Panda Bear quits blogging

Nothing mysterious about it. He explains his reasons. This is a great loss.

Additional blog reactions to Medscape paper on NCCAM’s chelation study

Science Based Medicine

Health Care Renewal

These are similar postings by one of the authors of the Medscape piece, containing an excerpt.

My reaction was here.

Quackademic medicine at Yale

It’s been a good week for the exposure of the fraud, corruption and pervasive conflicts of interest in high places in the world of woo. Just last Tuesday the Medscape Journal of Medicine published an article exposing the bad science and pervasive conflicts of interest behind the National Center for Complementary and Alternative Medicine’s ongoing chelation trial. Today David Colquhoun, blogging at DC’s Improbable Science, wrote about Integrative baloney at Yale in which he exposed, with videos and other examples, some of the wooiest of woo being taught there.

Junkfood Science recently blogged about the program at Yale. Concerning the general problem of medical academic woo she wrote:

Some have questioned if CAM-trained doctors are able to practice as primary care physicians and if we can trust their judgments. The concern that probably most comes to mind is whether these doctors are being taught the scientific process and how to recognize sound evidence from modalities that negate all known laws of science and biological plausibility.

She posted a follow up today. Both bloggers mentioned an astounding statement by Yale professor David L. Katz, MD, MPH, FACPM, FACP, associate professor, adjunct, of Public Health and director of the Prevention Research Center (PRC) at the Yale University School of Medicine. From DC’s post:

Pretty remarble uh? Dr Katz goes through several different trials, all of which come out negative. And what is his conclusion? You guessed.His conclusion is not that the treatments don’t work but that we need a “more fluid concept of evidence”.

That announcement by a prominent medical academic made it official: we are in the era of post-scientific medicine.

DC went on:

It’s equally bizarre to hear Richard Belitsky, Dean of Medical Education at Yale saying he is “very proud” of this betrayal of enlightenment values. If this is what Yale now considers to be education, it might be better to go somewhere else.

But where else is there to go? With quackery spreading like MRSA throughout academic medical centers the list of institutions with true scientific integrity is shrinking fast.

DC cited the Flexner report and made a point I wrote about before:

Flexner would have thought it quite inconceivable that in 2007 medical schools would be offering Continuing Medical Education in homeopathy.

He asked why other academics at Yale aren’t up in arms and suggested, earlier in the post, that it’s about money:

Very few university administrators have the intellectual integrity to turn down money, whatever the level of dishonesty that is required by its acceptance. You can buy a lot of silence for $100m…

…citing NCCAM and massive philanthropic funding of academic woo.

By the way, where’s the AAMC in all this? Aren’t they supposed to be guardians of integrity and professionalism in medical education? Are they asleep at the switch or is money silencing them too?

And a final note--- I got the idea for the term “post-scientific medicine” from the Carlat Psychiatry Blog. Dr. Carlat, writing about AAMC’s new proposal to limit the influence of pharmaceutical companies in medical academia, declared that we are now in the era of “post-deception medicine”. I respectfully disagreed.

On the AAMC’s proposal concerning Pharma gifts, I’ve changed my tune---somewhat

A commenter on my recent post about the AAMC proposal took me to task for not reading the report in the original. Although her reasons for suspecting me were wrong (I twice referred to the AAMC as AAMS, typo’s I’ve since fixed) it turns out she was correct that I hadn’t read the report in the original. I had read some blog reactions and the New York Times article, none of which contained a link to the report.

So I did what I should have done in the first place. I went and read the report. Turns out the proposal isn’t so bad. Not as bad as I thought, anyway. I disagree with the scope and the extent of the restrictions proposed and find it odd, even hypocritical, given all their talk about professionalism and integrity in medical education, that they turn their back on the shameful and pervasive problem of woo. Nevertheless, my characterization of the proposal as “simplistic and extreme” was too strong.

I think it was the NYT article that was simplistic. It implied a total ban on free food. Wrong. According to the AAMC proposal, industry-supplied food is permissible if served at an activity carried out according to ACCME standards and accredited for CME. Some academic medical center Grand Rounds, though perhaps not all, are accredited. So, this proposal will not banish free food from the academic environment. Many activities won’t be affected at all. What it may do is encourage more programs to get their Grand Rounds accredited. That would be a good thing.

Moreover, the report doesn’t ban drug reps from medical campuses. It merely sets standards for drug company presentations and requires oversight by faculty. In other words, drug reps can’t just wander in and, like self appointed faculty, proceed to “teach” students free of any administrative supervision!

My big mistake was that I dropped my guard and violated the cardinal RW rule: always, when possible, go to the primary source! That’s what I get for trusting the New York Times.

One more thing. I had to chuckle at Carlat Psychiatry Blog’s declaration following the announcement of the AAMC proposal: The era of post-deception medicine is finally here. No way. We can’t enter an era of post-deception medicine until we leave the era of post-scientific medicine. Selective outrage?

Cardiovascular risk in retired NFL linemen

They have increased cardiovascular mortality and approximately double the risk of metabolic syndrome as compared to other positions. Via the American Journal of Cardiology.

Cognitive errors in medicine

You don’t have to be a subscriber to the American Journal of Cardiology to read J. Willis Hurst’s editorial on cognitive errors in medicine---the full text is free. I highly recommend it.

The popular approach to limiting cognitive error was recently articulated in Jerome Groopman’s marvelous book How Doctors Think. I call it the negative approach to cognitive error because it emphasizes pitfalls to avoid. Hurst’s essay suggests a more positive approach. It outlines things to do in the systematic collection and processing of clinical data. These approaches are complementary and both ultimately address the same types of error.

Hurst’s approach centers around the medical record as a tool for teaching and learning (thus addressing gaps in the clinician’s knowledge), defining data that need to be collected, analyzing the data and applying the information to the patient’s problems. He advocates the problem oriented medical record (AKA the Weed system) of which he has been a champion for many years.

Most of us would say we use the problem oriented medical record as the ever present SOAP notes and problem lists attest. But a careful reading of Hurst’s essay suggests it’s merely a pretense. The problem oriented record as originally conceived is systematic and rigorous. While it seems cumbersome, Hurst notes that it can be utilized quickly and efficiently once proper habits are developed.

The problem list must designate each item at the level of resolution achieved, from symptoms and laboratory abnormalities at the low end to definitive diagnoses at the highest level. Moreover, diagnoses must reflect the most up to date disease classification and terminology.

That raises an important question. Is it possible to generate and maintain a true problem oriented medical record in today’s environment where the record is hijacked by coders, core measure police and others with competing agendas? Just one example of this problem is the basing of diagnostic terminology on the decades obsolete (created in 1977 and replaced in 1992) ICD-9 classification. In paper based records if you use precise and up to date terminology your patient’s chart is likely to “bounce back” from the coding department and ultimately find itself on the delinquent list. In the electronic world where all diagnoses are inseparably linked to ICD-9 codes the best terms may not be available.

An effective medical record is more than an accurate problem list. Hurst writes (italics mine):

The medical record should reveal the thoughts and actions of the physician in charge. The challenge for the physician is to make the record simultaneously brief and complete. The record should be easily understood by another physician. Each page of the record should be uncluttered, and important information should be displayed prominently so that it can be retrieved easily.

I wonder what Hurst thinks of today’s template generated charting.

There’s much more.

The John Ritter defendants---did they really win?

