Category Archives: Hospital and Critical Care Medicine

Physicians Grapple With Efficiency, ‘Do No Harm’

Two new books and a news article triangulate some interesting thoughts on improving efficiency in medicine while causing less harm to patients – and what that really means.

IMNG Medical Media reporter Alicia Ault’s feature story on “Can More Be Done with Less?” describes a recent conference on “Avoiding Avoidable Care” that brought medical experts together to strategize on how to avoid unnecessary tests and treatment, which can harm patients.

Dr. Vikas Saini, an organizer of the conference, told her that patients often demand tests or procedures because they seek certainty and want to know that the physician cares. But test results often lead to false knowledge, said Dr. Saini of the Lown Cardiovascular Research Foundation, which cosponsored the meeting. The key for physicians, he said, is to convincingly explain to patients why the test or procedure is or is not a good idea, and to practice evidence-based medicine.

To do that, though, requires an ability to interpret medical research and help patients understand it. That’s where Dr. Marya D. Zilberberg’s new book comes in. Between the Lines: Finding the Truth in Medical Literature is a breezy 170-page primer that spends most of the first half of the book cheerleading for scientific uncertainty. She also reviews the hierarchies of quality in research and touches on heterogeneity, biases, and a few general pitfalls in interpreting studies.

The second half of Between the Lines goes a little deeper in explaining study design, validity, statistical analyses, and more, though never so deeply that a nonstatistician’s eyes will glaze over. Dr. Zilberberg, a consultant, teacher, and blogger at Healthcare, Inc., explains these dry subjects in an eminently readable fashion.

I found it a valuable refresher (especially Part Two) even though I’ve been covering medical news for over two decades, and I imagine it would be a great introduction for the uninitiated. Dr. Kenneth W. Lin, a family physician who teaches a course in evidence-based medicine at Georgetown University, posted an online review that called Between the Lines “a rare book that bridges the gulf between medical publications and the real world of practicing clinicians.” Paul D. Simmons, Ph.D., who teaches family medicine residents in Louisville, Ky., said in an online review that he hopes incorporating the book will decrease the number of residents who finish his rotation thinking that evidence-based medicine is impractical, takes too much time, requires a Ph.D. in biostatistics, and doesn’t apply to their careers.

A separate book approaches these themes in ways that question medicine’s sometimes heavy-handed emphasis on “evidence” and “efficiency.” In God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine, Dr. Victoria Sweet eloquently recounts her 20 years of working at a chronic-care hospital for the ill and indigent (considered the “last almshouse in America”) as it morphs into a “modern healthcare treatment facility.”

Dr. Sweet’s scathing depictions of “efficiency” at the expense of time with patients bolster her call for “slow medicine” and the (missing) research to compare the two.

Disclosure: I’ve known Dr. Sweet for many years and even consider her a friend. I esteemed the book on its merits, and so did neurologist and author Dr. Oliver Sacks, whose book-jacket blurb called it, “A most important book, which raises fundamental questions about the nature of medicine in our time. It should be required reading.”

Dr. Abigail Zuger’s review in The New York Times began, “It is probably pointless to suggest that all the individuals presently shaping our health care future spend a quiet weekend with ‘God’s Hotel,’ Dr. Victoria Sweet’s transcendent testament to health care past. Who interrupts cowboys in the midst of a stampede? But if you’re one of the millions of doctors and patients out there choking on their dust, this is the book for you. Its compulsively readable chapters go down like restorative sips of cool water, and its hard-core subversion cheers like a shot of gin.”

The synchronicity of these three works is a sign of the times. As physicians are asked to do more with less, these writings help us understand what you’ve got to work with.

–Sherry Boschert (@sherryboschert on Twitter)

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Filed under Cardiovascular Medicine, Family Medicine, Health Policy, health reform, Hospital and Critical Care Medicine, IMNG, Internal Medicine, Uncategorized

Do Medical Tattoos Need Guidelines?

Should medical tattoos be standardized? Should there be guidelines pertaining to their design, and where on the body they’re located? Should physicians prescribe tattoos to patients with hidden medical conditions? And if the answer to any of those questions is yes, should medical personnel be the ones doing the tattooing?

Photo by Miriam E. Tucker / Used with permission

Those were among the questions raised by Dr. Saleh Aldasouqi in a poster presentation and at a press briefing at the annual meeting of the American Association of Clinical Endocrinologists.

Some patients with diabetes and other hidden medical conditions are choosing to be permanently tattooed rather than wear a necklace or bracelet to alert emergency personnel of their conditions. This is particularly common among patients with type 1 diabetes, for whom low blood sugar can result in unconsciousness or odd behavior that can easily be mistaken for drunkenness.

