Wednesday, June 30, 2010

So you've been sanctioned by ABIM over the Arora course---now what?

A commenter tipped me off to this piece from the WSJ Health Blog. Sanctioned docs are trying to figure out how to get due process. The comment thread is interesting too. A common theme there is that all prep courses, yes, even the “legitimate” board review courses, are heavily influenced by old exam content. That's why this is going to open up such a can of worms. Other courses (and their attendees) may feel threatened. Meanwhile the lawyers will be busy.

Ghost writing with a new twist

And this was supposed to be the administration that would keep politics out of science?

An article by Shannen Coffin, a deputy attorney general during the Bush administration, opens:

When President Obama promised in his inaugural address to “restore science to its rightful place,” he never explained what that rightful place would be.

Documents recently released in connection with the Supreme Court nomination of Solicitor General Elena Kagan suggest an answer: wherever it can best be used to skew political debate and judicial outcomes.

The documents involved date from the Clinton White House. They show Miss Kagan’s willingness to manipulate medical science to fit the Democratic party’s political agenda on the hot-button issue of abortion.

It's a case of ghost writing with a new twist.

I can't go on with this post. I'm about to blow a gasket, so read the rest at the primary source, as well as related content here and here.

Al Gore's second chakra

By now many of you have read the accounts of Gore's encounter with masseuse Molly Hagerty, gone bad. The inconsistency of Hagerty's actions after the incident weakens her credibility, so who knows what really happened.

But wait, what about the second chakra? She wouldn't make that part up, would she? Well, if true it raises a few questions about Gore's credibility. When he speaks on issues of science, I mean.

Image source Wikipedia. Author Mirzolot2. Creative Commons license.

Many professional organizations favor Donald Berwick's nomination

From DOTmed news:

On Monday, 10 leading hospital groups representing the bulk of America's hospitals, including the American Hospital Association, the Catholic Health Association of the United States and the National Association of Children's Hospitals, stood behind President Obama's pick for the top CMS post...

Other signatories to the letter include the American Medical Rehabilitation Providers Association, Association of American Medical Colleges, Federation of American Hospitals, National Association of Psychiatric Health Systems, National Association of Public Hospitals and Health Systems, Premier, Inc. and VHA Inc.

I'm perplexed. I can only conclude that this represents a very superficial understanding of Berwick based on his work at IHI which is very popular among hospital organizations. Do they know what he's really about?

Tuesday, June 29, 2010

ABIM, Arora board review and Frontrunners

I guess it's time for an update and a recap on this controversy. Here's what's happened so far:

From Bob Wachter and the WSJ Health blog we learned that the Arora board review company was harvesting questions from old ABIM exams submitted from memory by past attendees who had taken the exam and teaching its review course from these questions.

Over two thousand diplomats of the ABIM who had attended an Arora course (approved for 42 AMA category 1 CME hours) got a letter from ABIM expressing disappointment in their ethics for not blowing the whistle. A copy of this letter is to be maintained in those diplomats' ABIM files. According to comments on a related WSJ Health blog post many of these physicians feel they did nothing wrong, feel their professional record is unfairly besmirched by this letter and are considering legal counsel.

The ABIM sued Arora for teaching from old test questions.

In the discovery process of that suit emails between course attendees and Dr. Arora were examined, and a smaller number of physicians, 135 or so, were targeted for more severe sanctions (more than just the letter). In addition, a few of that latter group were sued by ABIM.

The three principal issues raised in the whole affair were 1) violation of the terms and conditions for candidates taking the exam (not to divulge exam content), 2) that ABIM test questions are proprietary information and 3) cheating. Premises 2 and 3 are questionable and may be topics for other posts.

The case was recently settled in ABIM's favor.

Meanwhile another board review company, Frontrunners, was being sued by ABIM on similar claims.

Frontrunners initiated an anti-trust counter-suit against ABIM.

I was recently informed by an ABIM spokesperson that a magistrate judge has made a recommendation that the suit by ABIM be decided in ABIM's favor and that the counterclaim was dismissed about a year ago. That's pretty much where I left it.

So what's transpired since then?

Frontrunners has issued an update, seemingly in response to the latest comments from ABIM. This came to my attention in the form of three comments to one of my blog posts. These were long and rambling. I have not posted them here. Readers can find the same material at the Frontrunners site. It is vitriolic, so be warned.

For those who don't want to read the whole thing I offer the following short version, as best I understand it, in the form of a point-counterpoint, minus all the accusations:

Point: ABIM cites a judicial opinion favorable to ABIM in their suit against Frontrunners.
Counterpoint: This was a recommendation by a magistrate judge. It was preliminary, and based on the judge's opinion that Frontrunners was hindering discovery efforts. Frontrunners expresses hope that the case will be decided on its merits.

Point: The Frontrunners counterclaim against ABIM was dismissed about a year ago and there is no suit pending at this time.
Counterpoint: Frontrunners, on their web site, states that the dismissal was based on the four year statute of limitations. However, they allege new damages which might be the basis for a refiling. No claim is now pending.

What's my stand in all this? I don't have enough information to come down squarely on one side. Arora's teaching methods concern me. Frontrunners' combativeness concerns me. Some of ABIM's actions concern me. I will be watching with great interest as this drama unfolds.

When woo intersects woo

---now that's some real integrative medicine.

Kimball Atwood casts a pretty wide net in his latest rant at Health Care Renewal. I particularly like the part about combining homeopathy with chiropractic. The synergy is amazing.

Donald Berwick not out of the running yet

---for head of CMS, but he didn't make the first cut.

Via Secondhand Smoke.

An assisted suicide clinic

---headed up by, of all people, a psychiatrist!

Imagine a psychiatrist pushing suicide! This should be considered a breach of professional ethics because it puts the authority of the mental health professions in favor of self destruction. Here’s a novel idea: How about a clinic to help people not want to commit assisted suicide? Nah. No news in that.

Monday, June 28, 2010

Procalcitonin ready for prime time?

A procalcitonin assay has recently been approved for use in the United States. Unfortunately many hospitals do not run the assay in house. The principles behind procalcitonin and the current state of use are covered in a recent review in LabMedicine (reproduced in full text at Medscape).

PCT seems to be useful as an adjunct to guide antimicrobial treatment. Questions remain as to its value in diagnosing or excluding infection.

LBBB and hyperkalemia

Contrary to popular belief LBBB does not mask the changes. Brief report and illustrative tracings here.

My, how we’ve changed

Hospitalist skill set, year 2000

Management of CAP and HCAP
Management of sepsis
Management of venous thromboembolism
Management of DKA, adrenal crisis and other endocrine-metabolic emergencies
Management of COPD, asthma and ARDS, including ventilator management
Management of renal, fluid and electrolyte problems
Management of acute decompensated heart failure
Management of toxicologic emergencies
Providing consultation for complex and difficult diagnostic problems
Providing consultation for medical complications in surgical, subspecialty and general medical patients

Hospitalist skill set, year 2010

Tweaking Press Ganey
Tweaking clinical documentation (DRGs)
Creative coding
Bed control
Admitology, roundology and dischargology for surgical and subspecialty patients
Cosmetic charting (performance measures)
Secretarial (CPOE)

Noninvasive positive pressure ventilation

Over the last few years several reviews have been published on this topic, reflecting an increasingly nuanced approach to NIPPV and growing indications. Here's the latest one from CCJM.

