Friday, May 30, 2008

Not as a Stranger

I watched the 1955 film on TCM the other night. For its time it was an incredibly perceptive commentary on the profession of medicine. Catch it on TCM when you can; it’s not available on DVD. Although it’s fallen into obscurity it’s a much better film than the schmaltzy block buster doctor movie Magnificent Obsession which came out the year before.

Do you really want to promote quality and safety at your hospital?

I really enjoy listening to Donald Berwick, the quality and safety maven who heads up the Institute for Healthcare Improvement. I think we have a lot to learn from him. (Careful, though: he can mesmerize you with a few non-evidence based claims and cause you to take the big leap that says quality equals single payer health care, and come out thinking they were all your ideas).

As I listened to his talk on the web archives of SHM 2008 I started feeling expansive about quality and safety. A few thoughts on the subject follow, some straight from Berwick’s talk along with others from my own random musings.

Although concern for patient safety is as old as the profession it began a 180 degree turn on October 4, 1984. On that evening an 18 year old college freshman was admitted to New York Hospital with fever and mental status changes. Cared for by sleep deprived and overworked house staff with no supervision, she died early the next morning. She was Libby Zion, daughter of powerful attorney and journalist Sidney Zion whose outrage set off a legal and media firestorm. Most readers are familiar with the case and know that it brought us the 80 hour work week rule for residents. Beyond that, it began a shift in the focus of patient safety.

The old notion was that a tireless and vigilant super doc hero was responsible for all details of the patient’s care, constantly intercepting dangers that lay at every turn in the treacherous hospital environment. If something went wrong it meant the doctor, ultimately responsible for everything, just had to work harder. I was trained in that culture. We could never do too much for the patient, even if we had to pass our own medications. A mentor who influenced me deeply, proud of the fact that he ran a very punishing residency program, once told us: “Each of you has the capability to be the best doctor in the world. If you’re not the best doctor in the world you need to work harder.”

Berwick was trained in that culture too, and it took him years to realize how wrong the thinking was. You won’t enhance patient safety by beating up on people to work harder. The new thinking? Systems and design. It’s Berwick’s first rule and it means that the safety nets and redundancies to intercept inevitable human error must be part of your system’s design. We’ve heard “systems approach” to patient safety until it sounds trite. But Berwick’s examples and arguments bring the concept to life.

Design is rule number 1. Rule number 2, my own rule, is to be proactive. Don’t wait for Joint Commission and CMS to tell you what to do. A corollary is not to limit yourself to what JC and CMS require you to do. The problem with the so called core measures is that hospitals, in their quest for good report cards, focus on them to the exclusion of quality improvements that matter more. The core measures as currently promulgated have been largely ineffective, not because they’re not evidence based (many are) but because unintended consequences of playing for the report card counterbalance benefits. Opportunities to put more robust measures into practice tend to be slighted. Examples are applied hypothermia after cardiac arrest and early goal directed therapy for sepsis, measures which have fallen short of widespread implementation years after publication of evidence. Getting a commitment from your institutional leaders, who no doubt want to “focus on the core measures”, may be a challenge.

Rule number 3 is not to get unnecessarily bogged down in your hospital’s committees. Your hospitalist group can brainstorm and formulate an initiative faster and more effectively than your hospital’s committee structure. Most proposals have to go through several committees, some of which may only meet once a quarter. If your proposal requires institutional commitment it will ultimately have to go through committees, but have the details and the supporting evidence ready to present first.

Thursday, May 29, 2008

Chylomicronemia syndrome

These patients present with extreme hypertriglyceridemia and abdominal pain which may or may not be associated with pancreatitis. Clinical manifestations and treatment are reviewed here. (Via American Journal of Medicine).

Hospitalists’ quest to define their value---are there lessons from emergency medicine?

Through the years I’ve watched emergency medicine mature and grow from humble beginnings into a well established specialty. There are parallels and lessons there for the hospitalist movement. Emergency medicine is a specialty defined by location. Like hospital medicine today, emergency medicine once competed with a “traditional model” of care. Under the traditional model emergency rooms, lacking dedicated physician staffing, were covered by community physicians. When emergentologists entered the scene community physicians viewed it as an intrusion and many chose to continue seeing their own patients in the ER. Patients asked “where’s my doctor?” and often complained to administration. How attitudes have changed!

But there’s one parallel I don’t see. I don’t recall an obsession among emergency medicine doctors with convincing others of their “value”. The value of emergency medicine was self evident. The need was there and emergency medicine responded.

Self promotion is a distraction. Maybe the hospitalist movement should relax. If we concentrate on taking better and better care of hospitalized patients others will see our value.

European docs aren’t adhering to evidence based heart failure strategies

---according to this paper in the European Heart Journal, anyway. Although at the bottom of the paper is says “Conflict of interest: none declared” I suspect the authors represent subspecialists who have an interest in heart failure patients being referred to them and in cardiac imaging being performed.

DB’s Medical Rants offers a useful perspective on the issue. I would only add that the BBC News piece which covered the story got it wrong about echocardiography. A caption reads: “An echocardiogram should be used to confirm heart failure.” Wrong. An echo is indicated to classify heart failure, better understand the patient’s cardiac anatomy and physiology and guide treatment, not to diagnose or confirm. The ACC guidelines say this about diagnosing heart failure:

It should be emphasized that HF is not equivalent to cardiomyopathy or to LV dysfunction; these latter terms describe possible structural or functional reasons for the development of HF. Instead, HF is defined as a clinical syndrome that is characterized by specific symptoms (dyspnea and fatigue) in the medical history and signs (edema, rales) on the physical examination. There is no single diagnostic test for HF because it is largely a clinical diagnosis that is based on a careful history and physical examination.

Unstable Angina and NSTEMI guidelines made simple

The 2007 updated ACC guidelines for unstable angina and NSTEMI are complex. At the UCSF hospital medicine conference last October Dr. Edward McNulty helped attendees make sense of it all, and the key points of his lecture are reviewed here in Today’s Hospitalist.

Wednesday, May 28, 2008

Orac debunks Stanford’s therapeutic touch “trial”

It looks more like promotion to me. Post-scientific medicine is on the march. Read here.

What’s hospital medicine’s raison d’etre?

One of Kevin’s commenters, writing in response to my post from yesterday, said:

I have long been a sole dissenting voice in the hospitalist debate; I do not think the model will last. Most hospitalist programs are subsidized under the argument that they save money. However, this has not been proven in a significant way. Eventually, they will have outlasted their usefulness and be replaced either by cheaper hospitalist midlevel providers or by the primary care doctors returning to hospital care (not subsidized).

So we need a reason for our existence---a raison d’etre as Donald Berwick put it in his address at SHM 2008. It was the topic of mental masturbation in San Diego last April and centered around the concept of value. As I posted yesterday, the opening panel talked around what seemed an elusive definition. A disturbing consensus emerged that hospitalists may have to reinvent themselves to take over the inpatient environment and function as “house doctors”, going beyond their comfort zone and training, admitting all patients, doing virtually everything. I noted serious professional satisfaction and burn out issues for hospitalists if that scenario plays out. I’m not the only one concerned. Today another one of Kevin’s commenters said this:

I was a hospitalist for 5 years at a major New York hospital. Their solution for getting the most for their money was by having us do a lot of non-hopsitalist work.. i.e. teach physical diagnosis to med students, farm us out to a nursing home, cover a dedicated service for a certain insurance company. It sucked, which is why I left. They say the average life span of a hospitalist is 5 years. There's a reason.

