPD and hospice I often blog about hospice and palliative care. We have an outstanding program at our VA hospital. Because of the program (and its dynamic leadership) our residents and attendings think palliation more broadly than most physicians. We do place many COPD patients into palliation/hospice. Apparently we are different. Few End-Stage COPD Patients Discuss End-of-Life Plans With Physicians
Our experience (admittedly anecdotal) suggests that many COPD patients willingly participate in these discussions. We do push hospice, because the patients seem to receive better home care. The patients appreciate the attention. I believe we improve their quality of life. And that is important. Posted byThe rock and the hard place F.D.A. Intensely Reviews Depression Drugs
I certainly would not want to be a member of that panel. The panel will try to view the evidence dispassionately.
Many do not want to view the data. Anecdotal evidence is really an oxymoron. We need to carefully evaluate this issue. The panel will take its job seriously. I hope we can take their conclusions seriously. Posted byWe can recommend - but then what? Doctors Tread a Thin Line on Marijuana Advice
I doubt that I would consider marijuana a first line agent for most patients. Clearly, we need well done studies to understand the risks and benefits of marijuana as palliation. However, when dealing with palliation, one want to have all possible tools available. Even if marijuana became a "last resort" drug, why should we not have the means to help patients? So physicians have won a battle, but we still have a war to win. We need to perform the correct studies to either show significant medical benefit or not. This should not be a political decision. This should not be a moral decision. This should be a medical decision. Posted byThe right to die Wow! I have tried to avoid this issue. But I do feel controversial today, and, Rangel has nailed this issue - A long slow death in Florida Like many such issues, the current arguments are rarely based on knowledge. Rather belief and hope reign. Rangel has beautifully discussed the details and implications of this unfortunate case. Please read his post. If you want a contrary view - check out Medpundit (Thursday Oct 23, and Friday Oct 17) - unfortunately her permalinks just never work. I side with Rangel's commentary. He has researched this issue and removed the hype. I also understand the controversy as I have seen such cases first hand. Posted byFor more on today's posts I counted on Robert Prather expanding on my economic arguments concerning health care. Read his comments - The Cost Of Health Care By the way, you should really read Robert Prather everyday. Unfortunately, or perhaps interestingly, he changes his blog's name every few months. He finishes today's post with these words of wisdom:
Posted by Dedicated to Robert Prather Robert Prather has written often about the problem of dissociating health care costs from patients. This NY Times piece explicates the problem beautifully. Do Some Pay Too Little for Health Care?
There you have it. We have a system which encourages overuse of some health care (actually, most health care plans underpay for prevention, making the analogy in this article more a straw man than real argument). Thus, libertarians (this includes me) would like a system which encourages patients to participate in the finances of medical decision making. "Liberals" define health care as a right, thus we should pay regardless of the stress to our society. I hope that I have correctly characterized the tension. And economists continue to debate:
I find this debate healthy. Those in my research field (Medical Decision Making) have understood this problem for 25 years. We have always discussed the constraint of limited resources. This concept drives the entire field of cost-effectiveness analysis. We could make the decision that health care is a right, and we should pay whatever it takes. If so, then we should not complain about rising health care costs. If we want to control costs, then everyone (physicians and their patients) should work to make cost decisions. Our current system does not stimulate such work. Posted byA bureaucratic system with political oversight Medicare represents a double edged sword. Certainly many 65 and older can afford care which they might not afford without Medicare. However, the Medicare program requires a bureaucracy with political oversight. As one contemplates that sentence, most would admit that bureaucracy with political oversight must lead to a bizarre system. Generous Medicare Payments Spur Specialty Hospital Boom
So the Senate wants to close a "loophole". What they must realize is that the system will always create loopholes (some would call these opportunities). A bureaucratic system with political oversight must (it seems to this observer) to muddle through health care, making the mistakes that all bureaucracies make, creating the unintended consequences that all politicians create.
I hope readers understand (please read the entire article) why many physicians find Medicare so frustrating. They create winners and losers, and do not even know that they create them. For those keeping score, health care does not reach its potential. But the intentions are pure. Posted byOn internists and family physicians A colleague blog (Family Medicine Notes) responds to my discussion of general internal medicine with an excellent discussion of his own - Internal Medicine. First, I must correct one minor error. The article appears in the Journal of General Internal Medicine - not Academic Medicine. Jacob Reider (the blog author) makes several important points.
I found these paragraphs very powerful. Jacob nicely defines the differences between family medicine and general internal medicine. Family medicine training has (and must have) much greater breadth than general internal medicine training. We still focus more of our training on hospitalized patients (although we have increased our outpatient teaching). We only care for adults (family docs have equal pediatric training). We have minimal training in gynecology, office orthopedics, etc. While some primary care internal medicine programs have worked hard to provide training in these additional fields, we remain internists. Our mind set comes from the complexities of inpatient medicine. We tend to attract older more complex patients. While "keeping up" remains a major challenge for general internists, our challenge pales when compared with the challenge of family docs. As our article discusses, the old GP often referred patients to the general internist. The Oslerian tradition was the general internist as consultant physician. The growth of subspecialties has decreased the family doc - general internist referral. According to colleagues it still lives in many rural communities. However, in the big city, the family doc more likely refers directly to a subspecialist. Now I love subspecialists, however, some patients (perhaps many patients) benefit from having one skilled general internist rather than 2, 3 or 4 subspecialists (e.g., cardiologist, pulmonologist, gastroenterologist and endocrinologist). Most family physicians have neither the time, nor the inclination to follow the complex patients. I hope that our article will stimulate thought processes about generalism. I see family medicine and general internal medicine as overlapping Venn diagrams. I hope that we can redefine the concept of primary care with the goal of understanding the primary care is not simple care . Rather, different patients need different types of generalists. Thanks to Family Medicine Notes for reading and expounding on my post. And for those who really care, db stands for Dr. Bob and da boss. On the golf course my buddies all call me db, short for Dr. Bob. At work they call me db for da boss. Hence db's Medical Rants! Posted byInternal Medicine in the 21st Century Sometimes one must toot the horn. I am a co-author on (what I believe) is a very important article - American Internal Medicine in the 21st Century: Can an Oslerian Generalism Survive? I understand that few readers will have access to this link. I will provide a few quotes from the article.
These paragraphs introduce a combination of historical perspective, philosophical musings, and the clear preferences of the three authors. We (Thomas S. Huddle, MD, PhD, Robert Centor, MD, Gustavo R. Heudebert, MD) try to place internal medicine into perspective. Even in medicine, one can learn much from history. Understanding how we arrived in our current straits helps us understand which directions we might now travel. We finish:
As an academic general internist, I worry about our field. Many patients would benefit from a general internist. General internists invite complexity, and have the skills to balance the many conditions which afflict our patients. Caring for the complex patient takes more time. We want to spend that time; we want to address the myriad problems; we want to make a reasonable salary. So where does our profession go now. Perhaps we can take the wisdom of the Cheshire Cat from Alice in Wonderland:
Since most of us do care where internal medicine goes, we must proactively choose our path. I only hope that we can. Posted byMore markers of coronary instability Myeloperoxidase and Glutathione Peroxidase 1 May Predict Cardiac Events
Over time, we add greatly to our understanding of acute coronary processes. These studies add to an ever confusing set of markers. Now we need the fundamental scientists to help us understand. Then we may one day use these data to tailor patient care. Meanwhile, the studies fascinate me. Posted byThank you readers Over the past week, readership has increased dramatically. I am not sure why, but it is quite pleasing. While I write this blog primarily for my own edification and enjoyment, having readers multiplies my pleasure. Blog writers would not have counters unless they were interested in how many readers they have. Having readership growth suggests that my writing and article selections resonate with you. So thanks! Please provide me with suggestions - which, in characteristic fashion, I will consider, then do what feels right to me! Posted byRemembering the Killip Classes For those who care for myocardial infarction patients - Physical Exam Useful in Predicting Mortality in Non-ST-Elevation MI
The important point here comes from the simplicity of this classification. The Killip criteria do not require sophisticated physical examination skills. These findings are straightforward and obvious even to brand new 3rd year students!! Posted byThe VA makes a great move Many physicians remember their VA training. No incentives seemed to encourage discharging patients from the hospital. Admissions would continue for days and weeks - for no good medical reason. Several years ago the VA changed. To many observers, these changes have surprised, and produced surprisingly positive results! V.A. Shift to Outpatient Care Is Efficient and Sound, Study Finds Kudos to the VA!!! Posted byI disagree - but we do read opposing viewpoints
The author avoids medical data and specializes in hyperbole. I have written often on the problems of supplements and particularly ephedra. This commentary represents the counter arguments. I would love to debate anyone on this topic. I completely disagree with the commentary - but then we promote free exchange of ideas. Posted byStress debriefing - a debriefing Should we relive stressful situations? I have always personally preferred suppression. The Debriefing Debate: One Popular Therapy Is Called Into Question
The entire article is interesting and provocative. Highly recommended.
Posted by On adherence Prescribing medications represents my major therapeutic tool. As an internist, I have my bedside manner and medications to offer. Some patients will need surgery, however, we try our best to avoid surgery if possible. Ask a group of generalists about medication compliance (more politically correct to use the word adherence), and they are likely to roll their eyes. Often we really know the right medications to prescribe. We have read the studies, and understand how and why the medications should work. However, no medication works if the patient does not take the pills or capsules. The real drug problem: forgetting to take them
If one reads the comments written to this blog, an incredibly high percentage discuss medication side effects. Many patients feel that if anything untoward occurs while they are on a new medication, that they should blame the medication. Patients who take a medication which makes them feel better (like PPIs for severe heartburn) often discount the side effects. Those who take medications for prevention seem to maximize possible side effects. I am glad that more research will occur in this realm. We need to learn how to help patients help themselves. Posted byType A and hypertension - just chill Are you type A? You could take this test - Type A Personality Test. Type A personalities do develop problems. This study highlights those characteristics of Type A personalities which put one at the greatest risk for hypertension - Study offers advice for Type A personalities
According to these prospectively collected data, most aspects of type A personalities do not put one at risk. I find this welcome news, as so many colleagues are clearly type A (this is a VERY common personality type in physicians). So the rest of the day your favorite new word should become chill ! Posted byMore on the athletes and steroids controversy Scientist Suspects Many Athletes Are Using Undetected Steroids
Put yourself in the athlete's position. He (she) is young and talented. This is the one time that they can profit from their talent. Once you reach a certain age, no more profit will exist. They live for athletic success. One can view this much like the story of Dr. Faustus.
This story should not surprise anyone. The athletes are young, immortal and will do anything for success. They will obviously risk their health. And some chemists will create chemicals for them. Follow the money! Posted byGood news on ASA and ACE inhibitors Previous studies suggested that ASA might diminish the effect of ACE inhibition on CHF. This study provides evidence against that hypothesis. Aspirin Not Harmful for CHF Patients Treated With ACE Inhibitors
This is an important study which affects many of our patients. Posted byCardiovascular exercise improves your brain! Age, exercise may boost memory
Posted by More details on the new steroid controversy Posted by On colonoscopy You would rather not have colon cancer. I have taken care of colon cancer patients, and I would go to great lengths to avoid this disease. Fortunately, most colon cancers can either be prevented or removed prior to spread with colonoscopy. Unfortunately many patients will not consider the test.
I have had friends and patients ask me about virtual colonoscopy. This procedure uses radiologic techniques rather than a scope. However, it just does not work as well - Virtual Colonoscopy Misses Nearly One Third of Lesions
In case you wondered, I put my money where my rectum is. I had a colonoscopy as I was turning 50. The prep was reasonably miserable, but did thoroughly clean my colon. I do not remember the procedure at all - the combination of medications used - Demerol and Versed (pronounced Ver - sed) decreases pain and anxiety and provides short term amnesia. Gastroenterologists tell me that sometimes a little amnesia is a great side effect. Bottom line - when you turn 50 seek out a colonscopy. Do your rectum and colon a favor - have them checked out! Virtual colonoscopy is not ready for prime time. Posted byA new steroid for elite athletes The drive to be the best clearly is a double edged sword. We all admire the doggedness and hard work associated with excellence. However, we disdain the cheater. Athletes (as a group) generally mirror society. This story speaks specifically about high performance athletes, but one could argue that it reflects how we view acceptable behavior. We do not live in a uniformly honest society. I fear we trend towards a win at any cost mentality. One reason that I find golf attractive is that it remains an honorable sport. Baseball has a long history of corked bats, spitballs and other cheating plays. Football lineman are taught how to hold without getting caught. Basketball players learn the same types of lessons. Thus, this article should not surprise anyone. Drug Agency Tells of Steroid Scheme by U.S. Athletes
Read the remainder of the article. The story is fascinating, quite disturbing, but not surprising. For another take on the story, read the Washington Post article - USADA: Elite Athletes Using 'Designer' Steroid Posted byFluoroquinolones and tendon ruptures The fluoroquinolones are rather new antibiotics which we use frequently. Several examples of this class are ciprofloxacin, levofloxacin and gatifloxacin. We have believed that these drugs have the unusual side effect of weakening tendons. This study confirms that belief - Study Confirms Increased Risk of Achilles Tendon Rupture With Fluoroquinolone Use
While the risk is minimal, Achilles tendon rupture does lead to significant disability. We generally consider the fluoroquinolones as having minimal side effects. This study reminds us that we should always think carefully prior to prescribing antibiotics. Antibiotics are very important for those with significant infections. They do not help viral infections. We must reserve their use for clear indications. Posted byOn medical marijuana Earlier this week, the Supreme Court refused to hear a case. This case upholds the rights of physicians (in California and other states with a medical marijuana law) to recommend medical marijuana. Today's "Daily Scan" in the Wall Street Journal has three important links on the topic. High court lets stand ruling over medical pot: Doctors may discuss option with patients. This article emphasizes the states' right to regulate and censor physician practice. As I read this article, one can argue that the Supreme Court wanted to avoid ruling on an issue which is really a state issue. Backers of Medical Marijuana Hail Ruling
Court rejects DEA press to censor doctors
Given that many patients (and physicians) believe that marijuana does have medical benefits (especially in palliation), having the government state flatly that it has no accepted medical uses seems disingenuous. We need well done studies of medical marijuana - especially since many patients feel so passionate about this subject. Several states have approved this in statewide votes. The people believe that it probably works. The government would better spend their drug abuse moneys supporting good testing of this hypothesis. As a final thought, this Supreme Court decision should relieve all physicians. We would hate the federal government having the ability to punish us for our opinions on medical issues. This non-review is truly a victory for physicians. I believe it is a victory for society also. Posted byMore evidence for low carb diets
I love studies which challenge conventional wisdom. While I do not understand how this happens, one cannot easily argue with the data. Since I want to lose around 5 pounds, I may go low carb starting next week (going to a medical meeting starting Sunday - and just do not want to start low carb until after that meeting). These results are indeed fascinating!! Posted byFlu shots I plan to get my flu shot this afternoon. The pain is minimal, and the potential benefit is great. Promoting Flu Shots for All
We have the nurses offer influenza vaccination to all patients. If you do not regularly see a physician, find a place to get your flu shot. If you are worried about the effects of flu shots - go read Medpundit's excellent post on this subject from yesterday. (Her links just never work). Posted byThe success of big agriculture, the expansion of our waistlines The (Agri)Cultural Contradictions of Obesity
This NY Times magazine article makes one wonder. Still, we must take personal responsibility and resist the marketing ploys to eat more. Posted byEncouraging exercise at work Obesity costs businesses money. They would like to stimulate exercise. Fight Against Fat Shifts to the Workplace
I stopped taking the steps at work 2 years ago, despite my office being on the 7th floor, and the VA ward being on the 5th floor. I find walking the stairs a simple but important discipline. Each time I walk the stairs I know the purpose behind my trek. Each such act stimulates me to think about both exercise and diet. Daily consideration of these factors helps me stay motivated. Perhaps external motivation can work as well as internal motivation. Perhaps it will stimulate a few workers to consider diet and exercise. If so, what a positive concept. Posted byNo blogging today I am on the road - giving grand rounds. Unable to blog again until Monday. Please frequent the excellent medical blogs listed on the blogroll. db Posted byEmbarassing The title says it all. Vatican claims condoms don't work
I am speechless. Why is the Church not thinking? Posted by Just another article on DTC advertising Drug Ads Don't Say Much, but Sell Big
You know how I feel about DTC advertising (I dislike it intensely). This report is "fair and balanced". Posted byOTC drugs - a cautionary note Over-The-Counter Drug Campaign
OTC drugs are potentially dangerous and potentially valuable. All patients should think prior to taking OTC drugs, or supplements. Unfortunately, most patients do not know enough pharmacology to make these assessments themselves. Posted byRethinking isolation - the unintended consequences One problem with policy making occurs when good ideas have unintended consequences. We see this problem often with government regulations. We can also see this problem with hospital policies. When I was a resident we had just opened the new medical ICU. We had a patient with resistent aplastic anemia. All known protocols had failed. The patient had profound neutropenia. Hospital epidemiology placed him on reverse precautions (all visitors had to glove and gown) to protect him from infection. He asked us soon thereafter if we could end the reverse precautions. He understood that he might get an infection sooner, but he wanted to hug his loved ones, see their faces and enjoy his final days. His request made sense to the team, and we ended the precautions - over the vociferous protestations from the hospital epidemiologist. The patient lived a few days. He smiled each of those days. He and his family expressed gratitude for our common sense decision. Isolation protocols need rethinking. The Risks Of Isolation
Sometimes isolation is very necessary. If you suspect active TB then you must isolate - to protect the health care workers. This article makes clear that we must consider both the costs and benefits of this process. Posted byUpdate on hepatitis C Those With Hepatitis C Still Face Long Odds I recommend this article as an update, and reasonable "handout" for patients. Posted byTwo important comments on drug benefits I ran a piece yesterday about employers decreasing drug benefits. Two comments deserve my commentary -
I disagree. We have lower cost alternatives available. Considering cost, we can still treat patients well. For example, rather than a newer ARB we can use a generic ACE inhibitor. Rather than a newer expensive sulfonylurea, we could use the first generation less expensive generic sulfonylureas.
I disagree. You can spend money for a more expensive PPI or a much less expensive PPI. Currently, patients want the advertised drug. If cost becomes important, then market share will suffer. The pharmaceutical industry worries about market share, just like any business. If patients actually consider cost, then the market will work. I believe that it will! Overhead will increase HHS eases interpreter mandate but doctors must pay the bills
Whenever the government mandates a program like this, physicians pay. This is a great example of increased overhead with no comparable increased fees. For those who wonder, this is a great example of a point that I make often. Posted byOn knee osteoarthritis I was playing golf with this guy - approximately 70 years old, and approximate BMI of 35-40. He kept complaining about his knee arthritis, and asked me what he should take. It's not the shoes but the weight gain
Just another reason to watch ones weight. Posted bySome logic on Medicare We cannot afford significant Medicare increased expenditures. From where will the money come? Well maybe those with more financial resources will pay more. Medicare Plan Lifts Premiums for the Affluent
This proposal seems logical. One would think that the Democrats would favor this plan, as it is really just a progressive tax. I suspect that we will see this. It does seem logical. Posted byRemembering Robert Palmer
But as you can see he smoked. Smoking is the number one preventable risk factor for myocardial infarction. If you smoke, stop. The day you stop your risk of a heart attack decreases. Also the risk of dying from a heart attack decreases (the carbon monoxide levels decrease rapidly, making oxygen more available to the remaining heart muscle). I hate to see people my age dying of preventable disease. We should make good health decisions. We only get one body, and we should pamper it! Patients learning that many drugs are expensive As Drug Benefits Fall, Workers Need a Strategy
The best way to influence the pharmaceutical industry to keep prices under control is for the marketplace to work. When a patient asks for the "purple pill" and I tell him/her that that pill costs $4-$5, and it the money comes out of their pocket, then the patient often will ask for alternatives. If they have a drug benefit, they just do not care about the cost. If they pay a percentage of the cost, they begin thinking differently. More patients will buy Prilosec OTC or generic omeprazole.
I believe the marketplace will have a greater effect on pharmaceutical pricing than any legislation. And as this article predicts, the marketplace will soon begin to work! Posted byOn the nursing shortage No matter how well I diagnosis the patient, without excellent nursing care, the patient may have a less than desirable outcome. Nursing care is extremely important. Actually, well educated nurses make a major difference. We have a growing nursing shortage. While one could postulate many reasons for the shortage, we better spend our energies understanding the solutions! This editorial addresses some ideas. Nursing shortage could kill you Just go read the editorial. It is good and it is important! Posted byBull market - diabetes and obesity Diabetes, obesity on rise in U.S.
As we worry about rising health care costs, we need to understand this component of prevention. If we would invest in exercise and weight loss, we would be healthier. Healthy people have lower health care costs. Our genetics have not changed in the past 5 years. But our waistlines have. We can only blame ourselves. We must change. We must all take personal responsibility for our health. Robert Prather understands that until each person understands the cost of health care, he/she will not have the motivation to act - Health Insurance Again But act we must. We need a different insurance system. One which keeps patients in touch with costs. Read Prather and the linked article from Reason. And by the way - eat smart, keep portions under control, and exercise. That plan really works. Posted byNo surprise to me Brain science reveals what men are really thinking
These concepts seem obvious to this product of X and Y chromosomes. Maybe this article (which refers to a book) will help some women understand the men in their life. Maybe it won't. Posted byBreast implants and suicide
Right now, please stop reading, close your eyes and think. What might cause this finding? Clearly, the data do not come from randomized controlled trials. Therefore, we must consider two possibilities - cause-effect or a confounding variable. I have difficulty imagining and cause-effect hypothesis (although someone may develop a reasonable one). I can more easily imagine a confounding variable. Now we must consider ways in which women who get breast implants differ from those who do not. These are (it seems to me) very different groups. The article speculates.
So what do we do with this information? I suggest that we consider these important thoughts:
Posted by Blogroll changes Periodically I do housekeeping. This morning I decided to update my blogrolls. I deleted a few and added two very important and well done blogs. If you do not already read them - check out GruntDoc and Cut-to-Cure. They are (as the British are wont to say) "spot on". Posted byThe waiting list problem As we consider health care costs, we must understand the implications of cost saving measures. Our friends to the north manage some costs by delaying some elective surgery. Cholecystectomy is one such elective operation. This excellent article discusses the implications of delaying surgery - Risk of emergency admission while awaiting elective cholecystectomy
This research points out a danger of long waiting lists. Emergency cholecystectomy is more dangerous and therefore undesirable. Patients who required emergency cholecystectomy have, in my mind, suffered needlessly. We need to understand clearly the risks of waiting lists for various surgeries.
Posted by You've come a long way baby While the benchmarks used in this study are questionable, the article does highlight an important problem. States Fail to Meet No-Smoking Goals for Women
Posted by Maybe genetics is the key Study: Fat or thin -one gene does it?
This is an interesting claim. We need more information to evaulate the claim. Hopefully we will see more stories on this issue over the next few months. Posted byWomen get heart disease also Please read this case. It tells an important story. Paying Heed to Problems of the Heart
Well said and important! Posted byOn the physiology of addiction Addiction: A Brain Ailment, Not a Moral Lapse
This article does a very nice job of summarizing our knowledge and lack of knowledge related to addictions. Interestingly, almost all addictions have the same final pathway.
Interesting statistics! Hopefully, continued research will allow us to better help addicts through their physiologic withdrawal.