Friday, June 25, 2010

ProBNP kinetics in acute onset atrial fibrillation

When a patient presents in atrial fibrillation, the time of onset impacts treatment decisions. In patients who lack tachycardia awareness estimation of the time of onset is difficult. This study suggests we can take advantage of proBNP kinetics to estimate time of onset. Not something to change practice yet, but interesting:

Results Mean plasma NT-proBNP levels and 95% CIs (pg/ml) during the 48-h period following onset of AF were: 0–6 h: 636 (395 to 928), 6–12 h: 1364 (951 to 1778), 12–18 h: 1747 (1412 to 2083), 18–24 h: 1901 (1549 to 2253), 24–36 h: 1744 (1423 to 2066) and 36–48 h: 1101 (829 to 1373). Mean time to peak NT-proBNP levels was 16.7 (0.7) h; 29 patients reached their peak levels within 24 h. The mean peak NT-proBNP level was significantly higher than those obtained at 0–6 h and at 36–48 h after onset of AF (p less than 0.001 for both). There was no correlation between ventricular rate and plasma NT-proBNP levels during any time period after onset of AF.

Conclusion In patients with new-onset AF but no clinical or radiographic evidence of heart failure, plasma NT-proBNP levels rise progressively to a peak during the first 24 h and then rapidly fall. This pattern may serve as an aid to assess the time from AF onset.

Rheumatologists in the U.S.

---accept implausible, non-evidenced based CAM to a surprising degree.

Posterior reversible encephalopathy syndrome (PRES)

PRES is best known as hypertensive encephalopathy but there are several other clinical associations. That is the subject of this paper from Mayo Clinic Procedings.

Portopulmonary hypertension

---can be the Catch 22 for liver transplant candidates. Review here.

New evidence regarding the best PEEP in ARDS?

A JAMA meta-analysis looked at higher vs lower PEEP. Overall, for patients with ALI and ARDS, there was no improvement in survival associated with higher PEEP. For the subgroup with ARDS there was a trend toward improved survival but the difference was of borderline statistical signifance (p=0.49, adjusted RR CI .81-1). If this difference is true the NNT would be 20. There was no difference in pneumothorax or vasopressor use. Is this enough to recommend change in practice?

Thursday, June 24, 2010

Diffuse alveolar hemorrhage

I have one quibble with this otherwise excellent review in Chest. The authors decry eponyms as not being descriptive of pathology but preserve what may be the most inappropriate eponym in the history of medicine. Thus Wegener's Granulomatosis becomes ANCA-associated granulomatous vasculitis while anti-GBM disease is still referred to as Goodpasture syndrome.

Whither naloxone?

Naloxone can reverse acute opiate intoxication. If the patient is narcotic tolerant it may precipitate opiate withdrawal. Conventional teaching holds that opiate withdrawal is a nuisance but never life threatening. But that's passive withdrawal. Precipitated withdrawal, as might occur with naloxone given to a narcotic tolerant patient, may be more problematic as it is associated with profuse vomiting and catecholamine surge. More here from Emergency Medicine News.

Which is better for patients with chronic pulmonary disease: regular maintenance primary care or reactive care?

From the JGIM:

The findings indicate that regular and proactive ‘maintenance’ primary care, as distinct from ‘reactive’ care, is beneficial to older CRD patients by reducing their risks of hospitalisation and death.

Prodigious doses of benzos

---were often needed for patients with DTs in a series presented at the ACCP annual meeting:

The 38 patients with DT who were admitted to the ICU received an average total dose of 905 mg of lorazepam (Ativan), and 37 required transition from oral to intravenous lorazepam.

Now, let's see, at an average ICU LOS of 10 days that's around 90 mg per day or almost 4 mg an hour. Yes, that's quite a bit, reflecting cross tolerance between benzos and alcohol.

Euglycemic hyperinsulinemia therapy for severe calcium blocker overdose

---and maybe beta blocker overdose has been the well kept secret among toxicology types for a decade. Supported primarily by animal data, physiologic rationale and case reports (many of which are dramatic), it is gradually emerging as an important component of treatment when the overdose is severe. Accumulating dramatic case reports support current use---we will probably not see higher level evidence. This review (accompanying commentary here) is probably the best evidence summary available. The authors advocate using it along side of (adjunct) rather than after failure of, more standard measures such as pressors, inotropes, glucagon, calcium salts, etc.

Commentary here from Emergency Medicine News.

Wednesday, June 23, 2010

Unrealistic expectations and unachievable time lines

---characterize meaningful use requirements for EMR adoption according to this article. Even large experienced institutions are saying they can't do it.

Via Todays' Hospitalist.

Steroids for COPD exacerbation: What route? What dose?

This study suggests lower dose oral steroids work as well as higher dose IV. The results section is complicated, and 22% of patients started on oral therapy were later switched to IV.

CT scanning to help differentiate the cause of pericardial effusion

From the American Journal of Roentgenology:

RESULTS. Twenty-eight cases of malignant and 46 cases of benign pericardial effusion were identified. Mean pericardial thickening was greater in association with malignant disease (7.25 ± 2.91 mm) than with benign disease (4.11 ± 1.39 mm) (p less than 0.05). Abnormal pericardial thickening (p less than 0.05) and mediastinal lymph node enlargement (p less than 0.001) were statistically significant findings of malignant pericardial effusion. The sensitivity of abnormal pericardial thickening was 42.9% and that of mediastinal lymph node enlargement was 60.7%.

CONCLUSION. CT findings of irregular pericardial thickening and mediastinal lymphadenopathy have the potential to be reliably specific findings suggesting the presence of malignant pericardial effusion. It would be useful, however, to obtain pericardial fluid or tissue for cause-based management of pericardial effusion, especially in patients with malignant disease.

Familial polyposis

Open access full text review here.

Gabapentin toxicity in chronic kidney disease

---is common and under-recognized. Gabapentin is excreted exlusively by the kidney.

Tuesday, June 22, 2010

Glycemic targets in hospitalized patients

---varies with patient characteristics and whether or not the patient is in the critical care unit. This article in Hospitalist News offers some pointers.

For critically ill patients, intravenous insulin infusion protocols are better for achieving and maintaining glycemic control, she said. Many hospitals further subdivide the protocol for critically ill patients to have different glycemic targets for surgical and nonsurgical ICU patients, added Dr. Korytkowski, professor of medicine at the University of Pittsburgh's Center for Diabetes and Endocrinology.

A 2009 consensus statement from the American Association of Clinical Endocrinologists and the American Diabetes Association recommended maintaining glucose levels between 140 and 180 mg/dL in most critically ill patients, but added that glucose levels of 110-140 mg/dL may be appropriate in some, such as those in cardiothoracic intensive care...

In noncritically ill inpatients, the consensus statement recommends targeting premeal glucose levels of 100-140 mg/dL and random glucose test results below 180 mg/dL (Endocr. Pract. 2009;15:353-69 and Diabetes Care 2009;32:1119-31).

Prolonged therapy with “sliding scale” insulin alone is not recommended, Dr. Korytkowski stressed. “This whole idea of putting patients on sliding-scale insulin and continuing it for the duration of their hospitalization independent of what their blood sugar levels are needs to be stopped,” she said.