From Emergency Medicine News:

In the Ritter case, the jury agreed with the defendant physicians and exonerated them of any liability. They were lucky. How lucky? They were able to spend four years with attorneys worrying about their future, including the potential that they would be ordered to pay tens of millions of dollars and be left penniless.

So, they didn't really win. They just lost less.

Read the rest here.

Medscape article blows the lid off of NCCAM’s chelation study

A Medscape article on the National Center for Complementary and Alternative Medicine (NCCAM) sponsored Trial to Asses Chelation Therapy (TACT) declares:

We conclude that the TACT is unethical, dangerous, pointless, and wasteful. It should be abandoned.

Orac has already written a wonderful post this morning in which he opines:

As I go to my office and lab this morning, to try to do high quality scientific research based on good science designed to improve our understanding of cancer and hopefully lead to more effective therapies, it galls me to no end to see the equivalent of 15-20 R01 grants going to fund this woo. Worse, it's TACT is not the only example of an unethical and scientifically worthless trial being funded not because the science is compelling but because powerful lobbies and legislators who are true believers in woo applied pressure to the NIH to do them.

I’ll take this opportunity to put in my two cents---not that I really have anything to add other than to say “I told you so” not only about this study but also about the under appreciated conflicts of interest in government funded research. When I first read about this study a couple of years ago I smelled a rat and have since written a number of posts, several of which Orac linked to this morning. The Medscape article reinforces some of the points I made in those posts, particularly regarding the dubious credentials and obvious conflicts of interest of many of the study site investigators. Just look at this jaw dropping paragraph from the article:

The TACT includes nearly 100 "chelation site" co-investigators who, in our opinion, are unsuitable to care for human subjects or to report trial data. Most espouse implausible health claims while denigrating proven methods; several have been disciplined, for substandard practices, by state medical boards; several have been involved in insurance fraud; at least 3 are convicted felons. Several were members of the ACAM or GLACM IRBs mentioned above. Few appear to have real expertise, required by TACT literature, in treating patients with CAD or in conducting clinical trials. Most continue to promote chelation while the TACT is in progress, contrary to good science, to human studies ethics, and to US Federal Code. The TACT consent form gives no hint of these points.

WOW!! Worse than even I imagined! This stuff belongs in the health pages of the New York Times. (I won’t hold my breath, though. They’re probably too busy exposing the pharmaceutical companies to notice. I hope I’m wrong!). If those ethical issues aren’t egregious enough consider that the study isn’t even securely blinded from the investigators, a concern I raised here and in other posts. The Medscape article describes the problem:

The experimental solutions must be mixed on-site. The 2003 TACT protocol describes a method to preserve blinding and reports that this "has been piloted successfully," presumably in a supervised, academic setting.[5] Nevertheless, the mixing procedure presents simple opportunities for distinguishing between the chelation and placebo solutions. For example, the site coordinator must inject 14 mL of concentrated ascorbate or sham solution into a 500-mL IV bag. The plan calls for the 14-mL solutions to have similar viscosity and to appear similar in color, but a tiny drop applied to the tongue during transfer would instantly identify the ascorbate by its sour taste. Ascorbate goes exclusively with the Na2EDTA solution.

Orac faithfully reported the same concern:

Not only was the protocol itself scientifically implausible, a mix of disodium EDTA and a bunch of supplements, as well as procaine and heparin added for unclear reasons. it is placebo-controlled, but the protocol stipulates that the chelation solution must be mixed on site, allowing ample opportunity for investigators to break blinding, either purposely or even inadvertently.

That may just be the tip of the iceberg concerning TACTs’ design problems. The authors note that the NCCAM was not entirely forthcoming with information in response to their FOIA requests:

Through FOIA requests, we obtained "redacted" copies of the original (2001) and 2003 TACT protocols,[4,5] the roster of the committee that approved the grant application,[39] and the June 2003 consent form.[6] Because the trial had already begun and because our initial FOIA requests were frustrated by delays and incomplete responses, we did not seek further revisions of the protocol or consent form, or other documents that are not available on the NCCAM Web site.

I knew from the get-go this trial was questionable. I didn’t know how bad it really was until I read the Medscape piece. This tops any example you can trot out about the corrupting influence of Big Pharma. What I didn’t cover in my posts was the extent of the pseudoscientific agenda and conflicts of interest that prevailed throughout the planning and implementation of the study. If you think government funding is the answer to Pharma involvement in research this article will give you pause.

Medicare’s no pay policy

---is only part of the DRG revamp rolled out by CMS last year. There’s also the new list of MS-DRGs which replace the old DRGs. And while it may seem like a lot of BS we’ll have to live with it, so we may as well attempt to learn it. An article in ACP Hospitalist offers some tips. Too complicated for me.

Healthy skepticism about practice guidelines

If you didn’t read DB’s rants carefully you might get the idea he was somehow against practice guidelines. That wouldn’t be accurate. There’s a difference between skepticism and cynicism. A Grand Rounds presentation he delivered on the topic at UC Davis puts his rants into perspective. Here are some of my take home messages from the talk:

Guideline developers have conflicts of interest. This is not unique to those supported by drug companies. Virtually all organizations and individuals involved in guideline development---governments, professional societies and individuals interested in their academic careers---have a stake.

Guidelines are not immutable rules and are no substitute for clinical judgment.

You can’t apply all guideline recommendations to patients with multiple complex problems---you must prioritize treatments.

Guidelines can provide impetus for ill conceived performance measures.

There’s much more. Follow the link above and watch the video. It’ll make you think.

What’s so great about CPOE?

My recent criticism of electronic medical records (EMRs) has focused on documentation templates. Now that I’m on a roll with EMR posts I may as well cover the other side of EMRs---computerized physician order entry (CPOE). The push for universal adoption of CPOE is on. Leaders in the patient safety movement tell us it’s a good thing. So what’s so good about it?

For starters let’s look at the description in AHRQ’s glossary:

Physicians (or other providers) directly enter orders into a computer system that can have varying levels of sophistication. Basic CPOE ensures standardized, legible, complete orders, and thus primarily reduces errors due to poor handwriting and ambiguous abbreviations.

It goes on to point out that many systems have decision support built in: suggested doses, allergy alerts and order sets which conform to evidence based practices. More sophisticated systems may integrate patient data such as weight and creatinine clearance.

No one would dispute that these are good ideas. The real rub is how CPOE does in the real world. Do the benefits outweigh the unintended consequences? Bob Wachter, who has written a couple of recent posts on health care technology, seems to think they do. In last Friday’s post he referred readers to AHRQ’s patient safety network where a search on CPOE yields 174 citations. But the top hit is an article on unintended consequences and contains a link to the fabled Pittsburg study showing an increased mortality following the implementation of CPOE. Then there’s this study showing that CPOE actually creates errors. Clearly there’s a trade off between errors intercepted by CPOE (which may or may not have been intercepted “downstream” in traditional paper based systems) and new and unanticipated types of errors introduced by CPOE.

What is the net result in terms of patient safety? To answer that question we need outcome based data. Such data are sparse, but the Pittsburg study is concerning. To be fair, the negative results of that study may reflect learning curve issues more than inherent risks of CPOE itself. On the positive side, Wachter cites this study. But it’s from Brigham and Women's Hospital, raising questions about real world generalizability. Moreover, the significance of the error reduction attributable to CPOE in the study is unclear from the paper. This very recent systematic review demonstrated CPOE’s ability to intercept many errors but failed to show improvement in patient outcomes.

