Saturday, July 31, 2010
Friday, July 30, 2010
The most unintentionally funny movie ever made---part 7
Local celebrity Nick Nixon is featured in the opening scene, “as himself.”
Do you really need hard core basic science in premed?
It may not be necessary according to this very small single institution study. Kids who majored in the humanities and skipped organic chem, physics, calculus and the MCAT did just about as well at Mount Sinai medical school as those who took the traditional path.
I have problems with this study, methodologically and philosophically. It was anything but a controlled study. The non-traditional students received a summer “boot camp” in basic sciences to meet state requirements. Baseline characteristics between the two groups were not compared, but it appears that the non-traditional students may have been a very select group on some measures. According to a New York Times report on the project the mean SAT score for the non-traditional students was 1444 (wow!) and “elite” undergraduate schools were heavily represented.
I have questions at a more basic level. I don't think anyone knows how much basic science preparation is optimal in either medical school or undergrad. Maybe we could do with a little less. Moreover, a better background in the humanities can only be a good thing. (You can still major in the humanities and meet traditional med school basic science requirements, by the way. Generations of med students have done it under the “old” pathway). On the other hand, and this is a purely subjective observation, I wonder whether we are seeing a dumbing down of medical education attributable to a gradual de-emphasis on basic science over the past two decades.
Organic chemistry was a pivotal course for premeds at my undergraduate school. It's one of those courses, at least when taught properly, where you can't get by with rote memorization. Basic concepts and patterns had to be understood and built upon. My professor was passionate in his belief that a fundamental understanding of the human body and the natural world was important for success as a physician.
When I see the pervasive move toward promotion and teaching of quackery in academic medicine these days I can't help but think we need more, not less, basic science.
I have problems with this study, methodologically and philosophically. It was anything but a controlled study. The non-traditional students received a summer “boot camp” in basic sciences to meet state requirements. Baseline characteristics between the two groups were not compared, but it appears that the non-traditional students may have been a very select group on some measures. According to a New York Times report on the project the mean SAT score for the non-traditional students was 1444 (wow!) and “elite” undergraduate schools were heavily represented.
I have questions at a more basic level. I don't think anyone knows how much basic science preparation is optimal in either medical school or undergrad. Maybe we could do with a little less. Moreover, a better background in the humanities can only be a good thing. (You can still major in the humanities and meet traditional med school basic science requirements, by the way. Generations of med students have done it under the “old” pathway). On the other hand, and this is a purely subjective observation, I wonder whether we are seeing a dumbing down of medical education attributable to a gradual de-emphasis on basic science over the past two decades.
Organic chemistry was a pivotal course for premeds at my undergraduate school. It's one of those courses, at least when taught properly, where you can't get by with rote memorization. Basic concepts and patterns had to be understood and built upon. My professor was passionate in his belief that a fundamental understanding of the human body and the natural world was important for success as a physician.
When I see the pervasive move toward promotion and teaching of quackery in academic medicine these days I can't help but think we need more, not less, basic science.
More from DB.
Another flawed PE review
---again making the non-evidence based recommendation that CTA is the preferred initial strategy for diagnosis. This time from NEJM.
Thursday, July 29, 2010
More on the dosage and route of corticosteroids for acute exacerbation of COPD
A recent feature on Med Page Today prompted me to revisit this study which showed equivalence of lower dose oral steroids and high dose IV steroids in treatment of AECOPD. The Med Page feature, which interviewed one of the study authors, made a stronger case for lower dose oral steroids than was apparent from the original study and pointed out that the oral route is associated with lower costs and a day or so reduction in length of stay. That makes intuitive sense. Traditionally when we admit a patient with AECOPD and use IV steroids we observe them, after taper to PO, for a day or so on PO treatment before discharge. Starting with PO from the beginning eliminates that step as well as the two or three days of IV steroid taper.
As for the doses compared in the JAMA study:
I was a little bit surprised at the claim that the guidelines recommend lower dose oral therapy, so I checked the primary sources. Sure enough, ATS, Global Initiative and ICSI guidelines all recommend oral therapy for patients who can tolerate PO, in the range of 40 mg or so of prednisone per day.
This will probably change my practice but I'm not sure how, just yet. The fact that 22% of patients started on PO crossed over into the IV group bothers me a little bit.
Med Page Today's video interview with one of the authors is shown here.
As for the doses compared in the JAMA study:
We excluded patients whose initial daily dose of corticosteroids fell outside a conventional range of treatment. This included patients who received less than 20 mg or more than 80 mg of oral prednisone and those treated intravenously at doses lower than 120 mg or higher than 800 mg of prednisone equivalents each day.
I was a little bit surprised at the claim that the guidelines recommend lower dose oral therapy, so I checked the primary sources. Sure enough, ATS, Global Initiative and ICSI guidelines all recommend oral therapy for patients who can tolerate PO, in the range of 40 mg or so of prednisone per day.