That should sound a note of caution regarding what we ask and expect hospitalists to do.

IHI CEO Donald Berwick, in the talk that followed, presented an even more grandiose vision that takes hospitalists outside the walls of the facility to become “integrators” in the grand scheme of public health and advocates for a universal system. But then we wouldn’t be hospitalists any more, would we? How many of us entered the field to be public health experts and policy wonks? Not many, I’d say.

Judging from today’s blog reactions I think I may have been misunderstood to say the movement is in jeopardy. I don’t believe that at all. Retired Doc said this:

Even as the future for hospitalist might appear less rosy, we should not forget that the safety and quality movement leader guru, Dr. Donald Berwick still has much for them to do as they become the change agents and integrators of a new medical system that will provide quality care, reduce costs and improve public health. I guess it is better that I did not become a hospitalist as all I could do on a good day was to take as good of care of my patients as I could leaving the problems of maximizing public health and obtaining universal medical coverage to someone else.

As a hospitalist I can take the same view. If I succeed in stabilizing a few patients and making my hospital a better place I’ve had a good day.

I’ve been an observer and a participant in the movement since the early years. For me the reason to be a hospitalist has always been simple. There’s a niche to fill. That niche was created by professional and economic factors in our health care system. And it’s not going away.

Tuesday, May 27, 2008

A bumpy ride ahead for the hospitalist movement?

As a member of the Society of Hospital Medicine I have the opportunity to view archived presentations of SHM 2008. Last night I watched the lecture by Institute for Healthcare Improvement CEO Donald M. Berwick, MD and the panel discussion immediately preceding. It was both fascinating and disturbing.

A recurring theme was that health care providers with competing agendas are seeking bigger and bigger pieces of a shrinking financial pie. How will hospitalists fare in the competition, particularly with Medicare’s impending move toward bundling of payments and even a proposal for combining payment to the hospital and the physicians for episodes of care? The panel, coming just short of considering it a fait accompli, would do well to remember a little history. Just such a proposal was floated in 1984: the Kennedy-Gephardt bill. Among other provisions it sought to:

Attempt to "improve' PPS further by including inpatient physician services within DRG payments to hospitals. "It will be the responsibility of the hospitals and the physicians providing the care to allocate the payment.'

Thank goodness it died. But if after 24 years it’s resurrected hospitalists will finally be employees in every sense of the word. Tension between white coats and suits will mount. Does it mean the bubble of increasing hospitalist salaries will burst?

Two answers emerged from the panel. The first was nebulous: hospitalists must demonstrate “value”. What does that mean, exactly? As hospitalists we think our model has value, but how is it measured? Not only is it vague, but, as the panel pointed out, it’s a shifting target. Early in the movement we thought we could demonstrate value in terms of reduced costs and better outcomes. But research on those metrics during the ensuing years was disappointing. Moreover, according to an abstract presentation at the meeting, the move toward hospitalist shift work and the resulting fragmentation of care during hospitalization may be eroding any slim advantage the model had in cost savings. So what’s left that we can demonstrate as value? Patient satisfaction in an age of consumer driven and “patient centered” care? Research suggests we’re value neutral in that area. So the latest buzz seems to be that hospitalists will take advantage of the fact that other doctors are fleeing the building faster than you can say “code brown”. That means admitting all comers, doing “everything” and functioning outside our training and comfort zones, essentially becoming “house doctors”. It's sure to create job satisfaction and burnout issues, already a problem for the movement.

The other answer was more down to earth: the bubble will burst the morning CEOs wake up and realize that there is no longer a shortage of hospitalists. Don’t expect that to happen for decade or so according to the panel. One thing we can all agree on---it’ll be a bumpy ride.

Friday, May 23, 2008

Guidelines for the evaluation of fever in the ICU

This guideline, jointly prepared by the Infectious Disease Society of America and the Society of Critical Care Medicine, is available as free full text at the IDSA web site and represents the first revision in 10 years. Points of interest follow:

A new fever should trigger a clinical assessment rather than automatic orders for laboratory and radiographic testing.

Blood cultures, however, are indicated in all patients except those in whom the clinical assessment strongly indicates a non-infectious source of fever. Paired cultures rather than single cultures are recommended.

A clear approach to fever in patients with central venous lines is outlined.

Consider chest CT scanning in patients with negative plain chest x rays who are suspected of having pulmonary infections, particularly if immunocompromised.

Don’t forget nosocomial sinusitis.

“Catheter-associated bacteriuria or candiduria usually represents colonization,
is rarely symptomatic…” (Clinical documentation specialists, take note!).

Information on post operative fever and empiric antibiotic therapy is presented.

Improve hospital efficiency by defining the goals of hospitalization

Do this at the outset. Otherwise patients and families may expect you to “fix everything” that’s wrong with the patient. From Hospitalist News:

…ensure patient and family “buy-in” to the hospitalization goal. As our hospital patients continue to get sicker, I have found that patients and their families see the hospital as a place to solve all of their medical problems. There has to be a limit on tangential evaluations that lead to testing that is unrelated to why the patient is in the hospital.

Thursday, May 22, 2008

Can the electrocardiogram help diagnose MI in patients with LBBB or ventricular pacing?

We were once taught that the presence of LBBB or ventricular pacing precludes electrocardiographic diagnosis of MI or ischemia. It ain’t necessarily so.

If ST changes of acute STEMI occur in the same direction as secondary ST changes of LBBB, exaggerated ST displacement may be noted. If they occur in the opposite direction highly specific concordant ST changes may be seen, reflecting a “tug o’ war on the stylus.”

For clues to old infarction look for Cabrara’s sign along with qS or Qs complexes.

Pseudoinfarcton patterns can be seen with cardiac memory, fusion and bi-ventricular pacing.

The electrocardiographic clues for infarction in patients with RV pacing differ slightly from those in patients with LBBB.

All the nuances were discussed, and fascinating tracings provided, in two reviews from Cardiology Clinics.

Allopurinol hypersensitivity syndrome

---is characterized by severe dermatologic manifestations and sometimes multiorgan failure. It is believed to be due to accumulation of a metabolite and may be dose related. Risk can be decreased by following labeling recommendations for dose adjustment in renal failure, but such recommendations are often ignored. A case summary and brief review are presented in the American Journal of Medicine.

Wednesday, May 21, 2008

Multisystem effects of spontaneous bacterial peritonitis

Dated but interesting, from Hepatology.

In conclusion, patients with SBP frequently develop a rapidly progressive impairment in systemic hemodynamics, leading to severe renal and hepatic failure, aggravation of portal hypertension, encephalopathy, and death. This occurs despite rapid resolution of infection and is associated with an extremely poor prognosis.


Reviewed in Chest.

Watch those bounce-backs

We all know about the bounce-back---the patient who is readmitted a short time following hospital discharge, often with the same problem. The growing primary care shortage along with economic incentives for hospitals to discharge patients ASAP often leads to fragmented (or nonexistent) post hospital care, thus aggravating the problem of early readmissions.