What’s my bottom line as of May 13, 2008? CPOE is a great idea. CPOE has potential. But the boosters of CPOE have a burden of proof which they have yet to satisfy. It has not been proven to help patients. Why is there such a disconnect between theory and real world results? The downside in terms of creating new errors is well documented.

But their’s a less tangible downside. For clinicians, CPOE is a distraction. What do I mean by that? It adds a new burden to our work flow: order processing. Doctors are trained to focus on clinical issues. We need to know what drug to give, when and how much, and what tests to order. We are not trained in how to search the computer for the appropriate orders, how to customize our therapy when the computer’s options are limited, how to be sure that our order entry is properly routed, or how to devise workarounds that are inevitably necessary in such systems. Those issues, formerly in the domain of clerical employees, are now foisted on doctors. They are time consuming and they take away from our clinical focus. The challenge for CPOE development is to create systems that allow doctors to concentrate on the clinical problem at hand, free of questions such as “Where can I find the basal/bolus insulin protocol?” or “Am I sure I entered this right?”

Wachter’s other post puts CPOE in the helpful perspective of the “Technology hype cycle”. New technologies are initially met with unwarranted enthusiasm. Then there follows a back lash when they don’t meet their initial expectations. Finally, gradually, the level of acceptance finds a middle ground in which users appreciate the benefits but realize that the technology isn’t nearly as good as originally hyped. It’s a useful model to keep in mind because it gives us a road map, a kind of sense of where we’ve been and where we hope to end up.

AAMC’s proposed ban on drug company gifts draws controversy

MSNBC ran a point counterpoint on the Association of American Medical Colleges proposed ban on drug company freebies for medical students. Dr. Edward V. Craig, Professor of Clinical Orthopedic Surgery at Cornell Medical School, writing in opposition to the ban, said:

Unfortunately, this proposal ignores all subtlety, is dismissive of the many benefits of industry relationships with medicine, and considers individuals and medical organizations rudderless in their efforts to be steered by a personal and professional moral compass.

If your medical school is being over run by drug reps or if they are creating a distraction in the learning environment, you as an administrator or faculty member should take action. But the AAMC proposal is simplistic and extreme.

The larger problem in medical education is the need to teach students to think critically. Although that would address not only the slanted information in drug company promotions but also the woo students are exposed to it’s not being done effectively. Instead, students are being asked to check their brains at the door to the classroom. If you have doubts on whether med students are embracing pseudoscience on a large scale check out the complementary and alternative medicine pages of the American Medical Student Association web site.

Via Kevin M.D.

How well do eICUs work?

The ones that are profiled in a recent issue of ACP Hospitalist seem to be working pretty well. Do they all work that well? It depends entirely on the quality of relationships between the personnel at both sites.

Electrocardiographic T wave inversion

Various forms are discussed in this review from the American Journal of Emergency Medicine.

Diagnosis: Fabry’s disease

Case description and literature review in Nature Clinical Practice Cardiovascular Medicine.

Precipitating causes of heart failure exacerbation

The OPTIMIZE-HF data base provided us with a wealth of information on heart failure. A report from that data base which focused on precipitating causes of exacerbations was recently published in the Archives of Internal Medicine.

In heart failure one can think about underlying causes and precipitating causes. While a good deal of evidence supported the importance of the former, there was little, up until now, on the importance of the latter even though expert opinion (as well as my mentors going all the way back to med school and residency) held that we should think about both. This paper, by showing that a majority of heart failure episodes had an identifiable precipitant, adds credence to that teaching. Precipitating causes matter.

DB of Med Rants provided a nice summary of the findings. I’ll just make a few observations I found interesting:

Patients with no identifiable precipitating cause had a modestly lower mortality. That’s counter-intuitive. You’d think the folks who decompensated for “no reason” would be those with the least hemodynamic reserve who are approaching “end stage”.

The distribution of length of stay was not a bell curve. The median length of stay was 4 days whereas the mean was 6.4. That tells me there were some outliers with very long stays. It matches real world experience.

Finally, I was a bit surprised that pulmonary embolism was not on the list of precipitating causes. That may reflect how hard investigators looked for PE rather than its actual occurrence. Recall that in COPD exacerbation, when you look for PE you find it in 25%. I’d like to see a similar study in hear failure.

So you want to be a doctor?

In Reasons Not to Become a Doctor Tara Weiss writes that physicians’ professional rewards are shrinking, and that is contributing to a growing shortage of doctors. She quotes three authors from the recruiting firm of Merritt and Hawkins:

This is not just a question of career choice---consumers will be affected greatly by this shortage. If you think there’s a long wait for an appointment now, it could be nothing compared with 15 years down the road. The three co-authors of Will the Last Physician in America Please Turn Off the Lights, all from the physician staffing firm of Merritt, Hawkins and Associates, say the wait will jump to three to four months to see a doctor for a non-emergency, and a routine doctor’s visit will cost two to three times what it does now—whether you are insured or not, they say.

I have a lot of respect for Merritt and Hawkins. They are uniquely in touch with physicians’ attitudes and working conditions. But you don’t need data from Merritt and Hawkins to know that what Weiss says is true. The shortage of doctors, particularly primary care, touches all of us.

Although all doctors realize the increasing frustrations of the profession, medical blog reactions have been somewhat more optimistic:

Kevin M.D.

DB’s Med Rants

JaneMarie MD

The Blog that Ate Manhattan

My take? I can’t see myself doing anything else. I love medicine. It is said that one of my medical school mentors was quite wealthy and worked for the university, at his own insistence, for a dollar a year. He’d say to his students “You should love medicine so much that if you were independently wealthy you would be willing to pay for the privilege of being a doctor.” I sometimes feel that way!

Nobody goes into medicine primarily to get rich. Perhaps a few consider it just a job. Most appreciate the professional rewards. For me the issue is not the profession of medicine; it’s the baggage. I love medicine but I hate the baggage. The baggage is growing and choking off the professional rewards. For many doctors, even the ones in the profession for the “right” reasons, the baggage has become unbearable.

Wanna be a doctor? Think long and hard, and count the emotional cost.

Medical blogging featured in ACP Hospitalist

---with mention of a few blogs including yours truly. Thanks for the link!

Dear blog, my patients are nuts. Signed, anonymous.

Doctors need a better quality of life

---according to this Medscape article. Docs are under too much pressure and that may negatively impact patient care. Not only do we face external pressures, but we bring a lot of it on ourselves. We’ve become an increasingly self-flagellating profession. That’s why it’s refreshing to read this:

Doctors are under too much pressure, experts warn, and this is having a negative affect on patients. Physicians who are overworked, overburdened, and generally stressed out are less available to patients and not as effective. Disregard the basic needs of healthcare professionals and patients are soon neglected too.

Complications of influenza

Reviewed In the American Journal of Medicine.

Almost all doctors think they’re above average

---when it comes to diagnostic accuracy according to Paul Mongerson in the foreword to a supplement in the American Journal of Medicine. The supplement examines the role of overconfidence in diagnostic error. Full text of the entire issue is available free of charge. Fascinating reading about the cognitive traps we fall into and potential remedies.

My take on the electronic medical record

Yesterday I took the curmudgeon role on EMRs. It’s not the first time and probably won’t be the last. DB responded here. He had previously posted a wonderful essay on the art of history taking. Maybe it was unfair to use his post (which was not a rant against EMRs at all) to support my own criticism of EMRs. At any rate, his response served to point out that I rant about EMRs at the risk of being misunderstood (the spike in blog traffic with the help of Kevin was a bonus). So, here’s my attempt at clarification:

I regard electronic medical records in much the same way I regard the pharmaceutical companies---with healthy skepticism (questioning things, not believing everything the promoters say) but not cynicism (seeking every opportunity to knock them down).

