Indoctrination in the eclectic healing arts yields CME credit for doctors

While examining the brochure cognitive dissonance set in: just as my trusty baloney detector was going off I said to myself “Wait---this activity is cosponsored by two reputable medical schools, accredited by the ACCME and approved by the AMA for credit toward the Physicians Recognition Award!” Not only that, there’s no support from Evil Pharma and the faculty list reads like a parade of stars including Andrew Weil, Larry Dossey and Tieraona Low Dog.

While a few scientific trappings are included in the language (“evidence based”, “critical”, “findings”) most of the titles are promotional or, at the very least, non critical. A sampling from the list includes Qi Gong: Enlivening Energy through Ancient Practice; Reiki: Healing Yourself and Others; The Ayurvedic Understanding of Chronic Diseases: Arthritis, IBS and Asthma; Revival of Curanderismo: Mexican Folk Medicine and Rituals and, finally, a sweat lodge ceremony.

Aldosterone receptor antagonists: who, when and how

This review in CCJM covers current and future indications and safety concerns.

Healthy skepticism on the quality movement by a hospitalist thought leader

Background: Recent posts from DB and Retired Doc.

Robert Wachter, one of the originators of the term hospitalist, has a commentary on the quality movement in the June 21 issue of JAMA. He first focuses on accountability for “core measures” promulgated by CMS, JCAHO and others and concludes with speculation on how the quality and information revolutions will change the medical profession.

He suggests, with examples from his own institution (UCSF), that this new accountability has fostered a perfunctory approach to quality with unintended consequences such as patients inappropriately receiving multiple pneumococcal vaccinations or receiving inappropriate antibiotics for heart failure. Worse, this obsession with report cards (“playing for the test” as Wachter terms it) may divert attention away from more important aspects of quality which don’t happen to be the focus of the current report cards. I’ll go a step further and suggest that the quality movement as is now being played out publicly may be of little more than cosmetic importance.

While many of the core measures are of proven effectiveness (e.g. angiotensin converting enzyme inhibition for heart failure and aspirin for acute coronary syndrome) pneumococcal vaccination may be an exception. According to this Cochrane review the pneumococcal vaccine currently approved for adults is not effective in preventing pneumonia or mortality from pneumonia. Although it appears to have some ability to prevent bacteremia the NNTs for bacteremia and mortality from invasive pneumococcal disease are 20,000 and 50,000 respectively! In spite of this fact, pneumococcal vaccination is a major target for public report cards and pay for performance programs.

Wachter goes on to sound a cautionary note about electronic medical records and computerized physician order entry, reminding us of the Cedars-Sinai debacle, increased mortality in a pediatric population after implementation of CPOE and other examples of adverse consequences. He notes that the success stories of EMR and CPOE come from “institutions that built homegrown computer systems over decades and were staffed with physicians, researchers, and administrators who believed strongly in the value of the systems.”

While Wachter’s skepticism about the current state of the quality and information technology revolution is welcome his predictions concerning the eventual effect on the medical profession are chilling. Citing known practice variations and publicly reported quality breaches he asks “….can there be any doubt that central control of physicians' practice will need to be exercised, especially when there is evidence of substandard performance on publicly reported measures?” Speaking of computer systems which can “ruthlessly enforce rules and standards” he entertains hope that high quality of care can somehow be “electronically ensured.” It all sounds a bit Orwellian to me.

Wachter envisions medical practice becoming increasingly formulaic and rote with diminishing need for the “virtuoso diagnostician” of old. Those arts of medicine that survive the revolution, he suggests, might include procedures, counseling and care coordination. Maybe those clinical and basic science skills I’ve ranted about won’t be so important after all. Get ready for the new breed of physician: the Stepford doctor.

Therapeutic desperation in pulmonary embolism

In a registry of 488 unstable patients reported in Chest who underwent thrombolysis for pulmonary embolism, 8.2% failed treatment, as evidenced by persistent hemodynamic instability and echocardiographically defined right ventricular dysfunction. Those patients were then subjected (not randomly, but at the discretion of their attending physicians) to either surgical thrombectomy or repeat thrombolysis. Outcomes were better in the surgical group (statistically significantly fewer recurrent PEs and a non statistically significant improvement in mortality). 79% of surgically treated patients had an uneventful subsequent hospital course.