The whole discussion about sliding scale insulin is confusing. The statement above may have a valid point if I could understand it. The dosing of sliding-scale insulin, after all, is dependent on what the patient's blood sugar is. What's more, titratable insulin drips, widely advocated by the same diabetes mavens who decry sliding-scales, are nothing more than sliding-scale insulin modified as to timing of monitoring and route of administration. Short acting “correction” insulin, also recommended by the diabetes mafia, is just sliding-scale insulin made more confusing by administering it on top of a fixed amount of short acting insulin.

The rationale against simple sliding-scale insulin (why wait for the patient to go out of control before giving insulin?) is sound but I am not aware of evidence that it is associated with worse clinical outcomes. Reading between the lines of that the experts say, I can glean the following principles, with which I am in general agreement:

Simple sliding-scale insulin by it self is not enough in many circumstances where patients need basal coverage.

Correction short acting insulin on top of a fixed amount of pre-meal short acting insulin is more physiologic than simple sliding-scale coverage.

The most rational coverage would be basal-bolus insulin. This may not be practical for all hospitalized patients because achieving suitable control may be a stepwise process taking days, according to the article. For patients with very short hospital stays who will be NPO a good portion of the time, sliding-scale coverage is appealing.

Some resources cited in the article can be found here and here.

Half dose TPA for massive and sub-massive PE

It may be just as good with less bleeding.

This is bound to cause controversy. According to an editorial in the same issue of Chest:

Physicians should consider using Wang and colleagues' reduced rt-PA dose regimen in lower body weight patients with PE with hemodynamic compromise or another indication for thrombolysis. As other peer-reviewed studies have reported, [14] , [15] efficacy failure might be addressed by re-treatment, with the same 50 mg or the approved 100-mg dose. Wang and colleagues' careful new look at rt-PA for thrombolysis is welcome. Although the results are not definitive, these data provide useful guidance that can favorably change practice.

IDSA Lyme Disease guidelines upheld

This was a long time in coming and I hope will bring some closure. Paul Auwaerter, clinical director of the ID section at Hopkins, reviews the history of the controversy as well as the current status in a Medscape video update.

Medication reconciliation: can we get it right?

Medication reconciliation was one of Joint Commission's most meaningful patient safety goals. Unfortunately, hospitals found it so difficult to comply that JC has eased up. While hospitals are still expected to comply with the original standard, they will not be surveyed on it. Moreover, JC has announced now that they will be field testing a revised (and presumably easier) med rec standard.

Medication reconciliation means that any medication changes at transitions of care should take place with therapeutic intent and explicitly take into account the patient's preceding regimen. According to a recent JGIM study that process fails at hospital admission an alarming portion of the time:

Over one-third of study patients (35.9%) experienced 309 order errors; 85% of patients had errors originate in medication histories, and almost half were omissions. Cardiovascular agents were commonly in error (29.1%). If undetected, 52.4% of order errors were rated as potentially requiring increased monitoring or intervention to preclude harm; 11.7% were rated as potentially harmful.

The authors have developed a med rec tool kit accessible on line here. It's loaded with links and resources and borrows from a variety of process improvement methodologies including Six Sigma. A recurring theme of the tool kit is the idea of the “one source of truth”: the patient's real med list. The problem with that is, for many patients who present to the hospital such a list has never been defined. For other patients the list is merely an ideal. Sometimes in practice what the patient thinks s/he's supposed to take, what s/he's actually taking, what the most recent provider thinks s/he's supposed to be taking and what the medical record says represent four different “realities”.

A special problem arises with insulin. For patients who self-adjust it's extremely difficult to cleanly list in the medical record. Some patients literally cannot, or will not, articulate their dosing schemes. Sometimes the easiest work around for that situation is to merely let the patients use their home supply and self-administer. The med rec standards make that approach difficult and nowadays doctors may be tempted to cop out with a sliding scale, start from scratch or just guess.

There's no clear solution to some of these problems, but the tool kit does address areas where hospitals can improve. One is to explicitly define areas of responsibility. Who, for example, is responsible for generating the “one source of truth” medication list? ER nurse, physician, pharmacist, inpatient unit nurse? Is it shared among all?

Medication reconciliation, elegantly simple in concept, proved inscrutably complicated in its implementation. The tool kit provides robust process improvement methods to help make it work.

Via Today's Hospitalist.

Should you avoid statins in patients with underlying liver disease?

No says Dr. Robert Perrillo of the hepatology section at Baylor University Medical Center.

Monday, June 21, 2010

Lessons from the 2009 flu pandemic

It may be a little premature for a postmortem, but in this Medscape piece John Bartlett, who always offers unique insights, reviews the lessons we've learned:

The experience with the 2009 Influenza H1N1 pandemic may be the most instructive flu season we have had in decades.

The Get With The Guidelines-Stroke project

---is the largest ever stroke database. A report on the first million stroke admissions appeared in Circulation: Cardiovascular Quality and Outcomes. The report is open access full text and is important for these reasons:

It is the largest database of its kind.

The process improvement tools and learning resources embedded in the project resulted in robust increases in guideline adherent care.

Although the cause and effect relationship is uncertain, improved guideline adherence was associated with reduced mortality and length of stay.

The report suffers from the unfortunate use of the term performance. This was a guideline adherence initiative more than a performance initiative in that it did not involve public report cards, reports to CMS or reports to Joint Commission.

Is metabolic syndrome a useless construct?

Harriet Hall over at Science Based Medicine thinks it is:

The concept of a metabolic syndrome originally seemed promising: it carried the hope of better identifying patients at risk, contributing to establishing an etiology related to insulin resistance, and determining better routes to prevention and treatment. These ideas haven’t panned out. It is still unclear whether obesity causes the associated findings or whether an underlying condition causes the obesity along with the other findings or whether something else is going on. It is becoming increasingly clear that identifying and managing individual risk factors is the way to go.

Should the concept of metabolic syndrome be abandoned? Probably. But human nature makes us reluctant to abandon any idea after it has rooted itself in our consciousness. The metabolic syndrome has become so well established in the popular medical mind that it will not go without a struggle.

There's a lot of good information in the post but I must respectfully disagree with the conclusion. Although the syndrome's definition may be imprecise it is a metabolic stew of disorders that tend to cluster together and have important things in common regarding diagnosis and treatment.

So let's look at both sides of the debate. It's to be acknowledged that the genetics and the interrelationships among the metabolic disturbances are incompletely understood. There are lots of “which came first” and “true, true and maybe unrelated” type questions to be asked. And, though the tendency of these disorders to cluster together is very strong, there is evidence here and there demonstrating that some of these disorders occasionally (though not usually) behave as independent risk factors (e.g. LDL pattern B and insulin resistance).

On the other side of the debate, favoring recognition of the syndrome, are several facts. Metabolic syndrome is important to identify because affected patients don't do well with statin drugs as monotherapy. For this reason they need to be recognized so that their residual risk after statin therapy can be recognized and addressed. Widespread failure to do this in the US has resulted in untold events. Metabolic syndrome is uniquely amenable to treatment with diet and exercise---more so than most of the traditional “LDL disorders.” Drug therapy is specific and focuses on niacin, and sometimes fibrate drugs. As understanding of metabolic syndrome improves we may come up with better terminology and perhaps a categorization of affected patients. Exciting findings over the past decade suggest a “final common pathway” by which the disorders of the metabolic syndrome operate, and maybe a unifying hypothesis: impairment of reverse cholesterol transport.

There are two classic review articles that are must-read for anyone with an interest in this topic. They point to primary sources of information for all the points I've raised and can be accessed here and here.

