Friday, October 08, 2010
Another performance system that doesn't work: SCIP
Being an Internal Medicine type I don't know a whole lot about SCIP so I'll leave the deconstruction to Skeptical Scalpel, guest blogging at Kevin MD. What's apparent from his analysis, though, is that the problems with SCIP mirror the problems of many other performance measures. It's not that they're not evidence based (they are) but when you turn then into a publicly reportable game the unintended consequences and the shortcomings of oversimplification come strongly into play.
Restriction of drug reps and samples in a family practice clinic
---resulted in decreased prescribing of promoted brands but an increase in overall prescription costs.
Via Med Policy.
Via Med Policy.
New combo pills may make a difference
Drugs like Caduet have been dismissed as mere gimmicks or patent extenders. So I found this study interesting:
Background
Prior studies have found that patients taking single-pill amlodipine/atorvastatin (SPAA) have greater likelihood of adherence at 6 months than those taking 2-pill calcium-channel blocker and statin combinations (CCB/statin). This study examines whether this adherence benefit results in fewer cardiovascular (CV) events.
Results
Of 1,537 SPAA patients, 56.5% were adherent at 6 months, compared with 21.4% of the 17,910 CCB/statin patients (p less than 0.001). Logistic regression found SPAA patients more likely to be adherent (OR = 4.7, p less than 0.001) than CCB/statin patients. In Cox proportional hazards models, being adherent to either regimen was associated with significantly lower risk of CV event (HR = 0.77, p = 0.003). A similar effect was seen for SPAA vs. CCB/statin patients (HR = 0.68, p = 0.02). In a combined model, the risk of CV events was significantly lower for adherent CCB/statin patients (HR = 0.79, p = 0.01) and adherent SPAA patients (HR = 0.61, p = 0.03) compared to non-adherent CCB/statin patients.
Conclusions
Patients receiving SPAA rather than a 2-pill CCB/statin regimen are more likely to be adherent. In turn, adherence to CCB and statin medications is associated with lower risk of CV events in primary prevention patients.
What's new with C. diff?
Not much in the treatment arena, but new epidemiologic patterns are emerging. From a recent review :
Free full text via Medscape. CA-CDI is community associated Clostridium difficile infection.
Clostridium difficile infection incidence is increasing in hospitalized patients and outpatients, with more severe disease and poorer outcomes...
A significant fraction of cases of CA-CDI are not associated with traditional risk factors, such as antibiotic exposure, increased age, other comorbidities or prior hospitalization. Therefore, the absence of these risk factors is unreliable for ruling out CA-CDI, and testing for CDI in patients with acute diarrhea, even without risk factors, should be considered.
Free full text via Medscape. CA-CDI is community associated Clostridium difficile infection.
Atrioesophageal fistula after radio frequency ablation
Thursday, October 07, 2010
How much basic science do you need to learn in order to be a doctor?
I'm revisiting this topic, which I blogged about a few weeks ago, because it has surfaced again with this post by DB as the jumping off point. It has led to an interesting discussion, so I'll dive in. Again.
Some of the discussion on this topic has centered around whether students need to take organic chemistry, so in my earlier post I said this:
I got a little flack for those comments. I certainly wasn't trying to make the case that organic chem is essential, or that if you skip it you dumb down your education. I do think it's a good example, because mastery of the subject requires fundamental understanding more than rote memorization. The same is true in the preclinical and clinical sciences. A fundamental understanding of disease is important.
So DB's post refers us to this Lancet article on the subject. The author, Donald Barr, a physician and a medical educator, makes one conclusion I can agree with:
Of course nobody knows what that threshold is. Research evidence addresses the question but hasn't provided the answer. So we have to be careful how much we devalue basic science.
After relating a story about a promising undergraduate student whose application to medical school was rejected because his science grades were not quite high enough, he notes:
I agree with his premise, but are admissions committees really disqualifying applicants with weaker science grades or is it a matter of available slots? I remember my premed advisers telling me that since there were many more applicants than available slots a lot of qualified students would be rejected. I got a few rejection letters that said the same thing.
Dr. Barr goes on to review the history of medical education and some of the research underlying it, citing this speech from 1914:
First, evidence or no evidence, isn't it axiomatic that medicine should be science based? And, as a matter of fact there was compelling evidence to support Vaughan's words. It was in the form of the Flexner Report, a meticulously conducted survey of medical schools in the United States and Canada, published in 1910. It's patently obvious that Vaughan's words echo the concerns of that report, which is why it's astonishing to me that Dr. Barr ignores it.
