DB’s Medical Rants

Regular readers know that I consider making the proper diagnosis the epitome of internal medicine (as well as many other specialties.)  We know that we often miss diagnoses, but we often do not know why.  I have often recommended Jerome Groopman’s book - How Doctors’ Think - as a primer on medical cognition.  Currently he has a regular column in the ACP Internist.  The current article gives a classic example of medical diagnostic error - Beware of ‘search satisfaction,’ a common cognitive error .

Dr. Ginsberg told us that he viewed this case as “a horse masquerading as a zebra.” Why didn’t we see the horse? To help answer the question, Dr. Ginsberg sent us this picture of how the mind may not perceive a visual abnormality.

If you see nothing wrong, try again. It took us several tries.

The current American Journal of Medicine has an interesting article on diagnostic error - Overconfidence as a Cause of Diagnostic Error in Medicine.  This article is long and detailed.  I recommend it only for those who want to study this problem in depth.

How important is diagnostic accuracy?  I would argue that if we could measure accuracy we would have the best single measure of physician quality.  However, we are forever challenged with developing a measure, because we have difficulty knowing the correct answer - that in fact is the problem.

Clearly, we should encourage physicians to take the time to think about diagnosis.  Perhaps, we could actually help patients through the act of spending money on cognition.  Perhaps, but then who would pay for me to think?

Was It the Drinking Binge?

Solution to "Was It the Drinking Binge?"

Becoming a better ward attending: Ten modifiable behaviors

This exploration is published in ACP Hospitalist.  We (db and Lisa Willett) developed the paper as part of a faculty development program conducted at the Southern Society of General Internal Medicine.  We are now using this framework for short (1-1.5 hour) teaching workshops.

For those who teach and learn, we would love your comments.

I have moved into cell phone technology.  Through a site called Wirenode, I now have cell phone friendly access.  I have an advertisement in the side bar, but here is the mobile phone web address -  http://medrants.wirenode.mobi

Please let me know if this addition has value.

The Experience of Pay for Performance in English Family Practice: A Qualitative Study

PURPOSE We conducted an in-depth exploration of family physicians’ and nurses’ beliefs and concerns about changes to the family health care service as a result of the new pay-for-performance scheme in the United Kingdom (Quality and Outcomes Framework [QOF]).

METHODS Using a semistructured interview format, we interviewed 21 family doctors and 20 nurses in 22 nationally representative practices across England between February and August 2007.

RESULTS Participants believed the financial incentives had been sufficient to change behavior and to achieve targets. The findings suggest that it is not necessary to align targets to professional priorities and values to obtain behavior change, although doing so enhances enthusiasm and understanding. Participants agreed that the aims of the pay-for-performance scheme had been met in terms of improvements in disease-specific processes of patient care and physician income, as well as improved data capture. It also led to unintended effects, such as the emergence of a dual QOF-patient agenda within consultations, potential deskilling of doctors as a result of the enhanced role for nurses in managing long-term conditions, a decline in personal/relational continuity of care between doctors and patients, resentment by team members not benefiting financially from payments, and concerns about an ongoing culture of performance monitoring in the United Kingdom.

CONCLUSIONS The QOF scheme may have achieved its declared objectives of improving disease-specific processes of patient care through the achievement of clinical and organizational targets and increased physician income, but our findings suggest that it has changed the dynamic between doctors and nurses and the nature of the practitioner-patient consultation.

Those who champion P4P make an unfortunate assumption.  They believe that you can push one button, and only impact the desired outcome.  They are obsessed with measurement, and believe that measurement will improve health care.  They are so dangerous.

I will state that those who champion P4P are mistaken in the most dangerous way.  Unless we carefully study the impact of incentives we could cause more harm than good.

Bob Wachter talked about this eloquently in March - The Great Quality Debate: Berwick’s Plea for Action vs. Evidence-Based Medicine. 

On the other hand, in our zeal to “do something,” vigorously promoting or mandating practices with weak evidence risks squandering scarce resources, diverts us from better strategies, and subjects the safety field to the whims of opinions and biases. Berwick worries that our EBM pushback gives intellectual ammo to the dark forces of status quo. This is a reasonable concern. But given the public interest in quality and patient safety, I worry more that the distance between “this seems like a good idea” to “let’s include it as part of a campaign” to “let’s make it a new Joint Commission standard” to “let’s make it a state law” is perilously short. Accordingly, we should require awfully strong evidence that we’re doing the correct thing as we traverse that path, particularly when practices are complex and expensive.

The Annals of Family Medicine article raises many legitimate questions about Great Britain’s P4P experiment.  We should learn from their experience. 