Emergency medicine podcasts from Vanderbilt

Keeping Up.


A dermatology education site. Free after registration. Via Clinical Cases and Images blog.

Saturday, June 19, 2010

The most unintentionally funny movie ever made---part 3

Recall that in part 2 Brad is framed for the murder of Shelly Johnson. Part 3 opens with a little woo. Gigong? Tai chi?

MI and stroke risks early after COPD exacerbation

---are increased:

There was a 2.27-fold (95% CI, 1.1-4.7; P = .03) increased risk of MI 1 to 5 days after exacerbation (defined by prescription of both steroids and antibiotics). This relative risk diminished progressively with time and was not significantly different from the baseline MI risk at any other postexacerbation time interval. One in 2,513 exacerbations was associated with MI within 1 to 5 days. There was a 1.26-fold (95% CI, 1.0-1.6; P = .05) increased risk of stroke 1 to 49 days after exacerbation.

Conclusion: The results suggest that exacerbations of COPD increase the risk of MI and stroke. This may have implications for therapy in both stable and exacerbated COPD.

Who has inner peace?

From the StlMedia blog.

How does the social mission of your medical school measure up?

MD and DO granting schools were ranked in this Annals article. Here's what was measured:

Measurements: The percentage of graduates who practice primary care, work in health professional shortage areas, and are underrepresented minorities, combined into a composite social mission score.

Here's a partial list of the ranking---top and bottom 20. Here's the complete listing for each of the measurement categories and for the composite score. What's interesting is that medical schools traditionally considered among the nation's best tended to be rated near the bottom. There's an interesting irony in my med school home town, Nashville. Vanderbilt, my alma mater, ranked last---dead last---among the 140 schools. Meharry Medical College across town ranked second. This was despite the fact that the two schools formed an alliance over ten years ago, to try and close the gap.

In fairness, Vandy is a research-heavy medical school with a strong dedication to the training and nurturing of physician-scientists. While the school has produced hundreds of primary care docs, a large percentage of students gravitate to subspecialties, basic research and academic medicine. We need physician-scientists as teachers and researchers just as we need PCPs.

Wisdom from Archie Bunker

I love the expressions on Edith's face.

Via Nashville Blotter.

Friday, June 18, 2010

New report about the ABIM-Arora board review flap raises questions

---in my mind anyway.

It's from HealthLeaders Media.

So why do board questions have to be a trade secret? Is it about money? After all, according to the report the ABIM

...was forced to have workers spend day and night crafting new tests, spending countless hours and money to undo the damage.

Countless hours and money. But no, according to ABIM's CEO the reason is:

Each question crafted for the American Board of Internal Medicine board certification exam "is like a precious jewel," says Christine K. Cassel, MD, ABIM's President and CEO. It sometimes takes two years to form the questions, with the right precision and nuance that elicits medical knowledge sought, she says.


She went on to say that there was an 88% pass rate in 2009, which makes you wonder about Medstudy's 97% pass rate.

Around 2000 people were identified as having taken the prep course and no one, not one person, notified ABIM, Cassel said, expressing disappointment that all those people saw unethical behavior and didn't report it. She maintained that the ethics breach was “not subtle.” If that's so how come none of 2000 attendees reported it? How bright was the line? Well, I don't know how explicit the pledge that candidates have to sign really is but here's the standard as described on the ABIM web site:

Each physician who signs up for an ABIM examination is directed, in writing, not to discuss exam content. In addition, before each test, physicians sign a ‘pledge of honesty’ to not disclose, copy, or reproduce any portion of the material contained in the examination and are warned that ABIM will impose severe penalties on any physician involved in efforts to provide examination question content to others.

Prohibiting discussion of “exam content” casts a pretty broad net. By that standard, comments like “they hit drug interactions pretty hard” or “you better know the screening guidelines inside out” would be prohibited. Granted that Arora was more aggressive and systematic in harvesting exam content and may be an egregious exception (we really don't know at this point), almost every “reputable” board review resource I've ever seen teaches about exam content in one way or another. How do they learn about the content? It may be mainly word of mouth, but they must get feedback. For that matter, many of the faculty of those courses have no doubt taken boards themselves.

I wonder what effect this will have on all the good courses and review publications out there. Will they be scrambling to revise their content? If nothing else, watch for the disclaimers.

Another call for defunding of alternative medicine research

---comes from Steven Salzberg at the Science Business blog.

From that post I just learned that there's not only the NCCAM but also the OCCAM, another national pseudoscience promotional agency. From what I can see OCCAM doesn't push as much hard core woo as NCCAM but it's still a waste.

The post also notes that the guv'ment has spent $3.1 million on Reiki. Here are his comments on NCCAM's weasel words about homeopathy:

In addition to funding pseudoscience, NCCAM also “educates” the public about alternative medicine. I put “educate” in quotes because much of what NCCAM has on its website is misinformation, which serves to mis-educate rather than to inform. For one example (and there are many),under homeopathy the website states that

“homeopathy is used for wellness and prevention and to treat many diseases and conditions.”

Note how carefully this is worded: homeopathy is "used for prevention", from which one might easily infer that homeopathy is effective. It is not.

NCCAM’s homeopathy page goes on to state that

“most analyses have concluded that there is little evidence to support homeopathy as an effective treatment for any specific condition; although, some studies have reported positive findings.”

Again, note the careful wording of that last phrase: strictly speaking, it is true, but let me state it a bit more accurately: “some poorly designed, poorly controlled studies with small patient groups, published in low-quality journals, have reported positive findings.”

Homeopathy is based on principals that scientists know to be false...

He concludes:

So, to Francis Collins (Director of NIH) and Kathleen Sibelius (Secretary of Health and Human Services, in which NIH resides), there you have it: an easy way to cut $250 million from the NIH budget.

Great try, Steven, but it ain't gonna happen in this administration.

With each passing day

---we learn new information about what was inside of the ObamaCare legislation. Many of the concerns that Tea Partiers raised about the legislation, that were dismissed as myths by the Obama administration have proven to be facts.

Hmm. I guess Nancy Pelosi was right. We really did need to pass health care reform so we could find out what was in the bill.

COI scare the new Y2K?

A pretty good analogy, given the recent debunking.

Absurdity of the new pharma gift rules

---nicely illustrated at ASCO meeting. From Minnesota, Massachusetts or Vermont? No coffee in the exhibit hall for you. (They'll swipe your badge and turn you in).

Via Respectful Insolence and the ACRE blog.

Coming soon: ObamaCAM

After the Obama administration came into power there was optimism, in some quarters, about the future of the scientific foundations of medicine. Bob Wachter said, for example, that the $1.1 billion allocated for comparative effectiveness research under Obama's stimulus package would provide the “scientific scaffolding” for a revolution to bring medicine into conformity with best practice. Meanwhile the good folks over at Science Based Medicine, excited about the new openness and transparency we were promised, hoped the administration would listen to an appeal from the scientific community to defund the NCCAM.

A year and a half later, unfortunately, the optimism is unfounded. In that morass of legislation known as PPACA, AKA Obamacare, reside many provisions supportive of non-evidence based, unscientific complementary and alternative medicine (CAM). Matt Roman, in a recent post at Science Based Medicine, exposes some of those provisions. Although Matt seems naively optimistic about the ability of government sponsored research to separate wheat from chaff among the many pseudoscientific treatments competing for the health care pie, the provisions he cites should dim anyone's hopes that the policy makers in this administration will promote a higher scientific standard. In fact, quite the opposite is more likely true. ObamaCAM is poised to be a big part of ObamaCARE, particularly with the nomination and likely confirmation of Donald Berwick, a big booster of CAM, to be head of CMS.

