---and there’s no sign of it getting better any time soon. DB has written another excellent post on the importance of Internal Medicine. He concludes with:
I hope that CMS will reconsider the current freeze on funding new positions for residency training. Increasing medical school positions and moving towards universal coverage will accomplish little if we do not have the right number of the right types of physicians. This unknown crisis in health care is not often addressed. I hope other internal medicine bloggers will join me in leading the process of explicating and championing this problem. So to Happy, RW, Kevin and others - pile on.
OK, I’ll pile on with this---
Among the many reasons for the decline of General Internal Medicine are these:
General Internists are among the poorest paid physicians in all of medicine.
Our most influential professional organization can come up with nothing better to promote our field than “Doctors for Adults.”
A proposal is on the table to phase out our specialty in the next 10-20 years.
Who in their right mind would sign up for that?
The Clinical Cases and Images Blog recently cited a study on how house officers utilize on line information resources at the point of care, comparing PubMed and UpToDate. It turns out that searchers found the answer to their clinical question 83% of the time via UpToDate and 63% of the time using PubMed. UpToDate searches took an average of about 4 minutes while PubMed searches took almost a minute longer.
What does this all mean? Is UpToDate better than PubMed? It depends on what you value in a resource. Given that virtually all of UpToDate’s content is based on PubMed indexed articles, searchers, theoretically, should be able to find everything in PubMed that is available in UpToDate. That, of course, would expand the time differential for most users, who are relatively unskilled in PubMed searching. PubMed training with the on line tutorial and a little practice greatly enhances speed and closes this time gap, but there are still the steps of critical appraisal and synthesis.
When all is said and done PubMed is more rigorous and precise. Unlike UpToDate with PubMed you, the searcher, control the search and know the exact strategy used. That precision is essential if you’re researching for a presentation or a systematic review. It may be less important in searching clinical questions for patient care.
According to the Clinical Cases and Images Blog UpToDate, at least in the minds of some, is becoming the “universal textbook of medicine.” They pose the question:
Do you remember the last time you opened Harrison's to consult about a clinical topic? Was that in 1997 or 2001?
Well, just the other day as a matter of fact. A traditional textbook like Harrison’s or Cecil’s is better suited for background reading. If you want, for example, a general overview of carcinoid syndrome encompassing clinical features, pathophysiology, diagnosis and treatment the traditional textbook is a better resource. This is the reading you’ll do for general learning, relaxing at home. UpToDate is designed more for focused questions, so that reading for background learning may require navigating through seemingly endless cross links. (By the way, Harrison’s now has a companion product, Harrison’s Practice, which is being marketed as an on demand point of care look up reference).
If UpToDate has one consistent advantage it’s time efficiency. Even four minutes can seem long for a busy practitioner at the point of care. The biggest barrier to widespread implementation of evidence based medicine is time. As I illustrated once before, the constraints of busy practice don’t usually allow time for all the steps in the traditional EBM drill: formulating the focused question, searching, appraisal and synthesis. As the field of EBM matures it appears that physicians are more and more willing to pay large sums of money to have someone else carry out those steps for them. Increasingly often that someone else is UpToDate.
A few vocal individuals and groups are beating the drum for the elimination of pharmaceutical industry support for continuing medical education. The detractors cite no evidence (there isn’t any) to back up their recommendations. Also conspicuously lacking from these discussions are the voices of practicing physicians. Survey after survey has indicated that practicing doctors overwhelmingly favor the preservation of industry support for CME. Here’s another one to add to the list, via CE Measure.
The agitators claim that by getting rid of drug company support the medical profession will take control of its education. But what’s becoming increasingly clear from these survey data is that the while the agitators may well hijack control of professional education they don’t represent the profession. Doctors in the trenches of patient care have been silent on this issue, seemingly oblivious to this growing agenda to restrict their CME choices.
Theresa Chan over at Rural Doctoring just attended Bob Wachter’s 12th Annual Hospital Medicine course. While there she did some profuse Twittering, serving up just enough information about the conference to remind me how disappointed I was that I was unable to attend this year. My reasons for skipping this year’s course (I have attended in the past) were largely economic. Like many doctors I have a budget. There are competing demands on that budget. There were a wife, kids and grand kids to think of. There were charitable giving opportunities. There were medical bills. I am an adult. I can’t have everything I want. But I’m disappointed.