Gut-wrenching

When I think of abdominal pain evaluation, I think of Cope’s Early Diagnosis of the Acute Abdomen

What does one say about the 21st edition of an authoritative clinical text first published in 1921? This revised edition by the eminent surgeon William Silen clearly demonstrates the beauty of succinct medical writing and the durability of clinical pearls. The previous edition was published in 2000 and the march of technology has continued relentlessly, threatening to overwhelm even the most ardent medical student’s or resident’s desire to obtain a complete history and perform a rigorous physical examination on patients presenting with symptoms and signs consistent with an acute abdomen.

Abdominal pain in many ways represents the epitome of history, physical exam and diagnostic testing.  Lisa Sanders writes about a challenging story of abdominal pain in an adolescent.  As usual she writes the story beautifully, and as a reader I kept trying to solve the story.

You will need a high speed connection to view this talk.  I gave this talk at UC Davis, and they kindly archived it. 

Long time readers will not be surprised by my comments, but I hope this discussions brings many ideas into focus.

Guidelines - a skeptic’s viewpoint

A premed student writes:

We see a trend that people are starting to say NP’s and CRNA’s, particularly in rural settings, are helping control costs while providing general care and limited anesthesia. I also see a trend that a lot of MD’s ad MD anesthesiologists are ranting that these types of advanced practice nurses are ruining general/family care and cannot and never will have the necessary training do to such a role without having been through med school - though not so much ranting about crna’s so long as they practice under an anesthesiologist and not solo.
So then nursing profession pumps out "Doctorate of Nursing Practice" to fill the void of internal medicine physicians.. though this is not a PhD role for academic/research settings.. it is for clinical settings. The AMA flips out again claiming ‘Dr. Nurse’ will confuse patients and cause problems.

Do you think advanced practice nurses like crna, fnp, nnp, etc., are doing an adequate job for their scope of practice..? Calling in the md for exceptional or issues out of their scope?
What do you think of crnas practicing solo without an md.. this seems to be a ‘problem’ in rural areas.

There is no doubt there is a shortage of health care professionals.. even down to lpns.. 

Being a medical professor and MD, what do you think?

Activated Vitamin D Associated with Mortality Drop in Chronic Kidney Disease

For patients with moderate-to-severe chronic kidney disease and hyperparathyroidism, activated vitamin D appears to lower the risk of death over two years, an observational study found.

The 429 patients with stage 3 or 4 disease who took oral calcitriol had a 26% reduced risk of death (P=0.016) and a 20% reduced risk of death or long-term dialysis (P=0.038) compared with 989 patients who did not take oral calcitriol, Bryan Kestenbaum, M.D., of the University of Washington here, and colleagues reported online in the Journal of the American Society of Nephrology. The results will be published in the August print issue.

These data have great importance to generalists and nephrologists.  These data support the hypothesis that the secondary hyperparathyroidism Is a major problem for these patients.

What makes a good clinical teacher in Medicine? A review of the literature

They conclude that superb teaching is a complex phenomenon.

The authors emphasize these common themes:

1. Medical/clinical knowledge - obviously this is a sine qua non
2. Competence and clinical reasoning
3. Positive relationships with students and supportive learning environment
4. Communication skills
5. Enthusiasm

This study suggests that excellent teaching, although multifactorial, transcends ordinary teaching and is characterized by inspiring, supporting, actively involving, and communicating with students. These activities produce an emotional arousal in the student. Sometimes a relationship is forged between the student and teacher. Sometimes this inspiration arises internally from a personal identification with that teacher. We remember our greatest mentors: we either developed relationships with them or patterned ourselves after them. With ease and aplomb, our teachers performed challenging surgeries, respectfully imparted teaching nuggets to students, and spoke with their patients with compassion, and we wanted to be just like them. Many of our behaviors were similar to those of a child following a parent.

We must recognize those who have these skills and reward them.  We must learn if we can teach good teachers to become great.  But most important we must value these teachers!

This week I have listened to Doctored Evidence by Donna Leon.  I have read a couple of her mysteries previously, but found these CDs at the library.  Some books are better read, and some books are better heard.  I think this one would work well either way.

Her main detective - Guido Brunetti - is a thoughtful man with a brilliant wife.  Their discussions at home inform his thinking on the job.  Donna Leon does a wonderful job writing interrogation scenes, and makes me think about my own questioning skills.

At one point in the book, Guido chides himself for the sin of premature closure.  While I cannot remember the exact words he expresses embarrassment that he tried to make the evidence fit his hypothesis rather than making his hypothesis fit the evidence.

Yesterday morning at morning report we discussed a very interesting patient in whom the attending and intern made this same mistake.  The patient presented with one rigor and drenching night sweat, along with increased dyspnea and a productive cough.  However, his oxygenation was not compromised, and his lung exam did not reveal any area of consolidation.  His chest xray was unremarkable.  He did have a warm area in his lower leg, which he attributed to vein stripping from a previous CABG.

