---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.
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.
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.
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.
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.
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 twoposts 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.
Is the electronic medical record, at its present state of development, better than paper? It depends. It depends on how it’s developed, how it’s implemented and how it’s used. Right now we don’t have an evidence based answer but there are plenty of opinions. We have a generous sampling this week.
The Dinosaur, writing in Medscape, says his paper records are legible and well organized and he’s doing just fine, thank you. Many docs are not as legible or well organized as the Dinosaur. For those who struggle with paper record chaos one of my colleagues in Northwest Arkansas has developed the problem-integrated charting (PIC) system:
Utilizing the system ameliorates many of the limitations of the human mind when dealing with multiple comorbidities and reduces undesirable redundancy. The system could lessen the impact of technologic impoverishment for practitioners still using paper records and has the potential to be utilized in electronic medical records.
Joseph J. Fins, an internist writing in the Hastings Center Report about his introduction to the EMR, laments the decline of the old fashioned narrative history:
When we were residents in the late 1980s, we would pride ourselves on how our charts read and looked. The chart was a place to tell a patient's story from our point of view. Although we had all been trained in the architecture of the medical note and the progression from Chief Complaint (CC) to History of Present Illness (HPI) on down to Assessment and Plan (A/P), each of us did it a bit differently. Each of us had our own voice. I recall marveling at the charting styles of my colleagues and professors: the long, obsessively complete note of the intern versus the almost aphoristic musings of the attending—the former chock full of unorganized information, and the latter synthetic in its encapsulation of the problem and plan of action. And in that transition, through our writings in the medical record, we all learned how to think as doctors.
One of the benefits of the old fashioned narrative history is that it tells the patient’s story and presents a time line. Electronic medical record templates are not conducive to this. DB, although he defends the EMR, realizes the importance of the timeline in the patient’s history. In a recent post he illustrates how construction of a timeline can provide the critical data necessary to understand a patient’s problem. Although electronic medical record templates can’t force how we think they can influence how we think and distract us from important patient data if we are not careful.
Dr. Fins will miss the paper based narrative, but at the end of his training he concludes that the advantages of the EMR outweigh the disadvantages.
Press Ganey is a survey firm used by many hospitalist programs to measure patient satisfaction. Erik DeLue, MD, writing in Today’s Hospitalist, explains a little quirk in Press Ganey reporting:
A quick lesson in Press Ganey, the most-used ranking system for patient satisfaction surveys, demonstrates how “good” can be so bad. On the survey, it turns out that a “very good” ranking translates to an absolute score of 100%, while a “good” corresponds to an absolute score of 80%—and puts a physician with that relative ranking in the bottom 1%. Myself, well, there have been times where I am sure the likes of Dr. Kevorkian would outscore me, this even with an absolute score that would make my parents proud.
That’s what he warned of in a 1961 address which predated his political career. He was speaking against the King bill (aka the King-Anderson bill), a precursor to Medicare. The bill, vehemently opposed by the AMA, was narrowly defeated. It resurfaced two years later in the Johnson administration, given new life by Johnson’s political influence and substantial democratic majorities in the House and Senate. It passed in the form of the Social Security Act of 1965 which gave us Medicare.
The address was recorded on a vinyl record distributed by the AMA. This was a time when the AMA staunchly supported what it believed to be the interests of doctors. It was a less cynical time when the interests of doctors were not believed to be invariably conflicted with the interests of patients.
I found the link over at Movin’ Meat, where Shadowfax gives a more favorable spin on Medicare (it’s efficient and wildly popular, he says) than I would. Efficient? If it’s efficient now (and that’s debatable) it clearly wasn’t during much of its history. In the early days of the program you could admit Uncle Freddie to the hospital for a barium enema. If Mom was a little stressed and overworked you could admit her for a rest and a check up. And if there was no one to watch Grandma while the family went on vacation, well…
The gravy train went on for 20 years. Medicare’s effort to improve efficiency and quality in the 1970s, via implementation of Professional Standards Review Organizations (PSROs), was a failure. It was dismantled in 1982. Then, in a panic over spiraling costs, Medicare abruptly (ironically, during the Reagan administration) switched from a gravy train to a mandate for the delivery of unreimbursed care in the form of its prospective payment system based on DRGs. Overnight Medicare became more intrusive, new crimes were invented and hospitals scrambled to discharge patients “quicker and sicker” and develop new forms of creative charting.