“There are a lot of patients with diabetes who are getting tattoos. Just Google ‘medical tattoos’ or ‘diabetic tattoos’ and you’ll find a large number from around the world.  The problem is they’re not consulting their physicians. They could have high sugar, which can affect wound healing. …There are so many issues now being talked about with regard to medical tattooing,” noted Dr. Aldasouqi, an endocrinologist at Michigan State University, Lansing.

He believes these issues should be addressed by professional medical organizations, possibly including those pertaining to diabetes, dermatology, and emergency medicine.

As for tattoo location on the body,  the wrist would be the most logical place since first responders will always check there, he said.

So who should do the tattooing?  Tattoo parlors that are licensed under state or local laws are typically clean and use sterile equipment, and require customers to read and sign consent forms that address medical conditions and risks.  Of course, tattoo artists would need to be educated about any new standard.

But dermatologists or plastic surgeons could do it as well. “We’re not competing with tattoo artists, but at least we can collaborate with them by standardizing at their level, or make it a minor surgical procedure. In fact, this is being done to mark the skin for radiation therapy in cancer patients, and in reconstructive surgery after breast cancer. Some medical tattooing is already being done  by medical specialists. So, it’s open for discussion.”

-Miriam E. Tucker (@MiriamETucker on Twitter)

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Making News at NEJM

Turns out there’s more to the process of deciding which studies to publish in top medical journals than simply peer review and the selections of sage editors. At the New England Journal of Medicine, editors conducted around a half-dozen informal polls in the past year to help them assess the worthiness of a particular research question, according to Editor-in-Chief Dr. Jeffrey M. Drazen.

Dr. Jeffrey M. Drazen (Sherry Boschert/IMNG Medical Media)

A case in point: When considering the study “Early vs. Late Parenteral Nutrition in Critically Ill Adults,” the editors knew that most ICUs in the United States don’t start parenteral nutrition for a week, and the study results supported this “late” start (New Engl. J. Med. 2011;365:506-517). So, was this a question that really needed to be answered?

Rather than rely on intuition or American self-absorption, the editors used an editorial intern who worked for the journal to do an informal survey by calling ICU doctors around the world. To their surprise, they found that ICUs in Australia, New Zealand, and most of Europe start parenteral nutrition earlier than in the United States, he said in a discussion at the annual meeting of the American Thoracic Society.

“Since we have more readers outside the U.S. than in the U.S., we figured this was something that was important to publish,” said Dr. Drazen, professor of medicine at Harvard University, Boston.

“I think it has a message for ICU interventions in general. Most of the things that we reasoned based on physiology – the physiology tells you that you need to provide these calories in order for the body to heal – may be wrong,” he added. “It’s hard to take the kind of physiology that we’ve learned in animals and translate it clinically to humans. We really didn’t test these questions one at a time.”

The journal sifts through 5,000 submissions to publish around 200 original research articles each year. “We take the job seriously,” and sometimes an informal poll helps the process, he said. The parenteral nutrition study didn’t seem to be so important at first, but “It turns out that we were wrong.

“We like to make decisions based on information rather than guessing,” Dr. Drazen said. “It should be the same when treating patients.”

–Sherry Boschert (on Twitter @sherryboschert)

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Rock as Remedy: Band Builds Work-life Balance

Lots of good advice got dispensed at a session on work-life balance at the Society of Hospital Medicine meeting recently, including the importance of honoring your inner self, having a supportive spouse, working with your hospitalist colleagues to support each other around scheduling difficulties, even hiring a nanny. Surprising to me, nothing was said explicitly about keeping creativity and fun in your life.

Dr. McIlraith is lead singer for The Remedies. (Courtesy Sam Hayashi/Zuma Light Works)

Dr. Thomas McIlraith knows about that last part. The chairman of the hospital medicine department for Mercy Medical Group, a large hospital medicine and multispecialty medical group in Sacramento, Calif., he’s also the lead singer and songwriter for The Remedies, a regionally popular five-member rock band that includes nephrologist Dr. David Pai playing bass and orthopedic surgeon Dr. Dan Anderson, who is the band’s sound engineer.

“My experience has been that if I don’t have music in my life, the rest of my life doesn’t live up to its potential. It’s kind of a left-brain, right-brain balance. I find that when I fulfill that creative need, I have more energy for other things,” he said. “It feeds back on itself; it pays back in the inspiration and energy you have for patient care.”