The team kept looking for the elusive pneumonia - and could not find it.

On the second hospital day, the blood cultures grew group B streptococcus.  We now assume that this was a most unusual presentation of cellulitis.

In this case the history taking was superb, and the history pointed strongly to a classic diagnosis of pneumococcal pneumonia.  However, the confirmatory data did not support the diagnosis, and thus eventually they had to look elsewhere.

Guido would understand their angst.

Tara Weiss, writing in Forbes, argues against becoming a doctor - Reasons Not To Become A Doctor

She paints a negative picture of the business of medicine.  Her arguments include:

1. Costs Of Practice Rise, Reimbursements Drop
2. Rising Malpractice Costs And Frivolous Lawsuits
3. School Debt
4. Salary
5. Decreased Autonomy
6. On-Call Responsibilities

All of these issues have some merit, but I believe she overestimates the negatives, and assumes that we will have no counter reaction to these problems.

I do believe we will have a payment revolution within 5 to 10 years.  Our current system of payment makes little sense.  Many writers and influence leaders now understand the problem.  More physicians are leaving insurance dependence, and I predict that this trend will only increase.

As a medical educator, I am distressed about the school debt issue.  At some point we (medical schools) must address this problem.

The case for becoming a doctor is a straightforward one.  Given what I know about medicine, I would do it again and I would encourage my children to do so.

Medicine remains the greatest profession.  Every day that I round on the wards, I know that my goal is to help people.  I make a nice salary, which helps, but the main goal when you are with the patient is the patient.  Patients sense that, and appreciate our doctoring.  Medicine satisfies my intellectual nature and my desire to help.

We have many financial issues to address in medicine, but many physicians still love the patient interaction.  My understanding of economics tells me that when demand exceeds supply sufficiently, the system will have to change.  I believe we are seeing many positive signs.  We have many states addressing the malpractice issues. 

We have increasing numbers of internists and family physicians refusing to take new Medicare patients.  Now you are probably scratching your head - how is that a positive action?  I would argue that as Medicare patients have a more difficult time finding a physician, they will put more pressure on Congress to fix our payment system.  More physicians and patients now understand that our payment system is bizarre and creates perverse incentives.  Change does not happen quickly, but eventually we will get change here.

So the economics need fixing, but the profession remains desirable.  I see primary care graduates making acceptable salaries.  I see other specialties making incredible salaries.  I do not understand the teeth gnashing and general wailing about medicine.  We must address many issues, but not forget that we belong to the greatest profession.

I see medical students and residents every day who love what they do.  The "job" is rewarding. 

I will agree that if your goal is to get Rich (rather then just very well off) you should choose another career.  But if you want to have the opportunity to positively impact people daily, become a physician.

I do not know if anyone will care, but I have decided to have a page devoted to books, movies and music that I like.  I will revise this list periodically.  Please feel free to comment.  If anyone wants to know why I list these pieces - I will gladly provide my motivations.

da Goddess makes an important point - good clinicians accept help from every member of the health care team.  I prefer that the nurse tell me the information, because most nursing notes are uninformative.  If I took the time to read every nursing note, I would get frustrated.  So when the nurse learns something potentially useful, he/she should tell me.

Dr. RW confuses history taking with the absurd current techniques for documentation - The decline in the art of history taking.  He has ranted about EMRs recently.  Earlier this week he wrote

The authors noted that the illegibility of the old handwritten doctors’ notes has been replaced by a new form of electronic illegibility: template generated clutter. A few clicks of the mouse generate paragraphs of repetitious, boiler plate verbiage with a low signal to noise ratio leading to reader fatigue.

I believe that he is confusing two phenomenon.  I do use an EMR at the VA hospital.  I understand why we have the cut and paste feature.

EMR allows one to bill a higher fee for the same work with less effort.  Our arcane documentation requirements  - see Coding Clinic 99232 -  reward us for documenting more history and more physical exam pieces.  They  are supposed to pay us for greater complexity, but only if we record several organ systems for both history and physical.  Since documentation means money, the EMR allows legitimate upcoding.

We could fix this problem if we could change the documentation requirements.  I would not blame this problem on EMR, the EMR just enables us to get paid more.

But I must separate documentation from history taking from documentation.  EMRs do provide cluttered notes.  I personally have a template that includes the medication list and the labs from the past 24 hours.  These data inform my notes.  I finish every note with impressions and plans.  Hopefully I make my thoughts clear in those sections.

But history taking is not about documentation, rather it is an exercise in understanding.  Through careful history taking, we understand who the patient is, what complaints the patient has, and possibly what likely caused the complaints.  We do not often record the nuance of the history.  We rarely have time to include all the details of our interrogation.  We should act on both the nuance and the details.  This is the lost art that we must protect. 