The accompanying editorial points out that although high level studies are lacking, this report, adding as it does to the recorded experience in treating such patients, provides some practical lessons. Surgical rescue is feasible. Clinicians should have contingency plans for failed thrombolysis based on resources available at their respective hospitals.

A fully accredited month of navel gazing and woo-woo for 4th year medical students

Sponsored by none other than the American Medical Student Association (AMSA). Founded in 1950 as the student subsidiary of the American Medical Association, the organization severed ties with the AMA in 1967. Although its PharmFree initiative purports to foster professionalism and scientific integrity, AMSA enthusiastically supports unscientific teachings and practices under the rubric of complementary and alternative medicine and receives support from the American Holistic Medical Association.

How do they resolve the inconsistency? By questioning the definition of science, and suggesting an “alternative” scientific standard for CAM. Their general information page on integrative, complementary and alternative medicine contains the statements that for CAM therapies “…the issue of what constitutes a scientific study must be resolved” and “…the type of study necessary and appropriate for CAM therapies needs to be addressed before significant advances will be made in the area of scientific evidence for CAM” and finally “…the type of study necessary to evaluate CAM is unclear.”

In keeping with this fuzzy philosophy of science AMSA is sponsoring HEART---the Humanistic Elective in Alternative medicine, Activism and Reflective Transformation, a nearly month long retreat for 4th year medical students during which students gain credit for a senior elective. Based on a sample schedule from a past retreat the elective will feature studies on the Healing Wheel, Yoga, meditation, naturopathy, Ayruvedic medicine, shamanism, Curanderos and traditional Chinese medicine. What scientific standard will be applied to these modalities during the elective? Perhaps it’s revealed in the slogan at the top of the HEART information page: “It is only with the heart that one can see clearly; what is essential is invisible to the eyes….”

DB weighs in on the definition of Internal Medicine

And well he should. After all he is president of the Society of General Internal Medicine. I share his vision for internal medicine. The curmudgeonly, somewhat tongue in cheek definition I lifted from the pages of Art and Science of Bedside Diagnosis, thought provoking as it is, may push some buttons.

I grew up with the older, somewhat more traditional view of Internal Medicine. My father was a GP who had great respect for internists. He would have become one himself had his training not been interrupted by the Second World War. He would refer his most difficult cases to internists. These were patients in need of special diagnostic sleuthing. In those days internists were often known as diagnosticians. Internists were clearly specialists.

Years later in medical school at Vanderbilt my notion of the internist as specialist-consultant was reinforced as I encountered internal medicine role models who were master clinicians and great teachers. The exemplar of the internist there was Thomas Brittingham. His example helped influence me to choose Internal Medicine.

Early in private practice I first became aware of Internal Medicine’s identity problem. Asked by an acquaintance what kind of doctor I was I replied that I was an internist. She, thinking I meant intern, asked “are you learning anything?” That day I became a “specialist in Internal Medicine.” I never again told anybody I was an internist.

Over the years many factors---the rise of Family Practice as a specialty, the pressures of managed care and the advent of “med-peds”---have further muddied the definition of Internal Medcine. Like DB and Dr. Sapira I believe primary care specialty is a poor characterization of the field.

So what is Internal Medicine? DB says internists provide comprehensive care. That statement is true but it doesn’t define the specialty. Is it a comprehensive care specialty slightly less comprehensive than Family Practice? Another definition I once read characterizes it as the specialty of non-surgical, non-obstetrical diseases of adults. These definitions are lacking. The American Board of Internal Medicine and the American College of Physicians have done a poor job of defining the specialty. Those of us who were trained in the “grand tradition” know what Internal Medicine really is. I only hope DB and other thought leaders in the field can come up with the magic words to define it.

What is Internal Medicine?

I’m trudging through the third edition of Sapira’s Art and Science of Bedside Diagnosis. Full of medical pearls, musings and humor, it’s much more than a reference on physical diagnosis. It’s a book to read at the beach or by the fire. On page 7 I found this definition of Internal Medicine:

"(1) (Obsolete) That nonsurgical medical specialty concerned with clinical diagnosis and scientific therapy. Previously a secondary-care consultant specialty, it underwent crisis by lysis in the late 1960s; (2) (contemporary) a biopolitical consortium of balkanized tertiary nonsurgical subspecialties, which, oxymoronically, claim it to be a primary care specialty."