Read this interesting article and you will better understand the challenge these patients face. Posted byOur challenge with morbid obesity The weight of obesity: Linking large people to care
If obesity is not a disease, then we can at least agree that it represents a major risk factor for (amongst other diseases): obstructive sleep apnea, type II diabetes mellitus, hyperlipidemia, osteoarthritis (especially of the knees). Smoking is not a disease, yet we try (and should try) to get patients to stop smoking. Right or wrong, I view morbid obesity as a lifestyle issue. Like other risky lifestyle issues, I keep trying to convince patients to modify their lifestyle to reduce the risk of complications resulting from that lifestyle. And if I do not, then I not honest to my professional ideal. Posted byL'Shana Tovah And I wish one and all a happy, healthy and sweet New Year! Posted byI will work on my prejudice Wow! This article comes out today almost as if I had planned it. Fat equals lazy, say doctors
Well, certainly there are genetic factors which we do not yet understand. I hope ongoing research will make those factors more clear. However, genetic factors do not explain the growing epidemic of overweight and obesity. Environment does matter. Blaming all overweight and obesity on genetic factors, and avoiding all personal responsibility seems disingenuous. We all see patients and friends who decide that they no longer want to be obese. They can successfully increase their exercise and control their portion sizes. They can lost weight. I know, because I did! And I have maintained my weight loss for more than 3 years (size 38 pants before, size 35 pants now). Perhaps we can find a happy medium here. We need to learn more about the causes of obesity. Some patients probably have overwhelming genetic factors leading to obesity. But many patients just combine poor dietary habits and minimal activity to achieve their weight. We should not throw our hands into the air and blame genetics. We should continue to try. For sometimes we succeed! Posted byOn breaking bad news How can I explain the pleasure and the angst of medicine? No simple essay can encompass the variety one experiences in medicine. We celebrate successes with our patients; we watch them go through their terminal illnesses. Many things that we do are rewarding, while others can frustrate. Breaking bad news may be the most difficult and important part of our profession. I remember being in medical school. I discussed this issue with my father, who is a retired psychologist. He gave me advice that helped me for the past 30 years. I try to pass that advice on to my students, interns, and residents. First, make sure you are in a comfortable room, which is quiet and where you will not be interrupted. Next (and this is most important in the hospital), sit down. I always try to relax mentally. My words and expressions are important here. When possible I make light physical contact. Then I start. I generally start by asking the patient his or her fears. What do they think is the problem? If they fear the diagnosis that we will discuss, then I proceed by confirming their fears. If the diagnosis comes without insight, then I try to go slowly and explain the diagnosis as completely as possible. When I can give hope of treatment I do. When I cannot, I always make certain that the patient knows that we will not abandon him/her. We often cannot cure lung cancer (for example) but we can promise great attention to quality of life until death. I make that promise. In the inpatient setting we generally spend a bit more time with terminal patients. I always try to sit down and explore their needs. Caring for them requires caring for their family members. It requires patience and answering many questions repeatedly. When I cared for outpatients, I would have the patient make frequent office visits (every few weeks or at longest once a month). We would mostly discuss symptom control, or just socialize a bit. I would end each session telling the patient how I looked forward to the next visit. This article discusses the pain of giving bad news. Bearer of Bad News. The article discusses the new quick HIV test. The story discusses the difficulty involved in telling patients they are HIV positive. While breaking bad news provides one of our greatest challenges, it also gives us an opportunity to make an important difference. Our professsional lives give us the exposure to patients from all walks of life, yet in these crucial moments, we are all alike. How we break bad news matters? Those interactions are painful for the patient and the physician, yet when done properly, with dignity, empathy and respect, they can help the patient start on their path to addressing another hurdle. We matter, and we should. Each time I break bad news on rounds, I have the students, interns, and residents in the room with me. We always spend some time "decompressing" after the converstaion. I ask them to reflect on what we just did, and what the observed. I challenge them to take my method, and then modify it to fit their personality (for there is no one right way to break bad news). Hopefully, I will help some of these learners as they break bad news to their patients. Posted byOn ad hominem attacks This is a request for commenters. Please avoid ad hominem attacks. I just received one -
The commenter is out of bounds. Without investigating my practice (which is primarily inpatient at this time), and knowing how I care for patients, one should not attack me (nor any other physician). I confessed to prejudice. Almost all human beings have prejudices. In medicine, I believe that I can have a knowledge of my own prejudices (which I cannot avoid), and yet provide excellent compassionate care. One should judge how I care for patients, rather than how I feel. I know of few physicians who have success with the excessively obese (morbid obesity +++). To admit that and receive an ad hominem attack for admitting my frustrations as a physician does not seem reasonable. The purpose of a blog is to make me and my readers think. Such commentary does not advance those purposes. I apparently have incited much thought with that rant. Please respond with the same considerations. db steps off his soapbox, shakes his head, and moves on. Posted byAnemia and CHF - a good question A cardiologist writes:
First, I apologize if my comments were misconstrued. I am not accusing cardiologists or internists of ignoring anemia. Rather, my posts mean to suggest where the field may move. I suspect that we will have an indication for using erythropoeitin in selected CHF patients within the next few years. Currently, our hands are tied. I am supporting further research on the benefits of erythropoeitin therapy for anemic CHF patients. We need to understand the magnitude of benefit, and the associated costs. Only then will we know whether such therapy may help patients. The anemia hypothesis does fascinate me, and should fascinate all physicians who care for CHF patients. On anemia and CHF I have written about anemia recently. The impact of anemia on congestive heart failure is a growing issue. The heart.org (links are not available - you need to scroll down to this article - Anemia linked to poor outcomes in CHF - dated 9/24/03.
So what levels of anemia are we considering? The report from one study -
In this study they refer to hemoglobins of less than 12 as anemia. I suspect that more prospective studies will help us understand the benefits of treating the anemia. Posted byMore on morbid obesity Well, that sure grabbed everyone's attention. I fear that I did not make myself totally clear. It would help if I define terms. I feel like I work successfully with the overweight and the obese. The small group of morbidly obese (unfortunately an increasingly common problem) present a particular challenge. It may help to give some weights and heights. If one assumes a goal BMI of 22, overweight BMI of 27, obese BMI of 32, and morbidly obese BMI of at least 40, then we can look at 2 heights - 5 feet 6 inches and 6 feet. For a patient 5 feet 6 inches the respective BMIs come from the following weights - 136, 167, 198, and 247. Thus, a 5 feet 6 inch person who weighs more that 247 is morbidly obese. At 6 feet the weights are - 162, 199, 235 and 294. In fact I probably do well at a BMI of 40. The patients who exceed even that BMI by 50-100 pounds represent the small subgroup with which I have difficulty. One commenter suggested that she hoped that I tried to find them a good doctor. I generally try to consider a surgical approach in these patients, as I believe that the probability of weight loss success in these patients is otherwise incredibly low. Posted byOn obesity I admit that I have a problem with morbid obesity. This article pertains to me. For Medicine, a Growing Problem
As a physician I admit to emotional prioritization. I have greater empathy for patients who have no obvious responsibility for their illness. I empathize with pulmonary interstitial fibrosis patients more than COPD patients (especially if they continue to smoke). Morbid obesity bothers me. There, I have written it. I am revealed. I cannot view all patients the same. I find these patients too frustrating. Perhaps morbid obesity patients are just too challenging. I know that their problems stem from their weight. When they complain that their knees hurt, what should I say? I know that I am thinking - if my knees had to carry 400 pounds of blubber I guess they would hurt also. I am not alone. I suspect that I have just been more honest than many physicians. But I will assert that as a physician I understand that I can only point the way to health. With the exception of acute hospitalization, I cannot control what the patient eats, drinks or smokes. I cannot make the patient take his or her medications. When it comes to guiding patients, I have become emotionally detached. I try to give the best possible advice. I want the patient to succeed an improve their health. But I can only recommend. When you make repeated recommendations, in various styles, and you get no success, then you become hardened. I have successfully convinced patients to stop smoking, stop drinking and become more adherent to medical therapy. I have never succeed with the morbid obese. I have many successes with the overweight, and a few successes with the obese, but no successes with the morbidly obese. So I am hardened. And I am prejudiced.
I have no glib answers. But you do have my confession. Posted byOn type II diabetes mellitus Doctors struggle to convey risks of diabetes
I can easily argue that for internists, diabetes prevention should become a major focus of adult care. Clearly prevention should work better than treatment. However, prevention generally requires more than a pill. It requires lifestyle change. And few people seem to succeed with major lifestyle changes. And we get frustrated. And patients still develop diabetes mellitus type II. Posted byMore thoughts on administrative fees We have had spirited debate on the article about which I ranted earlier today. In that article, a Dr. Gottlieb discussed her administrative fees for her general internal medicine practice. I am in favor of administrative fees and will advance the following argument - expecting more comments. As professionals, we do our best to care for our patients. This includes the visit (either office, hospital, home or nursing home). Recently, we have only charged for the visit, and have provided extra time (reviewing charts, dictating, telephone calls, filling out forms) gratis. We could do this when the visit reimbursement included (albeit implicitly) enough money to cover the administrative expenses. As one decreases visit reimbursement and overhead increases, income begins to decrease. Since (as I stated repeatedly) we have almost no control over visit reimbursement rates, and we also have little control over overhead, the impact of overhead becomes a pure bottom line impact. What physicians want is a fair reimbursement for time spent. We deserve reimbursement for all the time spent towards the patient's benefit, not just the office visit. The solutions are obvious. We either need an increase in visit reimbursement (to subsidize the non-visit time), or we need explicit financial recognition for "other time". We have an appropriate model - the law office. If you call a lawyer about a problem, the clock starts ticking. You make an explicit decision as to whether calling the lawyer is beneficial. One could argue (within a sound ethical and moral framework) that the same should apply to physicians. For most generalists, our only commodity is time. We help patients when we spend time working with them on their health care. That time should have the same value whether the patient is present in the room, or we are reviewing laboratory work, or sending a note about the lab work, or calling the patient to discuss that lab work. A fair system would recognize this time fairly. We do not have a fair system. Physicians like Dr. Gottlieb are making this point explicitly, and it seems to bother some readers. It does not bother me. She deserves reimbursement for her time. She is trying one such method. We do need a method, if not this one, then we must discover another one. The current imbalance is not working. Posted byExtra fees for generalists This article requires free registration - Doctors give extra fees a shot
This practice goes half-way towards retainer medicine, but is couched in softer terms. Nonetheless, the physicians have a reasonable point. Current fees do not allow one to provide desirable medical care. I find this solution palatable. And I believe that the insurance companies should pay the fees. Posted byOne day H. Pylori treatment One-Day Quadruple Therapy Effective for H. pylori Infection
For those who subscribe to the Archives of Internal Medicine, the reference - One-Day Quadruple Therapy Compared With 7-Day Triple Therapy for Helicobacter pylori Infection . And the regimen use:
Posted by On anemia `Tired Blood' Warning: Ignore It at Your Peril. Jane E. Brody does a nice job summarizing recent information on the health effects of anemia. As a ward attending, I emphasize the importance of anemia much more than I did 5 years ago.
Many physicians have accepted low hemoglobins (in the 10-12 range) as acceptable and a result of chronic disease. Recent information suggests that we may become more aggressive as treating these patients to raise their hemoglobins towards normal - improving both quality of life and survival. Posted byMuscle pains and NSAIDs You Took a Pill. You Still Hurt. Here's Why. Regularly, I have post workout muscles pains. I never take medications for these pains. I view these pains as a price that I must pay for increasing fitness. Medications probably would not help anyway.
If you get this syndrome, read the article. If you decide to take NSAIDs, please do not exceed recommended dosage. Posted byThe risks of St. John's wort One problem with supplements and herbals is that the physician often does not know that the patient is using them. Sometimes that can cause problems. Warning on herb widens
St. John's wort does have a modest effect on mild depression. However, it really works as an active drug. When I prescribe several drugs, the pharmacy runs them through an interaction program and notifies me (if I did not know already) of a potential problem. This rarely occurs with herbals. Posted byAn interesting case Lisa Sanders writes well, and writes about important stuff. Morbid Obesity, Difficulty Breathing, Drowsiness Posted byThe point on herbal "medicines" As usual we have a strong disagreement with Bernie. Perhaps I can never win this discussion, but I do love the repartee. To understand Bernie's viewpoint, visit his blog - The Careless Hand and scroll down to September 16, 2003 (his links do not work).
Bernie is wrong. People do not always know if something works. If you have heartburn, and try a remedy, you know if it works. But if you have breast cancer you cannot tell. Nor if you have congestive heart failure, or cirrhosis, or osteoporosis. If patients want to try unproven remedies, why should I care? My problem with this approach is that they might use unproven substances when a proven substance exists. So anyone who encourages them to try a supplement rather than obtain medical advice, may be offering them false hope and inferior care. If you work at a health food store , and give medical advice (and the advice they are giving is in fact medical advice) then you are implying that your supplements will work better than the medications I prescribe. This position is untenable. This industry leads to inferior medical care for many patients. Those who sell supplements will always argue without using scientific principles. Once we accept the scientific method, they always lose. Now I do understand that many people do not believe in science . I find that unacceptable, and believe those who support medical decision making which does not stem from scientific principles dangerous. I hope that I have made my point clear enough. You can sell any junk you want, but please do not put my patients in danger with your con artist marketting. Posted byPhone medicine We are rarely taught phone medicine. We do need to provide some service in this manner. This article makes that more explicit - Doctors treating more patients over the phone This article refers to a careful study of phone call decision making. Posted byAdvice in 'health food' stores Use caution in health food stores What do you really expect? Do you think that health food stores expect credentials prior to hiring employees? Have you ever heard of the test on supplements?
I hope this study does not surprise anyone. I occasionally have visited such stores and observed. I see probable high school graduates telling innocent victims how to part with their money. The owners of such stores are, in my mind, true con artists. But as Nicholas Cage says in Matchstick Men - (and I paraphrase) - "I never take their money, they give it to me!". Posted byA provocative response on retainer medicine RG Lacsamana (one of most loyal readers) writes:
This missive captures the thoughts of many. I have had several such discussions with colleagues in the past 24 hours (since the newspaper article came out). I believe that we will have an increasing access problem in this country over the next few years. Retainer medicine will not cause the problem. The problem comes from the economics of generalist care. We should not fool ourselves. While we do have altruistic goals, we also would like to make a decent living. This requires a fair return on our investment of 8 years of schooling and at least 3 years of residency. We often have school debts to pay when we start practice. As intelligent professionals, we will make some decisions based on economics. Unless the economics of generalist care improve, you will see either a decrease in access or a decrease in quality. Currently, retainer medicine provides niche care. There are a few patients who gladly pay the retainer few to get the access that all patients used to receive. We would love to provide that access to everyone. If we could afford it, we would have plenty of new graduates doing generalist medicine. I urge us to look at why retainer medicine has emerged. It brings a message. Do not attack the messenger, attack the problem. Posted byAnd sometimes I am proud of journal editors U.S. Medical Journal Questions Herbal Remedies
She is right on this issue. This industry threatens our patients' health. We must speak out, and continue to speak out. Bravo!! Posted byMedpundit on Medicaid Medicaid Mandarin (hint you may have to scroll down the page). Medpundit has struggled with the problem of whether to accept Medicaid or not. Read her story! Posted byWe enter the retainer medicine arena One of my colleagues will start our new retainer practice. UAB plans exclusive clinic access, for a price
Sounds a lot like Marcus Welby. The "debate" is always interesting to me. We live in a capitalistic society. If you want to spend more on something, you often get more value. This is true for legal advice (perhaps), automobiles, houses, clothes, and the list goes on. If a patient wants to spend money to ease access to care, to have the physician's cell phone number, to receive house calls, why is that immoral? If one states that retainer medicine is immoral, then it follows that capitalism is immoral. Since I believe that capitalism is the fairest system (although one could certainly point out some flaws), then retainer medicine is fair. Our hospital and clinic do much indigent care. We care for "all comers". We want the clientele who would want and pay for retainer medicine. They already support the institution and I suspect that their involvement will enhance our charitable receipts. But, what we are really talking about is how miserable our current system of care has become. Money has not caused this movement, the practice climate has. If any reader would like to write a dissenting view, given coherence and logic, I will gladly publish that view as a rant (with the proviso that as always I get a rebuttal). Posted byOn portion size The key - blame America. And perhaps we are to blame. We have pioneered the supersize. We have defined a lack of portion control. And this is the real problem!! 'Big portions' health warning
And how many times have you heard a restaurant criticized because their portions are too small. And how many times have you heard a restaurant praised because of their generous portions. Posted byHmmm Canada's medical marijuana leaves bad taste
I cannot even pretend to comment intelligently about this issue. Posted byHIPPA's unintended consequences Medical Privacy Laws Frustrate Police
I love that quote. The rules are so dense!! I suspect the rules' density reflects the density of the rules' authors. Posted bySurprise, surprise Media 'distorts risks to health'
Hmm, let me see if I understand. The media is not just concerned with reporting. Rather they want to garner market share - thus they pick dramatic stories in lieu of important stories. And they claim to be the fourth estate, keeping the government honest. Posted byThe death ritual My colleague, Dr. Amos Bailey, specializes in palliative and hospice care. He has written a textbook on palliative care - which you can read on-line - PALLIATIVE RESPONSE. Recently, he has discussed the problem that new interns have with the death declaration. We had discussed how to teach interns the proper way to go through this ritual. This piece (available for those who subscribe to the Annals of Internal Medicine) makes his point poignantly. Death Rituals . The author finishes:
Posted by The cost of a medical education Do you ever wonder why students select specialties? Many factors matter, one is income and debt. I received this email today:
More on Prop 12 The NY Times discusses this Texas vote today - Malpractice Suits Capped at $750,000 in Texas Vote. But the proposition is even better than the headline.
Good news for Texas!! Posted byGood advice for patients One might even send this article to new patients prior to their first visit. Doctor visits better with readiness
Amen! We must get a good history. We can only ask questions when you give us the proper clues. Do not hide information from us. Posted byTexans do the right thing Texans narrowly pass Prop. 12. If you are not familiar with Prop 12, read RangelMD - Regarding proposition 12; Trial Lawyers = Roaches Posted by15 minutes Wow! I wish that I had written this piece. Kudos! I'm Sorry, Your Illness Is Coded for Only 15 Minutes. Please read the entire article. Here is a taste:
This is powerful stuff. I rant about these problems regularly, but this article really does a great job of explicating the problem. Oh, and did I remind you to please read the whole article? Posted byRed wine
Our culture does seem to reward and support moderation. Somehow we need to make drinking less important, and more acceptable. Many cultures accept drinking in moderation for the majority. Our culture has a strange attitude about drinking - which I think leads to our binging. Unfortunately, the author has proved to himself that he cannot handle moderation. Posted byWhen health care costs are covered Patients in Florida Lining Up for All That Medicare Covers
And patients do not consider the cost of health care. When the consumer (the patient) spends money without accountability, we get the expected outcome. Our system (and not just Medicare) is broken because we have no relation between the cost of care and what the patient pays. This issue has complexity. We want everyone to have access to good health care. However, we would all agree that one can have excessive health care. We have choices that one could make, but no incentive to make them. In fact, physicians often have a perverse incentive - getting paid for doing more rather than doing less (when less may be indicated). Read the remainder of the article. It points out the plight of generalist care very well. It concludes:
We do need a better system. And that better system is not a one payor system. It is a system with patient accountability. Posted byAnd smoking still kills Smoking Killed Five Million Worldwide in 2000
Do not smoke. If you smoke, stop. If you know someone who smokes, get them to stop. Posted byAnd I thought Paternalism was dead Doctors should not discuss resuscitation with terminally ill patients - FOR. Their argument:
Their opinion goes on for several more paragraphs. I strongly disagree with this opinion, as does this response - Doctors should not discuss resuscitation with terminally ill patients - AGAINST This opinion in brief:
The article continues with other important points. I am somewhat surprised to see this debate. I had thought that we had resolved this issue over the past 15 years. Perhaps this debate is peculiar to Great Britain. I am not aware of such a debate in the United States. But I might have missed signs of these feelings. I feel so strongly about the value of palliative care, and advanced directives that I have assumed my feelings to be the norm. Let me know if they are not. Posted byOn John Ritter May he rest in peace. This one shakes me. John Ritter was the same age as me. He looked healthy. He suddenly died. This article explains why. For me knowing why is helpful. Aortic Tear That Killed Ritter Is Rare
Prior to this, the most famous person that I know had died of aortic dissection was Flo Hyman, who had Marfan's Syndrome - Marfan Syndrome: A Silent Killer. I suspect the John Ritter had known or unknown hypertension. Acute aortic dissection is one of the 7 deadly causes of chest pain that I use as a teaching session each month. These are all potentially treatable and potentially fatal. My list:
As a physician, when someone famous dies of an unusual cause, I try to learn and teach. In the future, when I discuss the 7 causes, I will include John Ritter's aortic dissection in the discussion. Posted byTreating syndrome X Surprise!!! Exercise and diet work. Exercise Plus Weight Loss Reduces Blood Pressure in Syndrome X Patients
Posted by On Oxycontin Panel Rejects Pleas to Curb Sales of a Widely Abused Painkiller
Wow! Let me frame the debate. What is more important? Should we have a great option for pain relief - especially for those with chronic pain? Should we have a valuable option for palliative care? Do these concerns outweigh the abuse concerns? Kudos to the committee for worrying more about the deserving patients. Maybe this committee could consider medical marijuana. The panel and the Bush administration do want physicians to use these drugs more intelligently.
Posted by Saying goodbye Sometimes we forget that we really never take care of one patient. We are always caring for the patient and those who love him/her. I just read this poignant tribute to a father - it reminds me. Everything Is Gonna Be All Right...
Posted by The National Review on Arnold and marijuana Regular readers know my position on drug legalization. While I admit that I do push the edge with that position, I am most adamant on the medical marijuana issue. Arnold agrees, as does this National Review writer. Terminator on Pot
As a major advocate for palliative care, I worry that the governmental position (which has existed over several administrations) decrease the ability of some patients to achieve their best possible palliation. We have no compunction about prescribing high doses of morphine (or similar such drugs). In fact, we are appropriately criticized when we do not help these patients achieve adequate pain control Narcotics are drugs of abuse, but they are also drugs of palliation. We should all understand that medical marijuana fits in the same definition. We need brave politicians who understand this issue and champion doing the right thing. One can wish. Posted byAn argument for our current health system Most physicians believe that the United States has the best health system in the world. I am aware of those who argue against that idea, but I dismiss them as a very vocal minority. They would argue that outcomes are the same or better in Canada and Great Britain. This article should make them pause. Op death rates 'far higher' in UK
As the health care cost debate accelerates, I hope we physicians make the case that better health care does cost more. I have argued before that improved health will take a greater share of GNP, and be worth it. Now I am not so naive to think that we could not decrease some expenses - especially administrative expenses. However, this article reinforces my belief that our system is far greater than a single payor system.
This article should make those who favor one payor systems reconsider their positions. The coming articles should shed even more light on this issue. Kudos to the physicians for performing this important research. Posted byDo traumatic events worsen PTSD? Some readers do not believe in PTSD. Perhaps the argument centers more around labels than observed behavior. How do we label that behavior? And does that label influence (in a positive way) our treatment options. The following article, in my reading, points out the pros and cons of the debate we have had over the past few days. Calculating the Toll of Trauma
One can easily explain the disparate findings. The first study looked for trends in patients who already carried the diagnosis of PTSD. It avoided anecdotal evidence, but rather collected data. And the data refuted the new trauma hypothesis. The latter study recorded more new diagnoses of PTSD. And that is no surprise. We make diagnoses that we expect. We often use the following expression: "If the only too a carpenter has is a hammer, then everything looks like a nail!". If after 9/11 psychiatrists expected PTSD, they would likely make the diagnosis more often. This article does not resolve our debate. It does clarify the issues a bit. Posted byMore on PTSD Some comments require their own space. Stef has provided the following comment concerning PTSD (I am moving it here for those who do not read many comments).