Do not blame the decline in history taking or decision making on the EMR.  Such comments make one sound like a Luddite.  Neither should we champion the EMR as the solution to quality care.  The EMR is a tool that makes data retrieval easier, makes orders legible, and makes it easier to spot laboratory trends.  We must learn to use the EMR as another tool in our toolbox.  When used properly the clinician can find truths, avoid unnecessary testing and quickly review old records.  When used improperly, we move around electrons without creating meaning.

"Variability is the law of life, and as no two faces are the same, so no two bodies are alike, and no two individuals react alike and behave alike under the abnormal conditions which we know as disease."  - Sir William Osler

I remember having senior clinicians tell me the value of a complete history.  As I recall, they told me that at least 90% of diagnoses would come from the history alone.

Of course in the 1970s we had access to automated lab tests and radiologic studies.  We could order tests. 

As my career has progressed those medical giants (here I refer fondly to the senior clinicians who taught me during medical school and residency) have become even smarter.  I now know the importance of a good history.

All medical schools have a course which teaches students the art (and science) of the history and physical exam.  Students learn a long list of questions.

This course is important, but 1^st and 2^nd year medical students do not know enough medicine to properly learn how to take a good history. Taking a history may seem simple, but it requires broad medical knowledge.  Master clinicians alter their history taking in response to the patient’s answers, their body language and observation.  As one performs the physical exam, more questions occur to the clinician.

The history does not end with the admission.  As one collects laboratory results, imaging studies, and clinical changes, more questions become relevant.  History taking represents an ongoing activity, designed to help both the diagnostic and therapeutic process.

How does one become better at history taking?  First, you must take many histories.  You must critique yourself as more information becomes available.  Second, you must think about the process of history taking.

The stimulus for this rant occurred as I was listening to a mystery book.  I love a mystery in which the detective carefully questions witnesses and suspects.  I pay attention to the rhythm and pacing of a good interrogation. 

One thing that I notice in these books is the manner in which the key question is surrounded.  While I know this is the key question, I will get a more honest answer if the patient is not aware of the questions import.

Perhaps history taking just takes time.  Perhaps physicians older than 50 have superior history taking skills to those below 40, just because of experience. 

Even if these postulates are true, I would submit that history taking has such importance that we should invest in helping our students and residents learn these skills more completely than they currently do.

"The good physician treats the disease; the great physician treats the patient who has the disease" - Sir William Osler

 I have previously criticized blind acceptance of EBM.  One of my good friends and previous colleagues, Roy Poses, recently engaged an interesting counterpoint to an op-ed criticizing EBM - ‘Evidence-based’ Rx miscues and What Influenced Derision of Evidence-Based Medicine as "One-Size-Fits-All?"

In reading their comments, I would note that they are making arguments about different things.  I hope in this rant to reframe the debate.

At the risk of insulting my religious readers, I will compare evidence based medicine with a belief in a religion, and EBM with a strict adherence to arbitrary rules of that religion.  I would argue that we all want to use the best evidence when we make medical decisions.  The true proponents of evidence based medicine recommend that we interpret the data in the context of our patients.  True evidence based medicine factors individual differences and multiple patient factors.

Unfortunately, too many groups have claimed that they are using "EBM" to make decisions.  These groups release prescriptive guidelines because of their interpretation of the evidence.

One need just compare guidelines that different groups make for the same problem.  The two that I would offer for your perusal are discussed previously in this blog - Guidelines not agreeing and When guidelines differ - prostate cancer.  In the  first example, we have 11 disparate guidelines addressing testing and management of pharyngitis.  These guidelines differ dramatically.  Similarly, the more recent discussion focuses on two camps in the prostate cancer screening debate.

Now in both examples, the guideline authors claim to use EBM to develop their recommendations.  How can we have such disparate recommendations?  As I have done many times, I refer the reader to Allan Detsky - Sources of bias for authors of clinical practice guidelines

In summary, the necessary human factor in making judgments based on multiple sources of data can result in biased recommendations. In the last few years, bodies that convene guideline processes have begun to recognize financial conflicts of interest. To improve the validity of their guidelines, they need to recognize all of the other sources of bias as well. In doing so, they will face the challenge of balancing the expertise of those with intimate knowledge, who are more likely to be subject to these forms of bias, with nonexperts who may have less knowledge but fewer of the influences that contribute to bias — no easy task. Although these other influences may be even more difficult to document and quantify than financial ties, they are no less important. Therefore, I recommend that guideline committees (and those who work on the methodologies they use) study the issue. Such action might further improve the rigour and transparency of the guideline process.

Guidelines are susceptible to many biases.  Dr. Detsky describes these biases clearly. 