Bob Wachter, writing about this on his blog late last year, noted that on the hospital side we’re not doing a very good job with transitions:

Although we’re not very good at washing our hands, we are terrific at washing our hands of patients who leave our medical radar screens.

Right now hospitals have no incentives to prevent bounce-backs. Keeping patients an extra day or two and making detailed arrangements for post hospital care costs money. So what if the patient bounces back in a week or two---the hospital gets a whole new DRG payment.

Wachter indicated in his post that that may be about to change:

All of this is about to change. Look for oodles of publicly-reported measures of case-mix-adjusted readmission rates coming online in the next few years, which will force us finally to focus on filling the post-discharge black hole. And that won’t be all. How about a measure of the percent of hospital discharge summaries that made it to the primary physician within 72 hours? The Joint Commission is considering it. Or try this one: a consultant doesn’t get paid until there is documentation that his or her consult report made it back to the requesting doc. Impossible? It’s being batted around in policy circles.

Now there are rumblings, via Hospitalist News, that Medicare is considering bundling payments for episodes of hospital care, which it defines as including the 30 days post hospital discharge:

At its April meeting, the commission (MedPAC) unanimously voted to include a bundling recommendation in its June report to Congress. As a first step, physicians and hospitals should be required to report to the Centers for Medicare and Medicaid Services (CMS) on resource use and readmissions during an “episode of care,” which is proposed to include the first 30 days post hospitalization. The data would be confidential initially, but should be made public by the third year, MedPAC commissioners recommended.

Once the resource and readmission data are in hand, CMS should start adjusting payment to hospitals, according to the recommendation. There would be the possibility for gainsharing among hospitals and physicians. The commissioners also voted to
direct CMS to study the feasibility of “virtual” bundling. With virtual bundling, the payment would be adjusted based on aggregate use of services over an entire episode of care.

Gainsharing? It sounds more like loss sharing to me. I don’t know what all the verbiage means, but it could mean a “no pay” policy for readmissions within 30 days.

If this causes hospitals to devote more resources to transitions (read Wachter’s suggestions about the Transitions Officer) it’s a good thing, right? It depends on the inevitable unintended consequences. Financially struggling hospitals may be forced to close. Others will continue to play the perpetual and ever changing game: Medicare sets rules---hospitals adapt---Medicare changes rules---hospitals adapt again---Medicare changes rules again.

Tuesday, May 20, 2008

Extraintestinal manifestations of Crohn’s disease

A case report of uveitis as the as the presenting manifestation is presented, along with a review of extraintestinal manifestations if IBD and differential diagnostic considerations.

Via Nature Clinical Practice Gastroenterology and Hepatology.

GI bleeding in the elderly

A review in Nature Clinical Practice Gastroenterology and Hepatology.

From meeting presentation to peer reviewed journal---POISE hits the pages of Lancet

The POISE (Perioperative Ischemic Evaluation) beta blocker study was presented at AHA last November. I blogged about it in a year end wrap up of developments in perioperative medicine. Last Tuesday the study was published in Lancet. The spin regarding this study has been largely negative. Missing from the discussion is the fact that the beta blocker use was associated with benefit for the primary endpoint. From the Lancet:

The primary endpoint was a composite of cardiovascular death, non-fatal myocardial infarction, and non-fatal cardiac arrest……Fewer patients in the metoprolol group than in the placebo group reached the primary endpoint (244 [5·8%] patients in the metoprolol group vs 290 [6·9%] in the placebo group; hazard ratio 0·84, 95% CI 0·70–0·99; p=0·0399). Fewer patients in the metoprolol group than in the placebo group had a myocardial infarction (176 [4·2%] vs 239 [5·7%] patients; 0·73, 0·60–0·89; p=0·0017).

But wait a minute. Secondary endpoints pointed to harm associated with metoprolol:

However, there were more deaths in the metoprolol group than in the placebo group (129 [3·1%] vs 97 [2·3%] patients; 1·33, 1·03–1·74; p=0·0317). More patients in the metoprolol group than in the placebo group had a stroke (41 [1·0%] vs 19 [0·5%] patients; 2·17, 1·26–3·74; p=0·0053).

Clinical trial experts criticize conclusions based on secondary endpoints when such endpoints are positive, as seen in the PROACTIVE controversy.

So, how should we view the POISE results? In the case of POISE the secondary endpoints were those that mattered more. The authors concluded:

Our results highlight the risk in assuming a perioperative β-blocker regimen has benefit without substantial harm, and the importance and need for large randomised trials in the perioperative setting. Patients are unlikely to accept the risks associated with perioperative extended-release metoprolol.

Understated, perhaps, but true. The second sentence was interesting in that it acknowledged the role of patient participation in decision making.

DB blogged about the study Friday as an important lesson for the performance and safety movement:

Second, the performance indicator and safety movement which has a "ready, fire, aim" philosophy, must reevaluate their strategies. One must wonder if our current push towards performance measurement has caused strokes and death in some patients. Finally, 30 years after finishing my residency, I continue to reshape my medical knowledge. As new knowledge appears we must quickly adjust our practice. I am interested in the ability of the performance movement to adjust. Of course, they will shrug off the unintended consequences that they caused here.

It gets you thinking---who makes up these safety and performance measures anyway? What are their credentials other than being effective cheerleaders (“champions” is the trendy term, I believe)?

DB also linked to Medscape’s Heartwire report about the trial. Dr Philip J Devereaux, who originally presented the POISE data at AHA, said in the report:

"If even only 10% of physicians followed these guidelines—which incidentally in the United States are used in quality assessments, where you have people going around ranking hospitals in terms of whether or not they are giving perioperative beta blockers—and if the POISE data are true, then in the past decade 800,000 people would have died prematurely and 500,000 would have had a major stroke perioperatively because we gave beta blockers….”

Where’s the press coverage of all these deaths? While a few reports such as this one hyped the results by and large the media response was modest. They didn’t have Big Pharma to pick on. What if, instead of an old, cheap off-patent medication the drug in question had been a new expensive block buster which had been heavily promoted by one of the big drug companies? I can only imagine.

Monday, May 19, 2008

We’re becoming aggressively inarticulate

Just discovered Taylor Mali today (H/T He’s, like, totally awesome.

Hyponatremic encephalopathy

Juan Carlos Ayus spoke last week at the American College of Physicians annual meeting on hyponatremic encephalopathy, as reported by DB’s Med Rants. Having heard Dr. Ayus speak on this topic before, I wish I could have heard the talk. Ayus has talked and written extensively on the dangers of hyponatremia and believes they are underemphasized, perhaps due to concerns about osmotic myelinolysis which can follow correction of hyponatremia. He co-authored this article from Nature Clinical Practice Nephrology (via Medscape, linked in DB’s post) in which he recommends a much more aggressive approach to the prevention of hyponatremia and the treatment of hyponatremic encephalopathy than is currently popular.

Hyponatremic encephalopathy is a dire emergency and must be treated rapidly. Reluctance to do so may stem from confusion between this condition and the more commonly encountered chronic hyponatremia which carries the greater risk of osmotic myelinolysis.

Of note, from the article:

In contrast with healthy persons who have a normal renal and neuron-humoral milieu, virtually all hospitalized patients are susceptible to hyponatremia. Elevated vasopressin levels can be taken for granted, as they have been associated with most hospital diagnoses.