Thursday, June 17, 2010

The pharmascold litmus test: intellectually lazy

Dr. David Gorski at Science Based Medicine recently weighed in on an issue that's been a favorite of mine on this blog. It concerns a type of ad hominem attack based on one's ties with or influence by the pharmaceutical industry, be it real or perceived. (The specific circumstances of his long post involve the latest in a series of attacks against him by the anti-vaccination crowd. Those details aren't important for this post).

Drawing from a discussion by fellow SBM blogger Mark Crislip, he wrote:

However, evidence is evidence, and, although it is reasonable to increase one’s level of skepticism if there is a major COI involving the authors, be it big pharma or otherwise, it is not reasonable to use that COI as the sole reason for rejecting its findings out of hand. That’s just an intellectually lazy excuse to dismiss the study, nothing more. Indeed, one prominent difference between a scientist and a pseudoscientist or quack is that in general scientists understand this and struggle to assign the correct degree of skepticism due to a COI when analyzing scientific studies, while quacks and pseudoscientists do not. It’s far easier for them just to put their fingers in their ears and scream “Conflict of interest! Conflict of interest!” and then use that to dismiss completely their opponent’s argument. It’s simple, neat, and it doesn’t require all that nasty thinking and weighing of evidence..

Yes, intellectually lazy. That's exactly how I've characterized this approach before, here, here and here. I've also referred to it as a case of selective skepticism.

But what I'm increasingly becoming aware of after reading this post, as well as several by one of his blogging buddies over at Science Blogs, is the closeness of the relationship between the pharmascolds and the quacks. Now, don't get me wrong. Not all quacks are pharmascolds and not all pharmascolds are quacks, but there seems to be a growing affinity and a good deal of overlap between the two camps.

Surgically correctable hyperaldosteronism

Open access full text review here.

One of the nicest complements I get as a hospitalist

I often explain to patients how important it is to follow up with their PCP. “Where do you practice?” they ask.

Life in the Fast Lane

A clinical blog which posts a variety of cases and images with a slant towards emergency medicine.

EMCrit Blog

This blog is a nice collection of handouts and podcasts on topics in critical care emergency medicine.

A Cartoon Guide to Becoming a Doctor

Funny stuff here.

H/T to Grunt Doc.

Wednesday, June 16, 2010

Proponents of a ban on industry supported CME won't accept their burden of proof

---because they have no evidence to sustain it. Instead they rely on a system of popular beliefs to support their arguments. That's what I said in my Medscape Roundtable piece on this subject last year. Despite personal attacks and misrepresentation of that article I stood by my premise.

Since that time there have been two important studies, one from Cleveland Clinic and the other from UCSF, which address this issue. Both were published in last January's issue of Academic Medicine. Both studies showed a lack of association between commercial support and content bias.

First the UCSF study:

Method: Cross-sectional study of 213 accredited live educational programs organized by a university provider of CME from 2005 to 2007.

Results: Mean response rate for attendee evaluations was 56% (SD 15%). Commercial support covered 20%-49% of costs for 45 (21%) educational activities, and less than or equal to 50% of costs for 46 activities (22%). Few course participants perceived commercial bias, with a median of 97% (interquartile range 95%-99%) of respondents stating that the activity they attended was free of commercial bias. There was no association between extent of commercial support and the degree of perceived bias in CME activities. Similarly, perceived bias did not vary for 11 of 12 event characteristics evaluated as potential sources of commercial bias, or by score on a risk index designed to prospectively assess risk of commercial bias.

Conclusions: Rates of perceived bias were low for the vast majority of CME activities in the sample and did not differ by the degree of industry support or other event characteristics. Further study is needed to determine whether commercial influence persisted in more subtle forms that were difficult for participants to detect.

The last sentence of the conclusion raises the question of whether participants' perceptions are valid outcomes to measure. These were large studies, and if the pharmascolds contend that they're not valid outcomes they'll have to premise that argument on credulity and lack of critical skills on a massive scale among the participants.

The Cleveland Clinic study was even more impressive:

Method: The authors analyzed information from the CME activity database (346 CME activities of numerous types; 95,429 participants in 2007) of a large, multispecialty academic medical center …

When analyzed by type of funding relative to commercial support—none (149), single source (79), or multiple source (118)—activities were deemed to be free of commercial bias by 98% (95% CI: 97.3, 98.8), 98.5% (97.5, 99.5), and 98.3% (97.4, 99.1) of participants, respectively. None of the comparisons showed statistically significant differences.

One of the Cleveland Clinic investigators was interviewed. He had this to say:

We thought we would find the highest rates of bias in activities with a single funding source and the lowest rates of bias in activities with no commercial support, and that multiple-supported activities would fall somewhere in between. We also thought we would find a higher rate of bias in activities that were commercially supported than in those that didn’t have any commercial support.

While we are proud of the fact that we’re very strict about complying with the Accreditation Council for CME’s Standards for Commercial Support, we thought if we tested the data, we would probably find these hypotheses to be true. In fact, we found the opposite—that commercial support did not result in a perception that the activity was biased.

Sometimes data refute popular assumptions. He went on:

The most surprising was that activities that have absolutely no funding associated with them—activities for which the Cleveland Clinic as a CME provider absorbs the cost within its operations—had a higher level of perceived bias than the other two categories. It was surprising because 1) it indicates that perceived bias is not associated with industry support; and 2) it points to bias in content being caused by something other than the funding source of the activity.

Our data ranked single-funded activities—which we thought would be most at risk of bias—as being most free of bias. Activities that were multifunded fell in between.

It should be re-emphasized that these differences were small and none were statistically significant. He concluded:

Policymakers need to pay attention to this sort of data because, if they’re looking to evaluate issues of bias, this shows that it’s not coming from the pharmaceutical industry’s provision of educational grants. What that funding is doing is allowing us to produce great education. Instead, policymakers should review what good CME providers do (the ones that follow the rules) and emphasize their best practices as examples to follow. Also, we all have to realize we’ll never be able to reduce bias to zero—everyone, faculty and learners alike, has some level of bias in their views. The results of our study show that the effect of industry support on participants’ perception of bias within CME activities is minimal. Further, CME providers that have suitable oversight to ensure compliance with the ACCME’s SCS can be successful in implementing commercially unbiased education, regardless of funding source. This quite conclusively shows that the prohibition of commercial support is not needed.

More from the Policy and Medicine blog here and here.

More on ABIM vs Frontrunners Board Review

I received an email from the Vice President for Communications at ABIM with an update and a clarification on the Frontrunners case. On February 23 2010 a United States magistrate judge issued a recommendation in the ABIM's case against Frontrunners:

Indeed, the only factor weighing against
such sanctions is the public policy favoring disposition of cases on
the merits. However, it is Defendant’s own willful behavior that has
obscured the facts and impeded Plaintiff’s efforts to proceed to the
merits. For these and the foregoing reasons, it is respectfully
recommended that Plaintiff’s motion for terminating sanctions be

In other words the judge seems to opine that tactics by Frontrunners interfered with discovery and prevented the case from being decided on its own merits, and is therefore recommending judgment for the plaintiff (ABIM).