He first noticed this in medical school at the University of Wisconsin in 1992, when he ran a 15-person band called The Arrhythmias. Scheduling practices, etc. in the era before e-mail was time-consuming. “I was worried that I’d flunk out, but that’s when I got my best grades,” he said.

Scheduling for The Remedies isn’t simple either, with three physicians on board plus drummer and geologist Greg Marquis, who is gone for long stretches in the field, and guitarist and recycling worker Walt Simmons. As the chairman of his department, Dr. McIlraith’s schedule consists of the leftovers after the other 55 hospitalists have claimed shifts to fill their schedules.

“I work a lot of nights, and then work some days, so it can be a little haphazard. Before our recent show, we went three weeks straight when we couldn’t manage to fit in a practice. Then we had two, and the show went great,” he said.

Dr. McIlraith (left) rocks with Walt Simmons (center) and Dr. David Pai. (Courtesy Sam Hayashi/Zuma Light Works)

Playing in the band is fun, but so is watching co-workers let loose at the shows. It’s a work-hard, play-hard thing. “We work very, very hard on very tough issues, and when we play, it’s nice to see these people cuttin’ loose and dancing. That’s very fulfilling for me,” he said.

The Remedies play mostly covers with some original tunes thrown in, including two that Dr. McIlraith wrote specifically about hospitalist work. “The Long Ride” recalls the early difficult days of establishing hospitalist medicine. McIlraith sings,

Switching back and forth between night and day

Getting’ no respect, never getting’ our way

Stood our ground and demanded a say

That’s why we’re all here today

The lyrics specifically call out the contributions of founding hospitalists Dr. Winthrop F. Whitcomb, Dr. John R. Nelson, and Dr. Laurence D. Wellikson, as well as the Society of Hospital Medicine itself:

Come together, stay strong, and SHM will help carry you on

Gonna do more than just get by

Who would have known it would be such a long ride

The CPOE Blues” is another original tune that physicians in many specialties might relate to, singing of the “joys” of computerized physician order entry:

Now, there are a few things I’ve come to hate

Like forgetting to click on “initiate”…

Everybody’s looking ’round for clues

On how they’re s’posed to deal with the CPOE blues

Dr. McIlraith’s roles don’t end with hospitalist and rock musician. He’s also a husband and father of two children. How does he juggle all this? Through the magic ingredient that every session on work-life balance emphasizes as a key factor: a supportive spouse.

His wife works at home as an investment manager and she handles much of the home care as well. “She really takes very good care of all of us,” he acknowledged. “I’m extraordinarily blessed in that regard.”

–Sherry Boschert (@sherryboschert on Twitter)

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Will the UK Win Gold in Public Health Preparedness?

In all likelihood, there will be no large-scale public health crises during the London 2012 Olympics. But Dr. Brian McCloskey has to prepare, just in case. That’s his job as the London director of the UK’s Health Protection Agency (HPA), the UK-government-funded yet independent public body charged since 2004 with protecting the health of the country’s population from all threats, including those from infectious disease, chemicals, violence, and anything else that may arise. The HPA also collaborates with the World Health Organization on “emergency preparedness for Mass Gatherings and High Consequence, High Visibility events,” Dr. McCloskey explained at the 22nd European Congress of Clinical Microbiology and Infectious Diseases (ECCMID), sponsored by the European Society of Clinical Microbiology and Infectious Diseases.

Dr. Brian McCloskey/Photo by Miriam E. Tucker

“Mass gatherings” are nothing new for London, which has routinely hosted large music and sporting events against a backdrop of ongoing terrorist threats. However, the Olympics represents one of the largest public health challenges yet, in terms of sheer scale and international media scrutiny, noted Dr. McCloskey, who has been with HPA since its inception and was director of public health with the U.K.’s National Health Service for 14 years prior to that.

The Olympics officially begins July 27 and ends 12 Aug. 12, followed by the Paralympics 29 Aug. 29 to Sept 9. In addition, London will also host the Olympic torch relay, Queen Elizabeth’s Diamond Jubilee beginning in May, Wimbledon in June, possibly the largest-ever gay pride festival in late June-early July, and the Notting Hill Carnival in August. “In other words, there will be one long party in London from May through September,” he commented.

In all, the Olympics will comprise 26 sports in 34 venues, with 10,500 athletes, 17,000 people living in the Olympic Village, 21,000 media and broadcasters, and approximately 180,000 spectators per day in the Olympic Park. The challenge, he said, is to plan to respond to anything that can happen without disrupting life for Londoners.

