What is it?

Beats me.

Blog reactions and personal reflections on the New York Times hospitalist article

As I re-read the New York Times article on hospitalists and surveyed blog reactions something else struck me. For all the uncritical praise of hospitalists for their value as business solutions there was not one word about what I think is really special about hospitalists: superior clinical skills developed on the ascent of the steep learning curve of caring for horribly ill patients day in and day out. Nothing about septic shock, respiratory failure or decompensated heart failure and the nuances of care. The Times even went so far as to characterize the specialty as a “breed of physician-administrator.” That was not a founding principle. If true, the field is devolving.

With the exception of a few negative anecdotes DB's and my reactions were the only critical blog posts I found. Most were mere regurgitations of the Times piece. The few that stood out were credulous in their praise. Bob Wachter thought the article hit the right notes. This post was effusive with unsubstantiated claims about the movement. So, good intentions may ultimately damage the movement, paving the way to misplaced expectations and false attributions.

Think we've found a mechanism for acupuncture? Think again

A cnet blogger, citing this recent study, asks Think acupuncture's a hoax? Think again. We just may have found acupuncture's secret, she writes. Here are the study findings:

We found that adenosine, a neuromodulator with anti-nociceptive properties, was released during acupuncture in mice and that its anti-nociceptive actions required adenosine A1 receptor expression. Direct injection of an adenosine A1 receptor agonist replicated the analgesic effect of acupuncture. Inhibition of enzymes involved in adenosine degradation potentiated the acupuncture-elicited increase in adenosine, as well as its anti-nociceptive effect. These observations indicate that adenosine mediates the effects of acupuncture and that interfering with adenosine metabolism may prolong the clinical benefit of acupuncture.

The release of the adenosine was local, right at the site of the acupuncture needle, as were the anti-nociceptive effects. Local tissue damage by the needle releases the adenosine precursor purines into the extracellular fluid. Through a series of dephosphorylations ATP is converted to ADP, then to AMP and finally adenosine. Although AMP piles up, as its dephosphorylation to adenosine is the rate limiting step, the overall effect is short lived, with adenosine levels down to baseline in an hour or so. Adenosine itself dissipates quickly. (As anyone who has ever pushed adenosine to convert AVNRT knows, if you don't push fast enough, in a vein close enough to the heart, it doesn't work. In the circulating blood adenosine is gobbled up by RBCs and endothelial cells with a half life of 9 seconds). In the study, any analgesic effects were gone by a matter of hours.

Because the adenosine effect is local and transient, this study contributes little toward an explanation for the claims of acupuncture, the principal ones of which are chronic pain relief and distant effects such as improvement in hypertension, nausea, headache and the like. It also does nothing to support the claimed mechanisms involving Qi, meridians etc.

Beautiful women get cheated on more often

---according to this report:

Guess what girls -- don't be envious of the most beautiful women in the world.

Look at Elin, look at Sandra Bullock, look at Halle, Britney,JLo, Reese, Julia Roberts, Jessica Simpson -- they've ALL been cheated on!

But what I want to know is, do they cheat more often? I mean, would this song be so funny if it didn't have a ring of truth? Just askin'.

New York Times on the hospitalist movement

New Breed of Specialist Steps In for Family Doctor.

DB linked to the article and noted:

Of course, even the Times cannot write a nuanced article about either primary care or hospital medicine. Since I have spent much time working in both fields, I can see the omissions and flaws in their articles.

If they must simplify this issue, then what happens in their other articles.

I’ve never known the Times to nuance much of anything concerning health care. So let’s go through the article. Concerning hospitalists it says:

Over a decade, this breed of physician-administrator has increasingly taken over the care of the hospitalized patient from overburdened family doctors with less and less time to make hospital rounds — or, as in Mr. Keita’s case, when there is no family doctor at all.

As DB pointed out, the piece fails to distinguish between family practice and internal medicine. The next paragraph reads:

Because hospitalists are on top of everything that happens to a patient — from entry through treatment and discharge — they are largely credited with reducing the length of hospital stays by anywhere from 17 to 30 percent, and reducing costs by 13 to 20 percent, according to studies in The Journal of the American Medical Association.

That paragraph, although literally true, is deceptive. Yes, hospitalists are widely credited with reducing lengths of stay and costs but that claim, as I have pointed out several times before, is not supported by evidence, bolstered by a huge case of publication bias.

In the next paragraph (my italics):

Under the new legislation, hospitals will be penalized for readmissions, medical errors and inefficient operating systems. Avoidable readmissions are the costliest mistakes for the government and the taxpayer, and they now occur for one in five patients, gobbling $17.4 billion of Medicare’s current $102.6 billion budget.

I have dealt with sloppy language about “medical errors” at length before and will not belabor it here. The next sentence on avoidable readmissions has no evidence to back it up. 30 and 90 day readmission rates have been cited for some diagnoses but we have no research data on how many of those are avoidable. It goes on:

“Where we were headed was not a mystery to anyone immersed in health care,” said P. J. Brennan, the chief medical officer for the University of Pennsylvania’s hospitals. “We were getting paid to have people in the hospital and the part of that which was waste was under the gun…”

That’s not entirely true. Since 1983 Medicare has not reimbursed hospitals for the care patients received and hospitals lose money on many Medicare admissions. Then a few paragraphs down:

Bad discharges generally result from hurried instructions to patients and families and little thought to where they are headed. One such situation was the centerpiece of a class taught for doctors at Mount Sinai Medical Center in New York. The patient, an elderly woman in the hospital for scoliosis, a spinal condition, was discharged by a hospitalist on a Friday night, with a prescription for a narcotic pain reliever that her pharmacy, as it turned out, did not stock. No one explained how her new medication differed from the old, or gave her a contact number for help. Without medication, by Tuesday, her ankles swollen and her breathing irregular, the woman was back in the hospital.