Unless there is a special situation requiring hypotonic IV fluids, normal saline should be used in all patients requiring IV fluid. Ringers lactate, by the way, often considered isotonic, is actually hypotonic.

If the hyponatremic symptoms are severe (active seizures, respiratory arrest) the article recommends a 100 ml 3% saline bolus over 10 minutes. Elsewhere Ayus recommended this same regimen for marathon runners suffering from severe symptoms of hyponatremic encephalopathy. Milder symptoms of acute hyponatremic encephalopathy (nausea, vomiting, confusion, single resolved seizure) can be treated with the traditional 3% saline slow infusion. I was never taught to bolus patients with 3% saline. I did a quick search of UPtoDate and the new editions of Harrision’s and Cecil Medicine, none of which mentioned the bolus regimen. Though it seems extreme it makes sense in the situations described---the patient is about to herniate.

With respect to the risk of osmotic demyelination the overall rate of correction at 24-48 hours is more important than the hour to hour rate during the first few hours of treatment of hyponatremic encephalopathy. The article describes counter-measures and precautions to help prevent excessively high sodium concentrations at 24-48 hours.

The article mentions the relationships between hyponatremic encephalopathy and respiratory disturbances. These relationships are complex and exist on several levels. Hyponatremic encephalopathy causes two forms of respiratory failure: hypercapnic respiratory failure and non-cardiogenic pulmonary edema. The pulmonary issues associated with hyponatremic encephalopathy are discussed in greater detail in this paper co-authored by Ayus.

More on the geriatrician shortage

The top three reasons for the shortage of geriatricians are: compensation, compensation and compensation. But the president of the American Geriatrics Society, interviewed at Med Page Today, doesn’t seem to get it. He waffles and talks around it, and talks about the “medical home”. Go to Kevin M.D. and watch the video.

Residency and fellowship conferences

---other than Grand Rounds. From morning report to CPCs to Jeopardy sessions, many academic medical centers post the content on the web. Many of the presentations are created by house staff and fellows and are of good quality.

Let’s start the list with the collection of medicine rotation topics covered at Cleveland Clinic, compiled by Clinical Cases and Images blog.

Here are some more (some are a bit dated, others are updated often):

UT Memphis Cardiology CPCs

UT Memphis Cardiology board review presentations

UT Memphis Cardiology morning conference presentations

UT Memphis Pulmonary pathophysiology conferences

UCSF Chief Resident cover sheets

UCLA Internal Med case conferences

University of Maryland Medicine resident lectures

OU Internal Med noon conference presentations

St. Louis University Anesthesia and Critical Care lectures

UW Internal Med lectures

Grady Hospital (Emory) Morning Report

UCLA noon conferences

Washington University Emergency Medicine lectures

Washington University core lecture series for residents 1

Washington University core lecture series for residents 2

Wake Forest Morning report

Wake Forest Resident Presentations

UW Intern lectures

Friday, May 16, 2008

Quackademic medicine at Yale

It’s been a good week for the exposure of the fraud, corruption and pervasive conflicts of interest in high places in the world of woo. Just last Tuesday the Medscape Journal of Medicine published an article exposing the bad science and pervasive conflicts of interest behind the National Center for Complementary and Alternative Medicine’s ongoing chelation trial. Today David Colquhoun, blogging at DC’s Improbable Science, wrote about Integrative baloney at Yale in which he exposed, with videos and other examples, some of the wooiest of woo being taught there.

Junkfood Science recently blogged about the program at Yale. Concerning the general problem of medical academic woo she wrote:

Some have questioned if CAM-trained doctors are able to practice as primary care physicians and if we can trust their judgments. The concern that probably most comes to mind is whether these doctors are being taught the scientific process and how to recognize sound evidence from modalities that negate all known laws of science and biological plausibility.

She posted a follow up today. Both bloggers mentioned an astounding statement by Yale professor David L. Katz, MD, MPH, FACPM, FACP, associate professor, adjunct, of Public Health and director of the Prevention Research Center (PRC) at the Yale University School of Medicine. From DC’s post:

Pretty remarble uh? Dr Katz goes through several different trials, all of which come out negative. And what is his conclusion? You guessed.His conclusion is not that the treatments don’t work but that we need a “more fluid concept of evidence”.

That announcement by a prominent medical academic made it official: we are in the era of post-scientific medicine.

DC went on:

It’s equally bizarre to hear Richard Belitsky, Dean of Medical Education at Yale saying he is “very proud” of this betrayal of enlightenment values. If this is what Yale now considers to be education, it might be better to go somewhere else.

But where else is there to go? With quackery spreading like MRSA throughout academic medical centers the list of institutions with true scientific integrity is shrinking fast.

DC cited the Flexner report and made a point I wrote about before:

Flexner would have thought it quite inconceivable that in 2007 medical schools would be offering Continuing Medical Education in homeopathy.

He asked why other academics at Yale aren’t up in arms and suggested, earlier in the post, that it’s about money:

Very few university administrators have the intellectual integrity to turn down money, whatever the level of dishonesty that is required by its acceptance. You can buy a lot of silence for $100m…

…citing NCCAM and massive philanthropic funding of academic woo.

By the way, where’s the AAMC in all this? Aren’t they supposed to be guardians of integrity and professionalism in medical education? Are they asleep at the switch or is money silencing them too?

And a final note--- I got the idea for the term “post-scientific medicine” from the Carlat Psychiatry Blog. Dr. Carlat, writing about AAMC’s new proposal to limit the influence of pharmaceutical companies in medical academia, declared that we are now in the era of “post-deception medicine”. I respectfully disagreed.

On the AAMC’s proposal concerning Pharma gifts, I’ve changed my tune---somewhat

A commenter on my recent post about the AAMC proposal took me to task for not reading the report in the original. Although her reasons for suspecting me were wrong (I twice referred to the AAMC as AAMS, typo’s I’ve since fixed) it turns out she was correct that I hadn’t read the report in the original. I had read some blog reactions and the New York Times article, none of which contained a link to the report.

So I did what I should have done in the first place. I went and read the report. Turns out the proposal isn’t so bad. Not as bad as I thought, anyway. I disagree with the scope and the extent of the restrictions proposed and find it odd, even hypocritical, given all their talk about professionalism and integrity in medical education, that they turn their back on the shameful and pervasive problem of woo. Nevertheless, my characterization of the proposal as “simplistic and extreme” was too strong.

I think it was the NYT article that was simplistic. It implied a total ban on free food. Wrong. According to the AAMC proposal, industry-supplied food is permissible if served at an activity carried out according to ACCME standards and accredited for CME. Some academic medical center Grand Rounds, though perhaps not all, are accredited. So, this proposal will not banish free food from the academic environment. Many activities won’t be affected at all. What it may do is encourage more programs to get their Grand Rounds accredited. That would be a good thing.

Moreover, the report doesn’t ban drug reps from medical campuses. It merely sets standards for drug company presentations and requires oversight by faculty. In other words, drug reps can’t just wander in and, like self appointed faculty, proceed to “teach” students free of any administrative supervision!

My big mistake was that I dropped my guard and violated the cardinal RW rule: always, when possible, go to the primary source! That’s what I get for trusting the New York Times.