Dr. McCloskey and his colleagues have been studying experiences at previous Olympics, as well as published literature on mass gatherings such as the yearly Islamic pilgrimage, or “Hajj,” to Mecca. Indeed, “mass gatherings” is an emerging area of medicine that was explored in depth earlier this year in a series of six articles in The Lancet. There is also a WHO advisory group on mass gatherings, and even a specialty curriculum being developed, he said in an interview.

Judging by previous experience, “The most likely thing to happen is nothing at all. Most Olympic Games go off without any problems, with only minor impact on the public health service and on public health. But, we do need to think about all the things that could happen.”

Mass gatherings have been associated with both food/waterborne and airborne/respiratory infectious diseases. Yet, less than 1% of healthcare visits in Sydney during the 2000 Olympics were for infectious diseases. In the 2006 winter Olympics in Torino, Italy, surveillance for acute gastroenteritis, flulike illness, measles, and other health-related events turned up nothing unusual as compared with non-Olympics time periods.

London Underground Billboard/Photo by Miriam E. Tucker

During the 2012 Olympics, the HPA will deliver a “Situation Report” each morning to Olympics organizers, describing the state of public health in England and highlighting any potential issues. Managing rumors will also be important, he noted.

Laboratory surveillance, clinical case reporting, and syndromic surveillance—based on patient complaints—will all be enhanced during the Games, with the help of primary care providers and hospitals around the U.K. Any triggers will be followed up, with a much lower threshold and greater speed than usual. In fact, most of these surveillance systems have been in place for at least a year now. “So we’re feeling very comfortable,” Dr. McCloskey said.

And these measures will last beyond the Games. “We will have at least two new surveillance systems in the U.K. as a legacy afterwards…What you get is improved public health systems but also better recognition of the importance of public health and better working relationships…Every country I’ve talked to who’s hosted the Games says we can expect that legacy. Provided nothing goes wrong. But of course, it’s not going to go wrong, it’s all in place, so come and enjoy it.”

–Miriam E. Tucker (@MiriamETucker on Twitter)

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Gender Bias May Influence Hospitalist Pay

It’s not every day that a medical conference includes a refresher on Feminism 101, but that’s essentially what kicked off the session on “Women in Hospital Medicine: Defining Common Challenges and Strategies for Success” at the Society of Hospital Medicine annual meeting this week.

The hottest topic was the persistent pay gap between female and male physicians, as reported in study after study after study and in a recent survey by the society. But before discussion began, the 70 or so hospitalists present (including 3 men) heard a review of the gender-based basics.

Dr. Rachel George (left) and Dr. Patience E. Reich (SHERRY BOSCHERT/IMNG Medical Media)

“There’s an old saying: Before you try to move a fence, find out why it was put there,” said Dr. Patience E. Reich, who chaired the session with Dr. Rachel George.

The studies suggest that at least some of the disparities in pay are due to gender bias, “many times unconscious,” after controlling for the effects of other factors, Dr. Reich said.

She recommends the Web site of the Gender Bias Learning Project of the University of California Hastings College of Law, where visitors can play Gender Bias Bingo and find other tools for understanding gender bias in our society.

The Project identifies four gender bias patterns that many female physicians can appreciate, Dr. Reich said:

 Prove it again! Men are judged by their potential, but women are judged by their accomplishments and have to prove themselves again and again. Women have to work twice as hard to get half as far as men.

The double bind. Men are perceived as assertive, but women who behave the same way are perceived as aggressive. To get ahead, women sometimes have to choose between being respected and not liked, or being liked and not respected.

The maternal wall. Mothers are considered to be uncommitted to work or incompetent. “People don’t bother hiding this one,” Dr. Reich noted. She gave an example of a time when she submitted the name of a female hospitalist for an open leadership position at a hospital where she worked. A committee member dismissed the idea, saying the candidate wouldn’t want the position because “she’s trying to have another baby.” Dr. Reich countered, “Why don’t we just ask her?” When they did, the candidate said she did want the job and applied for it.

Gender wars. Internalized gender bias creates conflict between women. One example: Older female academicians who sacrificed having children in order to have a career and who now resent younger women expecting to have both, and thus refuse to mentor them.

These issues need to be addressed systemically, not just on a case-by-case basis, in order to effect change, Dr. Reich said.

At a Society of Hospital Medicine women’s interest group meeting later the same day, one doctor said Dr. Reich’s and Dr. George’s “women’s issues” session was better than similar ones she had attended at other medical conferences. “It’s important that we talk about gender bias in the open, with women and men present, and not just talk about things like work-life balance, because it’s a systemic theme,” the physician said.

–Sherry Boschert (@sherryboschert on Twitter)

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Recycle to Reduce Drug Overdoses

Recycling and prescription drug overdoses have something in common.