EMRs have conceptual advantages that are very appealing. Making them work in the real world is problematic and filled with unintended consequences. It has to be done right. We’re not there yet. Most of us, anyway.

I’ve written before on the decline in basic clinical skills and cited many reasons other than the EMR. But templates serve the coders more than the clinician. Templates impede original thought and introduce challenges to the recording of a meaningful history. A good clinician can overcome the challenges but it takes effort---maybe some extra typing and editing. Templates are not unique to EMRs. We had them in the paper days. EMRs just took them to a new level.

Poor documentation and questionable coding, while facilitated by electronic templates, ultimately reflect on the physician.

My observations on EMRs are not scientific. They’re random. That being said I’ve seen some good electronically generated notes, but they’re in the minority. Most seem to have a low signal to noise ratio.

Has woo invaded your hospital yet?

Sooner or later it will. The cover story on this topic in ACP Hospitalist and its accompanying editorial comment are completely non-critical, offering as evidence in favor of the trend a single anecdote along with the usual statistics on CAM’s rising popularity.

So: You’re a hospitalist. Hospitalists are supposed to be the leaders of quality in the inpatient environment. When you see woo spreading through the wards of your hospital like MRSA whatcha gonna do?

The decline in the art of history taking

---may be facilitated by electronic medical records. Two bloggers offer contrasting perspectives. DB reminds us of what it should be:

Taking a history may seem simple, but it requires broad medical knowledge. Master clinicians alter their history taking in response to the patient’s answers, their body language and observation. As one performs the physical exam, more questions occur to the clinician.

The history does not end with the admission. As one collects laboratory results, imaging studies, and clinical changes, more questions become relevant. History
taking represents an ongoing activity, designed to help both the diagnostic and therapeutic process.

How does one become better at history taking? First, you must take many histories. You must critique yourself as more information becomes available. Second, you must think about the process of history taking.

Dr. Wes bemoans what it has become with the help of the electronic medical record (EMR):

The EMR has become not only the administrators' friend, but the proceduralists' as well. Thanks to text-generating "macros" (sometimes called "dot-phrases") the burden of the pre-op history and physical has been all but erased. If a patient has one cataract done thirty-two days ago (outside JCAHO's 30-day requirement), well then, no problem, just hit a few "dot-phrases" and presto! Away we go! "Dot phrases" can load up an empty history and physical form faster than you can say "operation."

A speaker extolling the benefits of the EMR once said that some conditions are so similar from patient to patient that one can often generate the entire H&P with just a few key strokes and little if any editing. It was an amazing demonstration but really, really sad.

The whole thing, of course, is driven by economics. The less time you have to spend on the H&P the more patients you can see, the more procedures you can do and up goes productivity.

Sooner or later we’ll all adopt the EMR. After all, it’s what everybody (except for physicians in the trenches) says will fix the patient safety problem. We’ll take advantage of its efficiencies but real effort will be needed to save the dying art of bedside diagnosis.

Unhealthy pressure to implement electronic medical records

Pressure to implement electronic medical records has been driven by hype, without due regard for the unintended consequences. Many thought leaders in medicine have contributed. IHI president Donald Berwick, in a Time Magazine commentary on how to “fix” healthcare, made this incredibly simplistic observation about EMRs:

My pizza parlor is more thoroughly computerized than most of health care. It's high time to put the paper medical record where it belongs — in the Smithsonian, next to the typewriter.

In a Medscape Webcast Video Editorial Dr. Carolyn Clancy, head of AHRQ, asked, in effect, “What are we waiting for?”

Doctors hesitate for good reasons. In their April 17 NEJM Perspective piece Pamela Hartzband, M.D., and Jerome Groopman, M.D. (author of How Doctors Think) sounded a note of caution. Concerning EMRs, they wrote:

We worry, however, that they are being touted as a panacea for nearly all the ills of modern medicine. Before blindly embracing electronic records, we should consider their current limitations and potential downsides

.

I made brief mention of the article the day it came out. I’ve since had the opportunity to parse it in greater detail and observe some blog reactions.

The authors noted that the illegibility of the old handwritten doctors’ notes has been replaced by a new form of electronic illegibility: template generated clutter. A few clicks of the mouse generate paragraphs of repetitious, boiler plate verbiage with a low signal to noise ratio leading to reader fatigue.

They also made this disturbing observation about how EMRs can undermine our professionalism:

As we have increasingly used electronic medical records in our hospital and received them from other institutions, we've noticed several serious problems with the way in which notes and letters are crafted. Many times, physicians have clearly cut and pasted large blocks of text, or even complete notes, from other physicians; we have seen portions of our own notes inserted verbatim into another doctor's note. This is, in essence, a form of clinical plagiarism with potentially deleterious consequences for the patient.

Yes, clinical plagiarism. In some EMR systems it’s not even necessary to go to the trouble to copy and paste. The text is imported automatically. It’s fine to incorporate information from previous records into your note. But in the paper days we had to read and think about the information first. (I previously noted another threat to professionalism: EMRs encourage doctors to over code). (original post by ER Murse).

The authors went on to say that electronic template generated notes discourage thought:

Writing in a personal and independent way forces us to think and formulate our ideas. Notes that are meant to be focused and selective have become voluminous and templated, distracting from the key cognitive work of providing care. Such charts may satisfy the demands of third-party payers, but they are the product of a word processor, not of physicians' thoughtful review and analysis. They may be "efficient" for the purpose of documentation but not for creative clinical thinking.

And this:

A colleague at a major cancer center that recently switched to electronic medical records said that chart review during rounds has become nearly worthless. He bemoaned the vain search through meaningless repetition in multiple notes for the single line that represented a new development. "It's like `Where's Waldo?'" he said bitterly. Ironically, he has started to handwrite a list of new developments on index cards so that he can refer to them at the bedside.

True, handwriting in charts is sometimes illegible and can lead to miscommunication. It might seem that the printed (or at least typed) word, which we are all conditioned to respect, would always be more definitive and have more impact than text written by hand. But we have observed the electronic medical record become a powerful vehicle for perpetuating erroneous information, leading to diagnostic errors that gain momentum when passed on electronically.

The electronic medical record, all too often a substitute for thought and critical analysis, will create new challenges in the teaching of students and residents. Excellent clinicians write notes that tell patients’ unique stories in narrative form and explain their clinical thought processes. Electronic template generated notes discourage the teaching of this skill.

The NEJM article is not entirely negative about EMRs, but it issues a plea for caution. It’s a must read if you’re involved in planning for an EMR.

Further reading: Health Care Renewal’s take on the NEJM piece.

Alpha-1 antitrypsin deficiency

This topic was updated in a recent issue of the American Journal of Medicine.

Key points:

The condition is under diagnosed, and all patients with COPD should be screened once in their lifetime.

Liver disease is due to accumulation of abnormal antitrypsin molecules in hepatocytes.

Unusual disease associations include Wegener’s granulomatosis, aneurysms and necrotizing panniculitis.

Nonalcoholic fatty liver disease

---is the hepatic manifestation of the metabolic syndrome. A topic review is presented in Nature Clinical Practice Gastroenterology and Hepatology.

