Thursday, June 30, 2011

Psychiatry's journey from talk therapy to pill pushing

Here's a New York Times piece profiling one psychiatrist who made the switch for economic reasons:

Like many of the nation’s 48,000 psychiatrists, Dr. Levin, in large part because of changes in how much insurance will pay, no longer provides talk therapy, the form of psychiatry popularized by Sigmund Freud that dominated the profession for decades. Instead, he prescribes medication, usually after a brief consultation with each patient.

Long sessions with psychiatrists doing talk therapy may seem foreign to young readers, except in old movies and novels. A psychiatrist colleague of mine who has psychoanalytic training misses the old tradition. He prescribes pills in his practice and does psychoanalysis as a hobby in his off time.

More from Daniel Carlat guest blogging at Kevin MD.

Wednesday, June 29, 2011

Expanding the use of checklists

Here's an interesting paper from the American Journal of Respiratory and Critical Care Medicine:

Intervention team physicians were prompted to address six parameters from a daily rounding checklist if overlooked during morning work rounds. The second team (control) used the identical checklist without prompting...
Compared to control, prompting increased median ventilator-free duration, decreased empirical antibiotic and central venous catheter duration, and increased rates of DVT and stress ulcer prophylaxis. Prompted group patients had lower risk-adjusted ICU mortality compared to the control group (OR 0.36, 95% CI 0.13-0.96, P=0.041), and lower hospital mortality compared to the control group (10.0% vs. 20.8%, P=0.014), which remained significant after risk adjustment (odds ratio 0.34, 95% CI, 0.15-0.76, P=0.008). Observed-to-predicted ICU length of stay was lower in the prompted group compared to control (0.59 vs. 0.87, P=0.02). Checklist availability alone did not improve mortality or LOS compared to pre-intervention patients.

The lesson? It's one thing to have checklists and another to use them for all they're worth.

HT to Happy Hospitalist.

Tuesday, June 28, 2011

AMA's membership decline

---has been talked about for years. This piece from Medpage Today is a little dated but is the best summary I could find about it:

Although the group boasts close to 240,000 members, 29% are students or residents, who pay sharply discounted dues. Still more of the members are retirees, whose dues are also cut...
Of those members, 20.5% are medical students, 9% are residents, and 36.5% are 56 or older. As one delegate put it, "we have a lot of students and a lot of old docs, but not a lot of practicing physicians."

Declining membership and diminishing relevance. Most in the rank-and-file, I suspect, would tell you AMA no longer represents their professional interests. Why? According to these posts the AMA repeatedly capitulates to increased government intrusion because they are conflicted: beholden to the government for their coding business. How so? AMA holds the copyright to the codes and CMS mandates them. There you go.

Monday, June 20, 2011

Saturday, June 18, 2011

The nation's leader in integrated health care rejects recent CMS proposal for ACOs

One of the main pro Obamacare talking points was the lack of integration of medical care and the inefficiencies reflected in marked regional variation of services provided. The Obamacare answer is the HMO on steroids known as the accountable care organization (ACO). In these discussions Mayo Clinic has been repeatedly cited as the ideal of integration. But it seems Mayo rejects the recent CMS proposal for ACOs.

More about this from We Stand Firm.

Friday, June 17, 2011

Intubation tips

This is the down-and-dirty version. One of the better explanations I've seen. Much more at EMS Airway Clinic.

Prehospital point of care lactate measurement

A study on in-the-field point of care lactate testing was discussed in a recent article in JEMS. Though the original study was a couple of years old it bears emphasis today given the poor rate of usage of the technique in the US. From the article:

The investigators conducted chart reviews on patients who had lactate levels measured prospectively, categorizing them into two groups: non-shock (lactate levels less than 4 mmol/L), and shock (lactate levels at least 4 mmol/L)...
The most staggering statistic was in-hospital mortality: the shock group had a 26.7% mortality rate compared with 1.2% for the non-shock group.

Staggering indeed. The benefit for patients is that the ER can be alerted from the field when a patient has a high lactate level and thereby get a head start in assembling the resources for EGDT (central line set up, etc), for which time is of the essence. In this respect it is analogous to the prehospital ECG in STEMI patients.

There are regulatory barriers in the US, well illustrative of the negative consequences of government intrusion, though they are not insurmountable. These are discussed in the article.