Since when does withdrawal from narcotics cause ankle swelling and irregular breathing?

What now? Global cooling?

Via Second Hand Smoke.

Is there finally evidence that CPOE reduces mortality?

Online ahead of print in the journal Pediatrics:

PATIENTS AND METHODS We performed a cohort study with historical controls at a 303-bed,freestanding, quaternary care academic children's hospital. All nonobstetric inpatients admitted between January 1, 2001, and April 30, 2009, were included.

RESULTS After CPOE implementation, the mean monthly adjusted mortality rate decreased by 20% (1.008–0.716 deaths per 100 discharges per month unadjusted [95% confidence interval: 0.8%–40%]; P = .03). With observed versus expected mortality-rate estimates, these data suggest that our CPOE implementation could have resulted in 36 fewer deaths over the 18-month postimplementation time frame.

It's not the greatest quality data but I don't know if we can expect much better. Reuters Health interviewed a health IT expert from UA Birmingham about the study:

"There have been a couple of studies previously that have taken a similar approach and have found the opposite result" of the current study, said Nir Menachemi, an expert in health information technology and policy at the University of Alabama at Birmingham. "I was more surprised by those studies."

The debate over whether CPOE is working as intended is hardly over, said Menachemi: "I think it would be foolish to believe that any one study can end the discussion."

Paul Levy at Running a Hospital thinks differently:

Let's go back to the basics. Hand-written drug orders are subject to transcription errors at both ends, the person writing them and the person reading them. Each time you add an intermediary in the drug ordering process, you add an opportunity for error. Also, unless there is real-time and accurate checking for drug-drug interactions, allergies, assessment of doses based on body weight and the like, there will be some percentage of preventable medication errors.

Maybe I live in a rarefied world of early CPOE adopters, but does anyone out there think this is still subject to debate?

Yes, I and a lot of other people do. Levy's problem in understanding this, I suspect, is not that he lives in the world of early adopters, but that he doesn't have experiential knowledge of what entering orders on the wards is really like in both systems, paper and electronic. Those intermediaries he's talking about are personnel who are trained in the secretarial skills of order entry and, by doing safety checks of their own, may actually reduce errors.

It cuts both ways. CPOE has theoretical advantages. There are also unintended consequences. The implementation of CPOE can be a mess. Take a bunch of time pressed doctors and suddenly add secretarial duties to their work flow. Not pretty.

The field of health information technology will mature. Doctors will gradually become more adept at the secretarial skills of order entry. Some day most practicing doctors will have grown up on CPOE, having never known any other system. By then maybe CPOE will have saved lives. I doubt that there will ever be a study to prove it. The debate about the risks and benefits of the electronic medical record is alive and healthy, and should go on.

Comparative effectiveness research is not new

It was just given a new name to serve political ends. A recent analysis in JAMA looked at studies on medications published between June 1, 2008, and September 30, 2009. There are fairly recent publications but reflect research that was designed and begun long before the present hype about CER. They found 104 CER studies, and this was probably a drop in the bucket, as the analysis was confined to only 6 journals.

Related post: We’ve been doing CER for years.

Another review of rapid response teams

---concludes:

In summary, RRSs take the skills and expertise of the critical care team beyond the walls of the ICU within minutes to the bedside of deteriorating patients, whose condition may well progress to cardiac or respiratory arrest. RRSs would stabilize patients, prevent development of critical illness or cardiopulmonary arrest and contribute to the optimization of the care of other patients through education of healthcare givers working in the general medical and surgical wards. Their implementation requires significant resources and involves a change in the culture of healthcare provision. Although their merits look obvious and thus their deployment in hospitals seems to be intuitive, the available evidence for their effectiveness in improving the outcomes of such patients is weak and of suboptimal quality. Whether they should become the standard of acute hospital care needs to be answered.

Ugly criminal defendants

---are more likely to be convicted and get more prison time than good looking ones according to a study. Does this cut the same way for malpractice defendants?

Variations in cardiology practice

Regional variation in practice and health expenditures was a hot topic in the health care reform debate. Much of this variation was attributed to greed although direct evidence to support that claim was lacking. Cardiology seems to have taken the brunt of this accusation. What does research evidence tell us about reasons for variations in cardiology practice? The fear of malpractice suits is the main reason.

Can you get functionally younger as you get older?

Dr. Helen reviews a book that says you can, but the news is apparently mixed:

Apparently, all kinds of terrible things happen to you as you age while male, according to the book. Hair grows out of your ears, you can't hear well and your balance begins to suck. Women, even those who are not so young, walk by as if you are not there. And everyone in the office sees you as retirement material. In addition, you get hit with something called "the Ugly Stick" where you wake up one day and find out that you've turned into a real dog...

Exercise, not surprisingly, is stressed.

Rap to teach CPR

At least it teaches compression only CPR.

Related content here.

Via Kevin.

A glimpse of the quackademic curriculum: mind-body-spirit medicine at UCSF

This video illustrates the Trojan Horse principle of integrative medicine departments, which Orac has often pointed out. The speaker starts out with some plausible alternative modalities (hypnosis, biofeedback), then moves gently into the real woo of Tai Chi, Yoga and even the teachings of Larry Dossey.