As to the counterclaim against ABIM, although the Frontrunners web page states that “litigation is ongoing,” according to the email from ABIM there is no active claim pending against them right now.

Many thanks to ABIM for the update and I hope this clears up any confusion.

The Boston Globe asks a great question about Donald Berwick's nomination

pRead it here:

PRESIDENT BARACK Obama was adamant: His health care overhaul would not put Americans on the road to British-style, government-run medicine. Speaking to the American Medical Association last June, the president dismissed as “scare tactics and fear-mongering’’ all talk of “socialized medicine and government takeovers; long lines and rationed care; decisions made by bureaucrats and not doctors.’’ A few weeks later he reiterated the message: “I don’t believe that government can or should run health care.’’

But if Obama is as opposed to a government-ruled health sector as he claims, why has he nominated Dr. Donald Berwick as director of the Center for Medicare and Medicaid Services — far and away the nation’s largest health-insurance programs, at a cost of nearly $1 trillion — a man who openly adores Britain’s socialized health care?

“I am romantic about the National Health Service,’’ Berwick told a British audience in 2008. “I love it.’’ He not only loves the National Health Service, he extols it as “an example for the whole world — an example . . . that the United States needs now.’’

This Berwick thing is a study in contradiction. First radical consumerism versus rationing, now this.

Arora Board Review is not the only company being sued by ABIM

It seems ABIM has also filed suit against the popular Frontrunners Board Review alleging that Frontrunners' content is “too similar” to the ABIM exam (see documentation here). Frontrunners filed a counterclaim against ABIM for antitrust violations, detailed here:

Indeed in August 2008, as ABIM's "educational division" or "silent partner" if you will, the ACP, began planning its online marketing campaign for its competing MKSAP product, ABIM proactively sued FRONTRUNNERS® complaining that FRONTRUNNERS content was too similar to ABIM's exams. After 21 months of litigation, ABIM has been entirely unable to prove their case against FRONTRUNNERS BOARD REVIEW. FRONTRUNNERS®, in turn, filed a 100-page cross-complaint against the ABIM for Antitrust Violations U.S.C. 15 §§ 1 & 2, detailing how, beginning as early as 2000 and continuing now, the defendant ABIM and co-conspirator ACP engaged in a combination of and conspiracy in unreasonable restraint of trade and commerce in violation of Section 1 of the Sherman Antitrust Violations Act (15 U.S.C. §1) and how, beginning as early as 2000 and continuing now, ABIM and ACP engaged in a combination and conspiracy to monopolize, or attempt to monopolize trade and interstate commerce in violation of Section 2 of the Sherman Antitrust Act (15 U.S.C. §2).

Although the suit was initially dismissed on the basis of the statute of limitations Frontrunners believes new and ongoing predatory business activities, as well as damage to Frontrunners, have occurred, and so the legal battles continue.

So now do the docs who attended Frontrunners courses have to worry that they'll get a “letter in the file?” Is Medstudy next? (How about that 97% pass rate ).

Physicians' comments at the WSJ Health blog about the internal medicine board review “scandal”

---are running strongly negative toward ABIM. Common concerns expressed in the comments:

Thousands of ABIM diplomats now have their records besmirched by a letter in their ABIM file just for attending the course (some are considering legal action).

The action is mercenary on the part of ABIM.

The idea that exam questions are proprietary secrets is unreasonable.

The ABIM, with a conflicting interest in ACP board review products, is trying to put private review companies out of business (they have a suit pending against one other).

Christine Cassel's guest post at Kevin MD

---gives a glimpse about how things may have gone down for docs selected for sanctioning in the ABIM board review brouhaha: ABIM sues Arora Board Review for copyright infringement. Emails from attendees are revealed in the discovery process. Docs to be sanctioned are selected from the “smoking gun” emails. In the post she provides a link to some of them. Although they do not, in my opinion, suggest a consciousness of guilt they do reveal a pervasive emphasis on teaching the test which would detract from the overall quality of the course.

Tuesday, June 15, 2010

Arora Board Review settles with the American Board of Internal Medicine

---in this matter, just reported at the WSJ Health blog. Here are some of the provisions:

Arora will pay an undisclosed amount to ABIM.

Dr. Rajender Arora, the firm’s principal, has surrendered his ABIM board certifications.

Arora is allowed to offer test-prep materials but won’t run live review courses.

A permanent injunction filed in the U.S. District Court of the Eastern District of Pennsylvania forbids Arora from “creating, reproducing, copying, distributing, offering for sale, selling and/or publicly displaying” any materials that infringe on ABIM’s exam copyrights or “were derived in any way” from the exams. And it agrees not to collect, solicit or encourage third parties to collect or share the contents of the exams.

Should past examination questions be a trade secret? The ABIM apparently thinks so and with this action has done a nice job of protecting its proprietary interest.

Do we over utilize or under utilize health care resources?

In popular debate surrounding health care these days the politically correct answer is that we over utilize, but is that really true? A careful look at all the evidence ought to lead to a more nuanced discussion.

Kevin MD talked about over utilization in a recent post: Unnecessary tests and treatments are commonly ordered for patients. He made some interesting points but I must respectfully disagree with his conclusion about an MSNBC (Associated Press) piece he cited:

Just when I’ve lost hope that mainstream media will stop perpetuating the myth the more medicine equals better care, the Associated Press came up this excellent piece.

...Responsible reporting like this can help sway some patients to be more critical of their physician’s recommendations.

...But to reach patients, mainstream media needs to pick up the baton and run with it. More articles like the AP piece would be a great start.

Articles like this are exactly what we don't need shaping public opinion and driving policy. Like much reporting in the popular media it's little more than a smattering of factoids and opinions form here and there, cherry picked to suit the author's biases, with no citation of primary research literature.

So what's the real truth in the too much versus too little debate? The answer is not headline grabbing stuff. We do a lot of both, and we lack a clear answer on which side we err overall. There is much research evidence, in fact, suggesting we do too little as demonstrated in this landmark paper. While that paper doesn't tell the whole story it's some of the best evidence we have to address the issue. And there's more. Look at device therapy for heart failure. Vastly under utilized, and expensive. What about statin drugs? Widely under prescribed when looked at against evidence and guideline recommendations. And while we know lots of kiddos get antibiotics they don't need of ear aches this paper (and others like it) show that critically ill patients arriving at the ER all too often get single agent antibiotic therapy started when big gun combination therapy might be live saving.

So we don't really know. Sometimes less is better while sometimes more is better. We don't have an evidential bottom line. If we all practiced flawless evidence based medicine would costs go up or down? Again we don't know. Maybe we need an updated systematic review. This is not a systematic review.

Monday, June 14, 2010

ABIM exam controversy

Bob Wachter reports this:

As a member of the executive committee of the American Board of Internal Medicine, I can’t provide too much of the inside scoop, so I’ll mainly point you to the published descriptions of a remarkable case: that of one Dr. Arora, who ran an ABIM board review course with a difference.

The difference was that attendees of the Arora Board Review were allegedly shown actual questions from past exams, fed to Dr. A from prior test takers – who shared dozens, and, in some cases, hundreds of questions.

So, the ABIM is sanctioning some docs and suing a bunch of people.

Understand that these questions were harvested from past exams. It's not as if someone hacked into the system and provided, ahead of time, questions that were going to be on the exam.