Knowing Stef (we actually work together) I would note that this commentary reflects a recent lunch conversation. I believe that he does a great job of explaining why many physicians use the label - labels make it easier to achieve our desired goal of helping these unfortunates. However, I wonder about the medication implications of this particular diagnosis. I see too many patients who receive this diagnosis and then an extraordinary cocktail of CNS active medications. How do we separate the bureuacratic need for PTSD with a more firm understanding of appropriate CNS active treatments? Criticizing the NEJM
While I believe the authors engage in hyperbole, their message is important. Too often our medical journals choose amongst many important and interesting submissions, those which excite them. The editors do have political agendas, and those agendas are manifest in article selection. How does this impact medical knowledge? The more presitigious the journal, the more likely that other scientists will read your article. If you choose to submit to prestigious journals, you often go through a cycle of submission, rejection, resubmission, etc. Sometimes an important article will take multiple journal submissions prior to acceptance. Let me give a personal example. I, along with several co-authors, have an article which is currently in press in the Journal of Clinical Epidemiology. This article was read and reviewed in multiple clinical journals prior to submitting to this journal (which, by the way, is very prestigious amongst clinical epidemiologists). I believe the message was one which the journal editors and reviewers did not want to hear. This article describes physician adoption of a guideline prior to the guideline's creation . The article explores who physicians adopt new information, and asks whether guidelines might sometimes just reflect practice. The article focuses on an important question - how does technology diffuse? We are please with the journal and the impending publication. We first thought of "prestigious" general journals because we thought the the findings would stimulate debate about guidelines. Perhaps the article is not as interesting as we thought. Perhaps the message is threatening to the establishment. And we will never know. Once the paper is published, I will post the details of the study for reader comment. In the meantime, remember that we should evaluate each article independent of the journal in which it is published. I have seen weak articles in the New England Journal of Medicine, and strong articles in supposedly weaker journals. We must never assume that the article is important because an important journal publishes it. Posted byGood carbs - bad carbs I have not ranted on this subject for a long time (malpractice, the insurance industry and the pharmaceutical industry kept getting in the way). This article stimulated my interest. For new readers, just search on "glycemic" and you will find a number of previous rants on this subject. Good carb, bad carb? Experts debate labels
The glycemic index refers to the speed of absorption and conversion to glucose. The higher the glycemic index the faster. High is bad, low is good.
And if the AHA and ADA dismiss the idea, then we have no major campaigns to educate the public. Without these influential organizations, we are unlikely to have food labelled for glycemic index (or even better glycemic load).
So now you understand the concept. We theoretically want to decrease glycemic load. The theory goes like this: the lower the glycemic load, the longer you stay satisfied. Therefore, you are less hungry at your next meal. Some research suggests this theory works.
The evidence is strong enough for authors of some popular diet books, who use the glycemic index as one of their primary rationales. "It's a new unifying concept that brings nutritional habits out of the dark ages and says it's all about the numbers," says Barry Sears, author of the Zone series of diet books. "It says diet does not have to be based on philosophy. It can be based on hard science." Major U.S. health organizations are less impressed. Ludwig expects this to change, in part because paying attention to the glycemic index can help everyone choose healthier carbs, whether they go low-fat or high. But that seems unlikely any time soon at the heart association. The head of its nutrition committee, Dr. Robert Eckel of the University of Colorado, says the theory that high-GI foods make people hungry is "ridiculous" and argues that a scientific case can be made for just the opposite. So now you see the nutritional debate. I believe the glycemic load proponents' side. Posted byA diagnostic dilemma Dr. Lisa Sanders writes regularly for the NY Times magazine. Each case that she presents makes one think, and generally teaches a good lesson. Hip and Buttock Pain, Difficulty Walking, Normal X-Rays
The remainder of the article discusses the evaluation, the diagnosis and the treatment. I like to "play along" on these presentations and see if I can figure out the problem myself. You might want to at least think through the presentation prior to reading the entire article. Posted byPTSD Working at a VA I see many patients who carry the label of PTSD. Some of them clearly have this disorder. This article raises a healthy skepticism about making this a psychiatric diagnosis. Is Trauma Being Trivialized? Posted bySuburbs - just something else to blame Another excuse, another target, we now can blame obesity on suburbs. As Suburbs Grow, So Do Waistlines As a long time suburbanite, I find this research line, and this reporting, bordering on silly. I have patients who live in the city tell me that they cannot walk in their neighborhood (because it is too dangerous). One can always find an excuse for being a cough potato. Walking trails are good; sidewalks are good; getting off ones butt is good. Blaming suburbia is silly. We each must take individual responsibility ... (excuse me for my political incorrectness here) ... for our actions and the results of our actions. Quit blaming society! Posted byOn PYY Study Finds Appetites Reduced by Hormone
The more we understand about physiology, the closer we get to being able to successfully modify the physiology. This study greatly advances our understanding of one particular hormone. This study will not translate to a weight loss program in the short run. However, in the long run, we may have better treatments for obesity thanks to this research! Posted byCynicism I post this link primarily to create controversy! Health Check: 'During the doctors' strike in the 1970s, death rates fell'
Posted by The risk of renal dysfunction Most generalists do not pay enough attention to renal function. Most cardiologists do not pay enough attention to renal function. We should consider renal function as an important risk factor in cardiovascular disease. Mild Renal Dysfunction an Emerging Risk Factor in Cardiovascular Disease
This issue requires more study and more attention. Posted byA Kentucky paper editorializes on the oxycontin problem Oxycontin (aka, redneck heroin) is a major problem in certain states. This editorial addresses the problem directly. Shifting the blame
Strong words! This editorial makes it clear that Kentuckians should accept the blame for their drug abuse and not shift the blame to the pharmaceutical industry.
Several observations are needed. First, thanks to the reader who sent me this link. The article does provoke much thought about prescription drug abuse. Second, oxycontin is a very good pain reliever. It has an important role in palliative care. Efforts to totally restrict this drug make no sense. Physicians who dispense large amounts of such painkillers should quickly lose their licenses and DEA numbers. Computers can identify these abusers. Finally, I am sure glad to read about this as a Kentucky problem and not an Alabama problem. Posted byACE inhibitors for all with coronary artery disease We already know this from several other studies. I am not sure why it is receiving billing as new information. Nonetheless, the message is worth reinforcing. All patients with coronary artery disease can benefit from an ACE inhibitor Pressure drug cuts heart deaths
We already do this with our patients. Having another study to reference only strengthens the argument. Posted byAggressively treating hypertension in diabetes mellitus Long time readers may remember the mneumonic that I developed for diabetes care - the FLECK(S) - I discussed this last year - Managing diabetes, more than the blood sugar. At that time my ending paragraph -
For a quick refresher, the initials stand for: feet, lipids, eyes, control, kidneys (which includes hypertension) and shots. With our residents we do focus on all the processes. Apropos today's NY Times has an important summary of hypertension management in diabetes mellitus. New Message Emerges in Treating Diabetes
For the readers who are diabetics, please remember to work to achieve a blood pressure for 130/80. This will require persistence for both the patient and physician. Posted byOne physician remembers residency It's Hard to Do No Harm When You've Had No Sleep
The author, who now works as a science and medicine reporter for the Washington Post, clearly views his residency differently than I view mine. He did his residency in the late 80s, early 90s, while I did my residency in the late 70s. His article focuses on the challenges of the work. I prefer to focus on the preparation for your life work. Herein lies the challenge. Residency should balance responsibility and dedication to patient care with working conditions. Most residency programs have already made the changes that the author discusses over that past 5-8 years. The new guidelines have caused most of us to tweak our residencies. Major scheduling changes have occurred prior to this year. While the working conditions are an important issue, so is the sense of responsibility to patient care. I worry (as do many practicing physicians with whom I discuss this problem) that in our new zeal to modify the working conditions, we may lose the sense of responsibility to patient care. Ultimately, we must instill and reinforce the importance of the patient. Sometimes physicians have to work very hard. Sometimes we have to work long hours. Sometimes we cannot avoid that. We must balance all the work changes with an absolute understanding that the patient comes first. The author believes this is not a problem.
Johns Hopkins needed to change. In multiple conversations with physicians and non-physicians this weekend (while attending a lovely wedding) we all understood that Hopkins was different. I would not call them an alpha dog, but rather an anachronism. The threat of losing accreditation signals to Hopkins that they in fact are not different nor superior. They now will join the rest of the programs in the country who already have addressed these issues seriously and generally successfully. The answer possibly is no, although personally I think it is yes. But in one sense the question is moot. There is no going back to the old system. The alpha dog got a whip across its back last week, and now it's doing just what it's told. The pack will follow. Posted byA large person writes about his body mass index It's a Weighty Problem, But A Crisis? C'mon
This opinion piece does provide some food for thought. As a non-obese person, I will respond concerning the financial implications. Obese persons consume more short term and long term health care costs than the non-obese. Thus, I am taxed to pay for your weight related disease. I would like to see adjustments made to health insurance premiums based on weight categories. This proposal is not a tax proposal. I believe that it would encourage personal responsibility. You would receive a financial incentive to control your weight. I believe this would represent a positive reinforcement for weight control. It also speaks of fairness to those who accept personal responsibility for their weight. Posted byTales of Hoffman moves Congratulations to Steve Hoffman, who writes Tales of Hoffman. He has moved his blog - I have changed my blogroll to direct you to the new address. He works for Medscape - my single favorite site for article summaries in internal medicine. He has pushed for a medical panel at "Bloggercon". He is right. Posted byBariatric surgery - a growth industry Hospitals Pressured by Soaring Demand for Obesity Surgery
This story makes one think. Clearly the surgery - which I must note carries small but major risk (including mortality) - helps many patients. I have seen patients whose lives have greatly benefitted. We (physicians) probably all have. However, I do find it sad that we have to resort to this extreme therapy for obesity. That severe obesity is epidemic (and perhaps endemic) saddens most observers. We should develop better prevention for this problem. Exercise and a healthy diet work. How can we reconfigure our society to encourage exercise and smarter eating? Posted byManaging constipation No snide comments allowed. Constipation does cause significant morbidity. Generalists often have difficulty helping patients suffering from chronic constipation. This article might help - Constipation and its management
Let me translate a few concepts here. First, diet is the first line. Many patients will have constipation decrease by changing their diet to include more fiber. Second, senna (e.g., Ex-Lax, Sennokot) plus a bulking agent (like Metamucil) will help many patients. Some patients with severe constipation will need chronic therapy with electrolyte solutions such as GoLytely (polyethylene glycol). Fiber can make some patients worse.
This article is very helpful for outlining a rational approach to chronic constipation. I plan to use it in the future for selected patients. Posted byOn staying healthy - or avoiding bad health Interesting piece - A Killer Top 10 List
You should peruse this very interesting list. Then think about how to stay off the list.
So who is Creagan? He is a Mayo oncologist and author - Introduction to 'How Not to Be my Patient Posted byMore on insurance companies and gastric stapling Insurers balk at obesity surgery costsMany who undergo the surgery have seemingly miraculous recoveries from chronic health conditions - at least in the short term - and report dramatic improvement in energy levels and quality of life. However, many insurance companies in the Northwest, where the Burcks live, including Health Net, Regence BlueCross BlueShield of Oregon and PacificSource, do not cover the procedure, or cover it only at an employer?s request. The companies cite a harsh economic climate and lack of long-term studies. "Of all the reasonable candidates, most haven't gotten approval through their insurance companies," said Dr. Bart Duell, associate professor at the Oregon Health & Science University School of Medicine and director of the institute's metabolic disorders clinic. Bariatric surgery has great risks (as I have written previously). Morbid obesity may have greater risks. The insurance companies are (in my opinion) showing no common sense here. They will likely save money from these operations (due to decreased medical costs in the future). I lament the need for these operations, however, they are often efficacious. Posted byNY Times supports drug comparison studies
Well said! Posted byHopkins reprimanded over internal medicine residency I have ranted about housestaff training often. Most internal medicine educators know that some prestigious programs have worked their residents harder than the standard program. Hopkins just got caught (analogous to Yale's surgery program problems last year). Hopkins Accused of Overworking New Physicians
The ACGME will enforce the rules. All programs should take heed. Hopkins will change their system (while grumbling I suspect). Posted byNew highlight Thanks to all the comments about highlighting. My summary was that highlighting was generally favored, but several readers felt it was too bold. I have tried to make it more subtle. What do you think? Posted byA question for readers While I write Medrants primarily for myself, I do want to provide an interesting site for you, the readers. I recently read a criticism of my formatting, and want feedback. Several months ago, I adopted a technique that I had seen on other blogs - highlighting. Here is an example: highlighted text in contrast with regular text. I like it personally, however, my question stems from the criticism. Does highlighting make you more or less likely to read a passage? Should I emphasize ideas with bolding or italics instead? Should I not bother to emphasize? While I am asking opinions let me ask two other questions? Please critique my quoting style (i.e. the dashed boxes that identify quoted material. Also, I would appreciate any feedback on what types of content you find most useful and interesting. I offer this disclaimer. This blog is not a democracy, rather I am a benevolent despot. However, even despots need good advisors!!! Thanks for reading and thanks in advance for your comments. Posted byMore on palliative care I write about palliative care periodically. Here is another good story about this important field. To read more - just search my archives. Finally (or Not), Relief: Palliative Care Aims to Soothe the Sickest, Even When Hope Remains Alive
The VA where I attend on the wards has a very active palliative care program. That program has improved the quality of life for the patients and the physicians. We no longer throw our hands up in dispair, but rather have an approach to help the patient. We better understand (thanks to our palliative care colleagues) that controlling symptoms in sick patients is often the appropriate goal. Posted byPediatricians declare war on obesity Rising Obesity in Children Prompts Call to Action
Posted by On olive oil and red wine I admit it - I love red wine and olive oil. These are good things to love. Mediterranean diet 'extends life'
Posted by On regaining sight This story is very interesting - Scientists Gain Insight From Man's Vision
Posted by US and Candian health systems The New England Journal of Medicine has several interesting articles today about the US and Canadian health systems. The NY Times is running this brief Reuters article: Health Costs Compared
That is the entire NY Times piece. The editor did not do his/her homework and omitted important parts of the article. Bureaucracy dogs health care: study
Better yet they and you should read the entire editorial which finishes:
For those who get the NEJM, read the editorial here: The Costs of Health Care Administration in the United States and Canada ? Questionable Answers to a Questionable Question Posted byMedicare will pay for lung reduction surgery in selected patients Medicare to Pay for Major Lung Operation
Simple advice - avoid getting emphysema. Do not smoke!!!! Posted byMost coronary artery disease patients have at least one risk factor Common wisdom has stated that many patients with coronary artery disease have no known risk factors. The advocates of that position then argue against aggressive cardiac prevention. I do not know from where this "wisdom" comes, but data in today's JAMA suggest that wisdom incorrect. Most Heart Disease Attributable to Common Risk Factors
These articles are very important. I agree with my UAB colleagues (disclaimer - I do research with Dr. Canto and we are co-authors on several papers - we also are working currently on a major grant which addresses risk factor reduction in post-MI patients). Posted byOn diabetes screening We would like to diagnose adult onset diabetes before it becomes symptomatic. Experts have argued that we should screen patients at risk to find early diabetes. It can work! Diabetes Screening Guidelines Could Catch All New Cases of the Disease: Study Posted byDefined contribution plans Consumers Take Charge: Defined-Contribution Health Plans
Well we have solutions - this ranter and my loyal commenters. We understand the problems - if they would only ask us.
I hope this prediction comes true. With defined contribution plans, patients will have a greater connection to health care costs. As I have ranted in the past, and Robert Prather rants often meaningful changes in expectation will only occur when patients have a stake in the financing of their health care.
This long article goes on to discuss the pros and cons of such plans. It also addresses the problems of managed care and many other issues. I highly recommend reading the entire piece. Posted byWhy costs keep rising? I rant on this subject frequently. Let me give the short version. Health care costs as a percentage of GNP keep rising. We can look at this in several ways. We could assume that costs are artificially inflated each year - so that the medical establishment can make more money. We could understand that the overhead of doing business is increasing - due to malpractice costs, the costs of federal regulations and the cost of labor. We could understand that some costs come from new technologies. All three possibilities probably have an effect, however, today we will read about possibility 3. New Therapies Pose Quandary for Medicare
This describes the quandry in a nutshell. Can we look solely at effectiveness or should we consider costs? We obviously must consider costs, we would only disagree on how much we would willingly pay.
As a general internist I am personally insulted. Medicare clearly does not value my services. They do limit our fees, yet they claim that cost is no object. Physicians are dropping Medicare patients, yet they (CMS) does not react - and yet they seemingly willingly pay for expensive new therapies. Posted byThe suit against the resident match Medical Establishment Hopes to Thwart Residents' Lawsuit
And residency is training. This suit really does not make sense. Without residency training, one cannot practice. One can restate residency as post-graduate training. The residency system prepares physicians for their future practice. While some programs might pay more for residents, I doubt that salaries would change dramatically.
Surprise, surprise, this challenge springs from a lawyer. He uses interesting language about educating people about a legal right. What he really wants to do is receive a large judgement (and the fees associated with that judgement). The match does work. Because of the match, we (the programs) get those students who want to train at our programs. Without the match, we would return to hard sells, arm twisting, and deceit. We would have to make deals to get students; they would have to decide on their residency slot prior to visiting a wide variety of programs. This suit would hurt future students more than programs. I doubt that it would change work hours or pay at good programs. But it would disminish the process of finding the best residency. Posted byMedicare follies As Yogi Berra reportedly said, it's deja vu all over again. Medicare Fees for Physicians in Line for Cuts
I really have nothing new to say about this issue. I disagree with the economist. This does represent a crisis. The crisis expands as each physician stops taking new Medicare patients. Patients want the best possible health care, but they do not pay. Patients expect health care and generally have insurance to pay. Health insurance dissociates the costs of care from the receiver of care. The best medical care costs money, and that cost is increasing. Politicians try to convince us that the costs of medical care are out of control. Everyone wants the best possible care; they want the latest technology; they want the newest medication; and they expect costs to hold steady or decrease. The economics do not make sense. And the economics of decreasing physician payments while passing laws which increase practice costs make even less sense. Most physicians have enough patients without accepting new Medicare patients. So the losers here are the patients. Posted byCreatine - for memory? This is interesting. In my previous post (see below) I slammed the herbal and supplement industry. Now I am ready to lean towards supporting a supplement - creatine. Creatine 'boosts brain power'
Creatine, unlike most supplements, has undergone very careful study. Scientists have used this supplement in randomized controlled trials. We have long follow-up studies looking for side effects. It helps many athletes gain muscle strength. While I am not ready to declare creatine a great advance, these data have captured my interest. I will try to follow this story carefully. We need more studies, but these findings do show promise.
Beware herbal claims I have to give the herbal and supplement industry kudos. They market well, and they develop plausible story lines. Unfortunately, when science checks them out, they usually get a failing grade. So it is for another herbal - Guggulipid Ineffective for Lowering Cholesterol
Another failure for herbal (or 'natural') treatment. I am not surprised by this finding. In fact, I expect herbals to fail. If they showed promise, the pharmaceutical industry would jump on the possibility, modify the compounds and have winners. Given the scientific basis for modern medical advances, we should all avoid the charlatans. Save your money. Avoid these unproven treatments. Posted byPotentially light blogging Going on a wonderful, short vacation - a wedding of the son of great friends. Should have much fun. I will try to do a smidgen of blogging now and each day - but you never know!! Posted byFair and balanced on Canadian IV injection sites First, I am not Al Franken, but like him, my columns are not really funny. I hope FoxNews does not have to sue me (although apparently it would increase readership). Last week, I ranted about Canadian IV safe injection sites - Canada providing safe sites of IV drug users . A Washington Post stimulated that rant. It also stimulated this opposing viewpoint in the Washington Times - 'Safe drugs'
This finishes the op-ed piece. I present the link here as a balance to my ranting. Of course, since this is my blog, I will counter. I find this issue troubling but solvable. While I am not in favor of addiction (of any kind) and especially of IV drug use, I do recognize that it occurs. My disapproval, either implicit or explicit, has (in my opinion) almost no effect on the users. The personality traits and social situations that addicts spring from do not generally produce a willingness to listen to the establishment, even the medical establishment. The road to recovery (ending addiction) is always there, however, only the addict can take the first step on that road. I can point out the road; I can give directions to the road; but I cannot take a step for the addict. While using IV drugs, the addict puts him/herself at great risk of communicable diseases, e.g., HIV, hepatitis B and C, bacterial infections (most seriously endocarditis). Until the user takes that first step, we as a society have two choices: we can show disdain for the addict and leave them to their own devices (showing no regard for their associated health issues) or we can treat them like any other patient, providing them with the best preventive care possible. I see these Canadian safe injection sites as preventive medicine. Many addicts do find the path away from addiction. We hope that they are free of disease at that time. Infected addicts infect others, even innocents. If we decrease the infection rate from IV drugs, are we not contributing to the public health. The image of an addict "shooting up" is deplorable. The images of AIDS, cirrhosis, hepatocellular carcinoma, bacterial endocarditis are more deplorable. Especially when they are potentially preventable. As I ranted previously, you feeling about this debate depends on how you view IV drug use. If you find it a disease, you may see the safe injection sites as a way to minimize complications. If you view this as simply a moral issue, then you can ignore the complications of IV drug use. One could argue (at least in ones mind) that the users who get AIDS (or hepatitis C or endocarditis) 'deserve' the infection because of their immorality. But how can one argue spreading an epidemic which does infect the innocent is moral? I believe this argument is really a risk benefit analysis. We should refrain from moral judgements, but first and foremost try to stem these epidemics. Perhaps when we gain the addict's trust, we might hasten the day when they take the first step on the path to recovery. And even if we do not, when they take that step, they have a better chance for a healthy life in the future. Posted byCaution on smallpox vaccine I have almost a full year of caution documented in the smallpox debate. I worried from the first about the risks of the vaccine. My early rants on the subject: Not excited by widespread smallpox vaccination , More on smallpox , Some teaching hospitals say no to smallpox vaccine . Today the Institute of Medicine provides this caution: Panel Urges Caution on Smallpox Vaccine
Posted by Do you need an annual physical Annual Physical Checkup May Be an Empty Ritual
For many years, I have found routine physicals unrewarding. As I read the data, I find little evidence that examining a seemingly healthy patient makes a difference. Of course, everything changes once the patient has symptoms. There are things we should do for prevention, but they rarely include routine examination.