I’ve done a lot of ranting lately about the folks who don’t want the pharmaceutical industry to help underwrite the expenses of CME. Doctors already pay a great deal for their continuing professional education. They want us to pay more. They argue that, for the individual doctor, money is no object in seeking the best quality CME. As real world experience of many practicing physicians can attest, they are wrong.
I started live blogging from meetings about a year ago. These are conventional blog posts (more my style than Twittering) including brief mention of some of the presentations that interested me most along with an overview of the conference and a word or two about commercial influence. (See examples here, here, here, here, here, here, here, here, here, here, and here.
How many attendees in San Francisco this year realize that CME is under attack, and that if practicing doctors don’t raise their collective voice against the rising inquisition (to borrow a word from Thomas Stossel) this may be the end for Bob’s course and others like it? (Bob himself has said so---see his comment thread in the link above).
We can’t take anything for granted in our professional lives these days. I’ll try to be optimistic, and hope to join Bob and the other attendees in San Francisco next year. We’ll probably see a wrap up post from Bob in the coming days about the course. Maybe he’ll weigh in on the “CME inquisition.”
I would like to thank Bob for his hard work and dedication in keeping this course going. I am especially grateful for his generosity in allowing free on line posting of the slides from most of the talks. I look forward to pouring over this content and examining the cited references! But if that’s the next best thing to being there it’s no substitute. A relaxing, spectacular location away from the tedium and hassles of home and work supercharges the mind for more effective learning. And, of course, there’s the opportunity to interact with an all star faculty as well as the networking and shared enthusiasm among the attendees.
For those of you who maintain that industry funding for this type of CME is corrupting, I issue this challenge. Examine the lecture slides. If you find content that is inaccurate, unscientific, unbalanced or distorted in any way please leave a comment. I would also be interested in comments from readers who attended the meeting.
A shrill minority of critics are calling for a ban on drug company support of CME. Though devoid of evidence and not shared by the vast majority of practicing doctors their arguments are getting a lot of attention in popular media, medical journals and public policy discussions. Concerned about this non-evidence based back lash and the threat it poses to CME, the Center for Medicine in the Public Interest (CMPI) recently held a symposium to examine the issue. Having gone through the audio presentations, transcripts and PowerPoint slides (all available here) I would like to highlight what I think are some key points.
The inquisition against industry funded CME is censorship. It is based on the premise that practicing doctors lack the skills to critically appraise content and are too lazy to look up primary sources. So, the reasoning goes, give intellectually lazy doctors an intellectually lazy solution: a simple litmus test---the presence or lack of industry support.
Medscape Editor in Chief Dr. George Lundberg said in his keynote that the arguments of the CME inquisitors are ideological (doctors ought to have to pay for their CME, doctors are being bought, drug company sponsorship is dirty, etc.) rather than evidentiary.
One of the arguments for doing away with industry support is that cliché about the medical profession needing to take control of its continuing education. If only the profession, with adequate representation of its rank and file members, would! Survey after survey, according to Lundberg, shows that doctors overwhelmingly favor the preservation of industry support. (Later in the program Marissa Seligman, Chief of Clinical and Regulatory Affairs at Pri-Med, a CME provider, presented some of the actual data).
One of the audience respondents to Lundberg’s remarks pointed out that by a ratio of eight to one doctors’ on line medical reading is NOT for CME credit. State requirements for CME hours are insignificant compared to the actual reading doctors do. Many doctors, when they go on line, already have their required hours and don’t bother seek additional credit. So what happens if the McCarthyites have their way? While the quality and choices of accredited activities will shrink dramatically the influence on what doctors read on line will be insignificant.
One of the speakers was Dr. Jack Lewin, the President of the American College of Cardiology (ACC), a major provider of industry supported CME. Addressing the question of whether existing safeguards enough, he gave this example:
….just in the last six months, two extremely prominent cardiologists in this country who inadvertently did not disclose their conflicts, they were removed from the faculty of the program they were going to participate in, banned for a year, publicly admonished on our website and instructed they could not serve on any committee function for that whole subsequent year and that if it happened again it was a permanent situation. Neither of these, these are both very distinguished academic individuals who had no intention of this, but that’s how serious we take it.