The changing spectrum of chronic pulmonary histoplasmosis

Conventional wisdom, based on reviews from decades ago, holds that chronic pulmonary histoplasmosis typically occurs as cavitary disease in patients with COPD. A recent review in Medicine suggests a wider spectrum of presentations.

Diabetic foot infection: is it osteomyelitis?

Featured in JAMA’s Rational Clinical Examination.

Prominent R wave in V1

Interpreting a prominent R wave in V1 is an exercise in differential diagnosis. The clinician must be able to list the causes. Here’s the list:

Left ventricular ectopy
Right ventricular hypertrophy
Acute right ventricular dilation (acute right heart strain)
Type A Wolff-Parkinson-White syndrome
Posterior myocardial infarction
Hypertrophic cardiomyopathy
Progressive muscular dystrophy
Dextrocardia
Misplaced precordial leads
Right bundle branch block
Normal variant

You’ll make fewer mistakes if you keep this list in mind when confronted with an electrocardiogram which displays an R wave in V1 of greater amplitude than the S wave.

Via the American Journal of Emergency Medicine.

Want to eliminate the drug company lunch?

You’re not going to get doctors to drop the practice. Those who oppose it have the loudest voices but they’re in the minority. Want to eliminate the practice? Criminalize it. Look for, among many other unintended consequences, a spike in direct to consumer advertising.

More on Medicare’s latest no pay list

A recent WSJ Health Blog post on the topic was more interesting for the comment thread than for the post itself. Aggrevated Doc Surg and Roy Poses of Health Care Renewal weighed in. One commenter best summarized the consensus of the thread:

Ridiculous. Why don’t we just not treat people. No risk of medical errors there! Comment by Student.

Whither health care reform?

As the election nears NEJM Perspective piece writer Lawrence R. Jacobs asks if it’s 1994 All Over Again. Recall that the 1994 elections marked the final finishing blow to the Democrats’ health care reform proposals, starting with the Clinton plan, then evolving to the much less ambitious Mitchell plan before meeting defeat. According to Jacobs the landscape of public opinion in the U.S. hasn’t changed much since that time.

Hospitalists and drug seekers

Despite evidence to the contrary, popular pain management dogma holds that narcotic addiction is rare among patients with chronic pain and that most patients who send up the red flags of drug seeking are really suffering from “pseudoaddiction.”

Most hospitalists, though, know that they are likely to encounter drug seeking behavior. Here’s an article in Today’s Hospitalist with some tips on how to deal with the problem.

Electrocardiographic manifestations of ventricular aneurysm

Left ventricular aneurysm often causes ST segment elevations in indicative infarct leads which persist after resolution of the infarction. Such findings may be difficult to differentiate from other causes of ST segment elevation, particularly acute infarction. A review in the American Journal of Emergency Medicine describes the electrocardiographic findings of left ventricular aneurysm and focuses on the differentiation form acute infarction. As opposed to acute infarction the ST elevations of ventricular aneurysm tend to be accompanied by well developed Q waves and reciprocal changes are lacking.

CNS infections: tips and pearls

Via Today’s Hospitalist.

More on the shortage of geriatricians

Despite longer training requirements as compared to FPs and internists, geriatricians earn less. Why? Their case mixes are virtually 100% Medicare. From the American Journal of Medicine:

Few other fields of medicine are faced with the challenge of proposing that residents complete additional training only to have their earning power decrease.

ST segment elevation: MI or not?

When confronted with electrocardiographic ST elevation it’s necessary to differentiate STEMI from early repolarization, pericarditis and other conditions. Look for reciprocal ST depression, which strongly favors MI. According to a study in the American Journal of Emergency Medicine sensitivity, specificity, positive predictive value, and negative predictive value for the electrocardiographic diagnosis of AMI were 69%, 93%, 93%, and 71%, respectively. This works only in the absence of confounding abnormalities such as bundle branch block, paced rhythm and hypertrophy.

Takotsubo cardiomypoathy: mechanisms and pathophysiology

There has been a recent explosion of literature on this underappreciated entity. Here’s another review from Nature Clinical Practice Cardiovascular Medicine.

What’s the practical importance of recognizing this syndrome? Patients, despite appearing to present with myocardial infarction and horrible ventricular function, are not doomed. Recovery of normal ventricular function is the rule provided they get appropriate supportive care.

Hospitalist News launched

From the introductory article:

HOSPITALIST NEWS will cover breaking news in clinical trials, new therapies, and regulatory and payment trends that have a direct impact on hospitalist practice. Our experienced journalists will write concise, easy-to-read, and balanced articles that are fact-checked for accuracy. They will report from medical specialty meetings where new research is presented, monitor regulatory agencies, and provide the perspectives of thought leaders in patient care.

I’ll be linking from there often.

Hospitalist News.

Via Clinical Cases and Images blog.

CMS defines nine more hospital “errors”

Last year CMS, in an ill conceived policy change, rolled out a list of hospital acquired conditions which could no longer be coded to increase DRG reimbursement, defining these conditions as “never events.” The media egregiously spun the issue as “Medicare no longer paying for mistakes.” I pointed out how manifestly unfair this was in several posts last year.

Now they’ve added nine more to the list for consideration. Included in the new list of “medical mistakes” are iatrogenic pneumothorax, Legionella infection and delirium.

Well, I’m at a loss for words, so go read what Bob Wachter and DB have to say about it.

Poses vs Pitts on EBM

Peter J. Pitts, president of the Center for Medicine in the Public Interest, wrote a negative commentary in the Washington Times on evidence based medicine (EBM). Dr. Roy Poses, blogging at Health Care Renewal, offered a rebuttal. I’m not going to take sides in this debate, as good points were offered by both. Correctly noting that Mr. Pitts used a straw man argument (Pitts unfairly portrayed EBM as “one size fits all” medicine) and explaining what EBM really is (or is supposed to be) Dr. Poses then went on to base much of his own argument on an ad hominem attack against Mr. Pitts (it seems Pitts has ties to Big Pharma, who may not be happy with EBM’s objective evaluations of their new and expensive drugs).

“One size fits all medicine”, while not a core notion of EBM, is one of EBM’s popular distortions. We’ve seen it many times. Older and cheaper drug A performs as well in the latest systematic review as newer and more expensive drug B. Ergo, drug A is the drug of choice for all patients. This type of thinking may drive an agenda behind government funded research. Pitts cites the CATIE trial. An even better example (or at least one more familiar to me) might be ALLHAT. (DB of Med Rants has a great post on the apparent agenda behind ALLHAT here).

A larger issue is conflict of interest. Dr. Poses has written a great deal on conflicts of interest inherent in pharmaceutical industry funded research. But government funded research is conflicted too. The government has an interest n promoting cheaper drugs. Cheaper drugs are sometimes, but not always, better for patients.

Via Kevin M.D.

The medical record has been hijacked by non-clinicians

And the electronic medical record has facilitated the process. Dr. Wes weighs in on the electronic nursing note:

No doubt completing these charting requirements are simplified for today's nurses, but these nursing notes provide lines and lines of very little of substance for doctors to read, read exactly the same from patient to patient (and hence are ignored) and once something is found (like the social issues noted), no description of the issue is provided.Aspects of the new electronic medical record was not made for doctors or our patients, but clearly for quality assurance administrators. Thanks, folks.

Geriatric medicine declining as a specialty

Funny, that. I can remember, 20 years or so ago, when it was where hospital medicine is now---an up and coming specialty, the wave of the future. The reason for the decline? Bad reimbursement.