I'm struggling to understand this but it appears that there were three issues here: ABIM considers its questions to be proprietary; discussing exam content is a violation of terms and conditions to which candidates agree when taking the test; and, in the minds of some, cheating.

The last one is the hot button issue. But is it really cheating? College kids do it all the time and it's not considered inappropriate. In fact, some profs encourage it by posting old exams on the web. (For example, here's where MIT posts a lot of its old exams).

Even assuming they should have known better, given the terms and conditions of the ABIM exam, did Arora and all its course attendees really know they were doing anything wrong? You have to wonder, given the fact that they were so open about what they were doing. The WSJ Health blog, for example, reports (my italics):

The physicians were identified from paperwork and emails collected from a board review course sued by the ABIM last year; the organization alleges instructors bragged that the questions covered in the course were real — acquired from previous test-takers — and then encouraged class participants to send in their own recollections of what was asked after their exams.

This sounds to me more like a case of “teaching for the test” than out right cheating. Granted Arora's efforts may have been uniquely deliberate and open compared to most (Bob says we don't know the inside scoop!), but all board review resources I've seen do this to one degree or another. (By the way, Arora isn't the only outfit ABIM has taken to court over this issue----more on that in another post). ACP's MKSAP, for example, has a companion resource for board prep. I've browsed one of my colleague's copies and it teaches the test in no uncertain terms. It's full of pointers about right and wrong answers, traps that commonly show up on exams, and testmanship. In fact it stretches ones imagination to believe its content has not been influenced by experience with ABIM exams! This might be a good time to point out that the ABIM has a somewhat cozy relationship with ACP and MKSAP when it comes to certification and maintenance of certification. More on that later, too.

Grunt Doc weighs in here.

Disclosure: I passed the ABIM exam in 1978. Like others who sat for boards in that era I'm grandfathered in. To prepare for the exam I spent a year plodding through Cecil's and picking up as many pearls as I could from my residency mentors. I did not attend any review courses or use any board review products before I certified. Since that time, in order to keep up in Internal Medicine, I've attended several courses and used MKSAP along with many other resources.

When you discharge patients after cardiac stent implantation

---tell them to get to the drug store right away.

What to do about pituitary incidentalomas

This paper in Expert Review of Endocrinology and Metabolism is reproduced as free full text via Medscape.

Medscape on state medical board rankings: Public Citizen has it all wrong

From the article:

Public Citizen concluded that most boards are underdisciplining physicians, partly on the basis of a previous report it published in 2006 finding that 67% of insurance fraud convictions and 36% of convictions related to controlled substances were associated with only "nonsevere" discipline by the boards…

Public Citizen has it all wrong. Boards should not be judged by the number of licenses suspended or revoked, but by how well they protect the citizens of their state. Its simplistic analysis is akin to judging a city's police department on the basis of the number of prisoners in its jails rather than the number of crimes committed.

Failure to continue diabetes medications at discharge after myocardial infarction

From a report in Circulation: Cardiovascular Quality and Outcomes---

There were 8751 patients admitted on at least 1 antihyperglycemic agent who met our inclusion/exclusion criteria. Of these, 7581 (86.6%) were discharged on antihyperglycemic therapy and 1170 (13.4%) were discharged off antihyperglycemic therapy. After multivariable analysis, as compared with those whose diabetes therapy was continued at discharge, patients who were not prescribed a glucose-lowering agent had higher 1-year mortality rate (hazard ratio, 1.29; 95% confidence interval, 1.15 to 1.45). Readmission rates did not differ significantly between the 2 groups (hazard ratio, 0.95; 95% confidence interval, 0.87 to 1.03).

Conclusions—In older patients with diabetes after AMI, discontinuation of antihyperglycemic therapy is common and associated with higher mortality rates. The reasons behind this practice as well as the specific effects of hyperglycemia after AMI merit further study.

Reasons for the patients not having their diabetes medications continued are unclear.

Friday, June 11, 2010

Quick look echo during CPR

This may be coming in future protocols:

Recent findings: Many studies have demonstrated the value of echocardiography in the assessment of critically ill patients in the intensive care unit and emergency room settings, including more recently the use of focused echocardiography. This can be performed within the time frame allowed during the pulse check of the advanced life support (ALS) algorithm. ALS-compliant focused echocardiography can be taught to nonexpert practitioners such that high-quality cardiopulmonary resuscitation is not compromised while diagnosing/excluding some of the potential causes of cardiac arrest.

Summary: Persistent and worsening haemodynamic instability are regarded as clear indications for echocardiography. The focused application of this well established technique within the ALS algorithm provides the resuscitation team with a potentially powerful diagnostic tool that can be used to diagnose/exclude some of the potentially treatable causes of cardiac arrest as well as to guide therapeutic interventions. The impact of routine periresuscitation echocardiography on patient outcomes both for in-hospital and prehospital care remains an exciting avenue for future research.

Southern Tick-Associated Rash Illness

This was a new one for me. CDC report here.

Most “never events” designations not supported by evidence

Via Archives of Surgery:

This study demonstrates that patient characteristics and procedural interventions are important predictors of the occurrence of 6 of the 8 never-event complications analyzed. Because predictive equations for these postoperative complications have substantial discriminatory power (ie, have C statistics substantially greater than 0.50), risk factors beyond the control of providers affect the occurrence of these adverse events. Calling these complications never events and refusing to pay for their treatment may advantage high-quality caregivers, but it also will penalize providers that care for the most vulnerable patients or that perform procedures with higher-than-average risk.

Did Anakin Skywalker have borderline personality disorder

---and that's what made him turn to the dark side? Some experts think so and use the character to help teach psychology students.

Over utilization driven by what the public wants

From a study published in Health Affairs:

We found many of these consumers’ beliefs, values, and knowledge to be at odds with what policy makers prescribe as evidence-based health care. Few consumers understood terms such as "medical evidence" or "quality guidelines." Most believed that more care meant higher-quality, better care. The gaps in knowledge and misconceptions point to serious challenges in engaging consumers in evidence-based decision making.

Well, then, Donald Berwick is right. Under his radical consumerist view of health care EBM will have to take a back seat.

Thursday, June 10, 2010

Malpractice risk at the transitions of care

Here's an interesting post on the topic at Kevin MD.

Various questions inevitably arise: “Did the primary doctor make sure that the hospitalist knows of the patient’s allergies? Did the hospitalist speak to the primary when the patient was admitted and discharged? Did the hospitalist convey the need for a follow-up computed tomographic scan in 3 months? Was there a delay in faxing the discharge summary? Does the patient know who he’s supposed to contact if complications arise?”

If something falls through the cracks and the patient sues over a bad outcome both the PCP and the hospitalist will be dragged in. The plaintiff attorney will encourage finger pointing between the two over who should have known what or who should have communicated what. Such finger pointing will only weaken the case for both defendants.

But things may get a little muddy if we don't have a standard for what constitutes adequate communication. The closest thing we have is this set of guidelines promulgated by the AAFP. Here are some points from the guidelines that may have impact on liability:

Before calling the hospitalist to admit a patient the ED physician should call the PCP. (Yeah, the plaintiff attorney will drag the ED doc in too). This puts the PCP in the loop and helps determine if admission is necessary.

The PCP should then communicate important clinical information to the attending hospitalist. The guidelines do not specify how this communication should take place.

During the course of hospitalization the hospitalist should communicate changes in clinical status to the PCP. Again, the guidelines do not specify the means of communication.