This will probably change my practice but I'm not sure how, just yet. The fact that 22% of patients started on PO crossed over into the IV group bothers me a little bit.
Med Page Today's video interview with one of the authors is shown here.
Berwick preparing a point-by-point rebuttal
---for his eventual hearings according to this article. Will he be asked the right questions?
Conventional CPR no better than compression only in two just published trials
Just out in NEJM, two RCTs. No difference in this study and a trend toward better outcomes for compression only in patients with primary cardiac arrest or shockable rhythm in this study.
Wednesday, July 28, 2010
I forgot my own fifth blogiversary!
I just realized it today, a few days late. Ordinarily I would have let it pass, but this is a milestone. It's a good time to reflect and reminisce, so here goes.Med Rants, Medpundit and Rangel MD were the first medical blogs I recall. Med Rants was the first blog to link to me, that I know of. Retired Doc was also an early supporter (thanks guys!).
In order to justify blogging in my own mind I had to find a niche, something not too many other medical bloggers were doing. Many medical blogs were news aggregators. I didn't want to do that because I believed then, as I do now, that scientific advances in medicine shouldn't be treated as “news” in the ordinary sense. Then there were the bloggers who related personal stories from their practices. There was plenty of that out there, and it was not where I felt I could make a unique contribution. Then there were the consumer information blogs, far too many for me to feel like starting a new one. Finally I realized that there was only a handful of blogs doing what really interested me---hardcore clinical blogging directed towards medical professionals in practice and training. That would be my focus, especially in the area of hospital medicine.
Before long I realized that public policy issues increasingly caught my blogging attention. That has seen a precipitous increase in this the most interesting political season in my memory. Despite that, the main focus remains clinical.
From the first I felt it very important to define my audience. I knew I couldn't write clinical content with any nuance or precision for professionals and consumers at the same time. It takes a special talent to do both. I realize that decision has cost me significantly in terms of blog traffic.
I will keep this endeavor going as long as it's still fun. Y'all will have to put up with me a while longer.
Center for Medicare and Medicaid Innovation pilot projects
---are in effect research on human subjects. What about the ethics of this research? asks Dr. Wes.
The UK's reality check about the National Health Service
Apparently they're not as romantic about their own health care system as Berwick is according to this government white paper (H/T to Dr. Wes). Arguments that the NHS is a model health care system are falling apart at the seams as is, apparently, the NHS itself.
Unraveling the enigma of Donald Berwick
In several earlier posts I said that Berwick's detractors as well as his supporters take a simplistic approach about his positions. A nuanced view of Berwick would be that his statements on health care are,at least on the surface, incoherent. How, for example, does he reconcile his contradictory positions, favoring rationing and central control on the one hand while at the same time espousing individual patient choice and consumerism?
A recent post at the Drug Wonks blog points to a primary source that may offer some insight. It's a document from the IHI entitled Best Health Care Results for Populations: The “Triple Aim.” The document isn't signed by Berwick but it is Berwickian. Berwick was head of the IHI and the document contains the substance of remarks he made in his keynote address at HM 2008. The subtitle lists the three incompatible aims and hints at Berwick's incoherency: Achieving the optimal balance of good health, positive patient experience of care, and low per capita cost for a population. So, if the document could explain away the incompatibility of these goals it could reconcile the inconsistency of Berwick's statements.
After the usual claims that the U.S. has the most expensive health care in the world with anything but the best quality the reader is offered this:
Is what's hinted here that we'll have to slash billions for hospital admissions, technology and diagnostic tests, but that's OK because we'll make it up in savings resulting from more basic care and prevention? Could this be the magical thinking that reconciles Berwick's positions?
A little later on in the document:
No doubt referring to those conditions prevalent at the end of life. I guess there's a sense here in which reduced care for the “episodic and urgent concerns” of the very ill and the very old, and improvement in the population's health, are compatible. If you know what I mean.
For the positive patient experience aim the IHI model would include a measure such as “They give me exactly the help I want and need exactly when I want and need it.” (Likert Scale: strongly disagree to strongly agree) . There's Berwick's extreme consumerism. Left unanswered is how that aim would be accomplished alongside central control and slashing services to the very ill and very old.
Another measure in the IHI triple aim model is how many people have a BMI of over 30. Think of the money we could save if we could solve problem! After all most of our health care expenditures arise from diseases of choice, not chance. So does Berwick intend to appoint an obesity czar equipped with all the legal muscle he can squeeze out of the Constitution? Would it work? If the grand experiment in my home state of Arkansas is any indication, no. Former Arkansas Governor Mike Huckabee was an obesity czar. After an epiphany concerning his own obesity he put the entire state on a diet. But despite being in the top two states for anti-obesity public initiatives Arkansas remains among the most obese states in the U.S.