In the pre-Flexner era medicine, and medical education itself, were indeed based on fraud, sham and superstition, namely homeopathy and other forms of snake oil. The past two decades have seen a gradual de-emphasis on basic science. Maybe that's not entirely bad but is it merely coincidental that pseudoscience and quackery have gained an increasing share of the curriculum at the same time? That acupuncture points and meridians have been introduced into the curriculum for first year medical students? That medical students purport the health benefits of wheatgrass and Voodoo? That promoters of quackery who now lecture med students would have been hooted off the podium 20 years ago? Just asking.
One other point about Barr's article deserves mention. He implies that once you exceed some minimum threshold, further increases in scientific knowledge and aptitude may make for worse physicians. The literature he cites in support of this idea, fascinating though it is, is soft. It's based on surrogate endpoints from psychological testing. Here's what he cites:
That finding is intuitive, and it's easy to understand why. More on that below, but back to Barr's article:
What are we looking at here? Is this a group of kids with high functioning Asberger syndrome? Concerning though the findings are they represent soft data. It's far too big a leap to conclude that excellence in basic science beyond a minimum threshold makes for an inferior physician. In fact, it's a leap into the absurd which is fraught with unintended consequences. If admissions committees wish to take into account non-cognitive attributes of applicants (and I agree they should) there are better and more direct ways to go about it than to devalue excellence in basic science. There are ways this could be addressed during the interview process. I know of at least one state medical school that, after narrowing the initial pool of applicants, gave candidates the MMPI. As extreme as that may seem it's better than devaluing excellent science grades. Besides, I think Barr creates a false dichotomy by implying that one can't be brilliant in the sciences and possess the human attributes that are desirable in a clinician.
DB talks about students who struggle in the basic science years, then do very well on the clinical rotations. It's a common observation. Some students, maybe a smaller number, display the opposite pattern. I was one of them. That's a fact which, I freely admit, may contribute to my bias in this debate. I loved my basic science courses. As third year approached I was eager to apply what I'd learned. I was in for a shock. Putting theory into practice was anything but straightforward. I struggled through most of third year. I finished fourth year doing sub-internships in emergency medicine and my chosen specialty of internal medicine. Thanks to some wonderful residents who mentored me with patience and understanding I finally hit my stride.
So there are two extremes among medical students. Some struggle in the basic sciences and thrive when they hit the wards, while others display the opposite pattern. Both groups have catching up to do. Both can make excellent physicians.
Some of the discussion on this topic has centered around whether students need to take organic chemistry, so in my earlier post I said this:
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.
I got a little flack for those comments. I certainly wasn't trying to make the case that organic chem is essential, or that if you skip it you dumb down your education. I do think it's a good example, because mastery of the subject requires fundamental understanding more than rote memorization. The same is true in the preclinical and clinical sciences. A fundamental understanding of disease is important.
So DB's post refers us to this Lancet article on the subject. The author, Donald Barr, a physician and a medical educator, makes one conclusion I can agree with:
There is a critically important threshold of scientific knowledge that forms the foundation on which a medical education is built.
Of course nobody knows what that threshold is. Research evidence addresses the question but hasn't provided the answer. So we have to be careful how much we devalue basic science.
After relating a story about a promising undergraduate student whose application to medical school was rejected because his science grades were not quite high enough, he notes:
25 years later I began advising undergraduates at Stanford University, many of whom had come to Stanford with the hope of eventually becoming a physician. From many of these students I heard what would become a mantra. “I used to be pre-med, but…” It seemed common knowledge among these students that a C+ in organic chemistry was simply incompatible with hopes of becoming a physician. If you can't do science, you can't succeed as a physician. If all you can pull is a C+ in chemistry, it's unlikely you'll get into medical school. By then I had more than two decades of clinical practice experience to teach me what a great physician was. A great physician creates a bond of communication and trust with his or her patient; a great physician can sense the feelings the patient is struggling to express or afraid to try; a great physician is also technically competent and conversant in medical science. For so many of these students, as for the applicant in the cafeteria, I had a clear, intuitive sense that, given the chance, they would become great as physicians. A quarter of a century after the interview in the cafeteria I had the confidence I was correct. To use a mediocre score in an undergraduate science class to disqualify these students from a medical career seemed indefensible.
I agree with his premise, but are admissions committees really disqualifying applicants with weaker science grades or is it a matter of available slots? I remember my premed advisers telling me that since there were many more applicants than available slots a lot of qualified students would be rejected. I got a few rejection letters that said the same thing.
Dr. Barr goes on to review the history of medical education and some of the research underlying it, citing this speech from 1914:
Addressing the CME in 1914, Dr Victor Vaughan, a founding member of the Council, spoke the core belief on which the American medical profession by then was built.