Not only evidence based medicine but science based medicine may take a back seat in Donald Berwick's vision for patient centered care

At last year's IOM Summit on Integrative Medicine, as I mentioned before, Berwick's speech was very friendly towards non-evidence based and implausible alternative medicine:

Don Berwick speaks: Even without regard to what he had to say it’s significant enough that Donald Berwick, M.D., CEO of the prestigious and (up to now!) very mainstream Institute for Healthcare Improvement, lent his good name to this woo fest. But what he had to say was rich. After introductory remarks about how happy and honored he was to be there he mentioned homeopathy and acupuncture, not to criticize them as health claims, but only to warn that they shouldn’t compete with each other, or with other modalities, for limited health care resources. In other words, let’s stop fighting and work together. (Groan). He praised the IOM for its contributions to the design of health care, starting (now get this) with “traditional, allopathic and curative care and now migrating into this distinguished and important new arena.”

But here’s the bomb. Berwick, who seems to believe that healthcare should be like any consumer industry, said that quality is defined by patients’ perceptions. This is his idea of patient centered care which he defines as the patient having all the control. The IHI’s metric for quality, he said, is (watch this, now, emphasis mine) “…give me exactly the help I need and want exactly when I need and want it.”

Think about that for a moment. The woosters and quackademicians of the world point to surveys like these which show that patients, in large numbers, really seem to want woo. They support their unscientific promotions by saying that because so many patients seek it out it must be valid. Adherents of science based medicine often point out the silliness of such thinking. Now, though, this argumentum ad populum is given new life and legitimacy because the Institute of Medicine and the Institute for Health Care Improvement endorse it!

The British NHS, which Berwick loves, funds homeopathy.

Smoking for asthma

Stramonium and related anticholinergic alkaloids were early asthma remedies which were ground up into a powder and smoked. Their anticholinergic properties included bronchodilation, the basis for modern day development of the atropine derivatives Atrovent and Spiriva.

Here is a review of the history of smoked remedies for asthma.

Politics can affect your cortisol levels

From Psychoneuroendocrinology:

In North Carolina, John McCain voters (losers) had increases in post-outcome cortisol levels, whereas Barack Obama voters (winners) had stable post-outcome cortisol levels. The present research provides novel evidence that societal shifts in political dominance can impact biological stress responses in voters whose political party becomes socio-politically subordinate.

Real quality can't be measured

Performance can, but real quality can't. Nice post from DB.

Berwick's love affair with the NHS

The transcript of his speech I embedded earlier is here.

More on Paul Levy

Bob Wachter, a long time admirer of Levy, weighed in yesterday:

Paul Levy, the blogging CEO of Boston’s Beth Israel Deaconess Medical Center, found himself in hot water last month over an inappropriate relationship with a female subordinate. While some of the details of the transgression remain sketchy, I think I now know enough to opine on it. To my mind, Paul has been an extraordinary healthcare leader, and – while the episode represents a lapse in judgment that deserves censure – he should not lose his job.

Pretty much the same sentiments I expressed here. Great things happened at BIDMC under Levy's leadership, but has he lost his moral authority? From a Boston Globe piece yesterday:

Levy’s signature moment, until recently, had been persuading his employees to take pay cuts last year that saved low-income workers from being laid off. He said he was able to win that concession because of his personal credibility, authority that has now taken a serious hit.

“I could go in front of them and say ‘I want to do what I can for the low-income workers but that means everyone will have to take a bigger sacrifice.’ I was able to do that because I had the moral authority to say those things,’’ he said. “If it were today, would I have the same amount of moral authority?’’

Well, that might depend on how much of a pay cut Levy himself took. In the interest of transparency it would be nice to know. But for the most part the legacy doesn't have to be about Levy or his moral authority. As I pointed out long before Levy's personal difficulties became public, on their own merits his claims regarding never events are implausible and his transparency selective.

Berwick: “I am romantic about the NHS...”

Read about Berwick's infatuation with the British health care system here.

Eosinophilic lung disease

Reviewed in Clinical Pulmonary Medicine.

Clarity regarding perioperative beta blockers

A brief evidence summary and commentary in JAMA.

Derm for internists and hospitalists

A slide show on cutaneous manifestations of systemic disease at Medscape.

Cardiac amyloidosis review

Via Cardiology in Review.

ALS review

Open access here.

Abdominal obesity increases the risk of dementia

Via Annals of Neurology.

Keep politics out of this picture

According to Abraham Verghese's lecture to the American Clinical and Climatological association the AMA combined this slogan with Sir Luke Fildes' famous painting,The Doctor, to help defeat Harry Truman's proposal for nationalized health care in 1949. What other words might we substitute for politics?

“Britain, you chose well”---Berwick dissing US health care to a British audience

Berwick talks about “the darkness of private enterprise” and how we “must, MUST redistribute wealth.”

Non-invasive ventilation in acute cardiogenic pulmonary edema

---has been the subject of controversy. A new meta-analysis still suggests it is useful:

Data Synthesis: Compared with standard therapy, continuous positive airway pressure reduced mortality (relative risk [RR], 0.64 [95% CI, 0.44 to 0.92]) and need for intubation (RR, 0.44 [CI, 0.32 to 0.60]) but not incidence of new MI (RR, 1.07 [CI, 0.84 to 1.37]). The effect was more prominent in trials in which myocardial ischemia or infarction caused ACPE in higher proportions of patients (RR, 0.92 [CI, 0.76 to 1.10] when 10% of patients had ischemia or MI vs. 0.43 [CI, 0.17 to 1.07] when 50% had ischemia or MI). Bilevel ventilation reduced the need for intubation (RR, 0.54 [CI, 0.33 to 0.86]) but did not reduce mortality or new MI. No differences were detected between continuous positive airway pressure and bilevel ventilation on any clinical outcomes for which they were directly compared.