The ultimate solution to reconciling these conflicting aims, according to the report, lies in the integrator. In its pure notion the integrator could consist of just about anything---a health care system, an insurance company, a group of leaders. Berwick even suggested at SHM 2008 that it could be the hospitalist movement (go figure). Ultimately, though, the discussion focuses on the British National Health Service and its Primary Care Trusts as the best model for the grand integrator:
How would it all work? The grand integrator would be given lots of power and charged with lofty goals. For example:
Grandiose, nebulous and intrusive are adjectives that come to mind.
So that's Berwick's thinking. You can decide whether it's merely outside the box or beyond the pale. Whatever IHI's Triple Aim document may tell us about Berwick's thinking it fails to articulate a coherent stance on effective health care. Only the credulous among us would be convinced that it does.
A recent post at the Drug Wonks blog points to a primary source that may offer some insight. It's a document from the IHI entitled Best Health Care Results for Populations: The “Triple Aim.” The document isn't signed by Berwick but it is Berwickian. Berwick was head of the IHI and the document contains the substance of remarks he made in his keynote address at HM 2008. The subtitle lists the three incompatible aims and hints at Berwick's incoherency: Achieving the optimal balance of good health, positive patient experience of care, and low per capita cost for a population. So, if the document could explain away the incompatibility of these goals it could reconcile the inconsistency of Berwick's statements.
After the usual claims that the U.S. has the most expensive health care in the world with anything but the best quality the reader is offered this:
“Health care systems have evolved around the concept of infectious disease, and they perform best when addressing patients’ episodic and urgent concerns. However, the acute care paradigm is no longer adequate for the changing health problems in today’s world. Both high- and low-income countries spend billions of dollars on unnecessary hospital admissions, expensive technologies, and the collection of useless clinical information. As long as the acute care model dominates health care systems, health care expenditures will continue to escalate, but improvements in populations’ health status will not.”3
Is what's hinted here that we'll have to slash billions for hospital admissions, technology and diagnostic tests, but that's OK because we'll make it up in savings resulting from more basic care and prevention? Could this be the magical thinking that reconciles Berwick's positions?
A little later on in the document:
The recent Dartmouth Atlas work reveals waste in resources for care at the end of life, but the financial incentives are misaligned to produce change. Per capita US health care costs continue to rise, spurred by increasing use of technology as well as increasing prevalence of various medical conditions.5
No doubt referring to those conditions prevalent at the end of life. I guess there's a sense here in which reduced care for the “episodic and urgent concerns” of the very ill and the very old, and improvement in the population's health, are compatible. If you know what I mean.
For the positive patient experience aim the IHI model would include a measure such as “They give me exactly the help I want and need exactly when I want and need it.” (Likert Scale: strongly disagree to strongly agree) . There's Berwick's extreme consumerism. Left unanswered is how that aim would be accomplished alongside central control and slashing services to the very ill and very old.
Another measure in the IHI triple aim model is how many people have a BMI of over 30. Think of the money we could save if we could solve problem! After all most of our health care expenditures arise from diseases of choice, not chance. So does Berwick intend to appoint an obesity czar equipped with all the legal muscle he can squeeze out of the Constitution? Would it work? If the grand experiment in my home state of Arkansas is any indication, no. Former Arkansas Governor Mike Huckabee was an obesity czar. After an epiphany concerning his own obesity he put the entire state on a diet. But despite being in the top two states for anti-obesity public initiatives Arkansas remains among the most obese states in the U.S.
The ultimate solution to reconciling these conflicting aims, according to the report, lies in the integrator. In its pure notion the integrator could consist of just about anything---a health care system, an insurance company, a group of leaders. Berwick even suggested at SHM 2008 that it could be the hospitalist movement (go figure). Ultimately, though, the discussion focuses on the British National Health Service and its Primary Care Trusts as the best model for the grand integrator:
Primary Care Trusts are the center of the National Health Service (NHS) in England and control over 80 percent of the NHS budget. There are over 100 Primary Care Trusts in England, each of which is responsible for the health of the population they serve. Each Primary Care Trust serves approximately 600,000 individuals. Trusts receive funding through the NHS based on a weighted capitation scheme that corrects for deprivation, age, and market forces.
How would it all work? The grand integrator would be given lots of power and charged with lofty goals. For example:
Identify the needs of the population.
Manage a population-based budget for the health care needs of a defined
population.
Help align the financial payment structure so that population health outcome is
rewarded. ..
Design standards for primary and acute care services.
Evaluate the effectiveness of new technologies and treatments.
Provide a mechanism for “remembering” each patient (could be an integrated
medical record). ..
Measure performance in new ways, including developing assessments that
measure health experience down to the patient level. ..
Connect individual health with public health.
Form partnerships with local communities.
Grandiose, nebulous and intrusive are adjectives that come to mind.
So that's Berwick's thinking. You can decide whether it's merely outside the box or beyond the pale. Whatever IHI's Triple Aim document may tell us about Berwick's thinking it fails to articulate a coherent stance on effective health care. Only the credulous among us would be convinced that it does.
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