Via Kevin M.D.

The AAMC wants to ban the pens and pizza

----at all 129 U.S. med schools. Great. Now when are they gonna ban the woo?

Shameless hypocrisy.

Via Dr. Wes.

Retired Doc weighs in.

Managing insulin in the hospital

There’s a nice little review in Today’s Hospitalist on the subject. The diabetes Nazis have made the term “sliding scale” taboo. While basal-bolus regimens are more rational the “correction” component of short acting bolus regimens is nothing more than a sliding scale, as are popular insulin drip protocols. Moreover, basal bolus regimens are problematic in hospitalized patients:

While basal-bolus regimens, also known as physiologic insulin, are the preferred way to give insulin to patients in the hospital, these regimens bring their own set of challenges. Inpatients may be eating one minute, then being told to stop for a procedure, throwing up or being switched to an entirely different type of feeding.

The review presents practical tips to deal with these situations. It’s really a very helpful article but I had to chuckle at this:

At Loyola University Medical Center in Chicago, on the other hand, the protocol for patients with continuous tube feeds calls for one shot of slow-release glargine, plus a blood sugar check every six hours “and using correction factor dosing to lower an elevated glucose,” says Mary Ann Emanuele, MD, a professor of endocrinology and medicine.

The “correction factor” sounds a lot like a sliding scale although none dare call it that.

ECG electrode misplacement

It’s hard enough to read ECGs. Your job becomes even more challenging when the tech throws you a curve by misplacing the electrodes. This is the most systematic treatment of the topic I’ve seen.

Via Resident and Staff Physician.

Hospitalists don the psychiatry hat

Psych beds are closing and psychiatrists are giving up hospital visits, leaving psychiatric inpatients underserved. Enter the hospitalist. Hospitalist groups, according to an article in Today’s Hospitalist, all too often become the default service for the care of these patients. But are hospitalists qualified?

When psychiatrists aren’t available, Dr. George points out, “some hospitalists are not comfortable prescribing the initial dose of certain psychiatric medications, like the newer antipsychotics.” While most hospitalists may be comfortable starting patients on antidepressants, “much further beyond that and their comfort level goes away.”

The problem surfaces in two ways. If the admitting hospital lacks psychiatric services the hospitalists often are called on to admit, bed and board the patient, attend to any acute medical needs and await placement in a suitable facility. If the hospital has psychiatrists on staff hospitalists are often called on to co-manage (there’s that buzz word again) those patients. Just as in the co-management of surgical patients, the arrangement creates problems if the lines of responsibility aren’t defined in stone.

What are the solutions? Some hospitalist groups have wisely demarcated the boundaries of their responsibility. Others are starting psychiatric hospitalist programs. The article discusses the ins and outs.

Near fatal asthma

The full text of a review appearing in Current Opinion in Pulmonary Medicine is accessible via Medscape.

Looking for a web based antibiotic guide?

There are usually several free pocket versions of the Sanford Guide lying around our place, left by the drug reps. I’ve found them difficult to navigate. The organization of content is suitable for electronic access but the book requires a lot of page turning. And if you can’t read the small font without a magnifying glass it’s just too cumbersome. I’d be willing to pay for electronic access but there’s no desktop version of the Sanford Guide.

An excellent alternative is the Johns Hopkins ABX Guide. Although dense in content it’s very easy to navigate due to extensive cross linking. You can browse by disease or drug, and can choose among brief summaries, tables and more lengthy monographs for each topic. There are extensive Q&A discussions and literature updates. The site is updated frequently---issues which have only surfaced in recent weeks are discussed. Handheld and desktop versions are included and the site is free after one time registration.

The debate over doctors and drug reps: a proposal

I’ve tried to be a voice for moderation in the debate. This proposal from Dr. James Alpert, editor of the American Journal of Medicine, is one of the better ones I’ve seen, but I don’t think it’s extreme enough for some.

Risk stratification in pulmonary embolism

Why is it important? Because there are now so many different management decisions. Is the patient a candidate for thrombolytic therapy? Does the patient need ICU? Is early discharge or out patient treatment an option?

Exciting research over the last few years has validated new tools for establishing risk. Right ventricular function assessment and cardiac biomarkers are useful. In February’s issue of Chest is a study showing high predictive value of the echocardiographic determination of RV to LV diameter ratio. An echocardiogram is often obtained in patients with PE. However, for a bigger bang for the buck, if the patient’s PE is diagnosed via CT, that study be used to obtain the RV to LV diameter ratio.

An editorial accompanying the Chest paper reviews the topic.

The electrocardiogram in hypothermia

Via the American Journal of Emergency Medicine.

Electrocardiographic findings in athletes

An electrocardiographic finding may indicate the effects of athletic training or underlying pathology which might contraindicate athletic participation. A review in the American Journal of Emergency Medicine offers tips in making the distinction.

The four hour antibiotic rule for pneumonia

Today’s Hospitalist has an update on antibiotic timing rules for pneumonia including the move by CMS and Joint Commission toward a six hour rule. Such a concession, in my view, will do little to alleviate the unintended consequences. The new IDSA guidelines have no timing rule, merely stating that antibiotics should be given as soon as possible in the ER.

The update mentions another problem with timing rules that has avoided the radar screen:

There is also the unproven but widely rumored suspicion that at least some emergency departments triage to favor potential pneumonia patients—even over individuals with other serious illnesses—so they will do well on publicly reported measures.

Yikes.

Statin withdrawal in ischemic stroke

---was associated with worse outcomes in this study published in Neurology. Statin continuation was associated with lower rates of mortality and dependency. That’s better than TPA!

Distinguishing the causes of prominent electrocardiographic T waves

Prominent T waves may represent early (“hyperacute”) changes of STEMI, hyperkalemia or normal variant. The various patterns are reviewed in the American Journal of Emergency Medicine.

Management of acute liver failure

A consensus document published in Critical Care Medicine (free full text via Medscape) outlines pre and post transplant issues.

HIT update

CME available. Via Medscape.

How to argue and why

The web, with its opportunities for interaction, lends itself to argument. How can we keep it constructive? Although there’s often a right and a wrong side to an argument seldom does anyone “win” by convincing the opponent to concede to a particular point of view. In most cases the best outcome is for both sides to gain a better mutual understanding, identify previously unrecognized areas of agreement, ultimately identifying the irreducible points where the parties may just have to “agree to disagree” and where further appeals to evidence and logic may or may not be productive.

Paul Graham, writing about disagreement in the cyber environment, has neatly schematized the analysis of argument by proposing a hierarchy of its various forms. The cheapest shot, level DH0 at the bottom of the list, is name-calling. As Graham points out, whether crude or articulate, name-calling is name-calling, and belongs at the bottom of the heap:

DH0. Name-calling.This is the lowest form of disagreement, and probably also the most common. We've all seen comments like this:

u r a #*@!!!!!!!!!!

But it's important to realize that more articulate name-calling has just as little weight. A comment like

The author is a self-important dilettante.

is really nothing more than a pretentious version of "u r a #*@."

Next up (DH1) is the Ad Hominem argument which, Graham notes, while occasionally useful, is still weak:

For example, if a senator wrote an article saying senators' salaries should be increased, one could respond:

Of course he would say that. He's a senator.

This wouldn't refute the author's argument, but it may at least be relevant to the case. It's still a very weak form of disagreement, though. If there's something wrong with the senator's argument, you should say what it is; and if there isn't, what difference does it make that he's a senator?