The hospitalist should communicate follow up needs to the PCP at the time of discharge. Concerning the means of this communication the guideline states: “This may be best accomplished by having the discharge summary dictated and faxed to the family physician.”

Family physicians, according to the guideline, are “encouraged” to maintain ongoing contact during hospitalization with the patient, the family and the hospitalist.

Hospitalists, performance and quality

Here's another study showing that hospitals which utilize hospitalists score better on performance measures. That doesn't necessarily equate to better quality. In fact, the main difference was seen in heart failure discharge measures which have NOT been validated as producing real quality.

Full text via Medscape.

Hep C related cryoglobulinemia

Review in the American Journal of Medicine.

Study questions 2005 ACLS guideline change

One of the changes recommended in the 2005 ACLS guidelines (GL 2005) over the 2000 guidelines (GL 2000) was that after a defibrillation shock CPR be resumed immediately without pause for a pulse and rhythm check. The rationale was two fold: 1) After a successful shock there is typically a period of several seconds of PEA, marked bradycardia or asystole before spontaneous circulation resumes and 2) the shock may be unsuccessful, in which case immediate resumption of CPR will more effectively replete myocardial ATP stores thus increasing the likelihood of success of the next shock.

Now there is a disturbing report of a possible downside to the guideline changes: resumption of compressions may shorten the time to recurrent VF:

Of 361 patients, 136 met the inclusion criteria: 68 were randomly assigned to GL2000 and 68 to GL2005. Rescuers resumed CPR 30 (21-to-39) and 8 (7-to-9) seconds, respectively, after the first shock that successfully terminated VF (P less than 0.001); VF recurred after 40 (21-to-76) and 21 (10-to-80) seconds, respectively (P=0.001). The time interval between start of CPR and VF recurrence was 6 (0-to-67) and 8 (3-to-61) seconds, respectively (P=0.88). The hazard ratio for VF recurrence in the first 2 seconds of CPR was 15.5 (95% confidence interval, 5.63 to 57.7) compared with before CPR resumption. After more than 8 seconds of CPR, the hazard of VF recurrence was similar to before CPR resumption.

Conclusions— Early CPR resumption after defibrillation causes early VF recurrence.

We don't know what this ultimately means in terms of outcomes. The advantages of the more aggressive CPR strategy in GL2005 may outweigh an increased risk of earlier recurrent VF.

Wednesday, June 09, 2010

Fast knowledge versus slow knowledge: the insufficiency of EBM

This is not the only post in which I will draw from Abraham Verghese's lecture to the American Clinical and Climatological Association on what it means to be a doctor. Drawing on David Orr's book The Nature of Design he contrasts two types of knowledge:

He differentiates between the two types of knowledge, saying that, “The aim of slow knowledge is resilience, harmony, and the preservation of long-standing patterns that give our lives aesthetic, spiritual and social meaning.”

Fast knowledge, by contrast, operates with the following (false) presumptions: if it can be measured, it is important, and if it can't, it isn't; more information is better and there is little distinction between information and knowledge; fast knowledge presumes that if we forget old knowledge, it doesn't matter since the new knowledge is better; it presumes that mistakes from new knowledge will be solved by more knowledge and, finally, that the acquisition of knowledge has no duty of responsible use.

Fast knowledge is information accessed instantaneously at the point of care. It is obtained by “evidence hunting” and is often prefaced by “Up to Date says...” It is at the core of the popular notion of EBM. Slow knowledge is many things including basic science leading to a fundamental understanding of disease. Fast knowledge is fleeting. Fundamental understanding of disease stays with you throughout your career. Fast knowledge without slow knowledge is of limited usefulness and may be harmful.

Early in my blogging career I wrote about the pursuit of those two types of knowledge, just in different terms.

Common mistakes in managing hospitalized patients with heart failure

Today's Hospitalist interviewed the speaker at Bob Wachter's hospital medicine course last fall.

Court challenges to health care reform: Do they have any teeth?

Joyce Frieden guest blogs at Kevin MD:

Partisan wrangling aside, the Supreme Court will have to address serious constitutional questions about the healthcare reform law, and it’s far from clear how the justices will decide the issues, legal scholars say.

Why assisted suicide, suddenly?

Wesley Smith, writing in Legatus Magazine, asks Why now?

A question amidst all of this Sturm und Drang naturally arises: Why now? After all, 100 years ago when people did die in agony from such illnesses as a burst appendix, there was little talk of legalizing euthanasia. But now, when pain and other forms of suffering are readily alleviated and the hospice movement has created truly compassionate methods to care for the dying, suddenly we hear the battle cry “death with dignity” as “the ultimate civil liberty.”

In fighting assisted suicide since 1993, I have often pondered the “why now” question. I’ve found two answers: First, the perceived overriding purpose of society has shifted to the benefit of assisted suicide advocacy, and second, our public policies are driven and defined by a media increasingly addicted to slinging emotional narratives rather than reporting about rational discourse and engaging in principled analysis. Add in a popular culture enamored with social outlaws, and the potential exists for a perfect euthanasia storm.

Beginning sentences with “so”

So what's up with this latest wave in the trend of beginning sentences with conjunctions? A New York Times article explains:

“So” may be the new “well,” “um,” “oh” and “like.” No longer content to lurk in the middle of sentences, it has jumped to the beginning, where it can portend many things: transition, certitude, logic, attentiveness, a major insight.

We are decimating the rules of grammar. “So” at the beginning of a sentence might mean “now hear this” as in “So---are you ready for the grand unveiling?” It could mean “What I'm about to say follows logically” or it could be an alert for incoming background as in “So: you're a hospitalist having a particularly difficult call night, and along comes...”

Tuesday, June 08, 2010

What hospitalist haters?

A guest blogger over at Kevin MD asks: So, can hospitalist haters bury the hatchet? That's funny. I was not aware of any hospitalist haters.

Gender differences in naming colors

It looks like the guys are lumpers, the gals are splitters.

Deposition tips

Ilene Brenner, guest posting at Kevin MD, provides some excerpts from her book How to Survive a Medical Malpractice Lawsuit: the Physician's Roadmap for Success. She explains why a united defense is important and why plaintiff attorneys cast such wide nets (my italics):

At the time of the deposition, all co-defendants should be cooperating with each other. Even if you think one of your co-defendants committed malpractice, this is not the time to mention that fact. Keep that information to yourself until backed into a corner where you have no choice but to reveal that. Why? You don’t want to help the plaintiff’s case at all.

You might think that revealing this information might get you out of the case leaving only the “true guilty party.” Wrong. Turning on your co-defendant won’t help you get out of the case. In fact, it will likely ensure your staying in the case because your co-defendants’ finger will now be pointing directly at you. Thus, you will fall into the trap set by the plaintiff’s attorney; sue everybody in sight and have them turn against each other so as to get money from at least one of you.

Her blog looks pretty interesting.

Dr. Brenner on Press-Ganey

I'm becoming aware of more and more frustration about those Press-Ganey scores. Dr. Brenner recently posted a nice little rant and listed several reasons why PG scores are meaningless:

First is that Press-Ganey has a complete monopoly. They are accountable to no one, despite their less-than-scientific method of procuring data. If I practiced medicine in the same "Evidenced Based" manner that the Press-Ganey does, I'd lose my license.

She listed several more.

Background: PG scores have not been vetted by research quality data.