Limitations: The quality of the evidence base was limited. Definitions, cause, and severity of ACPE differed among the trials, as did patient characteristics and clinical settings.

Conclusion: Although a recent large trial contradicts results from previous studies, the evidence in aggregate still supports the use of NIV for patients with ACPE. Continuous positive airway pressure reduces mortality more in patients with ACPE secondary to acute myocardial ischemia or infarction.

Republican outrage over health care reform

---is baseless and will poison future debate according to NEJM. Is such political ranting appropriate for an objective scientific journal?

Interview with SHM's president on RFP in hospital medicine

Via The Hospitalist.

Donald Berwick: I'm an extremist

Just a heads up for republicans. If you want to derail Berwick's nomination bring this article to the confirmation hearings and ask him point blank: “Would you consider ordering a non-evidence based MRI against your clinical judgment just because the patient wanted it?”

The most unintentionally funny movie ever made---part 2

After fatally wounding Shelly with his night stick George, faced with the prospect of life as a “cop behind bars,” must think fast.



View part 1 here.

More evidence that the surviving sepsis campaign saves lives

Reported here in Critical Care Medicine:

Conclusions: The implementation of the Surviving Sepsis Campaign guidelines was associated with a significant decrease in mortality. The benefits depend on the number of interventions accomplished within the time limits. The 6-hr resuscitation bundle showed greater compliance and effectiveness than the 24-hr management bundle. (Crit Care Med 2010; 38:1036–1043).

OHSU CAM Grand Rounds: Hypothyroidism

Here's another in my collection of videos from integrative medicine curricula in U.S. medical schools. It's part of the Oregon Health and Science University's CAM Grand Rounds series. For this program OHSU partners with a local naturopathic medicine college, a chiropractic college and an Oriental Medicine college. After a non-woo introduction by a general internist the program goes down hill rapidly.

Donald Berwick: let evidence based medicine take a back seat?

Donald Berwick's radical consumerist views often trump EBM. From the Health Affairs Blog:

For example, “leaving choice ultimately up to the patient and family means that evidence-based medicine may sometimes take a back seat,” Berwick says. “One e-mail correspondent asked me, ‘Should patient “wants” override professional judgment about whether an MRI is needed?’ My answer is, basically, ‘Yes.’ On the whole, I prefer that we take the risk of overuse along with the burden of giving real meaning to the phrase “a fully informed patient.”

The Republicans, who worry that Berwick would ration and restrict care, don't understand what he's really about. There's plenty to worry about, but not for the reasons they think. Related posts here and here.

Eight years of blogging at DB's Medical Rants

Yesterday marked the eighth blogiversary of DB's Medical Rants. Med Rants was one of the early influences on me as a blogger. DB has been a great supporter and helped me get started early on by being the first blogger to link to me. It's wonderful to see Medical Rants still going strong. Do stop by and read his reflections on eight years of blogging (great blogging, I might add).

Steroids for community acquired pneumonia?

Over the last couple of years there's been some noise about this. However a recently published RCT has found:

Prednisolone (at 40 mg) once daily for a week does not improve outcome in hospitalized patients with CAP. A benefit in more severely ill patients cannot be excluded.. Because of its association with increased late failure and lack of efficacy prednisolone should not be recommended as routine adjunctive treatment in CAP.

Related Medscape CME activity (where some important limitations of the study, such as how COPD patients fit into the mix, are discussed) here.

Vancomycin nephrotoxicity

Now that we are giving higher doses to get around the problem of MRSA treatment failure this issue is surfacing. Is it a real problem? The evidence suggests it is, but there are confounders. The topic is reviewed in a recent issue of the American Journal of Medicine:

Recent studies suggest that increased rates of nephrotoxicity are associated with aggressive vancomycin dosing. These increased rates are confounded by concomitant nephrotoxins, renal insufficiency, or changing hemodynamics. These studies also have demonstrated that vancomycin's nephrotoxicity risk is minimal in patients without risk factors for nephrotoxicity. Clinicians unwilling to dose vancomycin in accordance with clinical practice guidelines should use an alternative agent because inadequate dosing increases the likelihood of selecting heteroresistant methicillin-resistant S. aureus isolates.

Donald Berwick target of GOP criticism

From the Boston Globe:

Republicans have opened an assault on the nomination of Harvard professor Donald Berwick to lead the huge agency that runs Medicare and Medicaid, calling Berwick an advocate for “rationing’’ health care…

But GOP lawmakers are becoming increasingly vocal in their attacks on Berwick, citing his support of controlling costs and his statements praising aspects of the United Kingdom’s national health system. They contend his positions show that he would seek to transform US health care into a tightly controlled system, reducing patient choices and delaying treatments.

That may be true but on other occasions Berwick has taken to opposite position of advocating for radical consumerism, suggesting that patients should be the decision makers in their own care and receive whatever care they want, whenever they want it.

It appears that Berwick has been talking out of both sides of his mouth on this issue, and that’s what should be worrying both Republicans and Democrats. Maybe as people try and pin him down during the confirmation process we’ll find out where he stands. It should be fun to watch.

“Autoanticoagulated” patients with liver disease are protected against VTE: fact or myth?

Myth:

Conclusions: An elevated INR in the setting of CLD does not appear to protect against the development of hospital-acquired VTE. The notion that “auto-anticoagulation” protects against VTE is unfounded. Use of DVT prophylaxis was extremely low in this population.