Hyperkalemia review

This review of hyperkalemia appearing in the Texas Heart Institute Journal focuses on the acute complications of hyperkalemia, the mechanisms of cardiac toxicity and emergency treatment. Modalities of treatment for hyperkalemia can be grouped in three categories in descending order of urgency and rapidity of effect, and ascending order of duration of action. These categories consist of 1) membrane stabilization to directly antagonize the cardiac effects of hyperkalemia (calcium administration), 2) measures to shift potassium into the intracellular space (insulin with or without glucose, beta agonists) and 3) measures to eliminate potassium from the body (ion exchange resins, dialysis).

The authors recommend all three categories of treatment if there are ECG abnormalities or if the serum potassium exceeds 6.5. However, the indications for calcium administration are somewhat controversial. This emedicine review of hyperkalemia recommends calcium if arrhythmia, widening of the QRS or absence of P waves is present, but not if the only electrocardiographic manifestation is peaked T waves.

Calcium is recommended only in extreme situations if the patient is taking digitalis preparations, and only as a slow infusion (over 30 minutes). If digitalis intoxication is the cause of hyperkalemia digoxin-fab fragments (digibind) are indicated.

Antihypertensive agents and diabetes

Antihypertensive drugs have disparate effects on blood glucose regulation. This bench-to-bedside review in Mayo Clinic Proceedings covers physiologic mechanisms and clinical studies which show that thiazide diuretics and beta blockers increase the risk for diabetes while angiotensin converting enzyme inhibitors and angiotensin receptor blockers have the opposite effect.

Despite their diabetogenic effects thiazide diuretics improved cardiovascular outcomes in ALLHAT. However, the duration of follow up in ALLHAT may have been too short to detect adverse consequences of diabetes.

Background: additional commentary and links from DB here and here.

Tight white coat syndrome

Are doctors the next targets of the fat police? The medical profession gets a gentle scolding in this Medscape video editorial---we’re too fat. Obese physicians suffer a credibility gap says Dr. Michael Dansinger. We become less effective in helping patients because it’s a case of “do what I say and not what I do.” I can see it now---physical fitness tests incorporated into future certification exams.

Metabolic risks of schizophrenia and antipsychotic medications

Complex interactions exist between mental illness, antipsychotic medication and cardiovascular risk factors. The purported causal relationship between atypical antipsychotics and diabetes has been particularly newsworthy.

Evidence points to multiple causal factors. Schizophrenic patients have an underappreciated risk of cardiovascular disease which tends to be under treated. Antipsychotic drugs seem to be associated with increased risk of diabetes (and its associated dyslipidemias) and the risk varies among agents. Multiple mechanisms are involved including increased appetite and weight gain, effects on histaminic and cholinergic receptors and direct effects on the pancreas.

Recent evidence suggests that the use of antipsychotic agents for behavioral problems associated with dementia is associated with adverse cardiovascular outcomes.

The benefits of medications may outweigh the metabolic risks in many patients. In such cases a thorough baseline assessment of cardiovascular risk factors coupled with close monitoring during treatment is essential.

The topic is thoroughly covered in this review from Clinical Diabetes.

Is Fosamax the next Vioxx?

The lawyers are interested. The problem is osteonecrosis of the jaw, and class action status is being sought. Although fosamax is a major target, according to this systematic review in the Annals of Internal Medicine the major problem with biphosphonates and osteonecrosis is in patients receiving intravenous biphosphonates for myeloma and metastatic bone disease.

DIC review

February 21 Thrombosis Journal.

Just out in NEJM: old news about pulmonary embolism (PIOPED II)

Despite popular opinion CT pulmonary angiography has not emerged as the diagnostic modality of choice for PE. Finally, 16 years after PIOPED was reported in JAMA and 9 months after I posted the PIOPED II findings here PIOPED II is reported in NEJM.