Recycling has become second nature in many parts of America. Bins and containers to collect excess paper, bottles and cans are ubiquitous. Yet, only a few a few decades ago, recycling seemed foreign, was not convenient, and took some effort and resolve on an individual’s part.

Keith N. Humphreys, Ph.D. (Sherry Boschert/Elsevier Global Medical News)

That same evolution has to happen in the way that we handle leftover medications, Keith N. Humphreys, Ph.D., told physicians at the American Academy of Pain Medicine annual meeting. There’s an epidemic of opioid overdose deaths in the United States, and the most common source of misused opioids is leftover medications obtained from friends and family.

He’s talking about a huge cultural shift – with consumers going from saving and sharing costly medications that can be hard to come by in the current health system to recognizing their potential for harm and routinely returning leftover drugs on “take-back days” organized by law enforcement or even depositing them in specialized “recycling” bins.

The number of opioid prescriptions dispensed by U.S. retail pharmacies increased from 76 million in 1991 to 210 million in 2010, according to a report by the National Institute on Drug Abuse. And since 1990, the rate of drug overdoses has tripled, increasing approximately from 4 per 100,000 people to 12 per 100,000 people, the Centers for Disease Control and Prevention report.

As someone who worked in hospices for a decade, Dr. Humphries knows the valuable role that opioids can play in relieving pain. So, how do we make opioids available but reduce the risk of addiction, abuse and accidental overdose?

There is no policy framework that will eliminate the tension between these two goals, but some policies will help avoid it, said Dr. Humphreys, acting director of the Center for Health Care Evaluation, Veterans Health Administration, Menlo Park, Calif., and a professor of psychiatry at Stanford University. He recently served as senior policy adviser at the White House Office of National Drug Control Policy, and  reports having no financial conflicts of interest on this issue.

Here, he said, are five emerging public policies, codes of practice, and cultural norms that “most people can agree on” while working toward harder-to-implement options like expanding addiction treatment programs:

1) Build prescription monitoring programs (PMPs). The idea is that physicians could check to see if a patient has received another opioid prescription recently before handing over a new prescription, to prevent drug-seeking patients from “doctor-shopping” to get more opioids. Thirty-six states have PMPs, though most are early versions that are slow, clunky and virtually worthless. Fourteen states and the District of Columbia have enacted legislation to create PMPs, and two states have no PMP plans.

PMPs “may be resisted and resented by many professionals, but they’re inevitable” and deserve support to quickly improve, Dr. Humphreys said. Plus, there’s a bonus for prescribers: In some states, checking with the PMP before prescribing an opioid gives physicians presumptive immunity from legal liability.

2) Lock doctor shoppers into one prescriber. Every week, a West Virginian dies of a drug overdose while holding prescriptions from five or more health care providers. Public and private insurers could tell patients who have opioid prescriptions from multiple providers that they must get all prescriptions from a single provider if they want their insurance to cover costs.

Recycling bins at the Palm Springs (Calif.) Convention Center, where the AAPM met. (Sherry Boschert/Elsevier Global Medical News)

3) Make prescription “recycling” a cultural norm. Legally, opioid narcotics can be returned to any Drug Enforcement Agency law enforcer, though some states also allow pharmacies to take back leftover drugs. When sheriffs in one small Arkansas town (population 20,000) organized a drug take-back day, residents brought in 25,000 pills, Dr. Humphreys said. A physician at the meeting from Santa Maria, Calif., said a drug take-back day organized by sheriffs there was so successful that they installed a permanent drop-off box outside the sheriff’s office. Dr. Humphreys urged physicians to promote drug take-back days in their communities.

4) Make abuse-resistant medication approvals easier. Currently, developing an abuse-resistant version of an addictive medication requires a new drug application, engendering a lengthy approval process and potentially hundreds of millions of dollars in costs. Government regulators should find a way to ease this massive disincentive for pharmaceutical companies to develop safer pain medicines, he said.

5) Change opioid-related medical practice. A potpourri of short- and long-term strategies could improve practice, he suggested. Patients should be told that sharing opioids is dangerous and illegal. Both patients and physicians need to learn that opioids are not the only response to pain. Emergency physicians should break their habit of automatically writing prescriptions for 30 days’ worth of a drug, and write for shorter time lengths when appropriate. Health care workers need to get better at recognizing addiction, and more attention should go toward ways of preventing “iatrogenic” addiction caused by the health care system itself.

Physicians need to lead the way in these efforts. “Who else?” he asked.

–Sherry Boschert (@sherryboschert on Twitter)

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