What do resuscitation drugs do?

You've seen it over and over again. EMS personnel respond to the call. The victim has been “down” for an undetermined period of time. ACLS measures are in progress upon arrival. There has been no response but you continue resuscitation a while longer. After half an hour or so things look futile, then boom! The epi has kicked in and the patient has a bounding pulse. The patient is admitted to the ICU but never recovers brain function. Do we have resuscitation drugs to thank for these outcomes? Maybe in some cases according to this study:

Design, Setting, and Patients Prospective, randomized controlled trial of consecutive adult patients with out-of-hospital nontraumatic cardiac arrest treated within the emergency medical service system in Oslo, Norway, between May 1, 2003, and April 28, 2008.

Interventions Advanced cardiac life support with intravenous drug administration or ACLS without access to intravenous drug administration...

Results Of 1183 patients for whom resuscitation was attempted, 851 were included; 418 patients were in the ACLS with intravenous drug administration group and 433 were in the ACLS with no access to intravenous drug administration group. The rate of survival to hospital discharge was 10.5% for the intravenous drug administration group and 9.2% for the no intravenous drug administration group (P=.61), 32% vs 21%, respectively, (P less than .001) for hospital admission with return of spontaneous circulation, 9.8% vs 8.1% (P=.45) for survival with favorable neurological outcome, and 10% vs 8% (P=.53) for survival at 1 year. The quality of CPR was comparable and within guideline recommendations for both groups. After adjustment for ventricular fibrillation, response interval, witnessed arrest, or arrest in a public location, there was no significant difference in survival to hospital discharge for the intravenous group vs the no intravenous group (adjusted odds ratio, 1.15; 95% confidence interval, 0.69-1.91).

Conclusion Compared with patients who received ACLS without intravenous drug administration following out-of-hospital cardiac arrest, patients with intravenous access and drug administration had higher rates of short-term survival with no statistically significant improvement in survival to hospital discharge, quality of CPR, or long-term survival.

So resuscitation drugs increase survival to hospital admission but not discharge. It's tempting to think that arrival to the ICU with return of spontaneous circulation might give future patients a chance to benefit from some of the newer advances in post resuscitation science. However, it appears the patients in this study got state of the art post resuscitation care, with over 70% receiving therapeutic hypothermia.

It's not time to abandon resuscitation drugs just yet. We already knew this regarding amiodarone. Drug effects may be more meaningful for in hospital cardiac arrest and in the context of the new cardiocerebral resuscitation which will be more widely adopted in the near future.

Comparative effectiveness video

Comparative effectiveness is discussed in this video from the Medscape one-on-one series. My own view of comparative effectiveness research was vindicated in the opening remarks by panelist Milton C. Weinstein, PhD. He said that CER is not new. We've been doing it for half a century---it just has a new name.

JoAnn E. Manson, MD, DrPH, made a little appreciated point (about 7:30 in): research, even research that compares treatments, doesn't address real world situations very well. It's all about the distinction between effectiveness (how a treatment performs in the real world) and efficacy (how a treatment performs in the hands of clinical investigators in controlled conditions). What's popularly known as comparative effectiveness research, then, is really comparative efficacy research. Translating that into comparative effectiveness remains a challenge. True comparative effectiveness research is, almost of necessity, “lower level” on the EBM hierarchy, e.g. observational studies, before-and-after studies and the like.

Dr. Manson made another distinction (8:25): of equal importance to comparing treatments is comparing ways of doing and organizing health care. For example, are performance measures and bundles effective?

Finally, all the comparative effectiveness research and comparative efficacy research in the world (and we already have a great deal of both) won't address the fundamental problem: doctors do a poor job of using the research information they already have. But they need tools, not coercion (see below) to help them do better.

So, well and good, you might say. Comparative effectiveness is great. Sure it is in its pure notion. But listen carefully at 9:28, where Dr. Manson reveals the true agenda of comparative effectiveness as a government sponsored movement: to leverage more involvement by policy makers and payers in clinical decisions. In other words take EBM away from the doctors. Can that work in the U.S.? Look at the history of managed care or Medicare.

There's more. While I don't agree with everything the panelists said, this video adds needed clarity to the often confusing discussion on CER.

When anticoagulated patients need procedures

Here's a nice discussion in Today's Hospitalist with links to some recent literature and a protocol used by Harvard Vanguard Medical Associates’ anticoagulation management services.

Private practice is nearly dead

---according to this Kevin post. And, according to the panel of experts speaking recently at HM 2010, health care reform will be the final finishing blow.

Ayurvedic medicine at UCSF

Did you know---

that your doshas manifest at the cellular level?

that ER docs tend to be Pitta dominant and should eat more sweets?

Learn more from the video below.

Interpreting PA catheter tracings

This article from ACP hospitalist doesn't have much applicability for day to day practice because we infrequently use PA catheters now. I post it here because it rings so true to my experience of a couple of decades ago when we “Swanned” patients frequently. Measuring and recording hemodynamic variables with the PA catheter is not simple. It is a highly developed art. Measured and derived hemodynamic values must be understood physiologically and interpreted in light of clinical findings. Wedge pressure recordings must take into account the respiratory cycle. The fine points are explained in the article.

The principles of bedside right heart catheterization were sound, but I contend that relatively few physicians and critical care nurses recorded data correctly, whch is why research studies were negative and we finally pulled the catheter.

Guideline recommendations for TPA in ischemic stroke

---have traditionally been met with push-back from the specialty of emergency medicine. That is gradually lessening. The SAEM has rescinded its negative policy statement concerning TPA.