The ACC has sponsored many live CME events through the years. Lewin points out that the technology that supports these meetings is expensive and that without industry funding it would entail a cost of $2000-$3000 for each attendee to maintain that level of quality.
Under increasing pressure to deliver CME that impacts clinical practice education providers are finally collecting data. Marissa Seligman presented data collected from hundreds of thousands of Pri-Med CME encounters. These data indicate that Pri-Med’s CME offerings, the majority of which are industry supported, result in increased adherence to guidelines for a variety of clinical situations. Comparisons of attendees’ ratings of CME offerings demonstrated that industry supported activities were perceived as more balanced, scientifically rigorous and clinically relevant than non supported offerings. How could that be? Seligman offered this explanation:
…our thesis on this is that the faculty who are in commercially supported education are very sensitized by working with us and other organizations about the ACCME requirements and the standards for commercial support, the need for disclosure transparency, the need to do the education that is fair, balanced, objective, and scientifically rigorous, and in doing so, that translates them to education that is perceived by the attendees as, in fact, meeting all those requirements, as well as contributing to patient care.
Some final thoughts:
Policy mandates have unintended consequences. The unintended consequences of a ban on industry supported CME have not been adequately discussed. Are the arguments for such a ban meritorious enough to outweigh any unintended consequences? The burden of proof should rest on the purveyors of those arguments. Those arguments, so far, have consisted of little more than personal attacks and appeals to popular hatred of industry. They have no evidence.
What little evidence there is suggests that industry supported CME under today’s regulations and firewalls enhances evidence based practice and is perceived by participants as at least as rigorous as non industry supported CME.
The importance of CME accreditation is grossly inflated in public perception. State requirements are inconsequential compared to the actual reading doctors do. Doctors read and attend lectures primarily to learn, not to acquire credits.
I agree with the CME inquisitors on one point: The medical profession should take control of its own continuing education. This should be done, however, with fair representation of its members and not just a few of the most vocal academics. With such representation the profession will overwhelmingly choose to preserve industry support.
Hundreds of short lectures for health care providers and students are freely available for viewing on You Tube and the Clinical Cases and Images Blog has posted a large compilation. Based on my brief sampling, the quality of the content varies considerably. Many of the lectures are outstanding while some are “so-so.” There appears little in the way of disclosure and no information about Pharma influence or the lack thereof. So, (gasp!) viewers must rely on their own critical thinking skills to separate the wheat from the chaff. (That, after all, is the way it is, or should be, with all learning resources). There seems to be more than enough good material in this collection to make it worth adding to my list of links.
Retired Doc recently announced:
What with the downtime imposed by a hurricane and the confluence of a bunch of other family and personal stuff, I think it best to-at least for a while-take blog writing off the table.I probably can't resist posting a few wonderfully cogent comments on some of my favorite medical blogger sites but little more than that for a while. I have beaten to death a number of my favorite themes and I need to re-fire the belly.
Retired Doc is a loyal reader and commenter, and one of my favorite bloggers. Here’s wishing him the best and hoping this is merely a hiatus.
From Expert Review of Anti-Infective Therapy via Medscape.
In what would appear an attempt at being fair and balanced Academic Medicine has published a counterpoint to an earlier proposal to dissolve the specialty of general internal medicine. The authors note a rising agenda to differentiate internal medicine house staff, early in training, into ambulatory care providers, hospitalists or subspecialists:
Many changes now proposed would likely damage if not destroy the consultant-generalist ideal of traditional internal medicine training which remains critical to effective medical care in the 21st century.
In my many postings on internal medicine’s lost identity I’ve groped for a term to describe the original ideal of the internist. I think the authors of this piece may have found it: the consultant-generalist. It’s admittedly clunky but it’s a whole lot better than doctors for adults.
My internal medicine training followed the old ideal. When I started practice I was fortunate. I found a group that gave me the opportunity to function as a consultant-generalist. I was the only internist in a primarily family practice group. My patient population, largely filtered through the family practitioners, was a select group of referred patients with particularly complex problems. In return for taking more than my share of the hard cases I virtually never had to see the sprains, cuts, snotty noses and boils. The group, appreciative of my unique training and skills, paid me for what I was rather than what I produced. It was a wonderful experience which provided excellent training for my hospitalist career years later. (Now, mind you, my professional nirvana was gradually undermined by the economic realities of prospective payment, Stark rules and managed care. When that hospitalist job offer came along I was more than ready to jump).