This subject is not easy to discuss with patients or even most physicians. The data are clear, the emotions are not. Posted byWhy I love being a physician? A reader writes:
Yes! Yes! Yes! I do rant often about business issues in medicine ranging from the malpractice crisis to the imbalance between fees (holding steady) and overhead (increasing). I find the business of medicine disturbing in 2003. Yet, I love being a physician. Each day when I look in the mirror, I know that my goal is to help patients, either directly or by teaching students and residents - hopefully making them better physicians. While I have a very reasonable income, I rarely think about the money in relation to the job. Most physicians could make more money if they choose a different field. Few physicians really consider that possibility. Being a physician defines ones persona. I cannot imagine being anything else! Medicine satisfies my quest for knowledge. Each week we learn more which we strive to use to help patients. Patients are often like mysteries. They come to us with problems which we have to decipher. We collect clues - history, physical and appropriate diagnostic testing. Using those clues we strive to develop a management strategy which takes into consideration the patient's desires and our best knowledge of the evidence. But the doctor patient interaction adds a very important texture to our collective persona. When I introduce myself to a patient (as Dr. Centor), I almost always sense the patient trusting me and wanting to work with me towards the common goal of helping the patient. The doctor side of the doctor patient relationship provides me (and most physicians with whom I have discussed this feeling) a very special validation. We are fortunate that generally patients assume that we care and want to help. Being a physician is wonderful. We have business concerns today which I believe will lessen over time. The challenge of patient care and the non-monetary rewards will continue to make medicine a wonderful field. Finally, as I look back at my medical training I cannot really call it a sacrifice. I was generally happy during my training (well at times the 1st two years of medical school made me miserable). Even working every 3rd night as an intern, I found time for socializing, playing basketball and enjoying life. So I recommend to everyone who asks to pursue medicine, unless their goal is to make money. One should not choose medicine for money, rather for the joy you can bring to yourself and patients. Posted byReference on Pap frequency As an internist focusing primarily on VA hospital patients, I find this issue somewhat peripheral, yet very interesting. This past weekend I was debating this issue with several interested parties. This article provides more information and provides fodder for both sides of the debate - Safety of longer intervals between Pap tests debated Posted byMore on running late This story will not go away. Las Vegas physician appeals award in lawsuit over waiting time
Always remember the old adage, attributed to Claire Booth Luce - 'No good deed goes unpunished'. Posted bySomething is wrong with this picture Many non-physicians believe all physicians rich. I received comments implying this 'fact'. These comments most often come during malpractice debates or any general ranting about overhead costs. All physicians are not rich. Devalued Doctors
Posted by On PPIs A reader writes:
This reader raises some interesting questions. I will address dosing of PPIs and symptoms of reflux esophagitis. Proton pump inhibitors work by preventing the production of stomach acid. As I read the studies, there should be any major differences among the various PPIs. What does matter is the dose of the particular PPI. When one compares PPIs, one should compare equivalent dosing. As the writer surmises, she probably was taking an inadequate dose of Prilosec (omeprazole). Interestingly, the OTC version reportedly will have a dose of 20mg omeprazole. The second half of the question relates to the symptoms of reflux esophagitis. The classic symptom is heartburn. For unknown reasons, not everyone with significant reflux gets chest pain. Hoarseness is a fairly common associated symptom. This makes sense when one understands that the problem is acid 'splashing' up into the esophagus. Sometimes the acid goes all the way up the esophagus and reaches the upper airways. Patients can get hoarseness, cough and even asthma symptoms. I hope this answers the question and helps to clarify reflux esophagitis for some readers. Posted byACE inhibitor cough
I received this comment today. ACE inhibitor induced cough is a 'class' effect. If one ACE inhibitor causes a cough, likely all will. If one cannot tolerate the cough, often one can take an angiotension receptor blocker as an alternate drug, as ARBs do not cause cough. The ARBs are Losartan (Cozaar), Irbesartan (Avapro), Candesartan (Atacand), Eprosartan (Teveten), Telmisartan (Micardis), and Valsartan (Diovan). Posted byNot news, but important We all now understand the cardiac dangers of hormone replacement therapy. Here is another article on that subject - First Year of Hormone Treatment Is Found to Raise Risk of Heart Attack
So my position remains - hormone replacement only for those women whose quality of life has deteriorated secondary to menopausal symptoms. And I would even argue against that use in a woman a moderate or higher risk of coronary artery disease. Posted byA good idea Keeping up with the medical literature takes time ... and money. Medical journals are very expensive. As an author of many publications, I can assure you that authors receive no money for their articles. In fact, you are encouraged to spend money on reprints. I do favor capitalism, however, I wish that the medical literature was more accessible. So does the Dr. Harold Varmus. Open Access to Scientific Research
Posted by On adherence "A man may well bring a horse to the water, And so it goes for pharmaceuticals. We (physicians, medical researchers) often know how to improve quality of life and how to extend high quality life, however, our knowledge does not always translate to results. Our prescriptions mean nothing if the patient does not take the medication. Reinventing the medicine wheel
The author makes an important point. We need more once daily drugs (adherence climbs with once daily as opposed to 3 or more times a day). We probably need more combination drugs available. Patients with heart disease will benefit from multiple drugs. We would like to provide those benefits in a single formulation. My ideal solution would be a wide variety of combinations for ACE inhibitor, statin, beta blocker and aspirin. First, we would titrate each class, then we would have a combo pill to fit our titration. I do not know whether one could formulate such combo pills. They certainly would help patients. This is a good goal for the pharmaceutical industry. Posted byWasting physician time All physicians understand this article. It is not news. Yet, it is important - Doctors waste time on 'menial' jobs. While this article comes from Great Britain, it pertains to the US - and not just hospital work. Listen closely to physicians, and we often complain about the amount of "non-physician" work that we do. We have received extensive education and training. Why does anyone expect us to spend time on work that requires no such education? What is the opportunity cost?
I beg to differ with Dr. Eccles. We do not have such assistants - especially for our trainees. The point is an important one. Having physicians do non-physician work makes no economic sense. Posted byUniversal vaccination Rather than trying to tackle this subject anew, I recommend reading Medpundit's commentary - Public Health. This commentary refers to the National Academy of Science position paper - Panel Urges U.S. to Broaden Role in Vaccinations. Medpundit nails it. My comments would add nothing. Posted byFood choices inferior in poorer neighborhoods Chips for some, tofu for others
One cannot sort out causation from such a survey study. Perhaps the store in poorer neighborhoods only carry those food which their customers will buy. These data are interesting, and will require further study. Perhaps this could be a role for public health intervention. Posted byCanada providing safe sites of IV drug users Readers know that I favor drug legalization (even the 'dangerous' ones). This libertarian philosophy has practical underpinnings. I calculate (although I must admit this a very soft calculation, because I have no data on which to base the calculations) that the harm from our current prohibition exceeds the harm that would occur from legalization. This Canadian program makes sense to me - Canadian drug policy seeks a fix
So why is Canada approaching this problem so differently from the United States? I believe the problem is perspective. We (the United States) have elected a government which sees drug use as a moral problem. Thus, we easily condemn this immorality and stop all discussion. Canada has started to look at the overal implications of drug abuse. They are willing to weigh the pros and cons of any program (decriminalizing marijuana, providing a safe place of IV drug abusers to inject their drugs). As they dispassionately evaluate drug abuse, they conclude that the laws impede overall health, respect for the law, and encourage other criminal behavior.
We need this logical approach. The political hysteria over drug abuse in this country has too many adverse consequences. While these are unintended consequences, they are consequences nonetheless. We need politicians and leaders with the courage to look at drug abuse as a societal problem which needs societal answers. We should neither demonize the abusers nor the drugs. We should put the pushers out of business the old fashioned way, using capitalism. We should provide legal safe drugs - even those which we know will harm the users. As we sell the drugs, we can then invest money (the money which we are saving on law enforcement and HIV care) on user education and drug treatment programs. We already sell drugs that we know harm people - cigarettes and alcohol. While I lecture every patient why they should stop smoking, I would not try to make cigarettes illegal. Most people who drink have no problems - and the data even suggest that moderate drinking is good for one's health! I suspect that we would find the same with many illegal drugs (especially marijuana). I can only hope that we will approach this problem logically in the future. Perhaps Canada will teach us important lessons. But do we have receptors for such knowledge? Posted byWhy the medical media goes overboard I have previously ranted about medical articles being overhyped. Respectable newspapers will use sensationalized headlines. Findings sometimes receive an overenthusiastic response. This writer explains why - Health, Hope and Hype: Why the Media Oversells Medical 'Breakthroughs'
So after reading the entire piece, I am not sure whether the problem lies with the writers or with the editors. The medical blog world - growing and hopefully becoming more important - tries to put these articles into perspective. The longer one practices, the more careful one becomes when interpreting new studies. The perspective of time provides one with many examples over overhyped findings, diagnostic tests and drugs. This long view makes one look a bit more carefully at the data. We tend to ask more critical questions (although we are trying to teach this healthy skepticism to our trainees). Perhaps the medical blog community should provide a consortium to place these stories into perspective. Perhaps we already do. Posted byLyrics by Jack Johnson - you cant blame me This week I have started listening to Jack Johnson. If you have not heard of him, he is a former Hawaiian surfer turned songwriter/singer. Try to imagine influences like Bob Marley, Jimmy Buffet, John Mayer and Duncan Sheik. The music comes laid back with acoustic guitar, bass and drums only. He has two albums - 'Brushfire Fairytales' and 'On and On'. Here are the lyrics to one song from his newer CD - 'On and On'. It says a great deal about personal responsibility, something which we need to increase in our society.
Posted by On being a mother, a patient, a physician Posted by The doctor made him wait - he sued I saw this story on TV. I had thought about writing about it, but got busy doing other things. Fortunately RangelMD has two good posts - Don't like your doctor? Then sue! and More on suing the "late" doctor I have little to add to these excellent posts. But you know me, I have to rant just a bit!! I do understand the patient's problem When I was seeing outpatients, I would personally apologize to those in the waiting room when I was running late. I hated keeping patients waiting. On the other hand, sometimes you do fall behind. Patients arrive sicker than the office can handle. They require semi-intensive care. Or early patients come late, thus the later patients have a longer wait. Or you try to squeeze in a few patients as a favor - next thing you know your schedule has gone to hell. The physician could have probably avoided this suit by simply acknowledging the inconvenience (although I have never had a patient apologize for missing an appointment or arriving late). Regardless, I am shocked that the patient won the suit. If we see further such suits we will have to greatly change how we schedule patients. Rangel comments on these and more issues. If you have not already clicked on the links - get outa here - get over to RangelMD!!! Posted byACOG joins the bandwagon I have blogged about this issue back in May. ACOG has joined the American Cancer Society by endorsing less frequent PAP smears for some women. Fewer Women to Need Annual Cervical Testing
These new recommendations make sense. The data support the change. Posted byHarvey Fierstein on the increase in HIV infected young gays Please read this. Harvey has guts. He says what many of us believe. He has hit the nail on the head. The Culture of Disease
Bravo Harvey!!!!! Posted byStates's rights and marijuana Politicians tend towards being despicable. One trick they use is to turn the other sides strategy on its head and throw it back. This strategy makes clear the inconsistency in politics. All politicians will use any argument that they think will work. I like this trick, but that stems from agreeing with the proponents (o.k. I am a hypocrit sometimes). States' rights a solution to pot debate
Stated beautifully. The Republicans are clearly wrong here. Too bad more Republicans are not libertarians also. Posted byBeware tetanus Last year we had 2 cases of tetanus treated in our training program. This article gives an important reminder about keeping tetanus immunization up to date. Gardeners should get a tetanus booster Posted by Race, ethnicity and medical research I tread lightly today. Yet I must address this question. How should we include data on race in medical decision making? First, we must read what others have written. Race Plays Role in New Drug Trials
Well that certainly makes things perfectly opaque. We have many studies which examine how we provide differing quality of care based on the sociologic construct of race (that is actually easy - if the patient declares themselves a race we assume that true). We also have looked at how patients of different sociologic race respond to different medications (many physicians believe that calcium channel blockers work better in those of African-American descent). But the genetic construct alluded to above should make us more confused. Don't Base Drug Policy on Race, Geneticists Say
I hope you are just as confused as me at this point. Genetics clearly might matter. Our perception of race may or may not predict genetics. I find it unlikely that perceived race will have enough prediction of other genetics to make it a worthwhile construct for picking drugs. We need to move (as the article suggests) to explicit genetic evaluation for drug selection. That would represent a true advance. Posted byBerwick on safety I have known Don Berwick for over 20 years. He is bright and charismatic. His deep seated interest in improving quality of care combined with a captivating ability to communicate has made him a major leader in health care policy. He has an op-ed in today's Washington Post - Invisible Injuries
Whoa!! Slow down Don. This op-ed starts with an assumption - that the IOM has correctly estimated the number of deaths caused by errors. Almost all experts who have reviewed this report argue that the number is markedly too high. The number is important, as it informs public perception of hospital care. It obviously informs Don Berwick's perception. Rather than fanning the flames, I would prefer a careful analysis of what errors happen most commonly, and how do we avoid them. This seemingly simple goal actually has such complexity that we will probably continue arguing about errors rather than preventing errors. As a physician who spends almost half the year as a ward attending in a VA hospital, I see errors every day. We see errors of omission and errors of commision. The laboratory makes errors; the nursing staff makes errors; the pharmacy makes errors; we physicians make errors. Unlike many hospitals, we can tell when we make errors more easily because we do have an outstanding computerized medical record. Over the past few weeks we have seen laboratory tests not collected, or collected and not performed. We have seen radiologic reports not filed for weeks at a time. We see medications not given, or not delivered. We are generally understaffed for the actuity of our patients. At the risk of being chauvinistic, we need clinical physician leadership here. We are the coordinators of care. We must make the diagnoses and develop the management plans. However, we have little ability to insure that the other services (pharmacy, nursing, radiology, laboratory, dietary) have sufficient staff and sufficient accountability. I would agree with Don Berwick that we must reorganize medical care. Clinicians should once again have an influence on who hospitals run. Administrators have (in my opinion) too much concern for the bottom line, and not enough for quality of care. Until they who run hospitals have care as a true priority we will see errors. All that being said, few errors are major. I do not believe the IOM numbers. I do believe that we should strive to improve care. Physicians must lead the way. If they would only let us. (Damn that sounds whiny - I better think through this better, we should not let the current systems keep us from succeding). Berwick does hit the nail on the head:
Posted by More on work hours Go read what a surgeon has to say here - WORK HOUR LIMITS: HOW RESDIENTS FEEL and here - THE NEW 80-HOUR WORK WEEK. Posted byMore on resident work hours First, let me contrast two letters. The first is published in today's AMA news.
Read this letter carefully, for the author makes several strong points, but also exposes her hospital and residency program as not attacking these issues creatively. As our program has thought through these rules, we started with principles. We want to maximize continuity of care by a team. We understood that physicians deserved days off (this has been standard in internal medicine programs for several years). Thus, we (the attending, resident and interns) had to work as a team. As a team we make rounds daily, first discussing all the patients, then visiting every patient. These visits and discussions make clear to the entire team what the important issues are that the patient is facing. We work through decision making as a team (obviously I have the final say). We view abnormal physical findings together. I would argue that this system maximizes both education and patient care. Only when I can challenge the housestaff's decision making can they work through a process to improve. Only when we go to the bedside and examine a patient or interview a patient can we be certain that we are all on the same page. We need a common understanding of the patient and his/her problems. Using these principles, we are able to function very well under the new guidelines. When one intern is off, the other intern knows the patients. When the resident is off, I know the patients and can round with the interns satisfactorily. (Come to think, I am the only one who rounds every day - but then I do sleep in my own bed every night). Contrast this letter (from my comments section).
Well, Chris, I disagree with your premise. The workweek is in fact related to education. As one goes through training, one needs to see enough patients to understand the broad spectrum of ones specialty. Evaluating new patients does require enough time to think and observe. I have always assumed that there is an optimal time for being on call. In the old days, many attendings complained about every other night call. With every other night call, you miss half the cases! Now our challenge is to make certain that the housestaff see enough patients so that they are adequately prepared for practice (or further training). No amount of reading and studying substitutes for interviewing patients and caring for them. I believe the 80 hour work week actually is reasonable doing this stage of training. I would not want to go to a physician who had insufficient clinical experience. On the other hand, your girlfriend's residency program and hospital may well get into trouble. We have gone to great lengths to adhere to the guidelines. Many of our residents would like to abolish the guidelines. They remain concerned about continuity of care. Passing off care is hazardous. Housestaff will tell you that you never know a patient as well when you do not do the initial evaulation. The hospitalist example sounds good, but probably fails on two counts. At most teaching programs, the sicker patients go to the housestaff - because they provide better night coverage. Second, the hospitalists are already trained. They can pass patients off a bit better because of their previous housestaff training. As I have written previously, this year represents a year of adjustment for housestaff and training programs. We must find new methods of teaching while providing high quality care. Our program is reviewing our systems regularly, and we are prepared to continue to tweak the system until both education and patient care remain excellent. I only hope that all other programs are taking the same attitude. Posted byRetainer medicine spreads While I have not had any rants on retainer medicine recently, the movement continues to grow. As I had assumed, this movement stems from dissatisfication in our current system. This dissatisfaction occurs in both physicians and patients. Appeal of retainer practices: Boutique care goes mainstream
I have written about the potential advantages of such practices. These paragraphs summarize those thoughts.
Retainer medicine is about money, but it is also about time. I have written about time repeatedly. Time is the curse of internal medicine and family medicine. We cannot provide the highest quality care without sufficient time. Since time is money, current reimbursement rates combined with increasing overhead makes it nigh impossible to spend enough time with each patient. In rushing through patients several things happen. Shorter times tend to diminish the doctor-patient relationship. Short visits make physicians develop undesirable skills, like not giving patients the opportunity to raise new issues. The shortened times also decrease our ability to think through all the details of the patient. We should provide cognitive services, working through complaints logically, rather than ordering a few expensive tests, or referring quickly to a subspecialist. Patients have several complaints. As I talk with non-physicians, they often complain of the difficulty the have in finding a physician. When they find a physician, they then complain of not being able to get a timely appointment. The greatest compliment that I hear from patients is that a doctor spent so much time with them. Patients want to talk with their physicians. They understand the quickies are not satisfying. They (patients) need to tell the physician all their concerns, not just answer the questions that the physician wants to pose. I think this movement will continue to grow. The cited article does a nice job of presenting both the pros and cons of this movement. The opponents are fighting a losing battle (in my opinion). This practice solution makes too much sense. It will continue to grow. Posted byOn medical pimping Recently, two excellent bloggers have commented on pimping. For those readers who have never experienced medical school and residency, we must discuss the definition of pimping first. I must disclose at this time that I pride myself on pimping, and consider this a positive term. Hopefully my exposition will clarify my position here. According to one MEDICAL STUDENT DICTIONARY
This source clearly defines pimping negatively. A medical student provides a more balanced discussion - Clinical Pimping
I like this discussion very much. Pimping comes in varieties. Let me digress and contrast pimping styles. A patient is admitted to our service with abnormal liver tests. As the attending I start asking questions. I ask the students and then the interns to develop an exhaustive list of the causes of abnormal liver tets. We use that list to sort through the likely possibilities for the patient's presentation. The process of asking the questions is called pimping. If done right, pimping accomplishes much. When we discuss pimping in polite company, we state that we use the Socratic method in our teaching. One of my heroes is Kelley Skeff. He helped teach me how to teach - Demystifying Teaching. One thing that he taught me that has always stuck is that we must create mild anxiety in the learner so that learning can occur. I believe that I should ask questions which the learner understands that he/she should know. The process of exposing them to their incomplete knowledge should cause them to focus and seek to complete their information. This process is tricky. While we try to create mild anxiety, we also want to maintain a positive learning environment. Hopefully, we can accomplish this with positive feedback and a lack of dwelling on incorrect answers. I often start a ward teaching month with a brief speech. "I have been an attending for over 20 years. I know a lot of questions. My job is to find out what you know, and what you do not know. I should focus on teaching you what you do not know. Teaching you what you already know is a waste of your time. I will make you slightly uncomfortable at times. When you start to get nervous, remember that learning is about to occur." When done right, pimping as an art. The key to righteous pimping is in the pimper's attitude. When pimping, one must always remember one's days as a student and resident. As one remembers that, one can pimp with respect. This obviously does not always translate into a positive experience. The Art of Pimping
Force of Mouth (the blog) introduces what is clearly a sarcastic humorous description of pimping as if it were a serious exposition. One must read the article with tongue firmly in cheek. Finally, we get the surgical view (and for those who have never gone through a medical school surgery rotation, surgeon's are not known for gentle pimping). Pimping, Surgeon Style Well, time to quit typing. I have to read some medical trivia so that later today I can transform into my alter ego - Pimp Master!!! Posted byWhy some people do not get depressed? Do you have the resiliency gene? Have you heard about it? How do you respond to adversity? Do you seem to "spin" everything in a positive way? Perhaps your genetics allow you this resilience. Tapping the Mood Gene
So would you rather be resilient or become "normally" depressed. Which confers a greater advantage in life? Will this research provide us the tools to all become resilient? And will that be good? Posted byBanning ephedra? Long time readers know my feelings about the dietary supplement industry. I find it dangerous and cannot understand the law that allows its existence (without any proof of efficacy and minimal proof of safety). The FDA agrees with my stance. How many athletes have to die from ephedra before we agree to its danger? FDA Considers Banning Supplement Ephedra
This story fits my definition of a tragedy. We have a bad law, which has enabled these companies to market a dangerous drug - yes, I know it is called a supplement, but it fits every definition that I know of a drug. Still, many in the health industry support its use - SUPPLEMENTS UNDER SIEGE . These apologists believe that supplements are the answer (I still do not know exactly what the question is). They ignore data, just like the supplement sellers. We need rigorous data, not testimonials. Some supplements may have benefit. The data on creatine are impressive. The studies show efficacy and safety. We need such data on any supplement that consumers might buy. Until such time caveat emptor . Posted byThe Yips! If you do not play golf, this rant might seem boring. If you have the yips, this is fascinating. If you have ever seen the yips .... Yips, the Curse of Golfers, Are Put to the Test
I hope this research teaches us something about fine muscle control and why it sometimes goes bad. This research has relevance to more than golfers.
I eagerly await the results of this research. And for those interested, no I do not personally have the yips. But I have seen them and they are UGLY!!!! Posted byGo veggie Vegetarian diet may cut cholesterol as well as drugs - reports on a 4 week study.
This diet may well work. Perhaps some patients with hypercholesterolemia will try to duplicate the diet. It may well work for long time periods. I would certainly encourage patients interested in avoiding statins to try such a diet. Some very motivated patients will succeed in totally changing their eating habits. However, I doubt that I can convince many patients to accept this diet. Nonetheless, these finds are extremely interesting. We need more research on how and why this particular diet had such success. Those answers may help us design more modest and easily accepted dietary changes. Posted byOn communication - the value of apology Clinical care can result in undesirable outcomes. Sometimes we make mistakes. Sometimes the system fails. Sometimes undesirable outcomes just happen. Research suggests that patients and their families get frustrated (and then more often sue) when we do not acknowledge the problem - The power of an apology: Patients appreciate open communication
I hate the entire concept of risk management in medicine. I try to discuss all issues openly with patients. Probably I only succeed sometimes, but I will continue to work on improving my communication. Good communication skills do lead to better patient care, better enjoyment of the doctor patient relationship, and according to this article less need for risk management. I try to teach communication to students, interns and residents when we make bedside rounds. I only hope that I am sometimes successful. Posted byWhat is causing the bumps? Lisa Sanders writes medical stories for the NY Times Magazine. I recommend that all physicians read the clues carefully. Try to think through your differential diagnosis. Be honest and see if you would make the diagnosis. Here is the link - Severely Painful Ankles, Bruiselike Lumps
So we have our first clues. The patient has difficulty walking because of pain. She has a swollen reddened right ankle.
So she has systemic complaints, and finally has an abnormal exam.
This description made sense to me. Try to imagine the lesions, and assign a name to this finding. Does that help? The description and the pictures describe erythema nodosum . The author and her resident were stumped, but thought someone would make a connection. I actually did make the diagnosis while reading this case. Did you?
For the rheumatologist this diagnosis seemed simple. He sees sarcoid in a different context than most generalists (who much more commonly see the pulmonary variety). Context always helps make diagnoses. I love this case presentation. It reminds us of how internists think, and also how subspecialists think. This presentation may help me make a diagnosis one day. Maybe it will help you. And by the way, the patient recovered nicely making it indeed a great case . Posted byOn developing advanced directives You owe it to yourself and your family to consider advanced directives. Choosing a Final Care Plan
Please consider these issues especially when you develop any chronic disease. We need your input. We (physicians) want to tailor your care to your needs. You can help us greatly!!!! If you want to understand this issue in more depth - Patients Whose Final Wishes Go Unsaid Put Doctors in a Bind. If you are undecided about this issue - please read the article . Thanks! Posted byDangers of aldosterone blocking The RALES study opened an era of using aldosterone blockers to treat (and now prevent) congestive heart failure. Unfortunately, many physicians have started using these drugs (spironalactone and the new eplerenone) without a complete understanding of dosage. Here is the problem. We use spironalactone for cirrhotic ascites and use much higher doses than the RALES study used. Moreover, most CHF patients are already taking either an ACE inhibitor or an angiotensin receptor blocker, which increases the likelihood of full aldosterone suppression. While we want aldosterone inhibition, we do put patients at risk for the renal implications of hypoaldosteronism. These patients do risk hyperkalemia. Interaction of spironolactone with ACE inhibitors or angiotensin receptor blockers: analysis of 44 cases appears in today's BMJ.
Going back to the RALES study, they determined in their pilot study, that the doses of 25 mg and 50 mg led to few cases of hyperkalemia. As soon as one raises the dose to 75 mg in such patients (this does not apply to spironalctone given for cirrhotic ascites), the risk of clinical important hyperkemia rises to around 1 in 4 (25%). As one looks at the data provided in this study, many patients took 100 mg daily. A careful reading of RALES could have prevented the severe hyperkalemia that these patients developed.