The world's smartest dog

Is it DIC or TTP?

The distinction between DIC and TTP/HUS is critical for treatment decisions but sometimes difficult due to overlapping manifestations. This study published in the American Journal of Clinical Pathology looked at simple laboratory tests to help make the distinction:

Although the platelet count, prothrombin time (PT), and partial thromboplastin time were different (P less than .05) between the 2 patient groups, after regression analysis, only PT and profound thrombocytopenia remained associated with TTP-HUS (P= .001 and P= .003, respectively). A platelet count of less than 20 × 103/μL (20 × 109/L) and a PT within 5 seconds of the upper limit of the reference interval had a specificity of 92% for TTP-HUS. Our data confirm that readily available laboratory assays in the proper clinical scenario can increase the likelihood of TTP-HUS over DIC.

ABIM president on quality

Christine Cassel, MD is president and CEO of the American Board of Internal Medicine (ABIM). Guest blogging at Kevin MD, she writes about quality in the delivery of health care. In the first half of the post she develops the premise that it takes both good systems of care and good individual docs to do the job. That's self evident. Few would argue against it.

From there she goes on to address what skills (and consequently what training needs) are important for the individual doc, and that's where it gets muddy. She writes:

Physicians need new knowledge and skills – including the ability to manage teams, information, resources and population-level data.

It's not clear where she's going here, because none of these areas are new. The management of teams, which is multidisciplinary care under the physician's direction, has been a cornerstone of the quality and safety movement for at least a decade. The management of resources became critical, and a major focus of practice in 1985 with the advent of DRGs and later in the mid 90s with managed care. And what is the management of population-level data? It sounds like EBM, which started as a “movement” in 1992.

She goes on (my italics)---

More specifically, doctors need special expertise in longitudinal care for a population of patients – built by a trusting, personal relationship that is not limited to site of care, organ system or disease type.

Sounds like a move away from the hospitalist model back to traditional practice. Interesting.

EMRs hinder history taking

Insightful post at Kevin MD.

Compilation of web based toxicology resources

Via Emergency Medicine News.

Lisa Sanders on “House”

I'm amused by medical bloggers' reactions to the TV series “House.” These reactions come in two forms. Some are appalled because the main character is such a horrible example for the profession. Others see each episode as a plausible clinical scenario, an exercise in differential diagnosis. Both reactions miss the point because they take the show too seriously. The writers and producers are playing a joke on us and laughing all the way to the bank. “House” is a dark comedy.

Lisa Sanders writes seriously about real cases. But as technical advisor to the show, her suggestions are not always followed:

The lead character, Gregory House, MD, verbally abuses patients, goes overboard ordering tests and above all, he’s “a jerk,” Dr. Sanders said. But after all, it’s television, and the former CBS news producer turned med student turned Yale professor understands the difference between reality and good drama. Besides, as one of the show’s writers said after listening to Dr. Sanders’ lengthy lecture on proper medical procedures, “You’re right. But my way is funnier.”

Read the rest here.

The QRS-T angle as a predictor of arrhythmias

In patients with coronary artery disease undergoing device implantation, a widened angle predicted device therapy in this study.

The electrocardiograms of these patients will demonstrate “non-specific T wave abnormality.” Non-specific but not insignificant.

Reiki may work, practitioners feel the energy flow, some can do it from a distance: NCCAM

Read it here.

Another review of short QT syndrome

From Cardiology in Review.

Traditional Chinese Medicine taught at UCSF

This isn't just any wooster down the street. This is a lecture at UCSF's Mini-Medical school for the public. The speaker also lectures to med students there.

The UC Television description reads:

Nearly half the US populations turns to complementary, alternative and integrative practices to maintain or improve their health. Beverly Burns of UCSF's Osher Center for Integrative Medicine explores traditional Chinese medicine including acupuncture, meridians and chi. Series: "UCSF Mini Medical School for the Public" [12/2007] [Health and Medicine] [Show ID: 13073]

When you're about to run out of your homeopathic meds

---just add water.

Nashville is drowning. Did anybody notice?

It does seem this is being under reported.

How reliable are those patient driven rating sites?

I've ranted extensively on the unreliability of RateMDs. Now there's a site where patients rate pharmaceuticals. So how should we rate the latest rating site? Let's take a look.

ARBs are misclassified as ACE inhibitors.

Moricizine is rated as the number one antiarrhythmic, superior to beta blockers and amiodarone.

Metformin, arguably the best overall agent for type two diabetes, was rated 9th, below several sulfonylureas.

Binding resins are rated above statins for lipid lowering.

I could go on. Suffice it to say I'm not impressed.

H/T to Clinical Cases and Images.

Bingo!

One of the bloggers I follow scored with this post:

Before Barrack Obama's next televised speech, prepare your "Obama Bullshit Bingo" card by drawing a square. I find that 5" x 5" is a good size -- and dividing it into columns –five across and five down. That will give you 25 1-inch blocks.

Write one of the following words/phrases in each block:

Included are restored our reputation, strategic fit, leverage (as a verb), win-win, affordable health care, greed on Wall Street, empower...

Check off the corresponding block when you hear one of the words or phrases. See how long it takes you to get 5 across, down or diagonally.

Integrative medicine at OHSU

It's been a while since I've posted links exposing the teaching and promotion of quackery by U.S. medical schools, a megatrend for which I coined the term quackademic medicine. I'm afraid I fell down on the job. It was just the same old woo popping up at one med school after another across the country, and it got a little tiresome. Lately, though, my interest has been piqued by more and more postings of videos of actual lectures. These videos offer a closer look at what's actually in the curricula, which I've been compiling as I find them for eventual posting here.