If this reminds you of the critics of drug detailing to physicians it’s because they resort to the ad hominem argument over and over again. (“Don’t listen to anything they say because they’re trying to sell something”).

And so the list goes, onward and upward to the top category (DH6) which is “Refuting the central point.” The scheme can help you refine your own arguments. Moreover, by putting them in easily identifiable categories it gives readers a tool to spot weaknesses in other people’s arguments:

The most obvious advantage of classifying the forms of disagreement is that it will help people to evaluate what they read. In particular, it will help them to see through intellectually dishonest arguments. An eloquent speaker or writer can give the impression of vanquishing an opponent merely by using forceful words. In fact that is probably the defining quality of a demagogue. By giving names to the different forms of disagreement, we give critical readers a pin for popping such balloons.

Raising the standard makes your argument not only more civil but also stronger. Cheap shots and personal attacks, while they make entertaining blogging, can weaken your effect. Astute readers may perceive, often correctly, that it’s the best you have to dish out.

The CreateDebate blog has illustrated the hierarchy as a pyramid to highlight the fact that the lower forms of argument are more common.

H/T to STLmedia.net.

Regret that tattoo you got years ago

---in a moment of youthful indiscretion? Dr. Tattoff can help.



H/T to STLmedia.net.

ER boarding and mortality

A report last June in Critical Care Medicine concluded that ER boarding of patients for greater than six hours awaiting ICU transfer is associated with increased mortality and length of ICU stay. I was tipped off to the article by this rant from Emergency Medicine News. And quite a rant it was:

Although reasonable solutions to this problem have been suggested (e.g., putting admitted patients on the halls of the wards), most administrators have chosen not to contaminate the rest of the hospital with these excess patients but rather hold them in the ED where they make the department malfunction substantially. Their reasoning: It may offend the medical staff, patients' families, and hospital floor staff. The philosophy is to sacrifice the ED and its patients for the sake of the rest of the hospital. Until recently, the perceived consequence of this decision was to reinforce the general beliefs of the community that EDs are associated with long waits and a litany of other
indignities.

It sounds like more of the “us against them” finger-pointing I’ve commented on before. Here’s more:

We need aggressive medical staff leadership driving lengths of stay; we need administrators willing to close the hospital to elective surgery when the ED has no place to put its patients; we need options to efficiently discharge admitted patients; we need hospitalists committed to providing efficient, evidence-based care; we need ICUs open only to those qualified to admit patients to these units (rather than every Tom, Dick, and Mary on the medical staff). And, yes, some of these initiatives will upset the medical staff, but hospital and medical staff leadership need to jointly step up to the plate and take on the challenge.

ER crowding is a problem every hospital should be concerned with, and I agree with some of the suggestions above. But let’s get back to something more basic. From the introduction of the Critical Care Medicine paper (emphasis mine):

Emergency department (ED) “boarding” of critically ill patients (holding admitted patients pending ICU bed availability) is common and increasing in frequency in the United States, resulting in a prolonged ED length of stay (LOS).

Therein, perhaps, lies the problem. The patients were being boarded but were they being actively treated? Once the admitting doctor accepts the patient, that patient is considered “handed off.” There is a prevailing mindset that the ER is not a place for ongoing care once a disposition is reached. That mindset was expressed in the discussion section of the paper:

Whereas the ICU is a clinical environment that, by definition, enables close attention to the critically ill and allows for expeditious recognition of physiologic change and sudden deterioration, the ED under most circumstances is neither designed nor staffed to provide extended longitudinal care for the critically ill patient.

So, acknowledging that ER crowding is a problem with no quick fix in sight, perhaps, while we work on solutions, we should also look at what happens to ER patients during the delay. What kind of care are they getting? The study does not answer that question.

For some patients there’s evidence that definitive ongoing care in the ER for six hours before admission to ICU is associated with good outcomes. I’m referring, of course, to septic patients who are candidates for early goal directed therapy (EGDT). In the original protocol validated by Rivers, et al, patients were kept in the ER for EGDT. In fact, ICU personnel were not involved until the protocol was completed.

The solution is complex and multifaceted. Admitted patients who have no reason to remain in the ER for a specific intervention (e.g. EGDT) should be transferred as soon as possible. Inefficiencies in bed control should be sought and addressed. Ambulance diversion should be judiciously employed, Institute of Medicine recommendations notwithstanding.

This study raises another issue which hasn’t been addressed, and is ignored in the Emergency Medicine News piece: Given that ER crowding is going to be with us for some time, someone needs to address the quality of patient care during “boarding”, whether it takes place in the ER or other areas of the hospital.

Perioperative statin use

Evidence is mounting in favor of the perioperative use of statin drugs to reduce surgical risk. The ACC guidelines for perioperative evaluation and management of patients undergoing noncardiac surgery now give statins virtually equal status with beta blockers, recommending that patients already taking statins have them continued throughout the perioperative period.

I previously discussed perioperative statin use in a post from last September.

More recently this review of evidence and a summary of current recommendations appeared in Annals of Surgery.

Mortality of MRSA bacteremia in relation to MIC and vancomycin use

In MRSA bacteremia, when the vancomycin MIC exceeds 1 the mortality is increased in patients treated with vancomycin. The study was reported here in Clinical Infectious Diseases.

According to Medscape’s coverage of the study:

"These findings suggest that empirical vancomycin treatment when MRSA infection is suspected should be administered using a trough serum concentration of at least 20 mcg/mL as a target until a precise MIC is obtained, and it would be necessary to clarify whether new antistaphylococcal agents, such as linezolid, daptomycin, tigecycline or dalbavancin, could be superior to vancomycin when the strain has a vancomycin MIC > 1 mcg/mL," the authors conclude.

This study is from Spain. I’m not sure how it applies to the U.S., but I’ll be looking closely at the MICs of my patients with MRSA bacteremia.

Eco-anxiety

I thought I’d blogged enough for one day until I ran across this piece from Fox News. Many leaders in medicine are shaming us about global warming and related environmental issues. It’s even been suggested that psychiatrists subordinate the mental health of their patients to the health of the planet:

Therefore, instead of using psychiatric insight and techniques to reduce excessive anxiety, shame, and guilt for global warming these emotions will need to be increased in the unconcerned. This kind of 'help' runs counter to our usual goal of not making people feel worse!

Well, it’s working. The incidence of eco-anxiety appears to be rising. One sufferer is profiled in the Fox piece:

Sarah Edwards worries about the gasoline she burns, the paper towels she throws out, the litter on the beach, water pollution. She worries so much, it literally makes her sick.

The treatment? Hug a tree, take shorter showers, among other measures. Learn more at Sarah’s blog.

Harvard doctors speak out about downsides of electronic medical records

All too often they can be a substitute for thought, among other problems. White Coat Notes cited the NEJM article by Dr. Pamela Hartzband and Dr. Jerome Groopman, noting:

…computers make it too easy for doctors to lose focus on the patients before them. Residents and doctors can cut and paste one another's notes into the record, sacrificing the benefit of fresh eyes looking at a patient and distilling what is most relevant. Lab test results can flood the record with no selectivity on what matters for the current problem.

Computer template generated notes I’ve seen are often cluttered with boiler plate verbiage making it difficult to convey the patient’s story in meaningful form and nearly impossible to know what the doctor was thinking.

Via Kevin M.D.

Identifying heart failure from the get-go

This paper in the Journal of Hospital Medicine is more about the administrative diagnosis of heart failure than it is the clinical diagnosis. So is it even worth reading? Perhaps, but more for the clinical documentation specialists and core measure folks than for the clinicians.