Thursday, June 16, 2011

Ambulance diversion and acute MI mortality

The medical news services have been running with this story, a study of a large database in California which looked at the effect of ambulance diversion, finding an association with increased MI mortality.

A few caveats. The association only held up for the more extreme scenario of 12 or more hours of diversion. In this era of reperfusion, AMI is one of the most time sensitive conditions presenting to emergency departments. So no conclusions can be drawn about ambulance diversion overall. For other populations of patients it is not known whether the risk of diversion outweighs the risk of hospital crowding and ED or hallway boarding.

Wednesday, June 15, 2011

Cluster of zygomycosis infections in Joplin, Missouri tornado victims

The CDC is working on this although I cannot find anything about it on their website. I did find this story from JEMS, an EMS news service:

In the aftermath of the Joplin tornado, some people injured in the storm developed a rare and sometimes fatal fungal infection so aggressive that it turned their tissue black and caused mold to grow inside their wounds.
Scientists say the unusually aggressive infection occurs when dirt or vegetation becomes embedded under the skin. In some cases, injuries that had been stitched up had to be reopened to clean out the contamination...
"To my knowledge, a cluster like this has not been reported before," said Dr. Benjamin Park, head of the CDC team that investigates fungal diseases. "This is a very rare fungus. And for people who do get the disease, it can be extremely severe."

Of the several patients reported, three have died. Since they had multiple injuries and medical problems it is not known the degree to which the mortality is attributable to the infections.

A few observations. Zygomycosis is a term which describes infections with a group of closely related molds. The terminology can be confusing, and despite changes in the taxonomic classification the older term has persisted. It is also known as mucormycosis, a term which clinicians usually think of as a life threatening necrotizing infection of the oropharynx and neighboring structures in patients with DKA (always be mindful of the nasopharynx in your H and P when you admit a patient with DKA!).

Even nasopharyngeal mucor is rare and wound infection is virtually unheard of though not unprecedented. And it's not just the mucor group. Other molds can cause necrotizing skin and soft tissue infections. I recall a critical care CME meeting years ago where we were given an unusual presentation by a mycologist. He presented case after case of these infections involving species of molds I had never heard of. A huge variety of species inhabit trees, grass and other plants. Many cases did not involve known trauma. In the typical case the supposedly immunocompetent patient presented with a funny “dermatitis” and was shuffled around among the ER, the PCP and a dermatologist. Many patients were treated with antibiotics and referral to a surgeon was too late. In virtually all cases the outcome was bad, with loss of life or limb. (Did these patients have some not yet described immune deficiency or were they just unlucky?). The speaker, not a clinician himself, thoroughly scolded doctors for not “thinking fungus.” I can't remember the names of any of the species but the adage “think fungus” was indelibly emblazoned in my hippocampus. These are very aggressive infections requiring prompt antifungal therapy and surgical debridement with an urgency not unlike that of necrotizing fasciitis.

Confusing cookie cutter medicine with evidence based medicine

I agree with the premise of Diana Hsieh's video over at Black Ribbon Project: that Obamacare and other external forces are driving us closer and closer to central control and what she calls “cookie cutter medicine” (CCM), a bad thing for patients and the profession. Unfortunately she confuses CCM with evidence based medicine (EBM). Understanding that it was her personal and emotionally very compelling story, she used one of the worst possible examples: the treatment of hypothyroidism. Specifically it has to do with the question about whether triiodothyronine (T3) should be supplemented, alongside L-thyroxine (the standard replacement monotherapy), in some patients who say they still don't feel back to normal after laboratory monitoring indicates adequate replacement with L-thyroxine.

The widely accepted recommendation for monotherapy with L-thyroxine and against the use of products containing T3 is not cookie cutter medicine. Neither is it some guideline writer's opinion. Rather, it's in conformity with best evidence, and the evidence is extensive. The most definitive literature review is here. It concludes:

Conclusions: Until clear advantages of levothyroxine plus liothyronine are demonstrated, the administration of levothyroxine alone should remain the treatment of choice for replacement therapy of hypothyroidism.