It makes you wonder. What if the bill hadn’t passed in 1965? Could the free market, perhaps alongside a means based government health care program for the elderly, have done better?
A recent article in Today’s Hospitalist provided a roundup of recent clinical trials on this subject with links to primary sources. Although controversy persists it appears there is a role for salmeterol and fluticasone in combination.
They don’t have a clue. An October 4 NYT editorial opens with two faulty assumptions:
It is good to know that hospitals will no longer profit from their mistakes under a new payment policy just inaugurated by Medicare.
As I’ve already pointed out the majority of these events are not mistakes. But even worse is the notion that hospitals actually profit from such events. Modifications of DRG payments for unplanned events are modest. For the complication of sepsis, for example, it’s a little over $3000. That doesn’t even come close to covering the cost of an episode of sepsis which, according to a 2003 estimate, costs on an average of $22,000 per case! In typical popular media style the editorial writer didn’t try to cite evidence to back up the claim. Absurd. It gets worse as you read on.
Call and check on the patient. Many programs have tried this, but it’s very labor intensive.
Discharge summary to go. Now there’s an idea. It may be an underrated advantage of electronic medical records, because you can generate a summary on the spot and give it to the patient. Dr. John Nelson, a leader in hospital medicine and co-founder of SHM, counters the objections of those concerned about patients reading what we put in the record:
But he maintains that concerns about patients getting too much information or becoming unduly worried about a diagnosis haven’t been much of an issue. He is careful not to use labels like “drug seeker” in a summary; instead, he notes that a patient has “complex pain management issues.”And he doesn’t balk at including that a patient is obese, for instance. “I think we shouldn’t hide the reason behind the person’s health.”
Medicare’s prospective payment system, rolled out in 1983, was a mandate for unreimbursed medical care and, in effect, a provider tax on hospitals. In this week of economic turmoil the tax was raised in the form of Medicare’s new policy regarding adverse hospital events. It couldn’t have come at a worse time.
Along with the tax increase has come a redefining of some unpreventable events as medical errors. Egregious media spin regarding the new concept has gotten the attention of the legal community. The consequences? We may be about to see a shift in the burden of proof for malpractice claims whereby the legal doctrine of Res ipsa loquitur, once reserved for cases of self evident negligence (e.g. leaving a surgical instrument in the abdomen) becomes applicable to common unavoidable hospital complications. Brace yourselves for the next malpractice crisis and an even more rapid exodus of doctors.
DB and I, in dealing with this topic before, have offered many descriptive attributes. But what is the essence of general Internal Medicine? A wonderful article by one of the field’s great teachers, Dr. Craig Kitchens, got me thinking: Internal Medicine is a cognitive service.
We compare RBRVs with current charges and find several general patterns. Invasive procedures are typically compensated at more than double the rate of evaluation-and-management services, when both consume the same resource inputs. Imaging and laboratory procedures fall between invasive and evaluation-and-management services. We analyze the financial implications of the RBRVS by developing a simple model and simulating the effects of an RBRVS-based fee schedule on physicians' revenues in various specialties. We use Medicare data to perform the simulation under the "budget-neutral" assumption. Results show that an RBRVS-based fee schedule affects specialties differently. The average family practitioner could receive 60 percent more revenue from Medicare, whereas the average ophthalmologist could lose 40 percent of current revenues. The effects on other specialties fall between these two.
But then HCFA (now known as CMS) got ahold of the concept and as the government plan unfolded RBRVS came to be known as Real Bad Reimbursement Very Soon. Bad for everybody.
What is cognitive service? Read Kitchens’ paper. You’ll be inspired. You’ll also be frustrated when you realize that the present day distortion of RBRVS penalizes rather than rewards cognitive services. It’s just one more reason why general Internal Medicine is suffering.