One can only surmise that we might find the same effect when using the newer aldosterone blocker - eplerenone (trade name Inspra). The authors point out that in addition to the higher dose of spironalactone used in these patients, the patients often had decreased renal function and diabetes mellitus type II.
I had to search for the appropriate conversion factor for creatinine - this represents a value of 2.5. Thus, I interpret these data as a caution in patients with elevated creatinine or diabetes mellitus type II. Creatinine clearance does decrease with age, thus as patients get older, we must lower our creatinine threshold for worrying about hyperkalemia. The authors suggest using the Cockroft-Gault formula prior to starting aldosterone blockers. They do not mention their creatinine clearance threshold for using spironalactone, however I will state that I would have caution at clearances below 20 cc/min. I would also note that many patients in their report had diabetes mellitus type II. As these patients develop renal insufficiency, they often have type IV RTA (the hyporenin, hypoaldo syndrom). I wonder if some patients in their report had some decrease in renin and aldosterone prior to starting spironalactone. Thus, they would have more susceptibility to hyperkalemia. This article reminds us to think carefully about adding aldosterone blockade. It provides another example of the complexity of modern medical care - and how we must keep current so that we can weigh the risks and benefits of our therapeutic and diagnostic options. Posted byMore on Neurontin On July 12, I ranted about how Warner Lambert use deceitful practices to market Neurontin (gabapentin). I have done my research and want to provide more context. A major use for Neurontin is in painful neuropathies. The drug does work in some patients - Neurontin Significantly Reduces Chronic Neuropathic Pain.
Neurontin does work, although the results are clearly not dramatic. One must remember the side effect profile of this drug.
So let us figure out the "bottom line". Neurontin seems to work for some patients with neuropathic pain (number needed to treat of approximately 9 - i.e., about 1 in 9 patients treated will benefit - n.b. I originally made a math error which an astute reader corrected!!!!). If one starts neurontin, one should beware of adverse reactions. If the patient is receiving no benefit, please stop the drug. If the patient gets significant adverse effect, please stop the drug. Posted byDo dust covers work? Doubt Is Cast on a Remedy for Asthma
Strongly held beliefs die slowly. We should heed the data. Posted byMore on the metabolic syndrome New Definition of Metabolic Syndrome Improves CHD and Diabetes Risk Prediction
While we do not yet understand completely the physiology of this syndrome (one could call this problem the genotype), we certainly recognize the phenotype. Physicians implicitly recognize these patients. They populate our offices and our wards. I believe that patients can often prevent this syndrome. These findings strengthen the call for exercise and prudent diet. Now we need to develop methods for inducing ourselves and our patients to exercise and eat more healthy. As Hamlet says in his famous speech: Aye, there's the rub! Posted byOn hypothyroidism This story helps us remember the nonspecific presentation of hypothyroidism. We hate to miss this diagnosis, because the treatment is cheap, simple and effective. A Malady That Mimics Depression
So this story gives us a useful reminder about hypothyroidism. It also reminds me that we should always examine the medication list as a possible clue to new symptoms. Posted byOn HDL cholesterol Jane E Brody has written a nice discussion of the "good" cholesterol - Cholesterol: When It's Good, It's Very, Very Good
The article goes on to tout exercise, modest alcohol, and note the modest benefit from cholesterol drugs (like statins). Posted byThe new ACGME rules Over the past year, I have ranted periodically on the new ACGME rules for residency training. These regulations started on July 1st. Now that I have worked with my housestaff team for almost 1/2 a month I want to share some thoughts. Any new rules will have pros and cons. The major benefit to the housestaff comes from sleeping in their own bed more often. Our system (described in a June 30th rant - The end of an era) gives housestaff more opportunities to sleep in their own beds. For example, tonight my resident and one of the two interns will leave the VA around 9 and return at 7 tomorrow morning (at which time I will also arrive for post call rounds). The remaining intern will evaluate admissions overnight (up to our 10 patient max) along with a float resident. When I make rounds tomorrow morning I will notice several things (at least I have noticed these things thus far). The housestaff will be in good spirits. Sleeping in ones own bed does great things for attitude. I will have a receptive audience for teaching. Over the past few years, I almost eschewed post call teaching - but now it has returned! The intern and resident who slept at home will address clinical issues all day on Tuesday. I actually have little bad to say about our new system. My resident worries that he does not know some patients (those that he did not admit ) as well as others. I believe he actually does, but I understand those feelings. We all want the continuity which stems from the initial evaluation. I have not seen any patient care problems with the new system. We very carefully work through the "handoff" - including the resident, the float resident and me (the attending physician). The first hour of rounds tomorrow morning concern the "handoff". I hope some readers have also had experience with the new rules. I understand that our program has had long discussions to develop a workable system. Thus far I believe we are succeeding. I hope some readers can provide more information about their experiences. Posted byTeaching gets shorted We all want well trained physicians. We expect superb education. However, our current reimbursement and overhead problems are decreasing medical education volunteerism. Fewer clinical faculty volunteer to teach
The great schools will figure out how to prioritize education. We must figure out how to pay educators. Great education takes time and committment. Posted byFor those seniors who cannot afford their drugs As stated recently, I doubt that we will have a satisfactory compromise on the prescription drug benefit. In the meantime, there are options. Discount cards can help seniors until Congress passes a drug benefit This article has great information on the various drug discount programs. Many patients can benefit from these programs.
The article goes on to provide links to various programs. I have several comments. First, why do we need so many programs. Everytime I think about the number of different forms I fill out for free drug programs, I get aggravated. Why not have a single form for all companies? The industry works well as a single voice when lobbying. Why not develop a single program for all companies? Their organization - PhRMA - could sponsor such a program. Our seniors can get discount cards, but it rankles me that patients need so many cards! Second, we (physicians) must strive to minimize the drug numbers for each patient. I see too many patients who take too many drugs. My rule is that once a patient exceeds 6 prescriptions, we need a careful review. Often we can simplify the regimen, decrease side effects and save money. When patients develop symptoms, we should first think drug side effect - not add another drug. Third, generic drugs work great! The author uses the term generic pejoratively. I gladly take generics when available - including OTC drugs. The key is the chemical formulation. The FDA checks and regulates generics. They work, they work well, and they work for much less money. So I present you this article as a public service. It may help you, friends, family or patients. But please note my ranting! Posted byIs Legionnaire's increasing? We academic internists love inclusive differential diagnoses. Often we will include Legionnaire's in our differential diagnosis. This report suggests that the incidence of this infection may be increasing. Health Officials Baffled by Rising Number of Legionnaires' Cases
I will continue to look for Legionnaire's - including it my differential diagnosis. Often we use antibiotics which treat Legionnaire's as past of a more general protocol. Posted byWhat are they thinking? I hope readers understand that I am happy to criticize both parties. The Democrats behavior concerning tort reform and the Bush administration's persistent war on medical marijuana both deserve scorn. Today the Justice Department should feel db's Wrath! White House escalates pot war: It asks high court to let doctors be punished
In many ways this appeal aggravates me for the same reasons that tort lawyers aggravate me. In my opinion, the Justice Department lawyers want to make medical decisions. They have decided (without any clear data) that medical marijuana (1) does not help patients and (2) endangers the public health. Who are they to decide? Why is this a court issue? Medicine, while based on scientific principles, does require some artistry. Patients have circumstances which require creative solutions. If some patients and some physicians believe that marijuana can help symptoms (especially lack of appetite and nausea), then any law against that is a law against compassionate care. But then, why would I expect lawyers to understand? Their training and jobs involve decoding the law in ways that help the side that engages them. While truth is important, truth is not the only goal. Oft times lawyers must (and this is not meant as criticism) ignore truth so that they can advocate for their client. Here the Justice Department has (in my opinion) misunderstood their client. I wonder if the majority of our citizens would favor their interpretation here. Hopefully the Supreme Court will not accept the case. If they do, I hope they show common sense. Posted byOn improving quality I often focus on quality studies, since our research group specializes in such studies. Medicare has started an interesting experiment at the hospital level - Medicare test will tie dollars to quality of care
This test makes the credible assumption that a good way to improve quality comes from stimulating an organization (here the hospital) to develop systems to stimulate quality. Successful hospitals will not rely on individual physicians. Rather they will use a various methods to strongly suggest, question, and ultimately stimulate correct quality care. I hope this test has rigorous methods attached (and assume that it does). We may learn much from such a demonstration. Posted byOn the metabolic syndrome Periodically I rant about the metabolic syndrome. It is endemic in Alabama - we are number 1 in adult onset diabetes mellitus (per capita). This commentary in the BMJ brings us up to date on the syndrome. The metabolic syndrome
While defining the metabolic syndrome remains controversial, the goals of treatment and prevention are not. We need to increase our activity. We need to eat healthy foods and portions. Posted byMedical marijuana legal - in Canada Canada to Offer Marijuana to Medical Patients
We will follow the Canadian experience closely. Why are they socially more progressive? Posted byMore on the medical marijuana front I am beating this horse to death - but I find it necessary to continue to rant. Judge seeks help from pot advocates: Hunting for a legal 'hook' for injunction
So on this issue we have a judge who is strictly interpreting the law. Judges often interpret laws as they wish. This judge wants a rationale. What we really need is a new law! What national politicians will have the courage to address this issue rationally? Send me your suggestions. I have not seen anyone with the intestinal fortitude to walk down that street. Posted byThe problem with precise rules Desperate dieters gain weight to qualify for surgery
We must always remember that guidelines are just that - guidelines. Somehow we must insert a common sense factor into medical care. We make many decisions each day on whether or not to use a particular drug for a medical condition. These decisions weigh the pros and cons of the drug or surgery. Many such decisions take the patient's quality of life into account. The surgeons who tried unsuccessfully to separate the Iranian conjoined twins understood the risk of the surgery. The twins understood. They felt it worth the risk. How do we define morbidly obese? The definition should include some leeway for common sense. If a 5 foot woman is 90 pounds overweight, is she not morbidly obese. We need better definitions, but we always need room for careful clinical judgement. Posted byMy point exactly This week I have blogged several times on 'illegal drugs'. This policeman makes one of my points beautifully - Victims of the War on Drugs
Our current drug laws harm the fabric of society. They lead to less trust of government and the police. They create too many criminals. And I believe the laws are based mostly on moral objections. We should discourage drug use. We should penalize the combination of drug use and criminal activity or driving or working with heavy equipment. But much drug use represents an issue of personal responsibility. Just like responsible drinking represents an issue of personal responsibility. Laws are not the answer here. Posted byMedical marijuana Some readers, some physicians, and many politicians think medical marijuana an oxymoron. If smoking marijuana gives relief to a patient, why should we deny that relief. We provide high grade narcotics gladly to our palliative care patients. Medical marijuana should be a medical concern, not a legal concern. On this I strongly disagree with our government. Medical Marijuana Backers: Raid Illegal
The article continues with a clear discussion of the legal arguments. While I will sit here rooting for Santa Cruz, I regret that we need such lawsuits. The arguments against medical marijuana seems so puritanical as to be laughable. But then palliation is not a laughing matter. If marijuana provides another tool to maintain quality of life, why should we as a society deny patients. AAAAAARRRRRRGGGGGGGGGGHHHHHHHHHHH! Posted byWithholding information Sometimes we (physicians) do not do the right thing. Many Doctors Withhold Info From Patients
Interpreting these data are very difficult. We could quickly chastise physicians, insurers, or society. However, I remain skeptical about survey design. They did not ask physicians about specific situations. This report may induce unwise interpretations. Someone should have thought through the survey design prior to collecting the data. Posted byMore on drug legalization My post yesterday on drug legalization has received a healthy response. I love the give and take. Today I will take some comments and expand my thoughts. The toll in the number of destroyed lives, and of occasional deaths, testifies to the other side of this story. The rationale is being peddled that legalizing these drugs will reverse statistics. That is not likely to happen. Legalization will destroy the drug lords and all the pimps involved in their distribution, but they will not make Americans more virtuous and less dependent on them. If we go back to the Prohibition Act as a parallel, its demise did not curb the American instinct to drink; to the contrary, it has created a class of addicts who have populated the margins of our society. I do understand this argument. I personally am not advocating such drug use. However, I do not see our current laws preventing drug use. Perhaps, in a perverse way, our laws encourage drug use. Given the profit motive, drug lords work hard to get more people to use drugs. We always have to ask about the relative costs. I stake my position on a belief that the cost of our current laws (in violence, criminalization and even disease from 'dirty needles') greatly exceeds the costs of legalization. Some people will use drugs regardless of the laws. Some might try drugs if they were legal. I believe that we will have less problems as a society if we legalize than we currently have. I agree with your comments regarding drug policy. The impact of violence arising from illegal drug markets is even worse than you describe here, however. In countries where drugs are produced, entire regions or even whole countries have collapsed into warlordism and kleptocracy as armed gangs and juntas struggle for control of what may be the country's largest cash crop. Afghanistan, Burma, and Columbia suffer from our drug policies, too -- any hope of having a safe, democratically controlled country is dramatically undermined by large illegal drug operations run by warlords in cooperation with corrupt governments. These are points well made. Our drug laws have a negative impact around the globe. I haven't had a chance to read the Slocum article, but I'll say this -- I'm in favor of legalizing drugs, but I would be a lot more enthusiastic about it if there existed some reasonably effective (say, success rates of at least 75%) to treat drug addiction. The methods we have today are, to put it bluntly, ridiculous: people go off to a resort (of sorts), where they sit in a circle, complain about their lousy childhood, and promise to turn their will and their lives over to the care of God (AA's third step). After a month of this, they're returned back to society. Again, we have well made points which seem (to me) tangential to my main argument. I do not believe that we decrease drug addiction through laws. In fact our laws may make it more difficult to address the underlying problems. We must decide how to allocate our resources. Should we spend governmental moneys on jails, courts, lawyers, etc. or should we invest in a better understanding of addiction and its treatments? The answer seems so obvious that I cannot fathom why we have gone down this destructive path. Maybe we need to limit our efforts at one drug: marijuana. No deaths, so far as I know, have been reported with its use and is probably not any more toxic than alcohol. A few states in fact have decriminalized the drug although its use at present is mainly for medicinal purposes.Legalizing marijuana would represent a positive step (and one that I strongly support). Perhaps that is all our puritanical society can accept. However, the gains from legalizing marijuana actually pale when compared to the gains from more widespread legalization. Posted byOn our drug laws I argue here periodically that we should legalize all drugs. When I first announce this, I generally receive strange looks. We are so conditioned to view "drugs" as evil that we have a difficult time working through the pros and cons of our current prohibitions. The editor of Reason magazine (Jacob Sollum) has recently published a book which seems to explain my points better than I generally do. Saying Yes:
Now most readers (including me) will probably not spend over 20 dollars for the book. For you (and me) I provide this link to an interesting opinion piece from the SF Chronicle - Reefer gladness:
I would take the argument several steps further. Our current drug laws cause most college students become criminals and thereby distrust the law. Ask college students about marijuana and they cannot understand why we criminalize this drug. They all see less damage to and from marijuana smokers than alcohol causes. When any of our laws makes no sense, then one necessarily begins to question all the laws. This position will make sense to all readers with a libertarian bent, but will seem strange to those who want to use laws for moral enforcement. If that argument does not persuade, then I offer the cost argument. Our current drug laws artificially raise prices (supply and demand curves work extremely efficiently with illegal purchases). For those who become addicted (and yes I understand that some users will get addicted), then price becomes no object. If they need their drug, they will obtain the money. Hence, some drug use leads to crime. Moreover, illegal markets can lead to huge profits, thus competition thrives. Because the markets are illegal, and the profits are huge, we get violent competition. This violence undermines society, especially in financially disadvantaged neighborhoods. Thus, we have a war on drugs, which in many ways decreases respect for the police, the government and our legal system. We stimulate violent criminal activity through our laws. We send all the wrong messages. Why do we persist in such destructive behavior? Posted byThe food police This is a long article, but many will find it interesting. The Anti-Pleasure Principle: The "food police" and the pseudoscience of self-denial. This article discusses the pronouncements of the Center for Science in the Public Interest (CSPI). This group apparently tries to tell us what not to eat. The article goes into great depth on the evils of many foods. For example:
The author runs through many examples of CSPI pronouncements. He finishes with this humorous paragraph.
Posted by On carvedilol for CHF For years I have skeptically believed that all beta blockers should provide the same benefit for CHF patients. However, I cannot deny the data (although some do). Yesterday's Lancet has the COMET trial published. Medscape has a good summary - COMET: Late-Breaking Clinical Trial Results of the Carvedilol or Metoprolol European Trial
It always helps to carefully understand the patient population. This population looks like many patients that I see in the hospital. The entry criteria seem inclusive.
I believe this difference clinically significant and important. I cannot ignore the difference.
Physicians often ask for such studies comparing two drugs. Here we have the study for which we have clamored. This study has already changed my practice. I believe that carvedilol is likely worth the extra money. I will only use metoprolol in CHF now when the patient cannot afford carvedelilol and does not qualify for a pharmaceutical free drug program. Posted byOn knowledge translation I hope the title did not lose you. Knowledge translation represents the missing link between publication and practice change. The case for knowledge translation: shortening the journey from evidence to effect and From publication to change
Thus, the authors make the case that we need to study methods for translating knowledge into practice. Identifying suboptimal practice no longer should interest us. We know that many new findings are not quickly translated into practice.
As I have implied previously, our research group focuses on methods for knowledge translation. Contrary to the above quote, we have had success aiming at individual physicians also. For outpatient practice, one must develop methods for working with individual physicians. This field represents the action. We need to continue to understand the barriers to change, and then learn how to overcome those barriers. We should not berate physicians nor should we criticize their practices. Rather we (the medical education community and specifically the continuing professional development community) must strive to achieve improvement. The issues are too complex for most individual physicians to have complete success on their own. Posted byCervical cancer screening in the UK - new recommendations These recommendations make sense. I wonder about their practicality. Guidance on smear frequency
This represents a very different recommendation than we use in the US. The UK model is data driven and makes sense. Posted byOn feeding tubes When I am ward attending I have many rules. One rule is that feeding tube decisions require significant thought. Prior to placing a feeding tube we must understand what advantages the feeding tube will provide. Feeding tubes (here I am speaking most about PEG tubes) can help nutrition, in those cases when there is no reasonable alternative. Feeding tubes do not prevent aspiration. Feeding tubes are generally not indicated towards the end of life. Two reports on a JAMA article put feeding tubes into perspective. The first discusses ethnic differences in the use of feeding tubes - Study Finds Racial Differences in Use of Feeding Tubes
The author does discuss the ethnic differerences. Her speculations:
Another report on this study - Study Says Feeding Tubes May Be Overused. This report makes several important points -
I would add that this issue represents another argument for a strong palliative care service. We are very successful at avoiding unnecessary feeding tubes because we proactively discourage them! Our palliative care service uses them only in situations where everyone would agree on a strong indication. Posted byMore questions Yesterday I asked Donald Johnson to provide more questions concerning my worries about the hospitalist movement. He has provided more questions - some directly relevant, and some which move the discussion in unexpected ways. I hope these rants are interesting to some readers. They are interesting for me to consider and write. 1. How do you train medical students and residents to communicate their concerns and uncertainties to patients without alarming them? Can you?This question does challenge us. I would suggest that the higher level attending becomes a role model for students and residents. As an attending, I try to role model difficult discussion for these learners. After these discussions, we debrief. We discuss both style and content. I invite them to critique my performance, and I often critique myself. Hopefully, we make progress when we openly discuss the difficult situations in doctor patient communications. 2. You say there are no good studies of hospitalists and officists and their effectiveness. Business people---hospital administrators---like doctors have to make decisions with incomplete information. They have to speculate and use their common sense based on experience. If you were a hospital administrator having to decide whether to outsource to a hospitalist (inpatient physician) company, assuming all other factors such as medical staff politics were positive, what would you recommend to a hospital considering hiring hospitalists? I love these loaded questions! I would try not to outsource these important hires. Currently I am reading the book Good to Great (check out this interview concerning the book - Good to Great. The book makes a very important point:
Thus, I would argue that the hospital administrator should work to recruit great physicians who want to practice inpatient medicine. Using a firm will solve the short term problem, but could cause more long term problems. Recruit people! 3. Wachter and others have told me that medical groups are hiring hospitalists so that their physicians can be officists. If you were managing director of a group practice and your colleagues wanted to be officists and refer their patients 4. What would you ask the hospitalist company , what would you ask your colleagues and what would you ask the hospital involved? See my answer above. I would be reluctant to work with a company - I would much rather recruit people. The question is not nebulous, but it is unanswerable. Satisfaction can occur with either system. It depends on the physician and his/her ability to interact with patients. I do worry about 2 issues. First, we must all be very careful about "hand offs". I work on VA wards. When we discharge patients, I have the interns and resident personally call the outpatient physician to discuss our plans and changes to care. The hospitalist system also has hand offs within the system. Hospitalists rarely work every day. In some hospitalist systems the patient may have as many as 3 physicians in a 4 day admission. Everytime the physician changes, the risk of errors increases. To summarize, patients generally like physicians. We can make almost any system work. However, the hospitalist system requires more and better communication between physicians. 4. Medpundit brought up the expected arguments with Rand's methodology and priorities. On the one hand, it appears Rand went out of its way to create a credible study. And on the other, critics have some credible questions. What will physicians take from the Rand study as credible, and what will they brush off as impractical? The Rand study is "old news". It merely replicates many previous studies, albeit with an interesting new methodology. We all need to strive to provide indicated care (e.g. immunizations, checking cholesterol, using beta blockers after MI, using aspirin after MI). The study does not tell us (the medical community) how to improve. The study does not tell us why! I believe that the Rand study does a disservice if it stops at this point. We must conduct more research into causes and solutions. 5. Similarly, if you were the medical director of a teaching hospital or community hospital, what useable lessons come from the Rand study? And what lessons will important to group practices? See my above answer. We do not really have any useable lessons. I would look to other research to find out what methods work for improving adherence to guidelines. Medical directors should adopt the findings from such research to improve adherence to selected guidelines. The challenge is choosing (from the huge number of guidelines) those actions which need addressing. 6. Going a step further, the NEJM article and related editorial talk about strategies for improving use of recommended guidelines, some of which I feel are pie in the sky. What practical strategies can individual physicians, hospitals and group practices implement while we wait 20 or 30 years for reliable information systems, fair payment schemes and easier-to -follow guidelines? Yes, you can write your book right here on your blog. The answer to this question would require a several day conference. The first step is "buy in". We need to do a better job in our Continuing Medical Education of discussing the important guidelines, and developing system for adhering to those guidelines. The CME should not use lectures, but rather discussion amongst groups of physicians. Only when physicians agree on the importance of the guidelines will they have the motivation to change their practice systems. We need a culture of improvement, not a culture of finger pointing. When physicians feel motivated to improve practice, then we can provide tools to help them. 7. Say you have a Ph.D. candidate who wants to write a dissertation on the Rand study. What's the title? I cannot imagine such a dissertation. I hope my previous answers have clarified my beliefs on these issues. More on the new rules Hospitals Face Limit on Residents' Hours
I love reading this optimism, but I suspect that we will have some problems. As I stated yesterday, I will provide some updates on my experiences with our new system for handling the regulations. Posted byThe end of an era Tomorrow is the big day. Tomorrow the rules change. Tomorrow our residency changes - and we really do not understand how it will impact either resident education or patient care! My current resident expressed her concern clearly this past week. Our current system involves "team call". With team call, the resident and 2 interns take call for 24 hours, then resolve issues the next day. Teams develop working collegial relationships. Teams allow for appropriate increases in responsibility at all levels. Starting tomorrow we have a hybrid system. Sunday through Thursday nights, the resident and one intern will leave around 8 p.m. The "float resident" will work with the remaining intern on all new admissions. A "float intern" will handle all cross cover issues until the next morning. At 7 a.m., the team and the float resident will convene with the attending to present the admissions from after 8 p.m. By 8 a.m. the float resident should go home. This may work splendidly, or it may lead to "discontinuity" problems. I hope that this system does not adversely effect patient care. I also hope that the learning which results from team call is not hindered by this new system. I will rant periodically about the new system. It start tomorrow. My team takes call on Wednesday. Thursday morning will be different. Posted byMore on Primary Care I blog constantly about primary care. This opinion piece from the AMA news captures many points well - Primary care physicians being stressed to the max
Please go read her list. If you are not a primary care physician, please try to understand our perspective. She finishes with words that all should read.
