Disruptive physicians

Despite the fact that Joint Commission’s disruptive behavior standards now apply equally across all disciplines in the health care environment, in common usage the discussions usually focus on doctors. Even more so these days the attention seems to be shifting to hospitalists. As Bob Wachter noted in a recent blog post, hospitalists are now expected to be the “best behaved doctors in the building.” In part this is because, as Bob pointed out, hospitalists’ and hospitals’ incentives and accountabilities are aligned, like never before. Or so we would hope.

I’m thinking back to my pre-hospitalist days of traditional internal medicine practice. My medical group was one entity and the hospital was another. My accountability was to meet the requirements of medical staff membership. That was it. On a couple of occasions I and some of my colleagues did battle with the hospital. Back then we believed we were just advocating for better patient care, but things have since changed. I wonder if some of those actions would now be considered disruptive behavior.

How well aligned are those incentives, really? Every day I see competing agendas between the hospital and physicians, and within the hospital. These tensions can range from healthy to counterproductive. As hospitalists, the hospital is now one of the patients we must treat. That being said, our most important patients are the human beings that occupy the beds. The best I can do as a hospitalist is to advocate for those individual patients above all else. Occasionally that will conflict with the business incentives of the hospital. Will I be perceived as disruptive?

Neurologic prognosis after cardiac arrest

Updated in NEJM.

Key points:

…patients whose pupillary reactions were absent at day 3 after cardiac arrest had poor outcomes (false positive rate, 0%; 95% confidence interval [CI], 0 to 3).

...the absence of a corneal reflex at 72 hours was associated with no false positives for a poor outcome (95% CI, 0 to 14 in one study¹⁸ and 0 to 41 in the other).

If the patient received a therapeutic hypothermia protocol I assume time zero would be at completion of the protocol rather than the time of the arrest but the review is not clear on that point. It does mention therapeutic hypothermia as a potential confounder in assessing for these neurologic signs over time.

The motor response to noxious stimuli also provides useful prognostic information. Several prospective studies, including one multicenter study involving more than 400 patients with cardiac arrest, showed that a motor response to noxious stimuli that was no better than extensor posturing (i.e., a decerebrate response or no response) at 72 hours was associated with no false positives for a poor outcome …

The author cautions that if the patient received therapeutic hypothermia this sign may not be reliable until day 6 or beyond.

In a prospective study involving 407 patients, myoclonic status epilepticus at 24 hours after arrest was associated with no false positives...

The caution here is that this syndrome must be differentiated from other seizure like syndromes, which means you'll want to get an EEG and some help from a neurologist.

Theophylline to help wean patients from mechanical ventilation

Few patients require weaning from mechanical ventilation. Theophylline has largely been discarded from day to day pulmonary medicine. Interest in the use of theophylline as a stimulant to help in difficult weaning situations, however, persists. Pathophysiologic rationale, animal studies and low level clinical data indicate that theophylline improves respiratory muscle function. High level clinical studies simply have not been done.

This topic was recently reviewed in Clinical Pulmonary Medicine. The authors of the review were cautiously favorable towards the use of theophylline:

Overall, available data and experience suggest a role for methylxanthines in facilitating liberation from mechanical ventilation of adult patients, though the paucity of available studies invites further research regarding this specific application.

The authors suggest that when used, frequent monitoring of serum levels is advised, aiming for levels slightly below the usual therapeutic range.

Alcoholic hepatitis review in NEJM

In this update the use of corticosteroids with patient selection based on severity scores and the use of pentoxifylline were discussed.

Neutropenic precautions

There’s a nice post on this topic in the Clinical Correlations blog titled Neutorpenic Precautions Demystified. It should have been titled Neutropenic Precautions Debunked because it’s one of the most non-evidence based things we do in medicine. Save for a few notable exceptions these patients get infected from within rather than from without.

Should this well entrenched procedure be abandoned? I don’t know. I’d hate to foster a casual attitude in the care of these patients. As with the care of all patients hand washing is essential.

Spinning negative RCTs

---is very common, according to a presentation at the 2009 International Congress on Peer Review and Biomedical Publication. Comments from the presenter:

"We should be really careful about the way people present and conclude their articles. And for academics, they should be very careful about the way they write articles. I often work with principle investigators in writing their articles, and I always need to calm them down, because they believe that their treatments work and they try to frame the results in a specific way."

Considering all the negative studies that are buried as a result of publication bias this may be the tip of the iceberg, and it’s about much more than industry influence. Academic careers and reputations are at stake, and, besides, investigators just want to believe their treatments work.