One more thing. I had to chuckle at Carlat Psychiatry Blog’s declaration following the announcement of the AAMC proposal: The era of post-deception medicine is finally here. No way. We can’t enter an era of post-deception medicine until we leave the era of post-scientific medicine. Selective outrage?

Cardiovascular risk in retired NFL linemen

They have increased cardiovascular mortality and approximately double the risk of metabolic syndrome as compared to other positions. Via the American Journal of Cardiology.

Cognitive errors in medicine

You don’t have to be a subscriber to the American Journal of Cardiology to read J. Willis Hurst’s editorial on cognitive errors in medicine---the full text is free. I highly recommend it.

The popular approach to limiting cognitive error was recently articulated in Jerome Groopman’s marvelous book How Doctors Think. I call it the negative approach to cognitive error because it emphasizes pitfalls to avoid. Hurst’s essay suggests a more positive approach. It outlines things to do in the systematic collection and processing of clinical data. These approaches are complementary and both ultimately address the same types of error.

Hurst’s approach centers around the medical record as a tool for teaching and learning (thus addressing gaps in the clinician’s knowledge), defining data that need to be collected, analyzing the data and applying the information to the patient’s problems. He advocates the problem oriented medical record (AKA the Weed system) of which he has been a champion for many years.

Most of us would say we use the problem oriented medical record as the ever present SOAP notes and problem lists attest. But a careful reading of Hurst’s essay suggests it’s merely a pretense. The problem oriented record as originally conceived is systematic and rigorous. While it seems cumbersome, Hurst notes that it can be utilized quickly and efficiently once proper habits are developed.

The problem list must designate each item at the level of resolution achieved, from symptoms and laboratory abnormalities at the low end to definitive diagnoses at the highest level. Moreover, diagnoses must reflect the most up to date disease classification and terminology.

That raises an important question. Is it possible to generate and maintain a true problem oriented medical record in today’s environment where the record is hijacked by coders, core measure police and others with competing agendas? Just one example of this problem is the basing of diagnostic terminology on the decades obsolete (created in 1977 and replaced in 1992) ICD-9 classification. In paper based records if you use precise and up to date terminology your patient’s chart is likely to “bounce back” from the coding department and ultimately find itself on the delinquent list. In the electronic world where all diagnoses are inseparably linked to ICD-9 codes the best terms may not be available.

An effective medical record is more than an accurate problem list. Hurst writes (italics mine):

The medical record should reveal the thoughts and actions of the physician in charge. The challenge for the physician is to make the record simultaneously brief and complete. The record should be easily understood by another physician. Each page of the record should be uncluttered, and important information should be displayed prominently so that it can be retrieved easily.

I wonder what Hurst thinks of today’s template generated charting.

There’s much more.

Thursday, May 15, 2008

The John Ritter defendants---did they really win?

From Emergency Medicine News:

In the Ritter case, the jury agreed with the defendant physicians and exonerated them of any liability. They were lucky. How lucky? They were able to spend four years with attorneys worrying about their future, including the potential that they would be ordered to pay tens of millions of dollars and be left penniless.

So, they didn't really win. They just lost less.

Read the rest here.

Wednesday, May 14, 2008

Medscape article blows the lid off of NCCAM’s chelation study

A Medscape article on the National Center for Complementary and Alternative Medicine (NCCAM) sponsored Trial to Asses Chelation Therapy (TACT) declares:

We conclude that the TACT is unethical, dangerous, pointless, and wasteful. It should be abandoned.

Orac has already written a wonderful post this morning in which he opines:

As I go to my office and lab this morning, to try to do high quality scientific research based on good science designed to improve our understanding of cancer and hopefully lead to more effective therapies, it galls me to no end to see the equivalent of 15-20 R01 grants going to fund this woo. Worse, it's TACT is not the only example of an unethical and scientifically worthless trial being funded not because the science is compelling but because powerful lobbies and legislators who are true believers in woo applied pressure to the NIH to do them.

I’ll take this opportunity to put in my two cents---not that I really have anything to add other than to say “I told you so” not only about this study but also about the under appreciated conflicts of interest in government funded research. When I first read about this study a couple of years ago I smelled a rat and have since written a number of posts, several of which Orac linked to this morning. The Medscape article reinforces some of the points I made in those posts, particularly regarding the dubious credentials and obvious conflicts of interest of many of the study site investigators. Just look at this jaw dropping paragraph from the article:

The TACT includes nearly 100 "chelation site" co-investigators who, in our opinion, are unsuitable to care for human subjects or to report trial data. Most espouse implausible health claims while denigrating proven methods; several have been disciplined, for substandard practices, by state medical boards; several have been involved in insurance fraud; at least 3 are convicted felons. Several were members of the ACAM or GLACM IRBs mentioned above. Few appear to have real expertise, required by TACT literature, in treating patients with CAD or in conducting clinical trials. Most continue to promote chelation while the TACT is in progress, contrary to good science, to human studies ethics, and to US Federal Code. The TACT consent form gives no hint of these points.

WOW!! Worse than even I imagined! This stuff belongs in the health pages of the New York Times. (I won’t hold my breath, though. They’re probably too busy exposing the pharmaceutical companies to notice. I hope I’m wrong!). If those ethical issues aren’t egregious enough consider that the study isn’t even securely blinded from the investigators, a concern I raised here and in other posts. The Medscape article describes the problem:

The experimental solutions must be mixed on-site. The 2003 TACT protocol describes a method to preserve blinding and reports that this "has been piloted successfully," presumably in a supervised, academic setting.[5] Nevertheless, the mixing procedure presents simple opportunities for distinguishing between the chelation and placebo solutions. For example, the site coordinator must inject 14 mL of concentrated ascorbate or sham solution into a 500-mL IV bag. The plan calls for the 14-mL solutions to have similar viscosity and to appear similar in color, but a tiny drop applied to the tongue during transfer would instantly identify the ascorbate by its sour taste. Ascorbate goes exclusively with the Na2EDTA solution.

Orac faithfully reported the same concern:

Not only was the protocol itself scientifically implausible, a mix of disodium EDTA and a bunch of supplements, as well as procaine and heparin added for unclear reasons. it is placebo-controlled, but the protocol stipulates that the chelation solution must be mixed on site, allowing ample opportunity for investigators to break blinding, either purposely or even inadvertently.

That may just be the tip of the iceberg concerning TACTs’ design problems. The authors note that the NCCAM was not entirely forthcoming with information in response to their FOIA requests:

Through FOIA requests, we obtained "redacted" copies of the original (2001) and 2003 TACT protocols,[4,5] the roster of the committee that approved the grant application,[39] and the June 2003 consent form.[6] Because the trial had already begun and because our initial FOIA requests were frustrated by delays and incomplete responses, we did not seek further revisions of the protocol or consent form, or other documents that are not available on the NCCAM Web site.

I knew from the get-go this trial was questionable. I didn’t know how bad it really was until I read the Medscape piece. This tops any example you can trot out about the corrupting influence of Big Pharma. What I didn’t cover in my posts was the extent of the pseudoscientific agenda and conflicts of interest that prevailed throughout the planning and implementation of the study. If you think government funding is the answer to Pharma involvement in research this article will give you pause.