The article, available as free full text, is a must read. It explains internal medicine.
DB weighs in here.
---and that’s evidence based. Here’s an actual study to add to my growing collection of anecdotes.
---for critically ill patients? For patients with CAD? What about platelet transfusions?
A recent article in Today’s Hospitalist presents a round up of important literature and information from Dr. Jeffrey Carson’s presentation at SHM 2008.
Obsolete: Does the hospitalist model offer value?
Emerging: As hospitalists, what are our values?
What started out as a congratulatory note to hospitalist company CEO Adam Singer has morphed into a discussion thread about some of these values: Should hospitalists be employees of the hospital? Are we business agents first and clinicians second? Shouldn’t it be the other way around? What leadership styles and business models promote the best values?
When it comes to the risk of QT prolongation and Torsade de pointes, older psychiatric drugs are NOT better. According to this review in the American Journal of Health-System Pharmacy (free full text via Medscape):
Antipsychotics cause Q-Tc interval prolongation at a higher rate than do antidepressants, and the typical antipsychotics thioridazine, pimozide, and i.v. haloperidol all have the highest potential for Q-Tc interval prolongation. Tricyclic antidepressants have a higher rate of Q-Tc interval prolongation than do SSRIs, particularly at higher concentrations and in overdose situations.
Safety monitoring recommendations are given.
A collection from Today’s Hospitalist.
A largely promotional and uncritical treatment of CAM in Student BMJ.
These are some tips that medical director gives to new hospitalist recruits fresh out of training. Some of us old dogs may also find these pearls useful.
A previously healthy 38 year old woman presented with shock, elevated cardiac markers and low ejection fraction. I don’t usually link to case reports from journals but this one, which recently appeared in Laboratory Medicine, is rich. It contains important lessons and much food for thought.
You’ll test scads of patients for pheochromocytoma who don’t have the disease. If you finally do encounter it the textbook features you’ve been taught may be buried in a morass confusing findings and mimics.
The patient presented with a picture of cardiogenic shock and elevated cardiac markers. Although there was myocardial damage it wasn’t a territorial myocardial infarction due to coronary artery disease. One red flag against the diagnosis of classical myocardial infarction was the presence of cardiogenic shock and a profound drop in the ejection fraction despite only a mild troponin leak. Something else was going on. Although the article didn’t mention this red flag it did provide a nice discussion on the differential diagnosis of troponin elevation due to conditions other than classical myocardial infarction.
Buried in this constellation of findings was the triad we were all taught: headache, palpitation and diaphoresis. The authors noted:
Headache, palpitations, and diaphoresis are the most frequent symptoms of pheochromocytoma. If all 3 present together, the specificity of this combination of symptoms for the diagnosis of pheochromocytoma is greater than 90%.
Pretty astounding given the ubiquity of those symptoms.
Perhaps more telling was the patient’s left ventriculogram, which showed a markedly reduced ejection fraction and mid ventricular ballooning closely resembling the left ventriculograms in this series of patients with Takotsubo cardiomyopathy. Pheochromocytoma cardiomyopathy is physiologically similar to Takotsubo cardiomyopathy. I suspect that had this patient had a myocardial biopsy it would have shown contraction band necrosis.
Speaking of Takotsubo cardiomyopathy---will we see a spike following the Wall Street meltdown?
When criticized for their non-evidence based and unscientific claims the woomeisters like to counter with statistics pointing to the high rate of non-evidence based treatment in conventional medicine. It’s a specious argument, one which I have addressed here and elsewhere. The low rate of uptake of best evidence in conventional medicine is not a philosophical problem such as we find in the promotion of woo. Rather, it’s due to external barriers. These barriers are examined in a review from the Annals of Pharmacotherapy, published as free full text via Medscape.
Recently I wrote two posts in support of internal medicine as a unique specialty. Since then Happy Hospitalist and DB have weighed in. Concerning the recent agenda to dissolve internal medicine, DB is “struck by the naiveté of that proposal.” It’s encouraging to know that someone involved in the leadership of the American College of Physicians is listening.
Today’s Hospitalist reports on a presentation on this topic at SMH 2008 and links us to the free full text guidelines. This is an area of emerging importance and represents one of those new skill sets hospitalists will have to embrace.