Board certification for hospitalists

Recognition of focused practice is the more correct term. According to Bob Wachter it’s cleared the final hurdle of approval by the American Board of Medical Specialties and will be rolled out in about a year. I wonder if there are any board review resources available or in development. Stay tuned.

Probiotics to treat C diff?

Not helpful according to this brief update from CCJM.

Profiles in heart failure: clinical predictors of heart failure with preserved or reduced EF

From a new paper in Circulation:

Multivariable predictors of HFPEF (versus HFREF) included elevated systolic blood pressure (odds ratio [OR]=1.13 per 10 mm Hg; 95% confidence interval [CI], 1.04 to 1.22), atrial fibrillation (OR=4.23; 95% CI, 2.38 to 7.52), and female sex (OR=2.29; 95% CI, 1.35 to 3.90). Conversely, prior myocardial infarction (OR=0.32; 95% CI, 0.19 to 0.53) and left bundle-branch block QRS morphology (OR=0.21; 95% CI, 0.10 to 0.46) reduced the odds of HFPEF. Long-term prognosis was grim, with a median survival of 2.1 years (5-year mortality rate, 74%), and was equally poor in men and women with HFREF or HFPEF.

So if grandma has hypertension and a-fib her heart failure is probably associated with preserved EF. Male gender, prior MI and LBBB are associated with reduced EF.

Background: ECG predictors of dilated cardiomyopathy here and here.

The American Academy of Family Physicians promotes acupuncture

The best scientific critique of acupuncture I ever heard was by Wallace Sampson:

The other mistake people make about acupuncture, Sampson says, is that it offers specific cures. "It is nonspecific," Sampson says. "If it has the effect of, say, releasing endorphins through the application of needles, well, many things release endorphins -- a walk in the woods, a 5-mile run, a pinch on the butt."

Somewhat more pretentious (and promotional) articles on acupuncture have recently appeared in the journal American Family Physician. What’s ironic is that American Family Physician has a reputation as being a champion of evidence based medicine.

Health benefits of coffee

Works wonders for your cyclic AMP, too!

Comparative effectiveness research and the medical home

---was the focus of the latest Medscape Roundtable Discussion. This Roundtable, really a series of “cerebral burps” by a larger number of participants, was more of true panel discussion than its predecessors. I weighed in with predictable skepticism.

Obama on malpractice caps

There, he said it.

"You know, what I would be willing to do is to consider any ideas out there that would actually work in terms of reducing costs, improving the quality of patient care," Obama said in an interview with the CBS-TV show "60 Minutes."

"So far, the evidence I've seen is that caps will not do that," Obama added.

Nurses charged with felony for reporting woo pushing doctor to Texas medical board

I know I’m late with this. In fact, I’m woefully behind on blogging in general thanks to a couple of weeks on the road and a busy work schedule when I returned home. But, better to weigh in late than never. This is the case of Vicki Galle, RN, and Anne Mitchell, RN. I won’t cover the details---Orac has done that---but I have a few questions and points to raise which have not, as far as I can tell, been covered by others.

This episode raised issues on so many levels it’s hard to talk about it without conflating them. On one level it’s about abuse of prosecutorial discretion (not much to discuss there---it’s patently clear, and all seem to agree, this was excessive). On other levels it’s about whistleblower protection, cronyism and ill conceived hospital policies and procedures. Then there are the legal questions. The nurses, in referencing patient records in reporting Dr. Rolando Arafiles to the Texas medical board, were exempt from HIPAA penalties but is there some Texas statute that regulates release of information from public hospitals? It’s a stretch, but who knows? One of Orac’s commenters even raised the “nurses get no respect” issue which, in my view, is not what this is really about.

And what are the issues before the Texas medical board concerning Dr. Arafiles? That he endangered patients by pushing herbs? Most herbal woo is harmless. Was if fraud? Although I strongly believe herbal woo is fraud it is not considered so in the general public perception, or even as it is being taught in academic medical centers. Is it a violation of Stark rules prohibiting self-referral and, if so, is that in the jurisdiction of the medical board? I don’t know.

What hasn’t been discussed enough is that this is a story of incorporation of woo into conventional medicine and two individuals who called it out. Galle and Mitchell were not just a couple of RNs working at Winkler County Memorial Hospital; they had significant roles in quality review and credentialing according to their civil complaint. As they tried to go through the proper administrative channels they were stonewalled---concerns were ignored and meetings to discuss the matter were repeatedly canceled. The abuse here was not only on the part of the sheriff and prosecutor but also on the part of hospital administrators who, no doubt, considered Galle and Mitchell guilty of “disruptive behavior.”