Medicare’s no pay policy

---is only part of the DRG revamp rolled out by CMS last year. There’s also the new list of MS-DRGs which replace the old DRGs. And while it may seem like a lot of BS we’ll have to live with it, so we may as well attempt to learn it. An article in ACP Hospitalist offers some tips. Too complicated for me.

Tuesday, May 13, 2008

Healthy skepticism about practice guidelines

If you didn’t read DB’s rants carefully you might get the idea he was somehow against practice guidelines. That wouldn’t be accurate. There’s a difference between skepticism and cynicism. A Grand Rounds presentation he delivered on the topic at UC Davis puts his rants into perspective. Here are some of my take home messages from the talk:

Guideline developers have conflicts of interest. This is not unique to those supported by drug companies. Virtually all organizations and individuals involved in guideline development---governments, professional societies and individuals interested in their academic careers---have a stake.

Guidelines are not immutable rules and are no substitute for clinical judgment.

You can’t apply all guideline recommendations to patients with multiple complex problems---you must prioritize treatments.

Guidelines can provide impetus for ill conceived performance measures.

There’s much more. Follow the link above and watch the video. It’ll make you think.

What’s so great about CPOE?

My recent criticism of electronic medical records (EMRs) has focused on documentation templates. Now that I’m on a roll with EMR posts I may as well cover the other side of EMRs---computerized physician order entry (CPOE). The push for universal adoption of CPOE is on. Leaders in the patient safety movement tell us it’s a good thing. So what’s so good about it?

For starters let’s look at the description in AHRQ’s glossary:

Physicians (or other providers) directly enter orders into a computer system that can have varying levels of sophistication. Basic CPOE ensures standardized, legible, complete orders, and thus primarily reduces errors due to poor handwriting and ambiguous abbreviations.

It goes on to point out that many systems have decision support built in: suggested doses, allergy alerts and order sets which conform to evidence based practices. More sophisticated systems may integrate patient data such as weight and creatinine clearance.

No one would dispute that these are good ideas. The real rub is how CPOE does in the real world. Do the benefits outweigh the unintended consequences? Bob Wachter, who has written a couple of recent posts on health care technology, seems to think they do. In last Friday’s post he referred readers to AHRQ’s patient safety network where a search on CPOE yields 174 citations. But the top hit is an article on unintended consequences and contains a link to the fabled Pittsburg study showing an increased mortality following the implementation of CPOE. Then there’s this study showing that CPOE actually creates errors. Clearly there’s a trade off between errors intercepted by CPOE (which may or may not have been intercepted “downstream” in traditional paper based systems) and new and unanticipated types of errors introduced by CPOE.

What is the net result in terms of patient safety? To answer that question we need outcome based data. Such data are sparse, but the Pittsburg study is concerning. To be fair, the negative results of that study may reflect learning curve issues more than inherent risks of CPOE itself. On the positive side, Wachter cites this study. But it’s from Brigham and Women's Hospital, raising questions about real world generalizability. Moreover, the significance of the error reduction attributable to CPOE in the study is unclear from the paper. This very recent systematic review demonstrated CPOE’s ability to intercept many errors but failed to show improvement in patient outcomes.

What’s my bottom line as of May 13, 2008? CPOE is a great idea. CPOE has potential. But the boosters of CPOE have a burden of proof which they have yet to satisfy. It has not been proven to help patients. Why is there such a disconnect between theory and real world results? The downside in terms of creating new errors is well documented.

But their’s a less tangible downside. For clinicians, CPOE is a distraction. What do I mean by that? It adds a new burden to our work flow: order processing. Doctors are trained to focus on clinical issues. We need to know what drug to give, when and how much, and what tests to order. We are not trained in how to search the computer for the appropriate orders, how to customize our therapy when the computer’s options are limited, how to be sure that our order entry is properly routed, or how to devise workarounds that are inevitably necessary in such systems. Those issues, formerly in the domain of clerical employees, are now foisted on doctors. They are time consuming and they take away from our clinical focus. The challenge for CPOE development is to create systems that allow doctors to concentrate on the clinical problem at hand, free of questions such as “Where can I find the basal/bolus insulin protocol?” or “Am I sure I entered this right?”

Wachter’s other post puts CPOE in the helpful perspective of the “Technology hype cycle”. New technologies are initially met with unwarranted enthusiasm. Then there follows a back lash when they don’t meet their initial expectations. Finally, gradually, the level of acceptance finds a middle ground in which users appreciate the benefits but realize that the technology isn’t nearly as good as originally hyped. It’s a useful model to keep in mind because it gives us a road map, a kind of sense of where we’ve been and where we hope to end up.

Monday, May 12, 2008

AAMC’s proposed ban on drug company gifts draws controversy

MSNBC ran a point counterpoint on the Association of American Medical Colleges proposed ban on drug company freebies for medical students. Dr. Edward V. Craig, Professor of Clinical Orthopedic Surgery at Cornell Medical School, writing in opposition to the ban, said:

Unfortunately, this proposal ignores all subtlety, is dismissive of the many benefits of industry relationships with medicine, and considers individuals and medical organizations rudderless in their efforts to be steered by a personal and professional moral compass.

If your medical school is being over run by drug reps or if they are creating a distraction in the learning environment, you as an administrator or faculty member should take action. But the AAMC proposal is simplistic and extreme.

The larger problem in medical education is the need to teach students to think critically. Although that would address not only the slanted information in drug company promotions but also the woo students are exposed to it’s not being done effectively. Instead, students are being asked to check their brains at the door to the classroom. If you have doubts on whether med students are embracing pseudoscience on a large scale check out the complementary and alternative medicine pages of the American Medical Student Association web site.

Via Kevin M.D.

How well do eICUs work?

The ones that are profiled in a recent issue of ACP Hospitalist seem to be working pretty well. Do they all work that well? It depends entirely on the quality of relationships between the personnel at both sites.

Electrocardiographic T wave inversion

Various forms are discussed in this review from the American Journal of Emergency Medicine.

Diagnosis: Fabry’s disease

Case description and literature review in Nature Clinical Practice Cardiovascular Medicine.

Friday, May 09, 2008

Precipitating causes of heart failure exacerbation

The OPTIMIZE-HF data base provided us with a wealth of information on heart failure. A report from that data base which focused on precipitating causes of exacerbations was recently published in the Archives of Internal Medicine.

In heart failure one can think about underlying causes and precipitating causes. While a good deal of evidence supported the importance of the former, there was little, up until now, on the importance of the latter even though expert opinion (as well as my mentors going all the way back to med school and residency) held that we should think about both. This paper, by showing that a majority of heart failure episodes had an identifiable precipitant, adds credence to that teaching. Precipitating causes matter.

DB of Med Rants provided a nice summary of the findings. I’ll just make a few observations I found interesting:

Patients with no identifiable precipitating cause had a modestly lower mortality. That’s counter-intuitive. You’d think the folks who decompensated for “no reason” would be those with the least hemodynamic reserve who are approaching “end stage”.

The distribution of length of stay was not a bell curve. The median length of stay was 4 days whereas the mean was 6.4. That tells me there were some outliers with very long stays. It matches real world experience.

Finally, I was a bit surprised that pulmonary embolism was not on the list of precipitating causes. That may reflect how hard investigators looked for PE rather than its actual occurrence. Recall that in COPD exacerbation, when you look for PE you find it in 25%. I’d like to see a similar study in hear failure.