The real debate should contrast the proper use of evidence with EBM.  The proper use of evidence focuses on the patient as Sir William Osler clearly reminds us.  We do have a problem when experts or insurers recommend disease standards based on evidence without regard to individual patient context.

We must value evidence and do our best to advance our knowledge of best care.  In contrast we should remain skeptical about EBM proclamations.

I hope this rant makes sense.  While Roy correctly points out one bias that may effect Peter Pitts’ commentary, I would argue that Pitts makes an interesting point.  His "straw man" is correct, albeit for a complex reason.

The theory behind evidence-based medicine is simple: If the government were to run clinical trials testing the effectiveness of drugs and medical technologies, and then use the results to determine what to cover, taxpayers would avoid paying for treatments that aren’t effective enough to justify their price tag.

We must be skeptical of all clinical trials.  Rarely should we let one trial totally change our practice.  As scientists we should critique all studies, and look for the sources of bias, obvious and subtle.

As one who values evidence, I can still fear EBM.  I fear it because too many now proclaim that their data or their analysis answers the question.  In my 30 years since finishing my residency, I have seen too many standards in medicine overthrown to become overexcited about any one study or one proclamation.  I provide the following examples of historical EBM:

1. Hormone replacement therapy to prevent coronary artery disease
2. Avoidance of beta blockers in heart failure
3. Avoid anticoagulation after myocardial infarction
4. Antiarrhythmics after myocardial infarction

I challenge the readers to provide more examples. 

This interesting article describes a current Archives of Internal Medicine - Reasons Documented for Heart Failure Admissions

At least one identifiable precipitating factor was found in 61.3% of patients, the researchers said. In order of frequency, they were:

• Pneumonia or respiratory processes at 15.3%.

• Ischemia or acute coronary syndromes at 14.7%.

• Arrhythmia at 13.5%.

• Uncontrolled hypertension at 10.7%.

• Nonadherence to medications at 8.9%.

• Worsening renal function at 6.8%.

• Nonadherence to diet at 5.2%.

In the cohort as a whole, there were 1,834 deaths in hospital, Dr. Fonarow and colleagues found.

Being admitted with pneumonia increased the risk of dying in hospital by 60% (OR 1.60, 95% CI 1.38 to 1.85, P<0.001).

Worsening renal function was associated with a 48% increase in risk of dying in hospital (OR 1.48, 95% CI 1.23 to 1.79, P<0.001).

And ischemia was linked to a 20% increase in risk of death (OR 1.20, 95% CI 1.03 to 1.40, P=0.02).

On the other hand, being admitted with uncontrolled hypertension was associated with lower in-hospital mortality (OR 0.74, 95% CI 0.55 to 0.94, P=0.04).

I like this information, because it provides an excellent framework for considering CHF exacerbations.  I have often had the students and residents think abstractly about the possible causes of CHF exacerbation, but these data provide a hierarchy.

Well done!!

Monday night I had dinner with some residents.  We discussed the piece I wrote on training then and now.  As we discussed the changes in medicine over the last 30 years, I thought about the costs involved in providing better quality and quantity of life for patients with serious disease.  Let me suggest 2 examples.  First, CHF with systolic dysfunction was a rapidly fatal disease 30 years ago.  Patients admitted to the hospital with pulmonary edema had approximately a 50% 6 month mortality.  Similar patients today live for years. 

The dirty secret about extending life in chronic disease is that you increase health care costs.  Quick death saves money.

COPD patients died faster prior to home oxygen.  Home oxygen is costly, and COPD patients with home oxygen have frequent repeat hospitalizations. 

Our success does have an impact on health care costs.  While we do have some ways to decrease health care costs, we must remember that true management successes will increase spending.

I do not know what percentage of the increase of health care costs is due to success, but we should not forget this consideration in our discussions of rising health care costs.

The response to yesterday’s presentation was excellent.  The key point here is the markedly elevated alk phos suggests biliary obstruction.  The mildly elevated bilirubin suggests incomplete obstruction.

This patient needed a biliary evaluation.  The patient had an unfortunate diagnosis - cholangiocarcinoma.

Please create a differential diagnosis for the following liver tests in an 80 year old woman:

Yesterday’s numbers:

Additional information:

1. She had increased ileal output.

2. Serum albumin was 5.7

3. Urine Na 10, urine K 47 and urine Cl 72

• Her anion gap is 14, which is normal given her elevated albumin
• Her urine anion gap is negative, consistent with sufficient ammonium (NH₄⁺⁾ in her urine
• The urine anion gap results supports increased ileal output and bicarbonate loss as the cause of the normal gap acidosis

The respiratory response is appropriate.  Remember to use the calculated HCO₃^- when using the Winter’s formula.  The expected pCO₂ thus is 27.5 and close enough to the observed pCO₂ to exclude a primary respiratory alkalosis.