Although there were issues surrounding Dr. Arafiles besides the herbs clearly the herbal woo was a major focus of the complaint to the medical board, falling under the category of “non-therapeutic prescribing or treatment” according to exhibit B.

Given the increasing acceptance and promotion of quackery in hospitals and academic medical centers, the reporting of a doctor for promoting woo is a novel and courageous act. But it took place at a 25 bed hospital in Podunk USA. Can you imagine someone doing this at Yale or the University of Arizona?

Wake up and breathe

A summary of the protocol and the supporting evidence is provided here.

Emergency medicine's push-back on TPA for ischemic stroke continues

---but new evidence may be making a dent.

Emergency physicians have long been among the most vociferously opposed to tPA for stroke, but some are now reconsidering that stance. Most notable in that group is the Society of Academic Emergency Medicine, whose Board of Directors officially retired its policy questioning the use of thrombolytics in patients with acute ischemic stroke in January....

It is a stunning turnaround from the tumult surrounding the use of the clot-buster in stroke just six years ago when all of the major professional emergency medicine organizations - the American College of Emergency Physicians, the American Academy of Emergency Medicine, and SAEM - passed similar policies of no confidence in the emergency use of thrombolytics for stroke. ACEP is now reviewing its policy statement to determine if revisions are needed...

AAEM has not changed its policy, said the group's former president Robert McNamara, MD. He said the issue remains controversial, and will become more so as information emerges.

So where do emergency medicine physicians in the trenches stand?

In a study presented in May 2008 at SAEM's annual meeting, Dr. Scott and his colleagues found that 83 percent of the 199 emergency physicians who completed the survey would use tPA in an ideal setting. Seventy-two percent said its use in eligible patients represented ideal care but was not a legal standard of care while 27 percent said its use was ideal care and the legal standard. Forty-nine percent said existing data on the use of tPA in stroke are convincing, but 65 percent said they were uncomfortable treating without consultation. Sixty-six percent said a telephone consult was sufficient. Fifty-nine percent said they were concerned about the liability of not using tPA. On a 15-item test of knowledge about tPA, the median score was eight correct answers.

Another electrocardiographic pattern you need to know

Emergency Medicine professor James Roberts, MD is writing a series of articles on electrocardiographic patterns likely to be dismissed as nonspecific but which, in the appropriate clinical context, portend disaster. The latest is a discussion of Wellens syndrome.

Read it here.

A couple of important points about Wellens syndrome: It is highly predictive of proximal LAD disease. The electrocardiographic pattern evolves after pain resolution and apparent “response” of the patient to medical management, yet these patients are in need of early revascularization.

What Ezekiel Emanuel and his supporters don’t seem to understand

---is this:

Patients, especially when they are sick and least able to fend for themselves, are in dire need of an advocate, a professional who will take their part and protect their individual interests against the often competing interests of a hostile and complex healthcare system, whose only concern is reducing costs. Patients abandoned in such a system without their rightful advocate are in a very dangerous position indeed. This is why the classic doctor-patient relationship is so critically important. And this is why Emanuel’s position is wrong. If we are to control healthcare costs, we need to find some way of doing it other than to expect (or, more likely, coerce) physicians to place the needs of society ahead of the needs of their individual patients.

On the whole, Dr. Rich’s post offers a nuanced and respectful view of Emanuel’s writings. I’ve have a post in preparation in an attempt at a similarly nuanced view in response to a challenge from Orac, but Dr. Rich is a hard act to follow.

No one can fix health care on a grand scale

---but maybe your hospitalist program can create a little slice of Mayo in your own corner of the world. If enough of us do this, who knows?

Discharge summaries “grossly inadequate”

---according to this study.

Discharge summaries were available for 99.2% of 668 patients whose data were analyzed. These summaries mentioned only 16% of tests with pending results (482 of 2,927). Even though all study patients had tests with pending results, only 25% of discharge summaries mentioned any pending tests, with 13% documenting all pending tests. The documentation rate for pending tests was not associated with level of experience of the provider preparing the summary, patient’s age or race, length of hospitalization, or duration it took for results to return. Follow-up providers’ information was documented in 67% of summaries.

These were academic medical centers which should have been exemplars of quality documentation!

In today’s push for “efficient use” of hospital resources we see more and more patients shoved out the door with pending test results. This is a huge problem.

Most discharge summaries nowadays are generated by templates. Popular templates that I’ve seen, whether paper-based or generated by the EMR, tend to lack sections devoted to pending test results and follow up needs.

Via Hospital Medicine Quick Hits.