Let's kick it off with a lecture about the CAM perspective on pandemic flu from the Oregon Health and Science University's CAM Grand Rounds series. You can access it here. It's pure woo and, it seems to me, a little anti-vax in its slant.

Boston Globe to BIDMC regarding Paul Levy

---transparency, please:

To be very clear, no evidence has surfaced that Levy, financially speaking, did anything untoward. These are questions, not accusations. But when the CEO of a major Boston hospital has a relationship with a direct subordinate, who is transferred to a job with a better title before she departs with a severance package, it raises not just logical, but critical, questions. Left unanswered in a public setting, they are a cancer on the hospital’s leadership — and its reputation.

This, not Levy's personal life, is the issue. The extent it may have affected hospital operations and finances is as important for the public to know as is the hospital’s central line infection rate. BIDMC is fast distinguishing itself as a leader in selective transparency.

Acid suppression therapy is overused in hospitalized patients

From a paper in Southern Medical Journal:

Results: Seventy percent of patients were started on AST on admission. Of these, 73% were unnecessary. Stress ulcers prophylaxis in low risk patients or the concomitant use of ulcerogenic drugs motivated initiation of therapy most frequently. Sixty nine percent of patients started on inappropriate AST were discharged on the same regimen. Admitting diagnosis, age of patient, length of stay, or concomitant use of ulcerogenic drugs did not predict continuation of unnecessary AST at discharge.

The inappropriate use is an unintended consequence of performance measures, bundles and clinical pathways. Inappropriate continuation after discharge is a consequence of medication reconciliation.

I'd been hearing that the health care bill doesn't address tort reform

---but now I know this. Not only does it not address it, it discourages it. Tort reform is dead unless we get some help in November.

Interview with Richard D. Pinson, M.D., on clinical documentation

You can listen here to the interview, linked in a recent issue of The Hospitalist. Dr. Pinson, who is a coding expert with HCQ Consulting, says there are two different worlds of documentation. There's ordinary clinical language, the terms doctors use to convey meaningful information and another type of language, a set of magic words and phrases which administratively define diseases and enable coding for higher DRG payments. Administrative types want you to translate true clinical documentation into the more lucrative but sometimes less meaningful administrative documentation. That, says Dr. Pinson, is a core skill for hospitalists. Funny.

He goes on to give a few examples. About 3 minutes in he talks about how the coders want us to make the completely meaningless distinction between “simple pneumonia” and “aspiration pneumonia.” I guess they haven't heard that the pathogenesis of all bacterial pneumonia, including ordinary pneumococcal pneumonia, is colonization followed by aspiration.

How happy are hospitalists? Lessons from the Today's Hospitalist career satisfaction survey

Hospitalists like their work but there can be too much of a good thing, and that gets old after a while. That's my take on the survey results. Although 75.3% were “extremely satisfied” working as a hospitalist, 68.8% thought burnout was a “very significant” or “significant” issue for them personally, 79.3% thought it was for their colleagues and 86.7% thought it was for the specialty overall. 30.3% said they didn't want or weren't sure they wanted to make hospital medicine a career. Most who plan to leave hospital medicine are waiting on a fellowship.

The results are presented here along with some thoughtful and creative ideas from a few programs around the country to help improve retention. I observed nothing at HM 2010 to allay my long held concern that SHM is not doing enough to address this problem.

Nashville flooding

I guess my head's been the sand, but I just learned of this disaster. Worst in the city's history. Homes destroyed, 20 lives lost, and around a billion in damage. So sad. I have fond memories of the 4 years I lived in Nashville---went to med school there and fell in love with the place. I've since kept up with developments there and visited several times.

Some of the popular hang outs and watering holes downtown were damaged, not to mention the entire Opry complex. The Gaylord was evacuated and the Opry was forced to relocate to two of its former homes, the Ryman auditorium and the War Memorial Auditorium. Missing a show was not an option. The Saturday night show, the Opry's official version, has had over 4000 consecutive performances in the nearly 85 years of the Opry's history.

Here are a few local blogs:

Musings about Music City has posts here and here.

Posts at Fayfare's Opry Blog provide details about the far reaching effects of the shutdown of the entire Opry complex.

Local blogger and author Stephen Mansfield said it best:

Nashville is sophistication in denim. It is where the South meets Yankee culture with a smile and without letting go of too much. It is where the self-important never last but the art never ends. Nashville is my home. I love the accents, the heritage and the way the past calls gently through monuments and architecture to an all too unaware present. I’ve gotten use to how a road can change names three times before you get where you’re going and how the restaurant you loved last week is gone this week and how tourists think nothing of asking you if you’re somebody famous. I love Nashville.

Over this past weekend, my city drank in nearly 14 inches of rain. For perspective, the most rain she had endured at one time in all her history was just under 7. Now, much of my city is under water. There is fear and anguish, heartache and the disorientation that comes from the feeling that life is spinning out of control.

My city is going to rise.

Beth Israel CEO Paul Levy---disruptive administrator?

I guess when you're on top of the world---CEO of one of the nation's most prestigious medical centers, making around a million a year, bombarded with invitations to speak all over the country---you're in a situation that could lead to lapses in judgment. That's about all Levy choses to own so far in this controversy (H/T to Grunt Doc):

The Board of Directors of Beth Israel Deaconess Medical Center, with the assistance of outside counsel, has completed its review of allegations made involving President and CEO Paul Levy. The review focused on a personal relationship with a former employee of the Medical Center. The Board found that over time the situation created an improper appearance and became a distraction within the hospital.