Detailed findings, discussed in my earlier post, will not be repeated here. Suffice it to say that although CT is a useful addition to the diagnostic armamentarium it does not emerge as a clear cut stand alone modality of choice. Just as with V/Q scanning, the predictive power of CT is poor when test results are discordant with pre-test probability. A Bayesian approach using an integrated clinical algorithm is still the best method. There is a 17% false negative rate with CT. Fortunately small peripheral emboli, of questionable clinical significance, account for the majority of these false negatives. This is inferior to nuclear scanning which, if normal (as distinguished from “low probability”), demonstrated 100% sensitivity in PIOPED. Put another way, no patient in PIOPED with a normal perfusion scan had PE. Editorial comment in the same NEJM issue is here.

Questions raised by firing of CMAJ editors

Heated discussion continues about the Canadian Medical Association Journal (CMAJ) since my post May 20. The bitter dispute between the journal owners and the editors raises fundamental questions.

What should a medical journal strive to be?
As pointed out in this BMJ editorial from several years ago a journal’s niche could occupy any point on a broad spectrum, “from being like Brain, a forbidding, research based journal, to Cosmopolitan, a magazine full of froth and colour.” But such a niche needs specific definition. Confusion results when a journal tries to be too many things. Therein lies part of the problem at CMAJ. The journal should define what it intends to be---a scholarly research journal, a medical news magazine or a political rag. It can’t be all those. Who, for example, would think of publishing peer reviewed research in Medical Economics?

What is the appropriate role of an editor?
Perhaps that depends on the type of journal in question. If the journal purports to be a scholarly scientific publication the editor should be objective, neutral and “disinterested.” There should be no social or political agenda and no personal bent that might bias the selection or editing of articles. Dr. John Hoey, though, seems to have other ideas. In the May 11 NEJM piece in which he recounts his firing from CMAJ he writes that “the defining characteristic of an editor is quixotic idealism….” Quixotic idealism? Well, whatever that means it sounds anything but objective or neutral. Concerning the attributes of an editor he writes that “An eager propensity to poke a stick into something or somebody is also useful.” Useful, perhaps, for The American Spectator.

What is editorial independence and are there limits?
Dr. Hoey’s absolute notion of editorial independence amounts to a lack of editorial accountability. But editorial independence must be balanced against accountability. In a May 23 piece in CMAJ the interim editors write “Editorial independence should not confer immunity from accountability.” In that same article the authors note that the World Association of Medical Editors (WAME), which Hoey cites in defense of his views, has reconsidered the concept of editorial independence. Indeed, in its May 15 2006 revision, the section titled "Editorial Independence" has been retitled "The Relationship Between Journal Editors-in-Chief and Owners."

Is Hoey’s concept of absolute independence realistic? As pointed out in a recent Lancet editorial on this matter “The CMA might legitimately argue that they should not be saddled indefinitely with an editor whose policies and perspectives were not in keeping with its own views. The publisher of The Economist might not hire the editor of The Nation, and vice versa. So what is the voice that should be reflected in a journal owned by a medical association?” Consider the American Medical Association and its lobbying efforts for tort reform. Suppose the editor of JAMA, the AMA’s general medical journal, wrote and selected articles predominantly in opposition to tort reform. Would it be appropriate for the AMA to intervene? It would in such political issues where the membership had a stake, as opposed to purely scientific questions in which detached neutrality is essential. The only way to avoid such a conflict is to avoid mixing political commentary and science in the same journal.

What are the risks of political influence in a scholarly scientific journal?
Science influenced by any sort of agenda is biased and corrupt. I have given examples in the pages of this blog here, here and here. Orac gives an example here. Scientific discourse differs so fundamentally from political debate that the two are hardly compatible. The former involves objective discussion between disinterested parties while the latter involves impassioned contests between those with competing interests, with participants bolstering their positions according to their own biases. But as I posted on May 20, Hoey seems to have no problem mixing scientific inquiry with politics.