There has been nothing additional published since that paper to indicate benefits of the use of T3. Careful analysis of the published studies indicates that those patients who indicated they felt better with the addition of T3 tended to lose weight and be over-replaced. Over-replacement is bad because it increases the risk of atrial fibrillation and osteoporosis. In at least one study the subjective benefits were transient. That makes perfect sense. T4, the inactive prohormone, is only very gradually converted to T3. The gradual onset of effect may blunt subjective awareness. T3 given directly is rapidly absorbed and its relatively short half life results in an initial “buzz” with maximal effect achieved in days as opposed to weeks. As far as I know there are no comparative studies which followed patients long enough to assess how the potentially devastating effects of osteoporosis, atrial fibrillation and loss of muscle mass (all consequences of over-replacement) ultimately impacted quality of life!

It is claimed in the video that some patients lack the ability to convert T4 to T3. That claim is unsupported as far as I know. A related claim is that TSH monitoring is not enough to assess the adequacy of therapy. I won't belabor the evidence and rationale here except to say that God and the patient's pituitary (assuming the patient has primary rather than secondary hypothyroidism) know better than anyone else how much and what kind of replacement the patient needs.

There may be occasional patients, rare exceptions, who benefit from combined therapy. If this is done it should be with the appropriate expertise and great caution against the hazards of osteoporosis and atrial fibrillation. Unfortunately, though, it sometimes falls into the realm of quackery.

Like Diana Hsieh I am concerned about a coming era of cookie cutter medicine, but this was a bad example. Her policy points are great. Unfortunately the bad science used in this case to back them up weakened the credibility. We can have evidence based medicine without cookie cutter medicine.

Monday, June 13, 2011

Is the culture of medicine headed in the right direction?

The external environment is driving it the other way according to Beth Haynes, MD. Go read the article and note the choice Berwick quote. HT to the Black Ribbon Project.

Saturday, June 11, 2011

Do as I say and not as I do

---to save the planet, according to one NYT writer.

At least he's up front about the agenda: shrink the economy!

HT to Gateway Pundit.

This is just plain stupid

No comment needed. HT to Gateway Pundit.

Doctors as pit crews?

DB disagrees with some of Atul Gawande's remarks at a recent commencement speech:

Which brings us to the third skill that you must have but haven’t been taught—the ability to implement at scale, the ability to get colleagues along the entire chain of care functioning like pit crews for patients. There is resistance, sometimes vehement resistance, to the efforts that make it possible.

Vehement resistance???? Talk about assuming facts not in evidence. Is Gawande projecting from his early career as a surgeon?


Partly, it is because the work is rooted in different values than the ones we’ve had. They include humility, an understanding that no matter who you are, how experienced or smart, you will fail. They include discipline, the belief that standardization, doing certain things the same way every time, can reduce your failures. And they include teamwork, the recognition that others can save you from failure, no matter who they are in the hierarchy.

Gawande is flat out wrong to imply we've not had these values before. My earliest mentors taught the value of humility. Multidisciplinary was a buzzword early in my career.

Teamwork is important, but as DB points out we must be careful not to devalue individual expertise and judgment.

Friday, June 10, 2011

Sleep apnea and the involuntary siesta

Consequences for hypertension. (Via Clinical Cases and Images).

Primary source: BMJ research article:

Results 277 (81%) of the 340 patients randomised were men; the patients had a mean age of 52.4 (SD 10.5) years, a body mass index of 31.9 (5.7), an Epworth sleepiness scale score of 10.1 (4.3), an apnoea-hypopnoea index of 43.5 (24.5). No differences between groups were seen at baseline. Compared with placebo and analysed by intention to treat, the mean 24 hour ambulatory blood pressure of the CPAP group decreased by 1.5 (95% confidence interval: 0.4 to 2.7) mm Hg (P=0.01). The mean 24 hour ambulatory blood pressure monitoring measures decreased by 2.1 mm Hg (0.4 to 3.7) mm Hg (P=0.01) for systolic pressure and 1.3 (0.2 to 2.3) mm Hg (P=0.02) for diastolic blood pressure. Mean nocturnal blood pressure decreased by 2.1 (0.5 to 3.6) mm Hg (P=0.01).

Though statistically significant the magnitude of the effect was small and the authors were circumspect about the clinical significance. Patients with more severe symptoms, which were excluded from this study, may derive greater antihypertensive effect.