The Board believes that Mr. Levy should have recognized this situation in a more timely fashion and should have conducted himself in keeping with business protocol appropriate for the office of the CEO.

Mr. Levy agrees that it was a serious lapse in judgment and agrees with the Board’s conclusions. He has apologized to us and to the entire staff of the hospital.

Although our outside counsel found that Mr. Levy did not violate hospital policy, the board determined that he showed poor judgment and the board expressed its disappointment. Accordingly, the board has voted to take appropriate actions by:

1. imposing a financial penalty of $50,000 to be paid to the hospital in the current fiscal year.
2. instructing that this matter be considered in determining the CEO's compensation for the next fiscal year.

Although in this instance, Mr. Levy has not lived up to the standards we set for our CEO, the Board also considered his exemplary record over the course of his tenure at BIDMC...

What more do we know? The employee in question was a woman who worked in several positions in the organization, including as Levy's special assistant. The relationship was brought to the board's attention by an anonymous whistle blower. As reported here, (see video) the situation with the female employee created a distraction (can you say disruptive?) for the hospital.

Although a Boston Herald reporter was hounding Levy about the incident on the way to Columbus Ohio where he spoke to a group of physicians, at the meeting he deflected concerns about the media presence thusly:

The morning after a Herald reporter specifically quizzed him about the relationship as he headed to a keynote speech on hospital transparency, Levy insisted he did not know why the reporter was seeking his comment.

“Our hospital is subject to what they call a corporate campaign by Service Employees International Union,” an apologetic Levy told the crowd at the Columbus, Ohio, conference as he began his speech, “Why Transparency is Important to Patient Safety.”

“And one of the things they like to do is show up at events where I am and try to disrupt those events with irrelevant questions or demonstrations and the like,”...

Now I'm not sure about the $50K. Can a hospital fine its CEO? I'm guessing it was reimbursement for a severance package they paid the employee in question, but it's not clear.

A commentary from WBUR in Boston said this:

But for an administrator who has been such an aggressive advocate of transparency in medicine, Levy’s apology today is anything but. Now that he’s said sorry, and the matter appears to be resolved, will we soon read a post about what, actually, happened? I suspect Mr. Levy’s loyal readers would like to know.

So how much do we really need to know? A reporter from the Boston Herald has a blog devoted to the subject, and seems determined to uncover all the salacious details. Jaz-Michael King, blogging over at A Scanner Brightly, sees it differently:

It is my opinion, and my opinion only, that a figure with as much publicity as Mr Levy should not avoid the fact entirely on his many outlets, especially given his use of his blog as a glimpse in to his personal as well as his professional life. The modern world and its modern communications channels necessitate that we bloggers and tweeters and users of the Web cannot but give up much of our privacy, and separating personal from professional has never been harder now that we are all profiled and LinkedIn'ed...

But this pious outpouring that he should be fully documenting his tribulation for all of us to benefit from his transparency is nothing but sanctimonious codswallop.

Now a few observations of my own. If the reports are true Levy's behavior was disruptive. It was a distraction and, judging from comments from defenders and detractors, divisive. It may have resulted in the loss of an employee. BIDMC is to be applauded for recognizing that zero tolerance for disruptive behavior applies all across the organization, to administrators as well as physicians.

Levy's lapse was not only in judgment but also in transparency (about which he has been beating the drum for some time), as he apparently chose not to deal with this openly until someone blew the whistle. Do the principles of transparency apply to his personal life? Yes, to the key people at BIDMC who have responsibility to find out why this was allowed to happen and take preventive measures (a root cause analysis, if you will). But the public doesn't need to know more. There's Levy's family to consider.

I have no idea how institutional politics play out at BIDMC, but I hope the board dealt with the situation in a fair and even handed way. I also hope Levy stays on. I am glad that the board chose to honor him for his past accomplishments. Despite my previous skepticism about his statements on transparency and zero error rates, I believe the institution has prospered under his leadership. Finally, I hope the lessons here are not lost. Administrators, nurses and doctors should be held to an even standard regarding disruptive behavior. Transparency and disclosure are nuanced issues. They are difficult, and they have consequences.

The Ross Sisters

This has been circulating around the net lately. Kind of lame at first but it gets better. Amazing, actually.

Interview with Connie Leonard, director of CMS Recovery Audit Operations

You can listen here. The audio file is linked in a recent issue of The Hospitalist. The take home message is reassuring: the dreaded RACs will not be auditing E&M codes for patient visits just yet. Before that can happen the Recovery Audit folks will have to meet with the AMA, hammer out clear audit guidelines for providers, then disseminate the information.

RBBB and acute coronary syndrome

RBBB is a marker of risk in ACS and may, to the inexperienced observer, obscure the diagnostic electrocardiographic findings. The topic is reviewed in a recent issue of the American Journal of Emergency Medicine. Interesting tracings are provided along with a helpful discussion of concordant and discordant ST and T changes.

Pericardial disease review

Very comprehensive and helpful review of diagnosis and management. Via Nature Reviews Cardiology.

Auscultation tutorials on line

Compiled at Clinical Cases and Images.

The most unintentionally funny movie ever made?

I occasionally blog non medical items when they are culturally significant. What was the most unintentionally funny movie ever made? There’s quite a discussion here on the topic. The scene below is from a film that deserves consideration.



Weren't police officers trained in CPR in the 1980s? Grady didn't seem to know what to do after the pulse check at 6:26.