Posted by More on mecical care quality The AMA news has this piece today - Study outlines deficiencies in American health care. If you have been reading Medical Rants, you know the gist of the story. I want to highlight this commentary from the AMA news article:
I believe that quality medical care requires a quality financial investment. We complain all too often about the cost of health care, not understanding that you really do get what you pay for. With regards to generalists and primary care, we have undervalued their services and we are getting the predictable outcome. Nonetheless I suspect that the study markedly overestimates the problem. Posted by9 questions - and answers In response to my post on Friday - the "whole pie" - Donald Johnson of Business Word entered 9 questions as comments. Here are my responses: 1. Do you agree hospitalists improve the quality of patient care and reduce costs? This question - which implies the answer - assumes as true a series of suggestions from observational data. We do not really have a good prospective study determining the value of hospitalists. Let me define the problem. We would have to have random assignment of large numbers of patients to two systems - a hospitalist system and a non-hospitalist system. We would have to compare overall outomes and expenses. This study may not be achievable. We cannot look at the published studies, as they only look at hospital expenditures. Moreover, they look at convenience samples, often at academic centers. Logically, we should expect a physician who cares for hospitalized patients to spend a minimum amount of time on hospital work. I question what the right amount of time is. 2. Do hospitalists consult more or less frequently on difficult cases than other docs, and how does this affect quality and costs? I doubt that we know the answer to this question. We would like all physicians to consult exactly the right amount (neither too often not too infrequently). This question (while an interesting one) again is likely unanswerable. I suspect that some hospitalists are close to ideal. I suspect that some general internists (here I imply the internist who practices both in the office and in the hospital) are close to ideal. Is one group generally better than the other? I do not know. 3. Has medicine become so complex that mastering all the information that internists are supposed to command is impossible, or just difficult? What a wonderful hypothetical? The problem with this question is that the answer is irrelevant. Many general internists do have outstanding command of much information. The great internists know what they know, and know when to ask for help. I would argue that we have no good alternative. The patient often does not know which subspecialist to contact. Moreover, if the general internist has a challenge with knowing the breadth of the material, he/she generally knows more about the various subspecialties than each subspecialist knows about the other various subspecialties. Let me try to expand this concept more clearly. You have chest pain. Do you go to a cardiologist, a pulmonologist or a gastroenterologist? If you see the cardiologist, in general he/she will consider whether or not you have a cardiac cause for your chest pain. (One of my favorite sayings comes to mind - when the only tool a carpenter has is a hammer, everything looks like a nail). The cardiologist generally (and one can only generalize here) will not consider the breadth of non-cardiac causes as completely as the general internist. If the cardiologist does cardiac catheterizations, then the patient may well have a catheterization - just to be complete. In medicine, we often observe this phenemonon. The generalist, regardless of practice site, will probably more often consider the breadth of possibilities prior to assigning a diagnosis. General internal medicine is broad, difficult but not impossible. This question applies both to hospitalists and other general internists. I believe that I do have a good handle on the breadth of internal medicine. I suspect that I am no different than many internists in this country. 4. If you agree with the Rand study that physicians follow recommended procedures some 50% to 55% of the time, does that suggests they are spread too thin, trying to cover too much ground? First, please read my post earlier this week on the Rand study. Then read Medpundit's post from today. Now I will comment further on this study. Practicing medicine is not equal to being a car mechanic. We know the interval for changing oil, oil filter, air filter, et cetera. Medicine is not, and cannot be, cookbook. Let me give a few examples. The patient is a 64 year old man who had a heart attack 3 years ago. I tried a beta blocker after his heart attack, but he had reproducible bronchospasm, and could not tolerate the drug. Thus, I am no longer treating him with a drug that has an absolute indication after a heart attack. When you review my chart over the past year, you see no evidence of beta blocker use, nor any discussion of why I am not prescribing a beta blocker. As one analyzes this patient, one could argue that I have not met a guideline. But I may be practicing good medicine. Patient care involves complexity. We (physicians) must juggle competing problems, side effects and even financial considerations. Studies, like the Rand study cited, which use chart reviews, are prone to underestimation. As I stated in my previous rant: We must stop sensationalizing statistics on quality, but rather start researching the reasons for less than perfect quality. These studies must look at quality in new ways. Some guidelines have greater importance than others. We need to prioritize our research and our report cards. My colleagues at the University of Alabama at Birmingham developed a method called ABC - the Achievable Benchmarks of Care - A new quality improvement tool is being developed for deriving benchmarks of clinical care This method considers the underlying chaos of patient care and patients, and sets achievable goals. Studies like the Rand study sensationalize, but do not really add to the quality debate. We all want better quality, but we must understand quality not as an arbitrary standard, but rather as an achievable standard. 5. Is there a possibility that officists and hospitalists may follow recommended procedures more often and practice more evidence -based medicine than internists who practice both office and hosptial medicine? Anything is possible. This question must be meant rhetorically. It is unanswerable. 6. Is it possible that officists are more customer and people oriented entrepreneurs and hospitalists are more institutional and bureaucratic, and they may get more satisfaction from being round pegs in round holes 100% of the time instead of 50%? See the previous answer. 7. I've been told hospitalists often burn out after a year or so, and I'll bet a lot of officists are burned out, how do current trends affect burnout? Many physicians currently are either suffering burnout, or will soon develop burnout. Medical practice requires reflection. Good practice requires time to read and discuss. Our current practice environment - both inpatient and outpatient - is not conducive to developing healthy happy physicians. This problem is neither a hospitalist nor an officist problem. It is a problem of expectation and reimbursement. Until we value time in a better fashion, we will have rampant burnout. We need a system that allows physicians to spend time with patients, and the journals and colleagues. This question does raise an interesting question which I should rant on separately later this week. 8. Do you feel more specialization will improve or hurt the quality and cost of care? I like this question, because it asks for my opinion. I dislike this question because it is so nebulous. I believe the combination of a generalist (in both outpatient and inpatient settings) with appropriate subspecialty consultation leads to the best care. If you have diabetes, coronary artery disease, hypertension, hypercholesterolemia and chronic obstruction pulmonary disease, I would argue that you need an excellent generalist who can coordinate your care, obtaining subspecialty help as problems arise. This care will surpass the care the patient would receive from 3 subspecialists. The patient needs a generalist to consider him/her as patient with many medical problems. 9. Any feel for what percentage of internists feel the way you do, and what percentages would like to be officists or hospitalists? I suspect that most internists would like to balance inpatient and outpatient practice, but not in our current system. We have many residency graduates who specifically seek such jobs. They exist in smaller cities. I believe that practicing in the hospital makes me a better outpatient doctor, and vice versa. Many graduating residents believe that also. I hope these answers help somewhat. I will specifically ask Don Johnson to respond. At the risk of boring readers, I will probably continue this discussion for several days. Perhaps through this interaction - and the comments of RangelMD - we can all better crystalize our thoughts. Counterpoint I am getting ready to make rounds. Sometime later today, I plan to respond both to this post and to the 9 questions posed on my post from Friday. My greater blogging pleasure occurs when I stimulate passionate thought. Read Rangel's counterpoint to my rant - Are hospitalists a threat to general internal medicine? While I disagree, one should consider his points. Hopefully I can find time for a careful rebuttal later today. Now off to make rounds with my team. Posted byThe business word I often blog about the business of medicine. I also blog about many other issues. This site includes many news stories (with some commentary) that effect the business of medical care. The Business Word. I am adding it to my blogroll. You just might find it a worthwhile resource! Posted byThe whole pie This column is published in this week's SGIM Forum. You can get a pdf version online - SGIM Forum - open the May issue - pdf file. Here are my thoughts on general internal medicine: ACGIM COLUMN THE WHOLE PIE-ON THE FRAGMENTATION OF GENERAL INTERNAL MEDICINE Robert Centor, MD The field of general internal medicine has become sick. Division chiefs all see this. Amongst many threats (including reimbursement rates and articles belittling generalist physicians), the latest threat to general internal medicine, in my opinion, is the hospitalist movement. I must provide these disclaimers. First, I spent a year doing renal research (after residency) and quit my renal fellowship. Second, by almost any criteria, I am an academic hospitalist (5 months attending on the VA wards each year). Third, I spoke at the recent Society for Hospital Medicine (SHM formerly NAIP) meeting in a "Meet the Professor" session. General internal medicine is a wonderful profession. Unfortunately decreasing numbers of practicing general internists agree with that sentence. As I have said often in public (see my address in the July Forum), general internal medicine leaders wisely embraced the concepts of primary care, but allowed the field to be mislabeled as primary care internal medicine. The problems that the primary care label has caused are not our doing. I doubt that many in our field could have anticipated these problems. Nonetheless, we are left to address the current state of affairs. The thesis that I proposed is that general internal medicine includes the provision of primary care for patients, but is more than primary care alone. Primary care currently has an unfortunately narrow definition (at least from insurers and other payers). The dictionary defines primary care-"The medical care a patient receives upon first contact with the health care system, before referral elsewhere within the system." Nowhere in this definition does the comprehensive nature of general internal medicine fit. The April SGIM Forum in an article titled, "The Future of General Internal Medicine," addresses this issue. "Recommendation 2: The domain of general internal medicine should continue to be both deep and broad-ranging from providing or supervising uncomplicated primary care to delivering continuous care to patients with multiple, complex, chronic diseases. As the principal provider for adults, general internists need to have skills in gynecology, dermatology, orthopedics, otolaryngology, psychiatry, and the internal medicine subspecialties." General internists traditionally have treated both inpatients and outpatients. They provide comprehensive, complex care, involving subspecialists as necessary for specific consultation. General internists specialize in understanding the spectrum of disease and the interactions amongst multiple diseases, thus providing comprehensive care-from first contact care to general prevention to complex disease management. Most general internists chose our field because of its comprehensive and complex nature. As residents, we enjoy the spectrum of internal medicine-from the outpatient setting, to the hospital, to the ICU. As payment for office visits has deteriorated-forcing either markedly reduced income, or unacceptably short visits-so have the pressures on outpatient practice increased. Many general internists find providing both outpatient and inpatient care a financially unacceptable luxury. Out of this conflict between outpatient and inpatient care, the hospitalist movement has arisen. The hospitalists have filled a void in health care. Hospital care has become more complex and time consuming. Hospital administrators and insurers like the logic and economy of hospital care specialists. Graduating residents often like the lifestyle that hospital medicine offers. They also see the hospitalist as a natural extension of their residency experience. With these forces acting, the hospitalist movement has expanded and thus the outpatient practice option has become a reality for many internists. SHM has encouraged this new dichotomy-specialty defined by location. While I understand why we are moving in this direction, I continue to worry about the implications for the field. Who are the true general internists: the hospitalists, the officists, or the decreasingly common hybrid practice, which all practicing internists had in previous decades? I worry about how this fragmentation will affect general internal medicine. Most GIM divisions include all three practice options. As division chiefs struggle with varied faculty practice patterns, these changes are redefining general internal medicine. How do we unite these disparate practices? What signals are we sending to residents? I wonder whether this role fragmentation is contributing to the malaise in our field. Why would residents choose general internal medicine, when we have such difficulty defining the field? I see three different practice patterns confusing trainees. Many larger communities almost force one to choose between hospital and outpatient practice. We are struggling with redefining general internal medicine training. However, we should first consider how their practice will look when they finish training. As we allow the redefinition of general internal medicine, ones view of the field becomes hazy. Both ACGIM and SGIM are considering this problem. I hope that we can preserve and define the field. Perhaps we cannot resist the economic, medical and political forces causing these modifications. I hope that we can maintain the practice balance that general internists want and desire. I still love general internal medicine; I love the whole pie, not just a small piece! Posted bySteroids for COPD exacerbation I think we all really know this, it did make the NEJM - Outpatient Prednisone Reduces Relapses in COPD
I think this is already routine care. Posted byOn quality Sometimes we are our own worst enemies. Medicine has developed the knowledge to improve care. We have guidelines to help us provide high quality care. For varied reasons, not all physicians follow all guidelines in all patients. I am involved in several research projects which are investigating this phenemon and learning how to help busy practicing physicians provide higher quality care. While I find the article which informs this newspaper piece interesting, the "spin" about the article may not help our progress - Study: U.S. Doctors Ignoring Guidelines
Quality takes time. One cannot shorten patient appointment times and provide the highest quality medicine.
We must stop sensationalizing statistics on quality, but rather start researching the reasons for less than perfect quality. These studies must look at quality in new ways. Some guidelines have greater importance than others. We need to prioritize our research and our report cards. I also would urge more studies on how to improve quality, and less studies which highlight this challenge.
Posted by Alice and my depression post Alice has commented about my depression post. Read her post for more texture concerning this important issue - Depression. Because the link goes to blogspot, you may have to navigate a bit to find the right story. Posted byMore on anemia and CHF I ranted about this earlier this week. Here is the same story from Medscape. Anemia Increases Risk of Death in Patients With Severe Heart Failure
Posted by More on COMET A few months ago I ranted on the initial press release from the COMET study. This story posts this important study into more context. Study finds one beta blocker better at saving lives in heart failure
This study should change practice at this time. I have used generic metoprolol in lieu of carvedilol for my CHF patients, because of the significant cost difference. This study did test the hypothesis relevant to my practice. I can no longer justify metoprolol as being as good as carvedilol. The slow release metoprolol - Toprol XL - does not have the price advantage, thus I had not been using it. I will choose carvedilol now, unless and until further research changes our understanding. Posted byRead these data carefully Mixed Results for Drug Used to Prevent Prostate Cancer
So we have an intereting research dilemma. Finasteride decreases the incidence of prostate cancer, but increases the incidence of more aggressive cancers. Since many men die with prostate cancer rather than from prostate cancer, we should focus on the aggressive cancers. While the absolute difference in aggressive cancers is small (1.3%), this finding would dissuade me from taking finasteride. I cannot recommend it to patients at this time. Posted byOn primary care and depression For Depression, the Family Doctor May Be the First Choice but Not the Best. As I have come to expect, this title misleads. Family doctors and internists make most depression diagnoses. We also manage the majority of depressed patients. One must consider several factors. Many patients do not want to see a psychiatrist or psychologist. Many health care plans do not allow appropriate mental health referrals. We can manage much depression in our offices. For many patients, the generalist is indeed the best (and sometimes only) choice. A subset of depression does need more advanced care. These patients clearly need a psychiatrist or psychologist who specializes in depression. Even patients with those needs may or may not agree to see a mental health professional. Generalist programs are spending more time considering depression diagnosis and management every year. The residents that I work with are clearly better at considering the diagnosis of depression than their predecessors from 5-10 years ago. They also are becoming more comfortable with pharmacotherapeutic options. What few generalists can do is spend enough time for significant psychotherapy. We do have significant time restraints. We do spend a small amount of time counseling patients within our time constraints. The NY Times article is worth reading. Depression is very complicated. I think we should concentrate on helping generalists do a better job, rather than criticizing the soldiers on the front lines. Posted byAnemia and CHF = increased mortality An article in the Journal of the American College of Cardiology (June 4, 2003) adds to a growing body of knowledge about anemia and CHF mortality. In this study (a reanalysis from a prospective randomized controlled trial) the investigators found that in patients with severe CHF, progressive anemia leads to increased mortality.
In this study, mortality starts to increase as the hematocrit is below 38%. These results are consistent with previous results (as noted in the quoted section from the article's introduction). These data are consistent with growing data from the renal literature. While patients do not seem symptomatic with mild anemia (hct 25% - 35%), progressive anemia does stress the heart. As the hematocrit decreases in renal failure patients, left ventricular hypertrophy increases. Prolonged LVH leads to CHF and is a risk factor for coronary artery disease. We need larger studies which examine the impact of treating mild anemia for CHF. These data add support to the need for such studies. Posted bySupplements - lack of scientific rigor Frequent readers know that I dislike the dietary supplement industry. The 1994 law which allowed this industry to grow was, in my opinion, a menace to public health. While I have multiple problems with the industry, the hot button issue these days is ephedra. One must view each supplement individually, however one can attack the entire industry. Studies of Dietary Supplements Come Under Growing Scrutiny
The dietary supplement industry can endanger the public. The lack of regulation spells danger.
Read the entire article. Stay away from unproven supplements. Do not get duped by fancy glossy ads. This industry needs regulation - for the public health. Posted bySowell on prescription drug benefits Thomas Sowell generally makes one think. He views all problems from the Milton Friedman school. Here is his column on prescription drug benefits - Prescriptions and politics
Wow! Sowell views this problem from a logical stance, not a political stance. He states that the Medicare drug benefit plan comes more from politics than need. He strikes a nerve here. If we want to help the needy, we should not arbitrarily start that help at age 65.
I personally think that he has used hyperbole in this argument. The pharmaceutical industry will not stop research and development unless they are not allowed a reasonable profit. I wonder how one defines reasonable. At times drug companies focus, in my opinion, too much on profit. Their well documented shenanigans do not advance health care. We need checks and balances on the pharmaceutical industry. As Robert Prather points out frequently, the dissociation between drug prices and individual choice leads to an artificial market. As we consider the release of OTC Prilosec, we hear complaints because once a drug class goes OTC, insurance will likely no longer cover that class. Thus, having a $1 per pill OTC Prilosec will cost the consumer more than $4 per pill prescription Nexium. We need a better market to influence the industry. Patients do not make informed choices, because they are not individually aware of the trade offs. Until we have a financing system that involves individual decision making, we cannot champion the pharmaceutical industry, nor castigate it (on economic grounds). Drugs like Nexium succeed (in my opinion) because most patients do not explicitly pay the price. So I give Sowell a gentleman's B. He clearly provides an alternative to the proposed benefit, but may well miss the point on the pharmaceutical industry. I enjoyed this commentary because it did make me think. Posted byA sad story From today's Lancet -
As we consider explicitly the trade offs we must make in financing health care, we must consider stories like this one. Few economists or medical leaders will state this concept. Health costs are increasing because we are providing more advanced health care. If we (the American people) want "state of the art" care", we must pay the price. We should not obsess about the percentage of GNP devoted to health care. For the sick person, one can hardly place a price on improved health. Other countries implicitly ration important care. Many studies should statistically that delays generally do not lead to worse outcomes. Tell the cardiologist who bravely wrote this story. Tell the wife. Tell the schoolgirl. Posted byPreventing contract induced renal dysfunction An article in the current issue of the Journal of the American College of Cardiology discusses the prevention of contrast induced renal dysfunction.
The reported study tested a rapid IV protocol which allowed for prophylaxis shortly before a dye study, rather than the day prior. In this study, renal dysfunction decreased from 21% to 5%. My take home message from this study: always consider the possibility of renal injury from dye studies. N-acetyl cysteine (Mucomyst) does offer some protection, and we are wise to consider using it when patients have significant risk. Posted byAMA on 'boutique medicine' Here is the link - no commentary at this time. AMA Sets Ethical Code for "Boutique" Medicine
Posted by Patient confesses - lied to doctor
How do we as physicians help patients tell the truth? The first key is in our attitude (or at least how the patient perceives us). If we appear judgemental, then the patient will more likely lie. When we appear more accepting of the truth, then the patient will more likely tell us the truth. We need studies on how to deliver advice. How should I get this patient to stop smoking, start exercising, etc? What are the magic words? What tone should I use? What body language induces healthy behavior? Until we really understand this issue, we will continue our dance. We dance without touching. We each leave convinced that we are making progress. But how often do we make real progress? Posted byNew anti-smoking drug in the works I saw this story on TV last night. Apparently, this new drug binds the brain's nicotine receptors but does not give pleasure. Thus, it blocks the pleasant sensation of smoking and blocks withdrawal symptoms. Pfizer unveils anti-smoking drug
I hope that further clinical trials are successful. We need a better pharmacologic aid to smoking cessation. Posted byMore on the fiscal crisis I never know when a rant will create controversy and commentary. Last night I posted on the primary care fiscal crisis - Primary care fiscal problems. By this morning I have 4 comments and a "trackback". I do want to respond to my frequent correspondent - Bernie Simon - because his commentary demands a rant.
I agree with Bernie and I disagree. Let me try to clarify my thoughts here. I do believe that the free market is starting to work. Physicians are developing creative payment schemes (e.g., retainer medicine, chargers for phone calls and forms, cash only business, refusing new Medicare patients); primary care physicians are leaving the field (see comment 4); less students and residents are choosing primary care. This will lead eventually to increased pay for primary care and we will have a better balance. I have ranted about this previously - Physicians less interested in managed care and Medicare
One could argue (and apparently Bernie does) that we should just wait for market forces to correct the current situation. I would argue that we can and should act more proactively to fix problems before the become crises. We are entering an access crisis in primary care. Too many patients cannot find a primary care physician. Too many locales have insufficient physician numbers. We can wait for the invisible hand , but at what human cost. I will continue to try (through this blog and through medical societies) to highlight the current crisis. Since we do not really work in a capitalistic profession (my office rates are controlled), we must use the bully pulpit. I hope that this is a small bully pulpit. If you agree with me, tell another person or two. We just might start a movement (db fades out recalling Alice's Restaurant in a moment of free association). Posted byOn performing the physical examination Early in medical school we learn about the physical exam. Actually in the United States we generally start to learn about physical examination, but rarely become good at this skill. We rely on laboratory tests and imaging, and often underemphasize our physical examination - assuming that our own observations are somehow inferior to "objective data". Generally, residents from other countries have superior physical examination skills. They are taught the examination more carefully, perhaps because they do not have access to our technology. This article laments our skills, and discusses the many reasons for doing a good physical examination - Losing the Touch
The challenge for all physicians is to understand the physical examination as a diagnostic test. We need to teach examination skills and emphasize the sensitivity and specificity of each maneuver.
We do try to emphasize these skills in our residency. We refer to the JAMA series. However, we are fighting an uphill battle.
This article is important and reassuring to this medical educator. We still have a lot to teach. I only hope that our students and residents learn. Posted byAsking about herbs While I often rant against 'dietary supplements', I know that we cannot ignore them. Just this morning we discussed a patient admitted last night for whom supplements provided an important piece of our differential. We must ask about non-prescribed remedies. Questions the Doctor Never Asked I am skeptical of most 'alternative' therapies, however, I must know what the patient is doing for their own care. This article raises some difficult issues, but we must remember that asking may help us diagnose the patient's complaints. Posted bySunshine - not all bad We have become so fearful of skin cancer that we may not get enought sunlight. A Second Opinion on Sunshine: It Can Be Good Medicine After All
As I spend much time in the sun (playing golf), I find this article refreshing and welcome. Everything in moderation! Posted byPrimary care fiscal problems Primary-Care Doctors Suffer Fiscal Maladies I am going to quote the entire piece as I suspect the link will not be durable. A colleague sent this to me. The commentary hits the nail on the head!