So you want to be a doctor?

In Reasons Not to Become a Doctor Tara Weiss writes that physicians’ professional rewards are shrinking, and that is contributing to a growing shortage of doctors. She quotes three authors from the recruiting firm of Merritt and Hawkins:

This is not just a question of career choice---consumers will be affected greatly by this shortage. If you think there’s a long wait for an appointment now, it could be nothing compared with 15 years down the road. The three co-authors of Will the Last Physician in America Please Turn Off the Lights, all from the physician staffing firm of Merritt, Hawkins and Associates, say the wait will jump to three to four months to see a doctor for a non-emergency, and a routine doctor’s visit will cost two to three times what it does now—whether you are insured or not, they say.

I have a lot of respect for Merritt and Hawkins. They are uniquely in touch with physicians’ attitudes and working conditions. But you don’t need data from Merritt and Hawkins to know that what Weiss says is true. The shortage of doctors, particularly primary care, touches all of us.

Although all doctors realize the increasing frustrations of the profession, medical blog reactions have been somewhat more optimistic:

Kevin M.D.

DB’s Med Rants

JaneMarie MD

The Blog that Ate Manhattan

My take? I can’t see myself doing anything else. I love medicine. It is said that one of my medical school mentors was quite wealthy and worked for the university, at his own insistence, for a dollar a year. He’d say to his students “You should love medicine so much that if you were independently wealthy you would be willing to pay for the privilege of being a doctor.” I sometimes feel that way!

Nobody goes into medicine primarily to get rich. Perhaps a few consider it just a job. Most appreciate the professional rewards. For me the issue is not the profession of medicine; it’s the baggage. I love medicine but I hate the baggage. The baggage is growing and choking off the professional rewards. For many doctors, even the ones in the profession for the “right” reasons, the baggage has become unbearable.

Wanna be a doctor? Think long and hard, and count the emotional cost.

Thursday, May 08, 2008

Medical blogging featured in ACP Hospitalist

---with mention of a few blogs including yours truly. Thanks for the link!

Dear blog, my patients are nuts. Signed, anonymous.

Doctors need a better quality of life

---according to this Medscape article. Docs are under too much pressure and that may negatively impact patient care. Not only do we face external pressures, but we bring a lot of it on ourselves. We’ve become an increasingly self-flagellating profession. That’s why it’s refreshing to read this:

Doctors are under too much pressure, experts warn, and this is having a negative affect on patients. Physicians who are overworked, overburdened, and generally stressed out are less available to patients and not as effective. Disregard the basic needs of healthcare professionals and patients are soon neglected too.

Complications of influenza

Reviewed In the American Journal of Medicine.

Wednesday, May 07, 2008

Almost all doctors think they’re above average

---when it comes to diagnostic accuracy according to Paul Mongerson in the foreword to a supplement in the American Journal of Medicine. The supplement examines the role of overconfidence in diagnostic error. Full text of the entire issue is available free of charge. Fascinating reading about the cognitive traps we fall into and potential remedies.

My take on the electronic medical record

Yesterday I took the curmudgeon role on EMRs. It’s not the first time and probably won’t be the last. DB responded here. He had previously posted a wonderful essay on the art of history taking. Maybe it was unfair to use his post (which was not a rant against EMRs at all) to support my own criticism of EMRs. At any rate, his response served to point out that I rant about EMRs at the risk of being misunderstood (the spike in blog traffic with the help of Kevin was a bonus). So, here’s my attempt at clarification:

I regard electronic medical records in much the same way I regard the pharmaceutical companies---with healthy skepticism (questioning things, not believing everything the promoters say) but not cynicism (seeking every opportunity to knock them down).

EMRs have conceptual advantages that are very appealing. Making them work in the real world is problematic and filled with unintended consequences. It has to be done right. We’re not there yet. Most of us, anyway.

I’ve written before on the decline in basic clinical skills and cited many reasons other than the EMR. But templates serve the coders more than the clinician. Templates impede original thought and introduce challenges to the recording of a meaningful history. A good clinician can overcome the challenges but it takes effort---maybe some extra typing and editing. Templates are not unique to EMRs. We had them in the paper days. EMRs just took them to a new level.

Poor documentation and questionable coding, while facilitated by electronic templates, ultimately reflect on the physician.

My observations on EMRs are not scientific. They’re random. That being said I’ve seen some good electronically generated notes, but they’re in the minority. Most seem to have a low signal to noise ratio.

Tuesday, May 06, 2008

Has woo invaded your hospital yet?

Sooner or later it will. The cover story on this topic in ACP Hospitalist and its accompanying editorial comment are completely non-critical, offering as evidence in favor of the trend a single anecdote along with the usual statistics on CAM’s rising popularity.

So: You’re a hospitalist. Hospitalists are supposed to be the leaders of quality in the inpatient environment. When you see woo spreading through the wards of your hospital like MRSA whatcha gonna do?

The decline in the art of history taking

---may be facilitated by electronic medical records. Two bloggers offer contrasting perspectives. DB reminds us of what it should be:

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.

Dr. Wes bemoans what it has become with the help of the electronic medical record (EMR):

The EMR has become not only the administrators' friend, but the proceduralists' as well. Thanks to text-generating "macros" (sometimes called "dot-phrases") the burden of the pre-op history and physical has been all but erased. If a patient has one cataract done thirty-two days ago (outside JCAHO's 30-day requirement), well then, no problem, just hit a few "dot-phrases" and presto! Away we go! "Dot phrases" can load up an empty history and physical form faster than you can say "operation."

A speaker extolling the benefits of the EMR once said that some conditions are so similar from patient to patient that one can often generate the entire H&P with just a few key strokes and little if any editing. It was an amazing demonstration but really, really sad.

The whole thing, of course, is driven by economics. The less time you have to spend on the H&P the more patients you can see, the more procedures you can do and up goes productivity.

Sooner or later we’ll all adopt the EMR. After all, it’s what everybody (except for physicians in the trenches) says will fix the patient safety problem. We’ll take advantage of its efficiencies but real effort will be needed to save the dying art of bedside diagnosis.

Monday, May 05, 2008

Unhealthy pressure to implement electronic medical records

Pressure to implement electronic medical records has been driven by hype, without due regard for the unintended consequences. Many thought leaders in medicine have contributed. IHI president Donald Berwick, in a Time Magazine commentary on how to “fix” healthcare, made this incredibly simplistic observation about EMRs:

My pizza parlor is more thoroughly computerized than most of health care. It's high time to put the paper medical record where it belongs — in the Smithsonian, next to the typewriter.

In a Medscape Webcast Video Editorial Dr. Carolyn Clancy, head of AHRQ, asked, in effect, “What are we waiting for?”

Doctors hesitate for good reasons. In their April 17 NEJM Perspective piece Pamela Hartzband, M.D., and Jerome Groopman, M.D. (author of How Doctors Think) sounded a note of caution. Concerning EMRs, they wrote:

We worry, however, that they are being touted as a panacea for nearly all the ills of modern medicine. Before blindly embracing electronic records, we should consider their current limitations and potential downsides

I made brief mention of the article the day it came out. I’ve since had the opportunity to parse it in greater detail and observe some blog reactions.