Thus,  we have a normal gap acidosis secondary to GI bicarbonate losses.

A clinical pharmacology colleague has this wonderful interview published in Medscape this week - Drug Dosing in CKD — Comparing GFR Equations and the Role of the Pharmacist: An Expert Interview With Kurt A. Wargo, PharmD, BCPS

I like this interview and link it for my own future use.

Started rounds today and had several interesting laboratory findings.  I plan to post some patient quizzes for the next 3 days.

Today’s patient is well known to our service.  She is 32 and has a long history of Crohn’s disease, with an ileostomy.  Consider the differential diagnosis, and recommend tests to prove your hypothesis. 

During my trip to San Francisco, I missed Bob Wachter (he was out of town) but I did sit in his office!  He has a very important piece of Medicare’s new ‘never events.’  Message to Medicare: Whoa, Nellie!

With that in mind, as I look over the list of nine, I can’t find a single entity that meets my four conditions. Yes, many surgical site infections are preventable with perfect technique and antibiotic prophylaxis, but they suffer from non-standard, highly variable definitions. Ditto VAP. I can’t say I’ve seen a lot of hospital-acquired diabetic ketoacidosis, but I can live with the hospital not being paid extra if I ever do. Hypoglycemia – this measure will discourage hospitals from trying to achieve tight glucose control. As I noted previously, a more holistic quality measure might assess the amount of time that patients are kept in normoglycemic range, with points deducted for hypoglycemic episodes.

That’s it for the reasonable ones. What’s up with Legionnaire’s disease, which is usually community acquired? If it ends up on the list, you can bet that every pneumonia patient will have a Legionella antigen checked on admission to catch POA, a real waste. Delirium — expect it to vie with “early decubitus ulcer” for the title of America’s most common admission diagnosis. And does anybody believe that all cases of DVT or C diff colitis are preventable? I did a quick PubMed search on "Clostridium difficile" and "prevention" and could not find a single intervention trial demonstrating that the rate of this infection could be lowered in hospitalized patients.

I can’t argue with the premise – many of the AEs on this list are no doubt partly preventable with more religious implementation of certain safety practices (for example, for C diff, avoiding unnecessary antibiotics and adhering to strict infection control practices with suspected cases). But they are nowhere near ready for prime time. Adoption of this new list will lead to all kinds of gaming, POA shenanigans, wasted effort on preventive strategies with no supportive evidence, and nasty unintended consequences.

Bob is 100% spot on.  Medicare is trying to save money.  As our friend DrRich will point out, this is just Covert Rationing!

Once again, an insurer wants to improve patient care quality, but resorts to a nuclear device in the attack.  The collateral damage is likely unpredictable and profound.

I have spent time considering my blog’s look.  I have decided to try the current theme for at least a week.  I need feedback. 

Thanks

Yesterday, while visiting UCSF a colleague asked me to compare training then and training now. This question came as part of a one hour interview for interns and residents.  As I answered the question, I simultaneously thought that this question would make an interesting blog topic.

To set the context, I finished my internal medicine training 30 years ago.  I have taught residents continuously since 1980.  Most physicians from my cohort will tell you that our training was more difficult.

Training then

I worked every 3rd night as an intern, then averaged every 4th as a resident.  The only days I ever got off were Sundays after Friday night call.  We had no caps, and occasionally did admit more than 5 patients in a 24 hour period. We were explicitly expected to stay at least until 5 p.m. on our post call day.  We averaged over 100 hours each week.

Training now

My interns work every 4th night, but only stay over night on Fridays, Saturdays, and half of the remaining days.  They have a cap of 5 admissions.  They must leave work at 1 p.m. on their post call day.  They get at least 4 days off each month.  They have a 80 hour work week cap.

Training then

We had little pressure to discharge patients.  We had no utilization review nurses.  Length of stay probably averaged a week.

We had many less diagnostic tests and fewer treatments.  We had no CT, no MRI and limited ultrasound (really only M-mode echo.)  We never had to use vancomycin (no MRSA.)  We had no HIV. 

We treated MI patients with lidocaine, morphine and nitrates, but talked a lot about how great it would be if we could decrease infarct size.  Our major hospital did 3 cardiac caths each day.  We had no interventional cardiology.

CHF patients had an average life expectancy of 6 months after their admission.  We used digoxin and furosemide.  ACE inhibitors became available in 1988.  Beta blockers became available during my senior residency year, but they were absolutely contraindicated in CHF.

COPD patients usually developed cor pulmonale, because we had no home oxygen.

We treated hypertension with alpha methyldopa and a thiazide. 