“No man is fit to study medicine, unless he is acquainted, and pretty thoroughly acquainted, with the fundamental facts in physical, chemical, and biological subjects…The facts of the biological, physical, and chemical sciences are the pabulum on which medicine feeds. Without these sciences, everything that goes under the name of medicine is fraud, sham, and superstition.”
Was there evidence to support Vaughan's words? Is science the pabulum that nurtures young physicians? I went back in the literature of medical education 40 years before the time of Vaughan's comments, and found no scientific evidence to support his assertion.
First, evidence or no evidence, isn't it axiomatic that medicine should be science based? And, as a matter of fact there was compelling evidence to support Vaughan's words. It was in the form of the Flexner Report, a meticulously conducted survey of medical schools in the United States and Canada, published in 1910. It's patently obvious that Vaughan's words echo the concerns of that report, which is why it's astonishing to me that Dr. Barr ignores it.
In the pre-Flexner era medicine, and medical education itself, were indeed based on fraud, sham and superstition, namely homeopathy and other forms of snake oil. The past two decades have seen a gradual de-emphasis on basic science. Maybe that's not entirely bad but is it merely coincidental that pseudoscience and quackery have gained an increasing share of the curriculum at the same time? That acupuncture points and meridians have been introduced into the curriculum for first year medical students? That medical students purport the health benefits of wheatgrass and Voodoo? That promoters of quackery who now lecture med students would have been hooted off the podium 20 years ago? Just asking.
One other point about Barr's article deserves mention. He implies that once you exceed some minimum threshold, further increases in scientific knowledge and aptitude may make for worse physicians. The literature he cites in support of this idea, fascinating though it is, is soft. It's based on surrogate endpoints from psychological testing. Here's what he cites:
Gough reported that students' undergraduate science grades and MCAT science scores were associated with grades in the first 2 years of medical school, but were, “almost completely unrelated to performance in the fourth year and to faculty rating of general and clinical competence”.
That finding is intuitive, and it's easy to understand why. More on that below, but back to Barr's article:
He then compared the psychological profiles of these students with their performance in premedical sciences. He found that the students who did better in science were, “narrower in interests, less adaptable, less articulate, and less comfortable in interpersonal relationships”...
A number of others have found the psychological profile of students who perform best in the premedical sciences to be the reverse of what one might hope for in a physician. Writing in the 1970s, Witkin found students who were most successful in the sciences, “have an impersonal orientation: they are not very interested in others”. Tutton's studies of medical students in Australia in the 1990s found that students who did the best in the premedical sciences scored lower on standardised measures of empathy and tended to be “shy”, “submissive”, “withdrawn”, or “awkward and ill at ease socially”, characteristics the author suggested are, “the antithesis of what most of us would want in a clinician”.
What are we looking at here? Is this a group of kids with high functioning Asberger syndrome? Concerning though the findings are they represent soft data. It's far too big a leap to conclude that excellence in basic science beyond a minimum threshold makes for an inferior physician. In fact, it's a leap into the absurd which is fraught with unintended consequences. If admissions committees wish to take into account non-cognitive attributes of applicants (and I agree they should) there are better and more direct ways to go about it than to devalue excellence in basic science. There are ways this could be addressed during the interview process. I know of at least one state medical school that, after narrowing the initial pool of applicants, gave candidates the MMPI. As extreme as that may seem it's better than devaluing excellent science grades. Besides, I think Barr creates a false dichotomy by implying that one can't be brilliant in the sciences and possess the human attributes that are desirable in a clinician.
DB talks about students who struggle in the basic science years, then do very well on the clinical rotations. It's a common observation. Some students, maybe a smaller number, display the opposite pattern. I was one of them. That's a fact which, I freely admit, may contribute to my bias in this debate. I loved my basic science courses. As third year approached I was eager to apply what I'd learned. I was in for a shock. Putting theory into practice was anything but straightforward. I struggled through most of third year. I finished fourth year doing sub-internships in emergency medicine and my chosen specialty of internal medicine. Thanks to some wonderful residents who mentored me with patience and understanding I finally hit my stride.
So there are two extremes among medical students. Some struggle in the basic sciences and thrive when they hit the wards, while others display the opposite pattern. Both groups have catching up to do. Both can make excellent physicians.
Slideworld
Slides from lots of lectures in various areas of medicine. I don't know where these all came from or how good they are but the few I sampled look reliable. It has a consumer and a professional side of the site clearly demarcated, which is nice. Navigation is a little messed up but doable.
Erik DeLue on suing hospitalists
I always enjoy reading Erik DeLue's pieces in Today's Hospitalist. A recent article about the legal risks hospitalists face was prompted by his being asked to serve as an expert witness against another hospitalist who found himself within range of plaintiff attorney's shotgun, being sued just for “being there.” (Erik declined).