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.

They also made this disturbing observation about how EMRs can undermine our professionalism:

As we have increasingly used electronic medical records in our hospital and received them from other institutions, we've noticed several serious problems with the way in which notes and letters are crafted. Many times, physicians have clearly cut and pasted large blocks of text, or even complete notes, from other physicians; we have seen portions of our own notes inserted verbatim into another doctor's note. This is, in essence, a form of clinical plagiarism with potentially deleterious consequences for the patient.

Yes, clinical plagiarism. In some EMR systems it’s not even necessary to go to the trouble to copy and paste. The text is imported automatically. It’s fine to incorporate information from previous records into your note. But in the paper days we had to read and think about the information first. (I previously noted another threat to professionalism: EMRs encourage doctors to over code). (original post by ER Murse).

The authors went on to say that electronic template generated notes discourage thought:

Writing in a personal and independent way forces us to think and formulate our ideas. Notes that are meant to be focused and selective have become voluminous and templated, distracting from the key cognitive work of providing care. Such charts may satisfy the demands of third-party payers, but they are the product of a word processor, not of physicians' thoughtful review and analysis. They may be "efficient" for the purpose of documentation but not for creative clinical thinking.

And this:

A colleague at a major cancer center that recently switched to electronic medical records said that chart review during rounds has become nearly worthless. He bemoaned the vain search through meaningless repetition in multiple notes for the single line that represented a new development. "It's like `Where's Waldo?'" he said bitterly. Ironically, he has started to handwrite a list of new developments on index cards so that he can refer to them at the bedside.

True, handwriting in charts is sometimes illegible and can lead to miscommunication. It might seem that the printed (or at least typed) word, which we are all conditioned to respect, would always be more definitive and have more impact than text written by hand. But we have observed the electronic medical record become a powerful vehicle for perpetuating erroneous information, leading to diagnostic errors that gain momentum when passed on electronically.

The electronic medical record, all too often a substitute for thought and critical analysis, will create new challenges in the teaching of students and residents. Excellent clinicians write notes that tell patients’ unique stories in narrative form and explain their clinical thought processes. Electronic template generated notes discourage the teaching of this skill.

The NEJM article is not entirely negative about EMRs, but it issues a plea for caution. It’s a must read if you’re involved in planning for an EMR.

Further reading: Health Care Renewal’s take on the NEJM piece.

Alpha-1 antitrypsin deficiency

This topic was updated in a recent issue of the American Journal of Medicine.

Key points:

The condition is under diagnosed, and all patients with COPD should be screened once in their lifetime.

Liver disease is due to accumulation of abnormal antitrypsin molecules in hepatocytes.

Unusual disease associations include Wegener’s granulomatosis, aneurysms and necrotizing panniculitis.

Sunday, May 04, 2008

Nonalcoholic fatty liver disease

---is the hepatic manifestation of the metabolic syndrome. A topic review is presented in Nature Clinical Practice Gastroenterology and Hepatology.

The changing spectrum of chronic pulmonary histoplasmosis

Conventional wisdom, based on reviews from decades ago, holds that chronic pulmonary histoplasmosis typically occurs as cavitary disease in patients with COPD. A recent review in Medicine suggests a wider spectrum of presentations.

Diabetic foot infection: is it osteomyelitis?

Featured in JAMA’s Rational Clinical Examination.

Saturday, May 03, 2008

Prominent R wave in V1

Interpreting a prominent R wave in V1 is an exercise in differential diagnosis. The clinician must be able to list the causes. Here’s the list:

Left ventricular ectopy
Right ventricular hypertrophy
Acute right ventricular dilation (acute right heart strain)
Type A Wolff-Parkinson-White syndrome
Posterior myocardial infarction
Hypertrophic cardiomyopathy
Progressive muscular dystrophy
Misplaced precordial leads

Right bundle branch block
Normal variant

You’ll make fewer mistakes if you keep this list in mind when confronted with an electrocardiogram which displays an R wave in V1 of greater amplitude than the S wave.

Via the American Journal of Emergency Medicine.

Friday, May 02, 2008

Want to eliminate the drug company lunch?

You’re not going to get doctors to drop the practice. Those who oppose it have the loudest voices but they’re in the minority. Want to eliminate the practice? Criminalize it. Look for, among many other unintended consequences, a spike in direct to consumer advertising.

More on Medicare’s latest no pay list

A recent WSJ Health Blog post on the topic was more interesting for the comment thread than for the post itself. Aggrevated Doc Surg and Roy Poses of Health Care Renewal weighed in. One commenter best summarized the consensus of the thread:

Ridiculous. Why don’t we just not treat people. No risk of medical errors there! Comment by Student.

Whither health care reform?

As the election nears NEJM Perspective piece writer Lawrence R. Jacobs asks if it’s 1994 All Over Again. Recall that the 1994 elections marked the final finishing blow to the Democrats’ health care reform proposals, starting with the Clinton plan, then evolving to the much less ambitious Mitchell plan before meeting defeat. According to Jacobs the landscape of public opinion in the U.S. hasn’t changed much since that time.

Hospitalists and drug seekers

Despite evidence to the contrary, popular pain management dogma holds that narcotic addiction is rare among patients with chronic pain and that most patients who send up the red flags of drug seeking are really suffering from “pseudoaddiction.”

Most hospitalists, though, know that they are likely to encounter drug seeking behavior. Here’s an article in Today’s Hospitalist with some tips on how to deal with the problem.

Electrocardiographic manifestations of ventricular aneurysm

Left ventricular aneurysm often causes ST segment elevations in indicative infarct leads which persist after resolution of the infarction. Such findings may be difficult to differentiate from other causes of ST segment elevation, particularly acute infarction. A review in the American Journal of Emergency Medicine describes the electrocardiographic findings of left ventricular aneurysm and focuses on the differentiation form acute infarction. As opposed to acute infarction the ST elevations of ventricular aneurysm tend to be accompanied by well developed Q waves and reciprocal changes are lacking.

CNS infections: tips and pearls

Via Today’s Hospitalist.

More on the shortage of geriatricians

Despite longer training requirements as compared to FPs and internists, geriatricians earn less. Why? Their case mixes are virtually 100% Medicare. From the American Journal of Medicine:

Few other fields of medicine are faced with the challenge of proposing that residents complete additional training only to have their earning power decrease.

Thursday, May 01, 2008

ST segment elevation: MI or not?

When confronted with electrocardiographic ST elevation it’s necessary to differentiate STEMI from early repolarization, pericarditis and other conditions. Look for reciprocal ST depression, which strongly favors MI. According to a study in the American Journal of Emergency Medicine sensitivity, specificity, positive predictive value, and negative predictive value for the electrocardiographic diagnosis of AMI were 69%, 93%, 93%, and 71%, respectively. This works only in the absence of confounding abnormalities such as bundle branch block, paced rhythm and hypertrophy.

Takotsubo cardiomypoathy: mechanisms and pathophysiology

There has been a recent explosion of literature on this underappreciated entity. Here’s another review from Nature Clinical Practice Cardiovascular Medicine.

What’s the practical importance of recognizing this syndrome? Patients, despite appearing to present with myocardial infarction and horrible ventricular function, are not doomed. Recovery of normal ventricular function is the rule provided they get appropriate supportive care.