Bilateral adrenal hemorrhage

An under recognized cause of sudden hemodynamic collapse in patients with HIT.

A PubMed app for your mobile phone

Via Academic Life in Emergency Medicine.

Friday, June 03, 2011

New guidelines for glycemic control in hospitalized patients

---are out from the American College of Physicians. They recommend against intensive glycemic control for any patients, ICU or ward, with the exception of post surgical patients in the SICU. I've listened to plenty of speakers from the diabetes mafia at hospitalist meetings over the last several years and this turns everything they've said upside down.

Borderline personality disorder

Reviewed in NEJM. It's surprisingly common, often misdiagnosed as major depression or bipolar disorder, and carries a surprisingly high suicide rate. The prognosis with psychotherapy is not as grim as once thought.

Airway remodeling in asthma

Bronchoconstriction (even absent inflammatory stimuli) caused airway remodeling in this study. Airway remodeling took the form of increased mucus glands and an increased thickness of subepithelial collagen bands.

Thursday, June 02, 2011

Early goal directed therapy for sepsis: can it be non-invasive?

What if you substitute serial lactate measurements for ScvO2 and IVC assessment via bedside ultrasound for CVP? The ins and outs are discussed at the Academic Life in Emergency Medicine blog.

Herb Fred: master clinician and teacher

I've never met Dr. Herb Fred but sometimes I feel as though I'm on teaching rounds with him when I read his articles in the Texas Heart Institute Journal. Now there's a new book, reviewed here, which is a collection of Herb Fred sayings. From the review:

In person, Dr. Fred is the curmudgeon who will always ask the question that you forgot, point out the physical finding that you overlooked, or note the subtle deficiencies in your clinical approach that differentiate between merely good medical care and excellent medical care. He is the angel on your shoulder who elicits guilt when you allow technology to make a diagnosis in your stead, and he is the talented teacher who bestows the skills that make that technology less necessary.
The loss of physicians of this kind is slowly creating an intellectual anemia in the profession. For this reason, a collection of his aphorisms is of value. The Best of Herb Fred, MD: His Insights, Observations, and Everyday Reminders offers a return to real “doctoring,” for it emphasizes professionalism, duty to your patient, and bedside diagnosis. This concise assemblage of advice will serve physicians in any field of medicine.
It might make a nice gift for a graduating student or resident.

Wednesday, June 01, 2011

American Medical Student Association: Pharm free but in bed with woo!

The American Medical Student Association (AMSA) is the largest and most influential medical student organization. In 2002 AMSA launched PharmFree, a campaign to limit interaction between the medical profession and the pharmaceutical industry. The leaders of the campaign purport to be advocates for evidence based medicine. From the website:

AMSA promotes the conscientious, explicit and judicious use of the current best evidence in clinical care.

Sounds great. Straight out of David Sackett's landmark paper on EBM! But the credibility of the campaign is weakened by the fact that AMSA also has a long history of promoting non-evidence based alternative medicine. I was, as far as I know, the first to point out this hypocrisy in 2005. Other bloggers have since taken notice. Now Thomas Sullivan at Policy and Medicine has taken notice and writes:

AMSA sold the Association of Accredited Naturopathic Medical Colleges a booth at the 2011 convention. As the author pointed out, AMSA will not take money from pharmaceutical companies, but they have no problem with taking money from “pseudoscience.” Perhaps a conflict of interest?
Consequently, the author described how he went up to the booth to find out what naturopathy is. He was told that they are “primary care physicians” who treat the “whole patient in a holistic way.” In addition, one of the table reps told the author that naturopathy subscribes to the use of homeopathy, herbalism, acupuncture, therapeutic touch, and “all sorts of other nonsense.” The author also pointed out that their “written materials were more straightforward about their quackishness.” Ultimately, while AMSA “professes to support evidence-based medicine,” the author was disturbed by the fact that AMSA would legitimize “quackery of this sort.”

Zoonotic leprosy in the US

From a report in NEJM:

Wild armadillos and many patients with leprosy in the southern United States are infected with the same strain of M. leprae. Armadillos are a large natural reservoir for M. leprae, and leprosy may be a zoonosis in the region.

Evaluation and management of patients with osteoporotic vertebral fractures---NEJM review

Here is the discussion in the NEJM blog, which contains a link to the article.