We had no histamine 2 blockers, no PPIs, and no 3rd generation cephalosporins.

Training now

Obviously, our residents have the things that we did not have, and much more. Current residents have much greater supervision (and thus too often micromanagement.)  Current residents experience a much shorter length of stay, and have great pressure to discharge patients quickly.

We can do much more for each patient, and we make much more accurate diagnoses.

Which is better, more difficult, more appropriate

This comparison is impossible, because the context of the comparison has changed so greatly.  In the 70s, our senior attendings puffed out their chests and bragged about how much harder their training was.  Now most of my cohort would say the same thing about current trainees.

The older generation always view their history as being more relevant and more stringent.

I believe that internal medicine training has always required hard work, both intellectually and much time.  To try to compare then and now is really not possible.

I personally believe that training is more difficult than ever.  Our residents are dedicated to learning our difficult specialty.  They struggle with the current social context of patient care. 

Our field has changed.  We have more responsibility because we can do more.  Our subspecialists have deeper knowledge of their subspecialty field, but generally narrower knowledge of the breadth of internal medicine.

I hope that those of my generation will chime in.  I hope that current and recent trainees will comment also.

This short post is dedicated to Dr RW and Roy Poses.  Just read this book review - Suckers: How Alternative Medicine Makes Fools Of Us All by Rose Shapiro

Shapiro concedes that the biggest consumers of alternative medicine are middle-aged, middle-class women. But they’re educated enough to know what they’re paying for and if they prefer to spend money on an aromatherapist than a stiff gin, it’s hard to cry too many tears for them. Since the average amount of time a patient can speak to a GP before interruption is 23 seconds, it’s easy to see why someone might find it worthwhile to bung fifty quid to a reflexologist just to chat for an hour. As Shapiro notes, we have a grave suspicion of mental illness in this country and many people would feel it a sign of weakness to visit a psychotherapist. So it’s perfectly possible that the foot massage is just a cover for the opportunity to talk about your problems in all their banal detail, without boring the pants off everyone who used to love you.

Perhaps we should call it an Alternative to Medicine.  But always remember that it might just be dangerous.

I have written and talked about the problem of multiple guidelines on the same subject. Since I have published many papers on pharyngitis, I have often used pharyngitis as my example. Now I have another great example - A Step Backward: The ACPM Recommendations on Prostate Cancer Screening

Why do these recommendations differ so greatly?  First, we should understand the depth of the disagreement.

After reviewing the literature prior to July 2007, The American College of Preventive Medicine (ACPM) concluded that there is insufficient evidence to recommend routine prostate cancer screening with prostate-specific antigen (PSA) testing and digital rectal examination (DRE).^[1] Rather, they recommended that clinicians have an annual discussion with their patients about the potential risks and benefits of prostate cancer screening and the limitations of the evidence currently available. Furthermore, routine testing is not even recommended for high-risk groups, such as men with a positive family history and African-American men, and if the patient defers to the physician concerning the decision to screen, testing should not be offered.

Several other organizations have adopted a similar position, including the American Academy of Family Physicians, US Preventive Services Task Force, and American College of Physicians.^[2] These groups remain unconvinced that prostate cancer screening is worthwhile, despite the overwhelming emerging evidence that screening saves lives.

The rationale for the ACPM position involved a discussion of 2 randomized trials as well as case-control association studies that did not show a benefit.

They also expressed concern about false-negative and false-positive results, as well as the possible adverse psychological effects of screening on patients. Furthermore, they dismissed the use of various PSA-based adjunctive parameters to improve the accuracy of screening, because they found no evidence of a mortality benefit from using these variables.

The ACPM emphasized the high financial cost associated with the implementation of a national screening program and alluded to the additional costs of treatment in subsequent years. However, they did not consider the favorable cost trade-offs of treating early prostate cancer vs advanced-stage disease.

So we have multiple organizations agreeing against prostate cancer screening.

In contrast to the ACPM, the American Urological Association recommends offering PSA screening beginning at age 50 in men with at least a 10-year life expectancy.^[7] African-American men and those with a first-degree relative with prostate cancer are urged to consider screening at an earlier age. The American Cancer Society makes similar recommendations.^[8]

In our view, the National Comprehensive Cancer Center (NCCN) Guidelines on the Early Detection of Prostate Cancer are the most progressive, and provide the most helpful guidance to physicians and patients.^[9] Unlike many other guidelines, they incorporate much of the emerging information, including some that has not yet been validated in a randomized controlled clinical trial.

To really understand why, you should reacquaint yourself with Allan Detsky’s classic article - Sources of bias for authors of clinical practice guidelines.

Clearly the members of these panels have biases.  The preventive medicine group and the generalist groups worry more about costs and complications which follow the screening strategy.  The urologists and cancer experts worry more about curing cancer.  By implication, they worry less about the collateral damage  which comes from screening.