Read it and then reread it. The concepts are not new to medrants readers. They are important. This is society's crisis. Posted byUniversal health - a model Maine has done it. Maine's Big Health Coverage Step
We will watch this effort carefully. What will the program really cost? How will the uninsured respond? Will the state really save $80 million in unreimbursed medical costs? Posted byNY Times on the Medicare drug benefit The NY Times favors the current proposal. They rightly point out many flaws, but call some positive features flawed. This is a balanced editorial in my opinion - The Medicare Momentum
Posted by Drug formularies One way to limit prescription drug expenses uses drug formularies. Managed care companies generally use them. Many hospitals use them. Now many Medicaid programs have adopted this strategy. 22 States Limiting Doctors' Latitude in Medicaid Drugs
This strategy has legitimacy. It makes us as physicians better consider the indications for expensive drugs. When they are necessary (for the patient's benefit), we have a process for approval. The formulary system limits unnecessary use of expensive brand name medications. Posted byStatins for diabetes This study confirms what we already believed. Study backs statin drugs for millions of diabetics
We need to read the article - MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes: a randomised placebo-controlled trial - in The Lancet. Quoting from the abstract
These data make sense, given that most adults with diabetes have atherosclerosis prior to our diagnosis. I suspect this article will influence practice. I will spend some time reading this article and subsequent commentaries more carefully. Posted byGood reads on other blogs I have read some excellent relevant pieces on other blogs this week. Here is a sample:
As is obvious, I do read Prather and Rangel regularly. So should you. Rangel blogs episodically, but with great thought. He has been brilliant especially over the last month. If you do not read him, click, and read his recent archives. Prather writes about more than medical care. He and I share a marketbased liberatarian philosophy. I enjoy his wit, and the breadth of his commentary. Posted byFor physicians, appearance matters This article says it all - Patients prefer doctors who wear white lab coat
I will show this article to the new interns next week. Posted byOn the fat tax British physicians must read this blog. Our correspondent, the lovely Razzberry, had a guest piece here about a fat tax. British physicians are serious - British doctors urge 'fat tax'
So we must ask whether the problem is our diet or (as I ranted yesterday) our lack of activity. Perhaps we can blame both. I hope Great Britain passes this tax so that we can see the outcome. Of course, I live in Alabama and we will never pass such a tax. Posted byMedicare reform I have some fear concerning Medicare reform. The Washington Post opines today - Medicare Muddle
While I do not agree with the entire editorial, I do agree that the Congress plans to pass something, even a mediocre bill, rather than no bill. We should fear this political reality. This guest author at the National Review has strong opinions also - Daschle Doesnt Get It: The trouble with Medicare.
While I am not sure that "privatization" would answer all our problems, the author makes a solid argument that our current system is failing. The proposed changes probably make failure more imminent. But then no one is really asking the doctors. These decisions apply to elections not common sense. Posted byWilliam Buckley on the marijuana laws Reefer Madness: Our current Prohibition.
We (physicians) should have the option of using marijuana for patients. It does have some positive effects. The current laws have negative effects - and the public knows it. When will our government make logical decisions with regards to illegal drugs? Posted byGoldberg on the prescription drug plan I do not always agree with Robert Goldberg, but I always read him. He makes me think. I agree with much that he says in this piece about the Medicare prescription drug plan. Dangerous drug plan. His main point (one which I have previously made also) is that we do not need a blanket drug plan. We need one for the truly needy. He argues that we should not subsidize the wealthy elderly. His ideas will receive little attention. AARP is a more powerful lobby than common sense. We could save money and spend it more wisely if we did not have political realities. Posted byAspirin good for strokes Sometimes the latest and greatest does not surpass old faithful. Why the major papers have not picked up this story is unclear? I guess it did not pass the "sexy" test. This study has great importance. Aspirin May Be Better Than Ticlopidine for Recurrent Stroke Prevention in African Americans
You can read about this study here (if you do not have a Medscape logon) - Study: Stroke drug no better than aspirin As they describe the results -
So we will stick with an aspirin a day for our stroke patients. While the authors do not encourage us to continue ticlopidine, their reasoning seems flawed. I will stick with the cheaper (and probably more effective) old standby. Posted byEating right helps Admittedly these are epidemiologic data - but that is all we have. Eating fruits and vegetables will not hurt you, and they probably will help you. Healthy Diet in Midlife Saves on Healthcare Costs Later on
So keep eating those fruits and vegetables. This study assumes that the fruits and vegetables make the difference. Careful methodologists must ask whether eating fruits and vegetables serves as a marker for another healthy behavior. Nonetheless the evidence that eating more fruits and vegetables probably helps seems reasonable. Pass me that banana please. Posted byOn peripheral artery disease Too often we (physicians) do not focus on peripheral arterial disease. This excellent review from the NY Times puts peripheral artierial disease into perspective - Disease of the Peripheral Arteries Can Be a Crucial Warning Signal
For those who have access to the Archives on line - Critical Issues in Peripheral Arterial Disease Detection and Management and
Peripheral artery disease is very important. We know the risk factors - they are the same as coronary artery disease. We know the treatments - diet, exericise, and the same medications we use in attempts to decrease atherosclerosis elsewhere. The call for action seems reasonable, however, this adds to the time problem. We need to spend more time with our patients, and address more prevention - both primary and secondary. Time is money. So read the next rant. Posted byTime As I have considered this topic in the past and again since yesterday, I pondered cute titles which incorporated song titles or quotes. Time fascinates almost everyone. Time also frustrates many. Most physicians complain of being trapped by time. In workday race, doctors scramble, but clock often wins
To repeat a favored mantra, our current reimbursement system financially penalizes physicians for spending more time with patients. We have perverse incentives. These incentives do not align with good medical care. Read this entire article. It makes the points I keep trying to make with outstanding examples. Posted byRadu on smoking cessation Dr. Brad Radu is a senior scientist in our comprehensive cancer center. He writes and speaks extensively on the use of smokeless tobacco as a smoking alternative (he is pro). He writes this commentary in today's Washington Times - News you can't use
Now while not all experts agree with Dr. Radu, he makes a very important point. We must look carefully at the evidence, even if the evidence does not coincide with our preferred world view. He is asking, albeit in a challenging way, the Surgeon General to study prior to speaking out on an issue. In that Radu is correct.
We need scientific integrity even in political discussions. We also need common sense in leaders. Calling for a complete ban on tobacco is almost as stupid as alcohol prohibition was and marijuana prohibition is. Posted byGolfing injuries This information is important. I want to continue playing without injury. Warm-Up Helps Prevent Golfing Injuries
Posted by When is hope false? Read this poignant op-ed - False Hope in a Bottle
Posted by Commentary on JNC 7
This commentary puts the new guidelines into perspective. I rant frequently about adopting a healthy lifestyle. I believe (as apparently did my mother) that if I nag enough, someone will pay attention. Thus, the rants will not end, but continue each time an opportunity makes itself available. If you do not exercise regularly - please start. If you are not watching your diet and striving towards a good body fat percentage - please start. If you smoke - please stop. Posted byOn back pain As part of our residency program, we sponsor "outpatient morning report". This conference focuses discussion of common outpatient complaints. We hope to bring the same intellectual rigor to outpatient problems that internal medicine programs have traditionally brought to inpatient rounds. A common chief complaint in that conference is back pain. All generalists see back pain frequently. Today's JAMA has an important article relating to back pain - Radiographs as Good as MRI for Most Patients With Low Back Pain. The authors asked an important question: Are plain X-rays as good as rapid MRI in back pain patients who require an imaging study?
I suspect that we will soon here from the neurosurgery and orthopedic communities criticizing this study. The data speak louder than any anecdotes. I will continue to perform plain film LS spine X-rays when indicated. Posted byA colleague on patient centered decision making One of my colleagues has commented beautfully on a rant from last Thurday. I am quoting his long commentary to highlight his important contribution.
Beautifully stated and well worth reading carefully. Posted byWeinstein on rationing I love linking to commentaries written by friends. I have known Milt Weinstein for 20 years. He has greatly influenced our understanding of medical decision making and cost effectiveness at a policy level. Milton Weinstein is the Henry J. Kaiser Professor of Health Policy and Management at the Harvard School of Public Health. He wrote this piece for Sunday's Washington Post - We Ration Health Care. Better to Do It Rationally
Read the entire article; think about his approach. Milt challenges us to develop a rational, not a political, method for rationing health care. He makes the point that we can not avoid rationing, thus we should proceed logically rather than emotionally. I wish we could adopt his model. I doubt that it would withstand the lobbying efforts. Posted byHIPAA Problems I rant incessantly about unintended consequences. Apparently, I am not the only one. I started back as ward attending this Saturday. As we made rounds, I quickly learned that I would have to remember patient rooms, as most rooms no longer had the patient's name outside the room. While this is an annoyance for me, it has greater ramifications - A Privacy Law's Unintended Results
All too often our legislators make laws without working through the consequences of those laws. This law stems from an understandable concern, but I believe it has created more harm than good. But then I am not surprised. The road to hell is paved with good intentions. Good intentions are just not good enough. Posted byThis saddens me A colleague forwarded this link. The title bothers me - so does the article. Busy Harvard doctors balk at teaching
We academics know this problem. I stayed in academic medicine precisely so that I could teach. Teaching medicine is fundamental to being a physician. We must teach the next generation. We must find the wherewithal to teach or we can no longer be a great profession. Posted byOn atrial fibrillation The current issue of the Journal of the American College of Cardiology has 2 articles on the management of atrial fibrillation and an editorial comment. These articles add to a growing body of literature which has addressed the question of rhythm versus rate control in atrial fibrillation patients. Several years ago, a colleague and I debated this issue at Grand Rounds. I argued that as long as rate control provided symptom control, the potential adverse effects of the antiarrythmics outweighed the benefits of sinus rhythm. He argued that sinus rhythm would decrease thromboembolic complications and probably improve the quality of life. It appears that in most patients my arguments now receive clinical trial support! Several trials have taught us that in the absence of symptoms, rate control works at least as well, and probably better than attempts at rhythm control. Factors which influence these findings include:
If the patient has symptoms due to atrial fibrillation, then we should consider the possibility of rhythm control. If the patient has a decreased ejection fraction and symptoms, then one should consider nodal ablation and pacing. This treatment combination does seem to help symptomatic patients. Posted byPrather on Broder's commentary Yesterday I provided a link to Broder's commentary on the health insurance crisis. I am pleased that Robert Prather has commented eloquently on this issue. Health Care Costs Yet Again
Go read Prather's full commentary - then read his links. He champions Medical Savings Accounts for routine medical care. When one has such an account, medical expenditures become more tangible to patients. The patients will begin to notice cost, and perhaps make some decisions based on those costs. Prather is on to an important concept. Posted byDavid Broder on the health care insurance crisis Q&A later today sometime (off to make rounds soon). High Cost Of Inaction On Health Care
Posted by A cost problem CMS Draws Heat as Coverage of MADIT II ICD Decision Draws Near
It is about the money. And it probably must be about the money. Posted byThe cost of a false positive test False Positive (Can This Marriage Be Saved?) - tells a poignant story. I will make the case that overtesting can lead to problems because of the false positive problem. Over the years I have taught many students and physicians about diagnostic tests. Several principles concerning diagnostic tests are very important. First, each test has a sensitivity and specificity. Sensitivity defines the probability that a patient with the disease has a positive test. Specificity defines the probability that a patient without the disease has a negative test. The false positive rate equals 1 minus the specificity. Now that I have demonstrated my nerdiness once again, let us understand the problems that these definitions cause. The problem we are discussing today is the false positive problem. Patients and physicians often worry about false negative tests - missing a diagnosis. However, as this case demonstrates a false positive diagnosis carries important costs. I usually use the example of a colleague's patient (who happened to be a 45 year old lawyer). This lawyer went to give blood. The initial screening test for HIV read positive. The patient had no known risk factors for HIV. It took my colleague 3 months to prove to everyone's satisfaction that the patient was HIV negative. What was the cost to the patient? This occured early in the HIV epidemic, prior to any antiretrovirals. Our testing was rudimentary. Prognosis for AIDS was less than 1 year. Multiply this example by the extensive testing that many patients get. Even with a specificity of 99% (pretty damn good), 1 of 100 healthy patients will receive a false positive diagnosis. And they will have anxiety and doubt. Now read the story - especially these quotes:
This case (and the one I recalled) put faces and feelings into those numbers. We should never forget the faces and the feelings. Posted byPatient centered decision making During my medical career, we generally have moved from a paternalistic attitude towards medical decision making to a patient centered approach. Some physicians find the patient centered style uncomfortable. This case from the NY Times helps explain the conflict - Seeing Risk and Reward Through a Patient's Eyes
This story, about a psychiatrist who gained 45 pounds on Lithium, should reframe how we as physicians consider side effects. One of our greatest challenges is understanding the patient's perspective. But, I would argue, we must do that to provide the care the patient desires. Posted byRetainer does not equal capitation Another loyal reader wrote this comment yesterday:
I will explain my understanding of capitation versus a retainer or administrative fee. When dealing with a managed care company, they would provide several pools of moneys. One pool representative an administrative fee - several dollars per patient per month. We still receive this from our Medicaid managed care program. This fee (in many ways comparable to a retainer fee of small proportions) is not controversial. What was controversial were the at risk capitation fees. These pools were "set asides" for expenses. If physicians underspent, they profitted. If they overspent, it cost them money. Many have argued that the incentives here were malaligned. The physician might value protecting these money pools over the patient's best health interest. Having such a plan at best gives the appearance of a conflict between our income and your health. Many physicians and patient advocates have questioned the ethics of such schemes, making them no longer in vogue. Posted byH pylori eradication and weight gain Readers know that I favor testing and treating for h pylori in dyspeptic patients (below the age of 45). A loyal reader - Razzberry - asked yesterday
All experts believe that endoscopy is indicated for patients with alarm symptoms (weight loss especially) or those over 45 years. These groups have a high enough risk of gastric cancer to make endoscopy indicated. Thus, the test and treat strategy (which avoids endoscopy in many patients) is only recommended in otherwise healthy young patients. While I still favor the test and treat approach, I must caution physicians and patients about this new evidence - H. pylori Eradication Can Result in Significant Weight Gain
Posted by Hormone use and dementia Hormone Use Found to Raise Dementia Risk
With each study, we learn more about hormones. Our previous conventional wisdom was wrong. I see these studies as victories for scientific inquiry! Posted byDecriminalizing marijuana Sometimes Canada understands issues better than we do. Canada May Allow Small Amounts of Marijuana
Common sense from above the border will probably not translate to common sense in D.C. Many states would make these changes. When will we view recreational drug use as a medical issue? I include alcohol and tobacco in this category. We need medically directed management of these chemicals. We do not need further prohibition. Posted byLawyers and the pharmaceutical industry I have blogged about this previously. This commentary says it well. Lawyers who make you sick
Reading the commentary is worth your time. When will the madness end? Posted byCommon sense on the drinking age I believe that much unhealthy drinking comes from our approach to adolescent drinking. Read this piece to understand my viewpoint (if I could only write this eloquently) - Let My Teenager Drink
Posted by Billing like lawyers Regular readers know my position on the financing of outpatient practice. Our current model does not work. We live under reimbursement controls, yet have no expense controls. We receive the same reimbursement for most visits, almost regardless of the necessary time needed for the visit. We have not received any income for other time consuming tasks (directly related to our physician roles). Many physicians are changing that - That's Going to Cost You: Pinched Between Rising Costs and Lower Revenues, Some Doctors Are Charging Patients for Phone Time, Paperwork and Other Services While I prefer a modified retainer approach (patients would pay a set fee for a year of medical care), until we adopt such a system, these charges are ethical and necessary, for our only commodity is our time.
But then regular readers know about these factors. I keep saying that we must change our reimbursement system. I will keep saying this, as it does represent a major impediment to providing outpatient care for our population. Posted byA resident explains the importance of cost Medicare Must Take Cost Into Account
Posted by SARS vaccine - do not get your hopes up too quickly SARS vaccine booster - this article explains why developing a vaccine will take time.
Developing and testing a vaccine represents a major project. You cannot skip steps. A bad vaccine (either one which does not work, or worse yet causes significant side effects) would represent a major problem. We cannot afford to release any vaccine which does not protect against SARS and which has minimal side effects. Thus, we need to work on quarantine procedures until our scientists can proceed properly with their jobs. Posted byIllinois bans ephedra Illinois has done the right thing. I discussed this issue in my Q&A column yesterday. Illinois creates nation's first statewide ephedra ban
Posted by Data versus belief Many patients want to blame someone or something for their health problems (or even their perceived health problems). We see this often with drug side-effects. Readers of this blog can turn to any new drug discussion, then read the comments section. Any perceived side effect automatically is blamed on the drug. However, studies which include placebos generally show sizeable side effects from placebos. This makes the data driven physician wary of attributing symptoms to drugs, until we collect appropriate data. Most physicians that I know have remained skeptical about "Gulf War Syndrom". The British Medical Research Council has concluded that this syndrome does not exist. Gulf War Syndrome 'does not exist'
Patients and veterans groups do not want to hear this message. They are not interested in the data and scientific inquiry.
Having a "Gulf War Syndrome" to blame ones symptoms on makes life simpler. We all would rather blame than accept responsibility for our own health behaviors. Belief trumps data for many in our society. As a physician I must favor the data approach. Only through careful investigation of data can we discover medical truth. Anecdotes are interesting, but not scientific proof. Posted byLatex d-dimer assay for suspected DVT The new Annals of Internal Medicine has an important article on the utility of a new second generation rapid-turnaround quantitative latex d-dimer test for ruling out deep vein thrombosis (DVT). A Diagnostic Strategy Involving a Quantitative Latex D-Dimer Assay Reliably Excludes Deep Venous Thrombosis . This study first stratified patients using a standardized model for estimating pretest probability in patients with suspected DVT. The article includes the model. For those who cannot access the full text article, you can view the model here - Deep Venous Thrombosis and Thrombophlebitis. The article has a simple, yet important message. They found that the combination of a low or moderate pre-test probability of DVT and a negative d-dimer test safely rules out DVT. This can help us avoid doppler testing or more invasive testing in many outpatients and inpatients. This strategy can also decrease costs. Posted byOn dyspepsia and h. pylori I have ranted about this subject several times. Today I want to share two new observations, and try to place these observations into perspective. Recently, I debated this subject at Grand Rounds. I concluded:
Today's British Medical Journal addresses the evaluation of dyspepsia in patients 45 years or younger who have no alarm systems.
The article - Empirical prescribing for dyspepsia: randomised controlled trial of test and treat versus omeprazole treatment - supports previous studies suggesting that this strategy is both cost-effective and better for decreasing future symptoms. This article certainly supports the position I took in the debate. However, we may have another consideration for the future. H. pylori Infection May Protect Against Esophageal Cancer
I find these results bothersome. While I still favor treating h. pylori in dyspeptic patients, we must investigate this hypothesis further. We may have a difficult decision in the future. If treating h. pylori decreases the risk of gastric cancer and increases the risk of esophageal cancer, what are we to do? If we confirm this dilemma, then our decision making will remain very difficult for years. Unfortunately, we may be damned if we do and damned if we do not treat h. pylori. I can only imagine how this could translate to the courtroom (db transforms into Stephen King, writing a medical horror story). Posted byRead Prather on health care costs Robert Prather is a great blogger! There, I have typed it. Now read his rant on health care costs. I need not expand on his outstanding rant - Health Insurance Abuse Posted byOn surgery for emphysema They have released the study results, and I remain confused. Results of Costly Emphysema Operation Are Mixed, Study Finds
The surgery discussed here paradoxically is lung reduction surgery. Patients with areas of great destruction (and large blebs) theoretically would benefit when the worst areas are removed, allowing the remaining lung to function better.
This information could help us decide to recommend surgery for a small, but definable, subgroup of patients.
The problem with these subgroup analyses relates to the general problem of subgroup analyses. The investigators designed the study to look at the overall patient group. Re-analyzing data in subgroups increases the chance of statistical error.
We have a technique which may improve quality of life in selected patients. It is very expensive. The surgery probably harms patients who do not have the favorable profile. We need excellent pulmonologists to guide us in deciding about this surgery for individual patients. For those who are interested, the original articles are prereleased on the NEJM web site. Posted byThe right to be fat The government says you're fat
Here is the problem. I do not mind people making a conscious decision to ignore their future health, whether by smoking, drinking excessively, or eating enough to become obese. What I do mind is the economic consequences that effect me! If one chooses a lifestyle that increases health care costs, then one should pay those increased costs. Why should I pay the same health insurance rates as those who make unhealthy lifestyle choices? We need a health insurance surcharge plan. That plan would include Medicare! If we cannot get such a plan, then your lifestyle choices (a great euphemism for smoking, drinking excessively and eating excessively) cost me money. And that is intrusive. Posted byZetia -few if any side effects I get ongoing comments from readers who have taken Zetia and complain of side effects. Whenever I read of individual side effects, I wonder about causation. Thus, large placebo controlled studies generally provide more reliable data on side effects. An article in yesterday's Circulation (subscription required) indirectly addresses this issue - Effect of Ezetimibe Coadministered With Atorvastatin in 628 Patients With Primary Hypercholesterolemia . They have patients who received placebo, ezetimibe, atorvastatin or both. One table summarizes the safety data. For this rant, I will report only the ezetimibe (Zetia) versus placebo data. 10% of patients taking placebo and 6% of patients taking Zetia had GI side effects. Thus, we cannot blame GI side effects on Zetia. 5% of each group had muscle complaints. Again we cannot blame muscle complaints on Zetia. Analyzing these data makes an important point. The onset of symptoms which coincide with starting a new drug does not necessarily mean that the drug caused the symptoms. Placebos cause a lot of symptoms. Most patients believe their own anecdotes. They know that they can blame the drug. However, careful scientific inquiry may call that belief into question. Drugs can cause side effects. Many such side effects are well described and well known. However, prior to accepting that a drug causes a side effect, we should determine scientifically the incidence and severity of the effect. We should also prove that the claim cannot be explained by coincidence. In the case of Zetia, I suspect that most of the claims I receive in my comments section are in fact coincidence. Posted byOn pre-hypertension As I wrote last week, we have a new label - pre-hypertension. The committee chose to label patients with the hope that they would take action to prevent higher blood pressures. Some patients have hypertension regardless of lifestyle. They should not feel guilty, and we should not make them feel guilty. Others, however, develop hypertension as part of the "metabolic syndrome". They could, and should, prevent hypertension during the pre-hypertension phase. Lean Plate Club: Evading Hypertension
There are no surprises here. There are no magic bullets. Your probability for greater quality and quantity of life increases as you take care of yourself - especially with prudent diet, maintaining a good weight, and exercise. This message comes through in many forms and many studies. Now all we need is a way to stimulate self-discipline. Posted byThe importance of making a diagnosis As an internal medicine attending, I often stress the importance of making the correct diagnosis. This link, from the NY Times, makes that point well. First, read the presentation. Think of the probable diagnosis, then go read the article to check yourself. Treating Symptoms and Missing Disease Posted by Medrants 1 year old - personal reflections Today is Medrants birthday. When I started a year ago, I had not thought carefully about what daily blogging would mean. Why was I doing this? What did I hope to achieve? Two months after starting, I ranted a bit about blogging. Rereading those words puts today into perspective - About my blog . A year of blogging has helped me grow as a writer and as a thinker. I spend more time each day considering the latest medical literature and how it might impact practice. Prior to ranting, I mean to consider each finding carefully, providing my interpretation and trying to support my reasoning. These exercises have formalized a process that I did sporadically. I read more articles now. I stay more up to date. Blogging has made me more aware of the economic pressures on medicine. I try to include these issues in Medrants because I believe the readers care. Perhaps we (db and the readers) can influence the debate. While that idea seems grandiose, I do believe we can influence how people consider these issues whenever we engage in the debate. Personally, I find writing this blog a great pleasure. I believe that my writing has improved and I find myself writing more willingly and more often (even when not blogging). As I have said in the past, I mostly write Medrants for myself, however, I confess that my ego loves the attention that it receives from others. The daily comments that I receive and read tell me that my words mean something to others. The thank you notes that I receive are very special. Blogging is a joy. Daily I can express myself, be outrageous if I like, educate occasionally, and consider the medical world carefully. Blogging time allows me to think, consider, and grow intellectually. What a great decision I made a year ago! What a wonderful experience! Thanks for reading Medrants. Posted byMedrants 1 year old - the hot topics As I have reflected on this year of blogging, I have considered my hot topics. They have changed over the year. I suspect that they will change several times over the coming year. Last year resident work hours started as one of my major topics. Over the year, the ACGME made their decision (mostly correct, although I do disagree with a few details) and we (housestaff programs) are all preparing for July. I will be ward attending in both June and July, thus I will personally experience a new system in transition. How programs adapt to these new rules will be a story interesting mostly to insiders. I will however comment on the changes periodically. Over the past 6 months the malpractice crisis has attracted much attention on these pages. I suspect that I will continue to rant about malpractice suits, and the unintended consequences of those suits. This subject has helped me understand the economics of medical care. I now understand clearly that we do not work in a free market system. We need (as I have said, and will say incessantly) better methods of valuing and charging for medical care. Physician reimbursement methods are unsuited to current expectations and needs. Our system makes it difficult to increase collections, however there are few constrainsts on increasing expenses. The system is broken, and must be fixed for patients to receive the high quality care they deserve. Medical advances continually amaze me. Most weeks I can rant about an important new study which helps us understand disease, or even changes how we provide care. The study of medicine has fascinated me for 30 years and will continue to fascinate me for many more. Considering each day the myriad topics about which I could rant adds intellectual rigor to my day and my life. I hope that these topics interest you. I believe them important to physicians, other health care professionals and to all who may become patients. Posted byNY Times on China's handling of SARS The NY Times gets it! Diagnosing SARS in China
These words ring true. When political considerations threaten the public health, then the political system should change. The Times understands. Posted byGinseng has no effect in study Most readers know that I generally dislike herbal supplements. I want the same data on supplements that I expect on pharmaceuticals. Going to a pharmacy has become a nightmare to me. They sell stuff over the counter which can harm patients. Larry King's testimonial spooks me. Why would anyone take medical advice from him? He has touted Ginseng but never discusses data - because there are no data for its benefit. Ginseng fails to increase energy, immunity in tired people, study finds
Actually, ginseng did nothing for those volunteers. It only helped the unscrupulous supplement industry who sells this stuff. Unregulated tissue transplants I did not know this. I had not considered this. The information in this op-ed piece does disturb me. Do You Know Where That Cartilage Came From?
