Thursday, June 29, 2006

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.

Monday, June 26, 2006

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.

Thursday, June 22, 2006

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.

Sunday, June 18, 2006

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….”

Thursday, June 15, 2006

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.

Monday, June 12, 2006

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."

Sunday, June 11, 2006

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.

Tuesday, June 06, 2006

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.

Sunday, June 04, 2006

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.

Friday, June 02, 2006

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.

Thursday, June 01, 2006

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.