Now comes the difficult part.  What should a family physician do in their practice?  What do I want my physician to do for me?  And most important, should we evaluate performance on this issue?

The fact that guidelines differ highlights the problem of trying to measure practice.  Few of our decisions are crystal clear.  Trying to use algorithms to assess quality is a measurement flaw.  We can measure something, but can we interpret our measurement?

1. Fear of being sued - I do understand that many physicians worry about being sued constantly.  Email should not increase this fear.  You can use email to ask a patient how he or she is doing, to receive a request for medications, to report laboratory tests or to arrange a visit.  If a patient asks a question that you cannot answer without seeing the patient, your response is simple - tell the patient that you will need to see them.  If they ask for antibiotics, handle the request exactly like you would handle a telephone request.

2. HIPAA guidelines - if the patient emails you, then he or she is (in essence) waiving their HIPAA protection.  You can circumvent this concern with secure dedicated email web sites (as described in the NY Times article.)

3. We need to be paid to do email.  If you read my post, I agree entirely.  If I was still doing outpatient practice I would include email, while awaiting and advocating for payment schemes.  Email takes less time than phone calls, and is more clearly documented.  The monetary problem does need fixing, and I can understand why physicians make this decision.  I would strongly favor an email fee (if you want email communication, pay $X per month (perhaps $20 per month - but it would need a careful analysis.)

4. Anon wrote:

Doctors need to stop taking such a passive attitude towards how they get paid and instead decide how they need to charge in order to provide the service that their patients want–and then swim upstream and do it. In the final analysis they are independent businessmen and woman and have the final say so about the terms of their service–as long as they act like other businessmen and take a little risk.

Unfortunately, most physicians cannot fight the insurance industry (including Medicare.)  Your comment explains why I find retainer medicine or cash only practices a very good idea.  We do need a payment revolution, and this email situation highlights the problem.

Thanks greatly for all the comments.  I love when one of my rants creates such passion.  This issue is not simple and our discussion does an excellent job of framing the issues.

It’s no LOL: Few US Doctors Answer E-Mails From Patients

Kreuziger’s experience is shared by most Americans: They want the convenience of e-mail for non-urgent medical issues, but fewer than a third of U.S. doctors use e-mail to communicate with patients, according to recent physician surveys.

“People are able to file their taxes online, buy and sell household goods, and manage their financial accounts,” said Susannah Fox of the Pew Internet & American Life Project. “The health care industry seems to be lagging behind other industries.”

Doctors have their reasons for not hitting the reply button more often. Some worry it will increase their workload, and most physicians don’t get reimbursed for it by insurance companies. Others fear hackers could compromise patient privacy _ even though doctors who do e-mail generally do it through password-protected Web sites.

There are also concerns that patients will send urgent messages that don’t get answered promptly. And any snafu raises the specter of legal liability.

Many patients would like to use e-mail for routine matters such as asking for a prescription refill, getting lab results or scheduling a visit. Doing so, they say, would help avoid phone tag or taking time off work to come in for a minor problem.

Still, a survey conducted early last year by Manhattan Research found that only 31 percent of doctors e-mailed their patients in the first quarter of 2007.

Physicians eschew email for several reasons.  As is usual, it all comes back to time and money.

If you email your lawyer, you may well receive a bill for the time necessary to handle that email.  You will also receive a very long paragraph designed to protect that correspondence from liability.

As I write repeatedly, physicians are not paid for their time, they are paid by the widget.  The patient visit is our version of the widget.  Anything that we do to prepare for that visit, communicate between visits, review the tests induced by that visit or discuss you problem with another physician is gratis.  We cannot bill for the proper use of time to improve the patient experience.

I believe that the major reason that physicians avoid email is time.  Email takes time, and that time is not seen as a good business investment.  This same concept explains why physicians try to avoid telephone calls.

Some physicians are also concerned about liability issues.  I have heard lawyers advise that we should avoid email for this reason.

When I was still doing outpatient medicine, I used email with patients who so desired.  Naively I did not worry about these concerns.  Now I am obviously an early adopter of computer concepts.  I was more concerned about efficient patient communication than I was with “productivity.” (see my rant about productivity from Monday.  I did not worry about liability issues, but rather simplifying patient communication.

Retainer physicians use email.  When I interviewed my two retainer colleagues, they bragged about the use of email in their practice.

We have a disconnect between patient desires and physician convenience.  We are not in a service business (although we should be) because the patient is not paying for his or her service.  The third party arrangement (insurance) has a negative modifying effect on the desirable service relationship.

I know all the excuses for physicians to avoid email.  I reject the excuses, and urge my colleagues to join the 21st century.