Should there be a demarcation between scientific reporting and other content such as journalism and political commentary?
Although the essential importance of demarcation should be self evident, not all agree. Another Lancet editorial on the firing said “To distinguish between a journal's responsibility to publish peer-reviewed research and investigative journalism is false.” But all sorts of problems emerge when the distinction is not clear. As the same Lancet editorial points out, “According to the CMAJ, the journal's publisher ordered a news article containing a survey of women's experiences of trying to obtain the Plan B morning-after pill (levonorgestrel) to be withheld, after receiving a complaint from the Canadian Pharmacists Association. The CMA's withdrawal request was justified on the grounds that the survey of women's experiences constituted scientific research, rather than journalism, and the editorial team should therefore have sought ethical counsel and peer review of the article.” Jerome P. Kassirer and others in this CMAJ editorial disagreed with “Contrary to the claims of the CMA that the Plan B article could be construed as a scientific study and was subject to all the requirements of such an investigation, in the opinion of the Committee, the report (both as it was intended to be published and as it eventually appeared) does not meet the definition of 'research' as understood in medical science.” Though the informal survey of women seeking emergency contraception was not research these comments indicate that the point was in dispute. The distinction was blurred, and one of the essential points of contention between the publisher and the editors was whether it did in fact constitute research. Perhaps a clear distinction would have averted the crisis.

Are there solutions?
Political debate, medical journalism and rigorous scientific reporting, each of which has an important role, are best played out in separate venues. This not only avoids confusing the different forms of writing but also minimizes conflicts of interest by keeping politics and personal bias at arm's length from scientific inquiry. Structures are already in place to accomplish this. Most professional societies have companion publications which serve separate purposes. I’ll draw an example from my own specialty organization, the Society of Hospital Medicine, which has just launched its scientific journal, The Journal of Hospital Medicine. It is a pristine, scientifically rigorous publication devoid of politics, self-promotion or items of personal or economic interest to hospitalists. The Society’s companion tabloid style publication, The Hospitalist, contains all those things. That’s just fine, because it makes no pretense at being a scholarly scientific journal.

Heparin for ischemic stroke: still not evidence based

This study looked at low molecular weight heparin in various subsets of patients with atrial fibrillation, published in Stroke. Outcomes were not improved.

Platelets and vascular events

This bench to bedside review in Mayo Clinic Proceedings covers clinical trials of platelet antagonists and discusses the biologic mechanisms. Open access to the full text of this article is available 6 months after publication date.

Kudos to Medpundit

I knew there was another reason to miss Medpundit. She was, on occasion, willing to challenge the PC orthodoxy in medicine. In researching my post on the CMAJ mess I overlooked this.

Straight to the guts of the issue, she said: “Well, it is the Canadian Medical Association's journal, so they're well within their rights to tell the editors to tone down the politics, aren't they? It happens all the time to political writers and editors. It isn't as if the Association asked the editors of the CMAJ to suppress scientific research papers. Political proselytizing, like religious proselytizing, doesn't belong in a scientific journal. And if the editors want to make the journal political, then they should realize they have to play by the same rules as every other political editor.”

Wish I’d said it.

Are state medical boards becoming draconian?

Perhaps so, opines Chris Rangel. State boards, suffering from an image of being too lax, are under public pressure to police the medical profession more aggressively. And, according to Dr. Rangel, at least in the state of Texas, an increasing frequency of complaints to medical boards, often frivolous, may be an unintended consequence of successful tort reform in that state. He writes that physicians in Texas fear the board is getting out of control and notes the case of one doctor who was “fined $500, ordered to take classes on documentation, publicly reprimanded, and all for forgetting to time and date an addendum note in a chart.” (Though I have no hard data I’ve heard of instances of this sort of thing).

Rangel writes that board investigators tend to take the attitude that the doctor is guilty until proven innocent. If that’s not already true one influential consumer activist group wants the standard to move in that direction. The Public Citizen Health Research Group wants “A reasonable statutory framework for disciplining doctors (preponderance of the evidence rather than beyond reasonable doubt or clear and convincing evidence).” And just how “reasonable” is preponderance of evidence as a standard for disciplinary hearings? I had that standard of explained to me by a plaintiff attorney when I was on jury duty a few years ago. He asked prospective jurors to imagine preponderance as analogous to “one thousand and one grains of sand” balanced on the scales of justice against “one thousand grains of sand.” Wow. Two grains of sand shy of guilty until proven innocent.

Related post here.

Just the FACTTs (Fluid and Catheter Treatment Trial)

Just in: For patients with ALI and ARDS, pull the PA catheter and keep ‘em dry. These long awaited results have been posted on line ahead of print in NEJM along with related editorials here and here.

We’ve long suspected the dry strategy was better. However up to now the jury was still out on the PA cath.

I’ve previously commented on the PA catheter and the wet-dry debate.