These introduce a troubling question. Surgeons are tranplanting tissues, and have no trials showing efficacy. These tissues can carry infection. The author poses some excellent questions. Maybe this article will bother you too. Posted byControlling SARS, different than controlling AIDS Robert Goldberg certainly makes you think. Read this opinion piece on the lack of sound epidemiologic practice and the spread of HIV. Disease control
He asks why we can not treat HIV like another other communicable disease. What costs have we paid as a society by treating this poltically? Posted byJNC 7 - the newspaper hype versus the real message The reports first hit the net yesterday morning. Yesterday evening I heard commentary on talk radio, then saw news stories about the new guidelines. Rather than quickly linking to this story, I decided to read the guidelines carefully so that I would understand the key points - The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (published online in JAMA - hard copy comes out next Wednesday). It behooves us to carefully go through the key messages.
They are not making explicit a finding that we have known over the past several years. Systolic hypertension probably does more damage than diastolic hypertension. Thus, we should strive to get the "top number" within acceptable limits (especially for those of us > 50). They now define prehypertension because of message #2. Studies have shown that risk starts increasing once the BP exceeds 115/75. Thus, the prehypertension group (see message #3) does have some increased risk. Unfortunately, he third message has gotten the most press. For example, U.S. Lowers 'Normal' Levels for Blood Pressure Readings appears in the New York Times. The text reads better than the headline -
So this new category of pre-hypertension is meant as a "wake up call". Once your BP starts to increase, we (generalist physicians) should us this new label - prehypertension - to further motivate diet, weight loss and exercise. We should also carefully evaluate these patients for other cardiovascular risk factors. Is this really a big change? Perhaps, for some physicians it is, however, these guidelines merely codify current desirable preventive practices. The statement on thiazides is well balanced and therefore admirable. They recognize "compelling indications" for other anti-hypertensives as first-line therapy. In the absence of those indications they recommend thiazides first. With those indications, they recommend that we use thiazides as the second drug in combination therapy. They list the compelling indications in Table 6. This table appears accurate and worthwhile. They recognize that most hypertensive patients will need combination therapy to achieve the BP target of < 140/90 or < 130/80 if the patient has either chronic kidney disease or diabetes mellitus. In an interesting and logical new recommendation, they recommend starting 2 drug therapy for patients with BP for 160/100 or higher. They list the combination drug possibilities, stressing that combinations which include a thiazide are highly preferred. They finish their key messages stating that patient motivation keys our success. Physicians cannot treat hypertension, they can only provide the tools for patients to treat their own hypertension successfully. You can also read more about the guidelines on the NIH web page devoted to JNC 7 - The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). Overall, this is a well considered, logical and balanced report. It does not change dramatically my current practice, but does refine some details. Now I still need to understand how to get patients to diet and exercise. These lifestyle changes can improve our longetivity, and more important our ongoing quality of life. It seems so simple on paper, yet it is so difficult in reality. Posted byAnticholinergic better than beta agonist for COPD Several weeks ago in clinic I made this point. Another attending challenged me, questioning whether I had data for this claim. In COPD, patients have more larger airway bronchoconstriction (as opposed to asthmatic patients who have more smaller airway bronchoconstriction). Since anti-cholinergics provide more relaxation of larger airway bronchoconstriction, it seems logical that they would work better in chronic bronchitis (with some reversible obstruction). However, I did not know a specific article (although I thought that I had read something to that effect). Here comes a study to my rescue! Tiotropium More Effective Than Salmeterol in COPD
We always use ipratropium bromide (Atrovent) in our hospitalized COPD patients. I look forward to the FDA approval of this longer acting anticholinergic option. Posted byThe media and prescription drugs Prescription drugs can greatly improved our quality and quantity of life. Advances during my medical career (I graduated from medical school in 1975) have occurred in the treatment of almost every important disease. However, all substances that we ingest can have side effects. Some drugs have the potetential to do good, but the risk of causing problems. Apparently the media generally emphasizes the good - Media May Mislead on Drug Study Stories
We would hope as physicians that we could give excellent advice about each drug we prescribe. However, we must first gain the appropriate knowledge, and then have the time to educate the patient. As I write incessantly, time is our only commodity, and we do not have enough of that commodity. Thus, physicians often are not up to date on the side effect profile of every new drug. Moreover, they rarely take the time to educate the patient. Drug side effects are important, and should receive more attention. Perhaps if the media emphasized the side effects more often, patients would ask questions about side effects and prompt their physician to engage that discussion. Perhaps not. Posted byPossible SARS drugs Research on SARS continues to move at a rapid pace. This article suggests a possible treatment based on the biology of the virus - SARS drugs may already exist
As scientists learn more about the virus, they are more likely to find specific targetted treatments. The investments in HIV and hepatitis C research over the past 2 decades have given us great insights into viral workings. Hopefully, scientists will build on that knowledge to more quickly find specific treatments for SARS. Posted byCOMET results previewed Today's theheart.org features an article on the COMET (Carvedilol or Metoprolol European Trial) study - "COMET: Carvedilol improves survival more than metoprolol in CHF".
This report is apparently preliminary and does not include the percentages. I will follow this important story, as choosing the correct beta blocker for CHF has important patient implications, as well as cost implications (metoprolol is generic, carvedilol is only available as the trade drug Coreg). This story is important, and I will revisit it with the data as they are released. Posted byWomen and knee injuries Men and women have different athletic abilities and different injury susceptibilities. Muscle Groups: Women and the Susceptible Knee
The researchers have nicely identified the problem. We always hope that identifying a problem allows us to design a positive intervention.
These data could help many women athletes in the future. Posted byGreat summary on cervical cancer screening Many readers know that I am a big fan of Jane Brody. Her weekly column often has a wonderful summary of a complex issue. This week is no exception - Pap Test: Champion Against Cervical Cancer
Despite the excellent results we have achieved with routine Pap smears, we now can probably achieve even better results. The improvements take advantage of our growing knowledge of the cause of cervical cancer.
This screening adds important information to the routine Pap smear. In fact, most practices now have adopted the new guidelines for cervical cancer screening.
These guidelines do represent a significant change which responds to our newer better data. Some physicians might want to make copies of this article to hand out to patients! Posted byPoor choices of words Occasionally I get caught up in my own hyperbole. Like all commentators, I should be careful in my choice of wordings. In this piece - A contrary view on Scully , I was wrong to use this language: "Well, Mr. Goldberg (the editorialist) knows a lot about politics and perhaps even economics, but he does not know medicine. He continues this harangue with a spirited defense of Nexium and Aranesp. I admire his hyperbole and obfuscation, but he clearly is writing as a shill for the pharmaceutical industry. " I should not have called Mr. Goldberg a shill. I still disagree with him strongly in how he defends Nexium and Aranesp. Nonetheless, I believe that he believes his arguments. Thus, I apologize for calling him a shill. I do stand by my support of Scully. If we are to have a free market medical economy (which we do not), then each new drug requires debate and decision making based on benefit and price. I teach residents not to use Nexium for the same reasons that Scully argues against the high price of Nexium. This drug does not add to our therpeutic armamentarium. No reasonable cost-effectiveness analysis would argue for its use. The drug really is not different from omeprazole. In a free market economy, we (physicians) should speak out against unnecessary costs for our patients. The newest drug is not necessarily better. I do not want to destroy the pharmaceutical industry, rather I want to hold them to reasonable standards. I disagree with their marketing tactics, and believe it my right and duty to point out their deficiencies. I hope that Mr. Goldberg understands that point, and the medical judgement behind my beliefs. Posted byResident work hours Resident work hours change July 1. I have ranted extensively on this issue previously (just search on ACGME). At least one Senator is not satisfied. Resident work-hour bill lives on in Senate
Congress should not enter this fray. The ACGME has aggresively worked on this issue. The ACGME plan does not have uniform support from trainees. We have major changes in training, without any data on the effect on patient care. This issue is complicated. Meeting work hour requirements can effect continuity of care. We all worry about patient "hand offs". What happens when one doctor leaves and another takes over? Figuring out how to provide good continuity under these guidelines is a major challenge. Hopefully, with Dr. Frist as Senate majority leader, the Senate will wait a year or two to see how the ACGME guidelines work. Senator Corzine should focus on more important health care issues - malpractice reform, Medicare and Medicaid reform. Posted byHealthier Food I want to compare and contrast the current truth and the truth as proposed by my daughter. The current truth - Gov't Won't Force Cos. on Healthier Food
At least Thompson is using the bully pulpit. This represents a good start. Perhaps he should read this paper that my daughter wrote for a public publicy course. This assignment is written in the form of a memo to a senator. She advances an interesting proposal.
Congress has often used taxes as a policy tool. While I have not thought carefully through the policy implications of this concept, her reasoning looks sound. If I am missing unintended consequences please let us know. Needless to affirm, I am very proud of my daughter's reasoning and scholarship. Having this blog allows me to share her work with the blogosphere! (Disclaimer: she has given explicit permission for me to share this paper with you the reader) Posted byOn part-time VA work I write this rant with some trepidation. I am a subject in this investigation. I work part-time at the VA. However, I believe in truth and common sense - so here goes. Some VA Doctors Not Doing Scheduled Work
Let me try to put this report into perspective. Part-time VA work is divvied into eighths. If one receives 2/8ths VA, then one has 10 hours of responsibility to the VA each week. However, physicians really do not work in eighths. We do what is necessary, sometimes overworking, sometimes underworking. What is important is whether our average work meets the criteria. When I am on service (ward attending at the VA) I work many more hours than during the months that I am off service. How should we account those hours? On average I perform the expected work. Some weeks I do much more, other weeks I do much less. I submit that I am not defrauding anyone. Perhaps we should develop a group mentality. The VA could contract with general surgery for a 4/8ths general surgeon. Regardless of the individual assigned, the important question is whether patient care is appropriately provided. What this article omits is a discussion of WOC (VA jargon for WithOut Compensation)? At most academic centers, physicians do provide care WOC (generally covering for a paid physician). How do we appropriately account those contributions? Having talked with an OIG investigator, I would submit that they are asking the wrong questions. The real question depends on whether appropriate surgery is delayed. The VA must either pay surgeons fee for service, or contract surplus capacity so that they can handle those time periods when more surgery is necessary. This VA news piece greatly oversimplifies a complex relationship of care. Posted byMore on universal health care Thomas Sowell has thus far published 3 essays on universal health care. This link gets you to his column. If the column has changed from universal health care (or you want to read his first 2 essays) scroll to the bottom and click on archives to read the articles. Thomas Sowell columns
Thus, we have a brief history of health insurance per Sowell. Actually, health insurance started prior to WWII to pay for surgery. Nonetheless, health insurance is a relatively recent phenomenon.
Robert Prather has made this point repeatedly. I often make this point in a different way. Our current health system generally disconnects financial considerations from patient decision making. Some would argue that patients should not have to worry about cost in health matters. However, how else can we prioritize health care? Many years ago, while I was doing sore throat studies, we observed a much lower rate of group A beta hemolytic streptococcal pharyngitis in student health than in the emergency room. We reasoned (although never proved) that ERs represented a barrier to health care. The patients were generally sicker. Student health provides minimal barriers to health care. The location was convenient, and the price was minimal (if any). Thus, students checked out every sore throat. How large a difference did we find? ER patients had >20% strep throats and student health <10% strep throats. Our society does ration health care by access and ability to pay. Most essential care is provided regardless. Discretionary care depends on financial considerations (most plastic surgery for example). So we must consider the positives and negatives of any single payor system. Prior to supporting such a system, one must consider the unintended consequences . If health care is a right (and why should our system treat health care different from legal advice, food, shelter, etc) then we should strive to provide care to all. But should we provide the same care to all. If we try to do that, we will probably develop into a system much like Canada or Great Britain. There are clear advantages to these systems. However, there are undesirable consequences. Who will be the physicians of the future? What incentive will drive students into medicine? We want our physicians to be the best and the brightest. Would that happen with socialized medicine? How do we pay for increasingly expensive technology and pharmaceuticals? Who would invest in their development? Would this new system slow down medical advances? If we must ration care, (and I submit that we would have to ration care) who makes those decisions. Would we develop an age limit for dialysis (as many countries have done)? Would surgery waiting lists become a major problem (like in Canada and Great Britain)? Would the system ask primary care physicians to spend even less time with patients? What effect would this have on our quality of care? I worry about unintended consequences. I agree that our current system has major problems. However, prior to considering radical surgey, I want to review our options. Perhaps we can fix the system, without taking such a drastic step. What features would I tackle first? I have written occasionally about Medical Savings Accounts. This method could handle routine care and medications. Such accounts force one to make financial decisions about care. I would consider a standard interface between insurers and providers and patients. We need simple, standard forms. The proliferation of forms and rules add unnecessary costs to health care. We could solve this problem without a single payor system. I would develop a system that allows physicians to charge for time spent. Thus, if you need a 10 minute appointment, you would have a clearly different fee than if you need a 30 minute appointment. If you want to discuss an issue on the phone, then we would charge you. Emails would have charges, as would telephone calls to subspecialists. For those who find this too complicated, we could develop some modification of a retainer model. We must think creatively about providing health care. Universal health care has some surface appeal. I fear that the unintended consequences are greater than most advocates have considered. Posted byToo little time
An additional problem causing the sense of insufficient time is the fee for service reimbursement system. If I take 25 minutes with a patient, I get paid the same as if I spend 20 minutes. Thus, we feel a time pressure and this can lead to not satisfactorily addressing all necessary issues. I blogged on this issue on Tuesday. I will keep addressing this issue, as it remains a central one in our understanding of the current health care crisis. Posted byOn cost-effectiveness As a long time member of the Society for Medical Decision Making, I have done, and read cost-effectiveness studies for over 20 years. In the early 80s we discussed the problem of limited resources. How do we prioritize medical spending? What price is unacceptable? At the absurd one would argue that we could not spend a billion dollars to save a patient. If one accepts that statement, then the only question becomes agreeing on the magic amount to provide a year of life.
Thus, the debate over cost effectiveness studies is really a debate about relative value. This essay from the NY Times personalizes the question that many have wrestled with over the past 2-3 decades - Buying Time: Doctors Debate the Ethics of Care and Cost. While this article does a nice job of summarizing and personalizing the problem, it really does not cover new ground. A rational society would use cost effectiveness to ration health care expenditures. However, we do not live in such a rational society. We have many political considerations involved in our decision making. Read the article and consider the philosophical nature of the questions the author raises.
I submit that we should consider these issues. However, many patients and potential patients would then brand us (the medical community) as concerned with cost rather than their health. Thus, we have a true conundrum. Posted byNew estimates of SARS death rate The SARS phenomenon started only months ago. Clinical researchers continue to refine their observations of this disease. The latest information suggests an even more deadly disease than previously thought - Study in Hong Kong Suggests a Higher Rate of SARS Death
This article reports on a new Lancet article - Epidemiological determinants of spread of causal agent of severe acute respiratory syndrome in Hong Kong. While we do not know precisely the severity of this infection, it does appear to cause severe disease - with a high fatality. Posted byMore just talking Saturday morning I ranted about a new complaint from patients - all we did was talk. The comments have added great texture to the ideas that I put forth. Over the past few days I have considered my rant and the comments. I hope that I can expand on my first rant, and use the comments appropriately. We must try to understand what these patients meant when they accused the physician of 'just talking'. If the physician just lectured the patient, then the patient has a point. I doubt that was the problem. However, as one comment suggests, the key quality to consider here is listening. If the physician talks too much, and listens too little, then he/she deserves some criticism. Many patients are looking for a physician who will listen to their complaints and respond to those complaints . Since we do not know the context of the comments, we must consider lack of listening as a possibility. However, even when the physician does listen and respond, some patients (and most payors) will devalue the physician's time in comparison to procedures or even radiologic interpretation. This could probably represent the CSI phenomenon. For those who have not watched either of the two Crime Scene Investigation series, these shows trumpets the scientific analysis of crime scene data. The investigators in these shows base their investigations on hard science, not on interrogation. One can contrast these shows with an Agatha Christie novel, or Lt. Columbo. In that mystery genre, the investigator would ask questions, and reason out the sequence of events. The excellent generalist combines both genres. We must combine the clues from a careful history (which must include listening more than talking), a directed physical examination, and then a decision to order the appropriate tests (either laboratory or imaging). Sometimes we decide to refer the patient to a subspecialist for further evaluation, and even sometimes further history. What rankles me (and others) is the devaluation of our process? If I spend 20 minutes with you in the office, I then will spend an additional 5-10 minutes reviewing your record, my notes and any testing. Sometimes, I will go to my computer and read more information on your complaints (I personally use UpToDate). You may email me. Either I or my staff will probably call you about your laboratory results. We all know that time is money. And as a generalist, time is our only commodity. Lawyers have understood this concept and bill appropriately. While we joke about lawyers, when we need them, we pay those bills. We have a system which does not reimburse me for the time I spend talking, listening, examining, reflecting and communicating. I get paid a flat rate for seeing you, almost regardless of complexity and the need for time. (In fact there are slight adjustments for more complex patients, but in fact time is not a factor in reimbursement.) As the SGIM position paper (THE FUTURE OF GENERAL INTERNAL MEDICINE says
All generalists should aggressively support this recommendation. I believe that all patient advocacy groups should join in supporting this recommendation. Excellent medical care requires time. If we can spend the appropriate time with each patient, then we can provide better prevention, better education, and better take the time to analyze all the patient's complaints. Our current system creates perverse incentives - incentives to limit the time with each patient. Such incentives encourage inappropriate use of diagnostic tests and referrals. I do not argue against diagnostic tests and referrals, but rather we should use those aids appropriately. Physician time is the health care crisis. Lack of time translates to less satisfied physicians and patients. This phenomenon discourages students and residents from careers as generalists. And I still believe that each patient needs a conductor, someone who understands the entirety of the patient. Posted byWater dangers Hyponatremia can kill runners. New recommendations tell runners not to drink too much water when running long distances. New Advice to Runners: Don't Drink the Water
The International Marathon Medical Directors Association (IMMDA) proposed this advisory 2 years ago. IMMDA ADVISORY STATEMENT ON GUIDELINES FOR FLUID REPLACEMENT DURING MARATHON RUNNING So what is the problem here. Over time, in a long slow race (this is not a problem for elite runners) some runners can drink enouhg water to become hyponatremic. The actual physiology is unclear, although, probably some people get volume contracted during the run, increase ADH, and then drink back excessive amounts of pure water. This combination can cause hyponatremia, and hyponatremia can cause seizures and even death. I wrote about his problem last June - The dangers of exercise and too much water . Many patients running marathons will tell their physicians. We should explain the water situation to our patients. I tell patients and friends to choose the gatorade! Because of the solutes in gatorade, they will not develop hyponatremia. Posted byMedicaid cutbacks
This is a major problem. I do not know a solution. Posted byDesirably slow spread of SARS in the US Very interesting article in the NY Times - Aggressive Steps Help U.S. Avoid SARS Brunt
It is certainly very nice to read about some successes. Posted byJust talking For the past 4 days I have participated in the SGIM annual meeting. Yesterday, I went to a session on worklife balance. One of the speakers was a practicing internist in Connecticut. He told a story of a patient complaining about the charges, because, he said, 'All you did is talk to me.' Putting this into context, we must think about what patients think about their generalist, and how society values different aspects of medical care. This comment (which a colleague confirmed he had also heard from a patient) has lead to much reflection of generalism and what we provide patients. I read mystery novels. I view generalism as analagous to being a detective. Patients come to us with complaints, which we must decipher. Our clues come from questionning the suspect, examining the suspect (collecting the physical evidence), and ordering laboratory and imaging studies. We are taught early in medical school that most diagnoses come from the history (occasionally with laboratory confirmation). Thus, the outstanding clinician becomes a skilled questionner, using each response to trigger the next question, leading to an understanding of the problem (and once one makes the diagnosis, the answer often becomes apparent). Even when we shift to the treatment mode (seeing the patient on anti-hypertensives; performing a periodic visit with a diabetic patient; checking the patient with congestive heart failure), most of our clues about success, or drug side effects, or new problems comes from questions and answers. I love reading mysteries in which the detective works through inquiry. Such stories relate well to my daily life as a physician. For reasons unknown to me, some patients now apparently only see value in procedures (either therapeutic or diagnostic). Perhaps that explains much of the attraction of the whole body scan. Yet, for most patients that I see, the story tells all. We (generalist physicians) do a poor job of explaining our jobs. While we undertake the most complex task - sorting through patient complaints on the front lines, we rarely have our skills translated into a form understandable to the average citizen. I am still pondering this dilemma. We should be the heroes of health care, and yet we are treated as grunts. Help me explain this better. I need help here - as does the field. For if we lose our excellence in generalism, we will lose much of our health care excellence. Remember, if the only tool that a carpenter has is a hammer, then everything looks like a nail. Only the generalist carries the full toolbox, figuring out the appropriate way to diagnose, treat, and prevent disease. We are needed; we are value; yet we are not telling our story well! Posted byOn lecturing and learning Back in 1991 I spent one glorious month learning about medical teaching from Dr. Kelley Skeff at Stanford. A recent article about his courses appeared in the Stanford Medical Magazine (I am quoted extensively in the article). Demystifying Teaching Kelley taught me many things over the years (we remain friends and colleagues). One of the most important lessons occurred the day he helped me understand the chasm between lecturing and learning. His point (and I take credit for the interpretation here) is that the goal of teaching is to induce learning. Everytime we teach, we should think carefully about the learner, and therefore work to make certain that the learner actually learns. Otherwise we become a lecturer rather than a teacher! While I first learned these lessons with regard to teaching students, interns and residents, the same lessons apply to teaching patients. This study report tells me that we (most physicians) have a long way to go in this regard! Patients 'don't listen to their doctors' I like this article, but disagree with the title. It is not the patient's responsibility to listen, rather our responsibility to communicatge.
We can improve here. Repetition works. Taking more time works. Having the patient restate the point helps. Of course, no one reimburses us to take time and make certain that patient's understand. Some things we must do because they are the right thing to do. Posted by |