Particularly insightful is this:
Well, if leaders of the Society of Hospital Medicine really want to represent their members in this area they should promulgate explicit limits on scope of practice in various situations, as the leaders of Emergency Medicine have done. Up to now SHM has done pretty much the opposite. It is creating a huge vulnerability for hospitalists. Plaintiff attorneys will become aware of this. The chickens will come home to roost.
Particularly insightful is this:
Nonetheless, it is extremely important to come up with a clear definition of our scope of practice and make an effort to not overstep those boundaries to establish our legal culpability in such a case. We may be wise to always specify the limited consult for which we are brought in to provide care. Maybe I will sell rubber disclaimer stamps to my brethren to affirmatively exclude care for any and all other issues, except for the stated consult.
It seems that the outcome of future litigation against hospitalists will revolve around how our scope of practice is defined, given the fact that ours is a field in which we don't yet have a substantial case history. So who should come up with that definition?
Well, if leaders of the Society of Hospital Medicine really want to represent their members in this area they should promulgate explicit limits on scope of practice in various situations, as the leaders of Emergency Medicine have done. Up to now SHM has done pretty much the opposite. It is creating a huge vulnerability for hospitalists. Plaintiff attorneys will become aware of this. The chickens will come home to roost.
More on premed education and the predictors of med school success
A while back I blogged on this recent single center study which showed that a small, select group of students who bypassed the traditional premed basic science curriculum and the MCATs did as well in medical school as the rest of the students.
Of related interest, now there's this very large study looking at predictors of difficulty in medical school, particularly withdrawal or dismissal, and failure to pass USMLE on the first attempt. The most powerful predictor of difficulty was the MCAT score, and the lower the score the greater the likelihood of difficulty. This is difficult to interpret, because there was no breakdown of the MCAT categories, two of which are in the sciences and two of which are in the humanities.
The Skeptical Scalpel blog has an interesting take on both studies along with some general comments on medical education, here and here.
Of related interest, now there's this very large study looking at predictors of difficulty in medical school, particularly withdrawal or dismissal, and failure to pass USMLE on the first attempt. The most powerful predictor of difficulty was the MCAT score, and the lower the score the greater the likelihood of difficulty. This is difficult to interpret, because there was no breakdown of the MCAT categories, two of which are in the sciences and two of which are in the humanities.
The Skeptical Scalpel blog has an interesting take on both studies along with some general comments on medical education, here and here.
Wednesday, October 06, 2010
The changing profile of pyogenic liver abscess
Klebsiella pneumoniae is emerging as the most important pathogen. Some cases are polymicrobial. Reviewed in CCJM.
Anticoagulation for PE: start it in the ER
From Chest:
Results: In-hospital and 30-day mortality rates were 3.0% and 7.7%, respectively. Patients who received heparin in the ED had lower in-hospital (1.4% vs 6.7%; P = .009) and 30-day (4.4% vs 15.3%; P less than .001) mortality rates as compared with patients given heparin after admission. Patients who achieved a therapeutic aPTT within 24 h had lower in-hospital (1.5% vs 5.6%; P = .093) and 30-day (5.6% vs 14.8%; P = .037) mortality rates as compared with patients who achieved a therapeutic aPTT after 24 h. In multiple logistic regression models, receiving heparin in the ED remained predictive of reduced mortality, and ICU admission remained predictive of increased mortality.
Medscape CME on Alpha-1 Antitrypsin Deficiency
This Medscape CME activity is a general overview of clinical features, genetics, diagnosis and management of AATD.
Being sponsored by the makers of Prolastin, this otherwise excellent overview might be perceived as unbalanced due to commercial bias, since it failed to mention the recent Cochrane review which questioned the use of augmentation therapy. However, the omission may be more a matter of timing than commercial bias, since it was posted on Medscape very soon after the review came out and may have been in press before the review was released. That review has been criticized, and whether augmentation therapy should be abandoned is a matter of considerable controversy.
Being sponsored by the makers of Prolastin, this otherwise excellent overview might be perceived as unbalanced due to commercial bias, since it failed to mention the recent Cochrane review which questioned the use of augmentation therapy. However, the omission may be more a matter of timing than commercial bias, since it was posted on Medscape very soon after the review came out and may have been in press before the review was released. That review has been criticized, and whether augmentation therapy should be abandoned is a matter of considerable controversy.
Tuesday, October 05, 2010
Colchicine halves the incidence of postpericardiotomy syndrome
---with a NNT of 8. The treatment was well tolerated. Presented at the European Society of Cardiology 2010.
Campbellteaching You Tube channel
Lots of lectures on medicine and physiology. What I've seen looks good but caveat emptor.
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