How often have you seen this: The patient presents to the ER. Somebody casually mentions heart failure. Maybe the admitting doctor adds it to the differential diagnosis. The core measure team and clinical documentation specialists spring into action and clutter the chart with prompts and reminders. Come discharge time the patient, who turned out to have an exacerbation of COPD, not heart failure, is confused. She wants to know why a stranger came and told her to weigh herself every day, and what she’s supposed to do with the ream of paper on heart failure left on her bedside table. Or what about the patient whose correct diagnosis of heart failure was documented late in the admission resulting in a rush to comply with the core measures and the info packet being dropped in her lap as she’s wheeled out the door?

The paper presents a simple tool to help predict early on which patients will end up with a discharge diagnosis of heart failure. Show it to your core measure people. Maybe it’ll help.

Electrocardiographic manifestations of infectious diseases

Electrocardiographic changes are non-specific but may suggest a diagnosis or point to a specific complication. The topic is reviewed in a recent issue of Hospital Physician.

It’s yet another reason to do a “routine electrocardiogram” on really sick patients.

How much time should you spend washing your hands between patients?

Via a reader tip (my sister): Continually wash your hands while singing two choruses of Row, Row, Row Your Boat. Her source? Sixth grade science class.


Image source Wikipedka.

John R. Brinkley and the age of flimflam

There’s a new book out about John R. Brinkley. Harriet Hall has posted a review over at Science Based Medicine. In my post about Brinkley over a year ago I noted that we are much more tolerant of quackery now than in Brinkley’s day. In reading Harriet’s review (I haven’t read the book) I have to wonder if the author missed that point. Brinkley enjoyed success and wealth for a time, but much of this was gained in Mexico. He was virtually chased out of the U.S., losing not only his medical license but also his radio broadcasting license. When he constructed the first border blaster under a license from Mexico the U.S. tried once again to shut down his infomercials with passage of a law restricting the use of studio-to-transmitter links across international borders, known to this day as the Brinkley Act. While Brinkley’s surgical procedures would not be tolerated today his infomercials would thrive.

According to the review JAMA, decades ago, ran a regular quack busting feature. You won’t see that today in mainstream medical journals, which often promote quackery.

Old fashioned Grand Rounds

Not the medical blog carnival, but the traditional kind. More and more academic medical centers are archiving their presentations on the web. Here’s what I’ve found so far in Internal Medicine and related areas.


UTMB/JSC Aerospace Medicine Residency

University of Washington Television (Health and Medicine)

University of Nebraska

University of Florida

UC Davis

UA Birmngham

McGill

Dartmouth-Hitchcock

DAVE Project gastroenterology

FERNE presentations on neurological emergencies

UT Galveston

Wayne State University

Johns Hopkins Arthritis Center

University of Miami

NIH Clinical Center

UT Houston

UT Memphis

University of Arizona (until May 2007)

University of Arizona (After May 2007)

Ohio State

Drexel University

Heart Podcasts

POEM of the week podcast

Meharry Medical College

Medkast

UT Memphis podcasts

The Canadian Medical Association Journal

---looks healthy, now over two years following the announcement of its collapse. It still has a lot of useful articles, which I link to often.

More negatives concerning erythropoiesis stimulating agents in hospitalized patients

According to a study presented at the Society of Critical Care Medicine 37th Critical Care Congress, the use of erythropoietin and darbepoetin in trauma patients was associated with a marked increase in venous thromboembolism.

Via Medscape.

Background here.

I don’t usually blog about local issues

---but I thought this little piece about hospitalist programs in my neck of the woods was worth a link.

Things overheard at the Society of Hospital Medicine Meeting

Here’s some more of the buzz from SHM 2008.

From Wachter’s World: How do you say no to relentless demand for hospitalist coverage? The scope of hospitalist coverage varies from one place to another. Hospitalists cannot be “house physicians” nor can they cover for every doc in town. My take on the issue is simple. Just say no. Your hospitalist group will be of no value to anybody if it burns itself out.

Also from Wachter’s World, related to the topic above: Recruiting, recruiting, recruiting! It appears most programs are looking to expand, driven by the constant need for more coverage. Great if you’re looking for a job, not so great if your program is short staffed. Despite the grandiose ideas expressed at SMH 2008 about hospitalists leading the health care quality revolution I suspect most programs are just struggling to meet day-to-day demands of patient care and call coverage. Every hospital has opportunities for improvement. For hospitalists to really take charge somebody has to carve out the time. That means lightening the patient load. Good luck convincing your administration.

From an attendee: In the wake of the impending CMS payment rules for hospital complications the new meme is POA (present on admission). Be on the lookout for the coming pandemic of decubs and urinary tract infections POA as the sensitivity for diagnosing these conditions goes way up. (Does one WBC per high power field really make a diagnosis of UTI?).

Again from Wachter’s World: Are you co-managing surgical patients yet? We’ve come a long way from the House of God where specialty wars and turfing (dumping the patient to a different specialty service) were the norm. Co-management is a new buzzword among hospitalist types. Collaboration between specialties is a wonderful idea, but one in need of better definition. Demarcation of responsibility remains important. All kinds of problems arise if it’s not clear who’s in charge of what. That’s my problem with the idea of co-management. What does it mean, exactly? Here’s my bias: Hospitalists can make sure patients’ statins and beta blockers get continued, help keep their electrolytes from getting screwed up, manage post operative cardiac problems and run ventilators. I’m not sure they should be fiddling with NG tubes, chest tubes or post operative pain management. However it’s done, demarcate the lines clearly.

The electrocardiogram in the patient with syncope

In addition to occasional demonstration of the culprit arrhythmia, the electrocardiogram may yield clues to underlying conditions such as acute coronary syndrome, Brugada syndrome, long QT syndrome and hypertrophic cardiomyopathy. The topic is reviewed in the American Journal of Emergency Medicine.

ICU sedation

I’m not sure about the title of this article in Chest: Patient-Focused Sedation and Analgesia in the ICU. I thought everything we do is supposed to be patient focused. Anyway, it’s a helpful review which covers the ins and outs of various classes of agents and makes these key points:

Establish a specific rationale and specific goals at the start of treatment. (In other words, instead of “hurry up and snow the patient before the intubation meds wear off” take a few minutes to think).

Use a protocol.

Use daily sedation interruption.

Know your pharmacology.

Differentiation of narrow QRS tachycardias

An algorithm is presented in the American Journal of Emergency Medicine.

Clopidogrel rebound

When clopidogrel (Plavix) is stopped following a course of treatment for acute coronary syndrome, whether medically managed or with stent placement, cardiac events tend to cluster in the first 90 days after discontinuation according to a disturbing report in JAMA.

According to Medscape’s coverage of the study, the lead author commented that:

…there were two possibilities as to how to deal with it: keep the patient on clopidogrel for longer periods or taper the dose when stopping. "We need to study each of these possibilities to find out which one is best. But until we know for sure, physicians should discuss with each patient how they want to handle the situation after they have taken clopidogrel for a year after an ACS event. A patient who is doing well on clopidogrel, has no bleeding issues or other side effects, and can afford it may want to stay on the drug long term. If they want to come off the dug, then tapering the dose over a few weeks may be a good idea. Or perhaps the dose of aspirin could be doubled for a while. I can't recommend any of these things as we haven't got the data; they are just suggestions.”